Part II

[Federal Register: April 25, 2006 (Volume 71, Number 79)]

[Proposed Rules]

[Page 23995-24472]

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

[DOCID:fr25ap06-18]

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Part II

Book 2 of 2 Books

Pages 23995-24550

Department of Health and Human Services

Centers for Medicare & Medicaid Services

42 CFR Parts 409, 410 et al.

Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2007 Rates; Proposed Rule

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 409, 410, 412, 413, 424, 485, and 489

[CMS-1488-P]

RIN 0938-AO12

Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2007 Rates

AGENCY: Centers for Medicare & 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, and to implement a number of changes made by the Deficit Reduction Act of 2005 (Pub. L. 109-171). 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, 2006.

In this proposed rule, we discuss our proposals to refine the diagnosis-related group (DRG) system under the IPPS to better recognize severity of illness among patients--for FY 2007, we are proposing to use a hospital-specific relative value cost center weighting methodology to adjust DRG relative weights and in FY 2008 (if not earlier), to implement consolidated severity-adjusted DRGs or alternative severity adjustment methods.

Among the other policy changes that we are proposing to make are changes related to: limited revisions of the reclassification of cases to DRGs; the long-term care (LTC)-DRGs and relative weights; the wage data, including the occupational mix data, used to compute the wage index; applications for new technologies and medical services add-on payments; payments to hospitals for the direct and indirect costs of graduate medical education; submission of hospital quality data; payments to sole community hospitals and Medicare-dependent, small rural hospitals; and provisions governing emergency services under the Emergency Medical Treatment and Labor Act of 1986 (EMTALA).

We are also inviting comments on a number of issues including performance-based hospital payments for services and health information technology, as well as how to improve data transparency for consumers.

DATES: To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on June 12, 2006.

ADDRESSES: In commenting, please refer to file code CMS-1488-P. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.

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

1. Electronically. You may submit electronic comments on specific issues in this regulation to http://www.cms.hhs.gov/eRulemaking. Click

on the link ``Submit electronic comments on CMS regulations with an open comment period''. (Attachments should be in Microsoft Word, WordPerfect, or Excel; however, we prefer Microsoft Word.)

2. By regular mail. You may mail written comments (one original and two copies) to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1488-P, P.O. Box 8011, Baltimore, MD 21244-1850.

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

3. By express or overnight mail. You may send written comments (one original and two copies) to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1488-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

4. By hand or courier. If you prefer, you may deliver (by hand or courier) your written comments (one original and two copies) before the close of the comment period to one of the following addresses. If you intend to deliver your comments to the Baltimore address, please call telephone number (410) 786-7195 in advance to schedule your arrival with one of our staff members. Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201, or 7500 Security Boulevard, Baltimore, MD 21244-1850.

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

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

Submission of comments on paperwork requirements. You may submit comments on this document's paperwork requirements by mailing your comments to the addresses provided at the end of the ``Collection of Information Requirements'' section in this document.

For information on viewing public comments, see the beginning of the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT:

Marc Hartstein, (410) 786-4548, Operating Prospective Payment, Diagnosis-Related Groups (DRGs), Wage Index, New Medical Services and Technology Add-On Payments, Hospital Geographic Reclassifications, Sole Community Hospital, Disproportionate Share Hospital, and Medicare- Dependent, Small Rural Hospital Issues. Tzvi Hefter, (410) 786-4487, Capital Prospective Payment, Excluded Hospitals, Graduate Medical Education, Critical Access Hospitals, and Long-Term Care (LTC)-DRG Issues. Siddhartha Mazumdar, (410) 786-6673, Rural Community Hospital Demonstration Issues. Sheila Blackstock, (410) 786-3502, Quality Data for Annual Payment Update Issues. Thomas Valuck, (410) 786-7479, Hospital Value-Based Purchasing Issues. Frederick Grabau, (410) 786-0206, Services in Foreign Hospitals Issues. Brian Reitz, (410) 786-5001, Obsolete Paper Claims Forms Issues.

SUPPLEMENTARY INFORMATION: Submitting Comments: We welcome comments from the public on all issues set forth in this rule to assist us in fully considering issues and developing policies. You can assist us by referencing the file code CMS-1488-P and the specific ``issue identifier'' that precedes the section on which you choose to comment.

Inspection of Public Comments: All comments received before the close of

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the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. We post all comments received before the close of the comment period on the following Web site as soon as possible after they have been received: http://www.cms.hhs.gov/eRulemaking. Click on the link ``Electronic Comments on CMS

Regulations'' on that Web site to view public comments.

Comments received timely will also be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1-800-743-3951.

Electronic Access

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

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

Acronyms

AHA American Hospital Association AHIMA American Health Information Management Association AHRO Agency for Health Care Research and Quality AMI Acute myocardial infarction AOA American Osteopathic Association APR DRG All Patient Refined Diagnosis Related Group System ASC Ambulatory surgical center ASP Average sales price AWP Average wholesale price BBA Balanced Budget Act of 1997, Public Law 105-33 BBRA Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Balanced Budget Refinement Act of 1999, Public Law 106-113 BIPA Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Benefits Improvement and Protection Act of 2000, Public Law 106-554 BLS Bureau of Labor Statistics CAH Critical access hospital CART CMS Abstraction & Reporting Tool CBSAs Core-based statistical areas CC Complication or comorbidity CDAC Clinical Data Abstraction Center CIPI Capital input price index CPI Consumer price index CMI Case-mix index CMS Centers for Medicare & Medicaid Services CMSA Consolidated Metropolitan Statistical Area COBRA Consolidated Omnibus Reconciliation Act of 1985, Public Law 99- 272 CPI Consumer price index CRNA Certified registered nurse anesthetist CY Calendar year DRA Deficit Reduction Act of 2005, Public Law 109-171 DRG Diagnosis-related group DSH Disproportionate share hospital ECI Employment cost index EMR Electronic medical record EMTALA Emergency Medical Treatment and Labor Act of 1986, Public Law 99-272 FDA Food and Drug Administration FFY Federal fiscal year FIPS Federal information processing standards FQHC Federally qualified health center FTE Full-time equivalent FY Fiscal year GAAP Generally Accepted Accounting Principles GAF Geographic Adjustment Factor GME Graduate medical education HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems HCFA Health Care Financing Administration HCRIS Hospital Cost Report Information System HHA Home health agency HHS Department of Health and Human Services HIC Health insurance card HIPAA Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 HIPC Health Information Policy Council HIS Health information system HIT Health information technology HMO Health maintenance organization HSA Health savings account HSCRC Maryland Health Services Cost Review Commission HSRV Hospital-specific relative value HSRVcc Hospital-specific relative value cost center HQA Hospital Quality Alliance HQI Hospital Quality Initiative HwH Hospital-within-a-hospital ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modification ICD-10-PCS International Classification of Diseases, Tenth Edition, Procedure Coding System ICU Intensive care unit IHS Indian Health Service IME Indirect medical education IOM Institute of Medicine IPF Inpatient psychiatric facility IPPS Acute care hospital inpatient prospective payment system IRF Inpatient rehabilitation facility JCAHO Joint Commission on Accreditation of Healthcare Organizations LAMCs Large area metropolitan counties LTC-DRG Long-term care diagnosis-related group LTCH Long-term care hospital MCE Medicare Code Editor MCO Managed care organization MCV Major cardiovascular condition MDC Major diagnostic category MDH Medicare-dependent, small rural hospital MedPAC Medicare Payment Advisory Commission MedPAR Medicare Provider Analysis and Review File MEI Medicare Economic Index MGCRB Medicare Geographic Classification Review Board MMA Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 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 NCQA National Committee for Quality Assurance 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

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OSCAR Online Survey Certification and Reporting (System) PRM Provider Reimbursement Manual PPI Producer price index PMSAs Primary metropolitan statistical areas PPS Prospective payment system PRA Per resident amount ProPAC Prospective Payment Assessment Commission PRRB Provider Reimbursement Review Board PS&R Provider Statistical and Reimbursement (System) QIG Quality Improvement Group, CMS QIO Quality Improvement Organization RHC Rural health clinic RHQDAPU Reporting hospital quality data for annual payment update RNHCI Religious Nonmedical Health care Institution RRC Rural referral center RUCAs Rural-urban commuting area codes RY Rate year SAF Standard Analytic File SCH Sole community hospital SFY State fiscal year SIC Standard Industrial Classification SNF Skilled nursing facility SOCs Standard occupational classifications SOM State Operations Manual SSA Social Security Administration SSI Supplemental Security Income TAG Technical Advisory Group 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. Inpatient Rehabilitation Facilities (IRFs)

b. Long-Term Care Hospitals (LTCHs)

c. Inpatient Psychiatric Facilities (IPFs)

3. Critical Access Hospitals (CAHs)

4. Payments for Graduate Medical Education (GME)

B. Provisions of the Deficit Reduction Act of 2005 (DRA)

C. Major Contents of this Proposed Rule

1. Proposed DRG Reclassifications and Recalibrations of Relative Weights

2. Proposed Changes to the Hospital Wage Index

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

4. Proposed Changes to the PPS for Capital-Related Costs

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

6. Payment for Services Furnished Outside the United States

7. Payment for Blood Clotting Factor Administered to Inpatients With Hemophilia

8. Limitation on Payments to Skilled Nursing Facilities for Bad Debt

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

10. Impact Analysis

11. Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services

12. Discussion of Medicare Payment Advisory Commission Recommendations

13. Appendix C--Combinations of Consolidated Severity-Adjusted DRGs and Appendix D--Crosswalk of Consolidated Severity-Adjusted DRGs to Respective APR DRGs II. Proposed Changes to DRG Classifications and Relative Weights

A. Background

B. DRG Reclassifications

1. General

2. Yearly Review for Making DRG Changes

3. Refinement of DRGs Based on Severity of Illness

C. Proposals for Revisions to the DRG System Used Under the IPPS

1. MedPAC Recommendations

2. Refinement of the Relative Weight Calculation

3. Refinement of DRGs Based on Severity of Illness

a. Comparison of the CMS DRG System and the APR DRG System

b. Consolidated Severity-Adjusted DRGs for Use in the IPPS

c. Changes to Case-Mix Index (CMI) From a New DRG System

4. Effect of Consolidated Severity-Adjusted DRGs on the Outlier Threshold

5. Impact of Refinement of DRG System on Payments

6. Conclusions

D. Proposed Changes to Specific DRG Classifications

1. Pre-MDCs: Pancreas Transplants

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

a. Implantation of Intracranial Neurostimulator System for Deep Brain Stimulation (DBS)

b. Carotid Artery Stents

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

a. Insertion of Epicardial Leads for Defibrillator Devices

b. Application of Major Cardiovascular Diagnoses (MCVs) List to Defibrillator DRGs

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

a. Hip and Knee Replacements

b. Spinal Fusion

c. ChariteTMSpinal Disc Replacement Device

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

6. Medicare Code Editor (MCE) Changes

a. Newborn Diagnoses Edit

b. Diagnoses Allowed for Females Only Edit

c. Diagnoses Allowed for Males Only Edit

d. Manifestations Not Allowed as Principal Diagnosis Edit

e. Nonspecific Principal Diagnosis Edit

f. Unacceptable Principal Diagnosis Edit

g. Nonspecific O.R. Procedures Edit

h. Noncovered Procedures Edit

i. Bilateral Procedure Edit

7. Surgical Hierarchies

8. Refinement of Complications and Comorbidities (CC) List

a. Background

b. Comprehensive Review of the CC List

c. CC Exclusions List Proposed for FY 2007

9. 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

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

E. Proposed Recalibration of DRG Weights

F. Proposed LTC-DRG Reclassifications and Relative Weights for LTCHs for FY 2007

1. Background

2. Proposed Changes in the LTC-DRG Classifications

a. Background

b. Patient Classifications into DRGs

3. Development of the Proposed FY 2007 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 2007 LTC-DRG Relative Weights

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

1. Background

2. Public Input Before Publication of This Notice of Proposed Rulemaking on Add-On Payments

3. FY 2007 Status of Technologies Approved for FY 2006 Add-On Payments

a. Kinetra[supreg] Implantable Neurostimulator for Deep Brain Stimulation

b. Endovascular Graft Repair of the Thoracic Aorta

c. Restore[supreg] Rechargeable Implantable Neurostimulator

4. FY 2007 Applicants for New Technology Add-On Payments

a. C-Port[supreg] Distal Anastomosis System

b. NovoSeven[supreg] for Intracerebral Hemorrhage

c. X STOP Interspinous Process Decompression System 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 the Proposed FY 2007 Index

1. Development of Data for the Proposed Occupational Mix Adjustment

2. Calculation of the Proposed FY 2007 Occupational Mix Adjustment Factor and the Proposed FY 2007 Occupational Mix Adjusted Wage Index

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D. Worksheet S-3 Wage Data for the Proposed FY 2007 Wage Index Update

E. Verification of Worksheet S-3 Wage Data

F. Computation of the Proposed FY 2007 Unadjusted Wage Index

G. Computation of the Proposed FY 2007 Blended Wage Index

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

1. General

2. Effects of Reclassification

3. FY 2007 MGCRB Reclassifications

4. Proposed FY 2007 Redesignations Under Section 1886(d)(8)(B) of the Act

5. Reclassifications Under Section 508 of Pub. L. 108-173

6. Proposed Wage Indices for Reclassified Hospitals and Proposed Reclassification Budget Neutrality Factor

I. Proposed FY 2007 Wage Index Adjustment Based on Commuting Patterns of Hospital Employees

J. Process for Requests for Wage Index Data Corrections

K. Labor-Related Share for the Wage Index for FY 2007

L. Proxy for the Hospital Market Basket IV. Other Decisions and Proposed Changes to the IPPS for Operating Costs and GME Costs

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

1. Background

2. New Procedures for Hospital Reporting of Quality Data

3. Electronic Medical Records

B. Value-Based Purchasing

1. Introduction

2. Premier Hospital Quality Incentive Demonstration

3. RHQDAPU Program

a. Section 501(b) of Pub. L. 108-173 (MMA)

b. Section 5001(a) of Pub. L. 109-171 (DRA)

4. Plan for Implementing Hospital Value-Based Purchasing Beginning With FY 2009

a. Measure Development and Refinement

b. Data Infrastructure

c. Incentive Methodology

d. Public Reporting

5. Considerations Related to Certain Conditions, Including Hospital-Acquired Infections

6. Promoting Effective Use of Health Information Technology

C. Sole Community Hospitals (SCHs) and Medicare-Dependent, Small Rural Hospitals (MDHs)

1. Background

2. Volume Decrease Adjustment for SCHs and MDHs

a. HAS/Monitrend Data

b. HAS/Monitrend Data Book Replacement Alternative

3. Mandatory Reporting Requirements for Any Changes in the Circumstances Under Which a Hospital Was Designated as an SCH or MDH

4. Proposed Payment Changes for MDHs Under the DRA of 2005

a. Background

b. Proposed Regulation Changes

5. Proposed Technical Change

D. Rural Referral Centers

1. Case-Mix Index

2. Discharges

E. Indirect Medical Education (IME) Adjustment

1. Background

2. IME Adjustment Factor for FY 2007

3. Technical Change to Revise Cross-Reference

F. Payment Adjustment for Disproportionate Share Hospitals (DSHs)

1. Background

2. Technical Corrections

3. Proposed Reinstatement of Inadvertently Deleted Provisions on DSH Payment Adjustment Factors

4. Enhanced DSH Adjustment for MDHs

G. Geographic Reclassifications

1. Background

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

3. Multicampus Hospitals

4. Urban Group Hospital Reclassifications

5. Effect of Change of Ownership on Urban County Group Reclassifications

6. Requested Reclassification for Hospitals Located in a Single Hospital MSA Surrounded by Rural Counties

H. Payment for Direct Graduate Medical Education

1. Background

2. Determination of Weighted Average Per Resident Amounts (PRAs) for Merged Teaching Hospitals

3. Determination of Per Resident Amounts (PRAs) for New Teaching Hospitals

4. Requirements for Counting and Appropriate Documentation of FTE Residents: Clarification

5. Resident Time Spent in Nonpatient Care Activities as Part of Approved Residency Programs

6. Medicare GME Affiliated Groups: Technical Changes to Regulations

I. Payment for the Costs of Nursing and Allied Health Education Activities: Clarification

J. Hospital Emergency Services Under EMTALA

1. Background

2. Role of the EMTALA Technical Advisory Group (TAG)

3. Definition of ``Labor''

4. Application of EMTALA Requirements to Hospitals Without Dedicated Emergency Departments

5. Clarification of Reference to ``Referral Centers''

K. Other Proposed Technical Changes

1. Proposed Cross-Reference Correction in Regulations on Limitations on Beneficiary Charges

2. Proposed Cross-Reference Corrections in Regulations on Payment Denials Based on Admissions and Quality Reviews

3. Proposed Cross-Reference Correction in Regulations on Outlier Payments

4. Removing References to Two Paper Claims Forms

L. Rural Community Hospital Demonstration Program

M. Health Care Information Transparency Initiative V. Proposed Changes to the PPS for Capital-Related Costs

A. Background

B. Treatment of Certain Urban Hospitals Reclassified as Rural Hospitals Under Sec. 412.103

C. Other Technical Corrections Relating to the Capital PPS Geographic Adjustment Factors VI. Proposed Changes for Hospitals and Hospital Units Excluded From the IPPS

A. Payments to Existing Hospitals and Hospital Units

1. Payments to Existing Excluded Hospitals and Hospital Units

2. Separate PPS for IRFs

3. Separate PPS for LTCHs

4. Separate PPS for IPFs

5. Grandfathering of Hospitals-Within-Hospitals (HwHs) and Satellite Facilities

6. Proposed Changes to the Methodology for Determining LTCH Cost-to-Charge Ratios (CCRs) and the Reconciliation of High-Cost and Short-Stay Outlier Payments Under the LTCH PPS

a. Background

b. High-Cost Outliers

c. Short-Stay Outliers

7. Technical Corrections Relating to LTCHs

8. Proposed Cross-Reference Correction in Authority Citations for 42 CFR 412 and 413

B. Critical Access Hospitals (CAHs)

1. Background

2. Sunset of Designation of CAHs as Necessary Providers: Technical Correction VII. Payment for Services Furnished Outside the United States

A. Background

B. Proposed Clarification of Regulations VIII. Payment for Blood Clotting Factor Administered to Inpatients With Hemophilia IX. Limitation on Payments to Skilled Nursing Facilities for Bad Debt

A. Background

B. Changes Made by Section 5004 of the DRA

C. Proposed Regulation Changes X. MedPAC Recommendations XI. Other Required Information

A. Requests for Data From the Public

B. Collection of Information Requirements

C. Public Comments XII. Regulation Text Addendum--Proposed Schedule of Standardized Amounts Effective With Discharges Occurring On or After October 1, 2006 and Update Factors and Rate-of-Increase Percentages Effective With Cost Reporting Periods Beginning on or After October 1, 2006 I. Summary and Background II. Proposed Changes to Prospective Payment Rates for Hospital Inpatient Operating Costs for FY 2007

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

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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 2007 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 the Proposed Prospective Payment Rates for FY 2007

1. Federal Rate

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

a. Calculation of Hospital-Specific Rate

b. Updating the FY 1982, FY 1987, FY 1996, and FY 2002 Hospital- Specific Rates for FY 2007

3. General Formula for Calculation of Proposed Prospective Payment Rates for Hospitals Located in Puerto Rico Beginning On or After October 1, 2006 and Before October 1, 2007

a. Puerto Rico Rate

b. National Rate III. Proposed Changes to Payment Rates for Acute Care Hospital Inpatient Capital-Related Costs for FY 2007

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

1. Projected Capital Standard Federal Rate Update

a. Description of the Update Framework

b. Comparison of CMS and MedPAC Update Recommendation

2. Proposed Outlier Payment Adjustment Factor

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

4. Proposed Exceptions Payment Adjustment Factor

5. Proposed Capital Standard Federal Rate for FY 2007

6. Proposed Special Capital Rate for Puerto Rico Hospitals

B. Calculation of the Proposed Inpatient Capital-Related Prospective Payments for FY 2007

C. Capital Input Price Index

1. Background

2. Forecast of the CIPI for FY 2007 IV. Payment Rates for Excluded Hospitals and Hospital Units: Proposed Rate-of-Increase Percentages

A. Payments to Existing Excluded Hospitals and Units

B. New Excluded Hospitals and Units V. Proposed Payment for Blood Clotting Factor Administered to Inpatients With Hemophilia 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 2005; Hospital Wage Indexes for Federal Fiscal Year 2007; Hospital Average Hourly Wage for Federal Fiscal Years 2005 (2001 Wage Data), 2006 (2002 Wage Data), and 2007 (2003 Wage Data); Wage Indexes and 3-Year Average of Hospital Average Hourly Wages

Table 3A--FY 2007 and 3-Year Average Hourly Wage for Urban Areas by CBSA

Table 3B--FY 2007 and 3-Year Average Hourly Wage for Rural Areas by CBSA

Table 4A-1--Wage Index and Capital Geographic Adjustment Factor (GAF) for Urban Areas by CBSA--FY2007

Table 4A-2--Wage Index and Capital Geographic Adjustment Factor (GAF) for Certain Urban Areas by CBSA for the Period April 1 through September 30, 2007

Table 4B--Wage Index and Capital Geographic Adjustment Factor (GAF) for Rural Areas by CBSA--FY 2007

Table 4C-1--Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That Are Reclassified by CBSA--FY 2007

Table 4C-2--Wage Index and Capital Geographic Adjustment Factor (GAF) for Certain Hospitals That Are Reclassified by CBSA for the Period April 1 Through September 30, 2007

Table 4F--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF) by CBSA--FY 2007

Table 4J--Out-Migration Wage Adjustment--FY 2007

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 2005 MedPAR Update December 2005 GROUPER V23.0

Table 7B--Medicare Prospective Payment System Selected Percentile Lengths of Stay: FY 2005 MedPAR Update December 2005 GROUPER V24.0

Table 8A--Statewide Average Operating Cost-to-Charge Ratios-- March 2006

Table 8B--Statewide Average Capital Cost-to-Charge Ratios--March 2006

Table 8C--Proposed Statewide Average Total Cost-to-Charge Ratios for LTCHs--March 2006

Table 9A--Hospital Reclassifications and Redesignations by Individual Hospital and CBSA--FY 2007

Table 9B--Hospital Reclassifications and Redesignation by Individual Hospital Under Section 508 of Pub. L. 108-173--FY 2007

Table 9C--Hospitals Redesignated as Rural Under Section 1886(d)(8)(E) of the Act--FY 2007

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 2006

Table 11--Proposed FY 2007 LTC-DRGs, Relative Weights, Geometric Average Length of Stay, and \5/6\ths of the Geometric Average Length of Stay Appendix A--Regulatory Impact Analysis I. Overall Impact II. Objectives III. Limitations on Our Analysis IV. Hospitals Included In and Excluded From the IPPS V. Effects on Excluded Hospitals and Hospital Units VI. Quantitative Effects of the Proposed Policy Changes Under the IPPS for Operating Costs

A. Basis and Methodology of Estimates

B. Analysis of Table I

C. Effects on the Hospitals that Failed the Quality Data Submission Process (Column 2)

D. Effects of the DRA Provision Related to MDHs (Column 3)

E. Effects of the Changes to the DRG Reclassifications and Relative Cost-Based Weights (Column 4)

F. Effects of Proposed Wage Index Changes (Column 5)

G. Combined Effects of Proposed DRG and Wage Index Changes, Including Budget Neutrality Adjustment (Column 6)

H. Effects of the 3-Year Provision Allowing Urban Hospitals that Were Converted to Rural as a Result of the FY 2005 Labor Market Area Changes to Maintain the Wage Index of the Urban Labor Market Area in Which They Were Formerly Located (Column 7)

I. Effects of MGCRB Reclassifications (Column 8)

J. Effects of the Proposed Wage Index Adjustment for Out- Migration (Column 9)

K. Effects of All Changes (Column 10)

L. Effects of Policy on Payment Adjustments for Low-Volume Hospitals

M. Impact Analysis of Table II VII. Effects of Other Proposed Policy Changes

A. Effects of LTC-DRG Reclassifications and Relative Weights for LTCHs

B. Effects of Proposed New Technology Add-On Payments

C. Effects of Requirements for Hospital Reporting of Quality Data for Annual Hospital Payment Update

D. Effects of Other Proposed Policy Changes Affecting Sole Community Hospitals (SCHs) and Medicare-Dependent, Small Rural Hospitals (MDHs)

E. Effects of Proposed Policy on Payment for Direct Costs of Graduate Medical Education

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1. Determination of Weighted Average GME PRAs for Merged Teaching Hospitals

2. Determination of PRAs for New Teaching Hospitals

3. Requirements for Counting and Appropriate Documentation of FTE Residents

4. Resident Time Spent in Nonpatient Care Activities as Part of an Approved Residency Program

F. Effects of Proposed Policy Changes Relating to Emergency Services Under EMTALA

G. Effects of Policy on Rural Community Hospital Demonstration Program

H. Effects of Proposed Policy on Hospitals-Within-Hospitals and Satellite Facilities

I. Effects of Proposed Policy Changes to the Methodology for Determining LTCH CCRs and the Reconciliation LTCH PPS Outlier Payments

J. Effects of Proposed Policy on Payment for Services Furnished Outside the United States

K. Effects of Proposed Policy on Limitation on Payments to SNFs VIII. Effects of Proposed Changes in the Capital PPS

A. General Considerations

B. Results IX. Alternatives Considered X. Overall Conclusion XI. Accounting Statement XII. Executive Order 12866 Appendix B--Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services I. Background II. Inpatient Hospital Update for FY 2007 III. Secretary's Recommendation IV. MedPAC Recommendation for Assessing Payment Adequacy and Updating Payments in Traditional Medicare Appendix C--Combinations of Proposed Consolidated Severity-Adjusted DRGs Appendix D--Crosswalk of Proposed Consolidated Severity-Adjusted DRGs to Respective APR DRGs

I. Background

A. Summary

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

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

The base payment rate is comprised of a standardized amount that is divided into a labor-related share and a nonlabor-related share. The labor-related share is adjusted by the wage index applicable to the area where the hospital is located; and if the hospital is located in Alaska or Hawaii, the nonlabor-related share is adjusted by a cost-of- living adjustment factor. This base payment rate is multiplied by the DRG relative weight.

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

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

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

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

Although payments to most hospitals under the IPPS are made on the basis of the standardized amounts, some categories of hospitals are paid the higher of a hospital-specific rate based on their costs in a base year (the higher of FY 1982, FY 1987, FY 1996, or FY 2002) or the IPPS rate based on the standardized amount. For example, sole community hospitals (SCHs) are the sole source of care in their areas, and Medicare-dependent, small rural hospitals (MDHs) are a major source of care for Medicare beneficiaries in their areas. Both of these categories of hospitals are afforded this special payment protection in order to maintain access to services for beneficiaries. (Until FY 2007, an MDH has received the IPPS rate plus 50 percent of the difference between the IPPS rate and its hospital-specific rate if the hospital- specific rate is higher than the IPPS rate. In addition, an MDH does not have the option of using FY 1996 as the base year for its hospital- specific rate. As discussed below, for discharges occurring on or after October 1, 2007, but before October 1, 2011, an MDH will receive the IPPS rate plus 75 percent of the difference between the IPPS rate and its hospital-specific rate, if the hospital-specific rate is higher than the IPPS rate.)

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

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

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

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inpatient psychiatric facilities (IPFs)), as discussed below. Children's hospitals, cancer hospitals, and RNHCIs continue to be paid solely under a reasonable cost-based system.

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

Under section 1886(j) of the Act, as amended, rehabilitation hospitals and units (IRFs) have been transitioned from payment based on a blend of reasonable cost reimbursement subject to a hospital-specific annual limit under section 1886(b) of the Act and the adjusted facility Federal prospective payment rate for cost reporting periods beginning on or after January 1, 2002 through September 30, 2002, to payment at 100 percent of the Federal rate effective for cost reporting periods beginning on or after October 1, 2002. IRFs subject to the blend were also permitted to elect payment based on 100 percent of the Federal rate. The existing regulations governing payments under the IRF PPS are located in 42 CFR Part 412, Subpart P. b. Long-Term Care Hospitals (LTCHs)

Under the authority of sections 123(a) and (c) of Pub. L. 106-113 and section 307(b)(1) of Pub. L. 106-554, LTCHs that do not meet the definition of ``new'' under Sec. 412.23(e)(4) 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. These LTCHs that do not meet the definition of ``new'' may elect to be paid based on 100 percent of the Federal prospective payment rate instead of a blended payment in any year during the 5-year transition. For cost reporting periods beginning on or after October 1, 2006, LTCHs will be paid 100 percent of the Federal rate. The existing regulations governing payment under the LTCH PPS are located in 42 CFR Part 412, Subpart O. c. Inpatient Psychiatric Facilities (IPFs)

Under the authority of sections 124(a) and (c) of Pub. L. 106-113, inpatient psychiatric facilities (IPFs) (formerly psychiatric hospitals and psychiatric units of acute care hospitals) are paid under the IPF PPS. Under the IPF PPS, some IPFs are transitioning from being paid for inpatient hospital services based on a blend of reasonable cost-based payment and a Federal per diem payment rate, effective for cost reporting periods beginning on or after January 1, 2005 (November 15, 2004 IPF PPS final rule (69 FR 66922) and January 23, 2006 IPF PPS proposed rule (71 FR 3616)). For cost reporting periods beginning on or after January 1, 2008, all IPFs will be paid 100 percent of the Federal per diem payment amount. The existing regulations governing payment under the IPF PPS are located in 42 CFR 412, Subpart N. 3. Critical Access Hospitals (CAHs)

Under sections 1814, 1820, and 1834(g) of the Act, payments are made to critical access hospitals (CAHs) (that is, rural hospitals or facilities that meet certain statutory requirements) for inpatient and outpatient services based on 101 percent of reasonable cost. Reasonable cost is determined under the provisions of section 1861(v)(1)(A) of the Act and existing regulations under 42 CFR Parts 413 and 415. 4. Payments for Graduate Medical Education (GME)

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

B. Provisions of the Deficit Reduction Act of 2005 (DRA)

On February 8, 2006, the Deficit Reduction Act of 2005 (DRA), Pub. L. 109-171, was enacted. Pub. L. 109-171 made a number of changes to the Act relating to prospective payments to hospitals and other providers for inpatient services. This proposed rule would implement amendments made by the following sections of Pub. L. 109-171:

Section 5001(a), which, effective for FY 2007 and subsequent years, expands the requirements for hospital quality data reporting.

Section 5003, which makes various improvements to the MDH program. It extends special payment provisions, requires MDHs to use FY 2002 as their base year for determining whether use of their hospital- specific rate enhances payment (but permits them to continue to use either their 1982 or 1987 hospital-specific rate if using either of those rates results in higher payments), and removes the application of the 12-percent cap on the DSH payment adjustment factor for MDHs.

Section 5004, which reduces certain allowable SNF bad debt payments by 30 percent. Payments for the bad debts of full-benefit, dual eligible individuals are not reduced.

In this proposed rule, we also discuss and invite comments on the requirements of section 5001(b) of Pub. L. 109-171, which require us to develop a plan to implement, beginning with FY 2009, a value-based purchasing plan for section 1886(d) hospitals. This discussion also includes the provisions of section 5001(c) of Pub. L. 109-171, which requires a quality adjustment in DRG payments for certain hospital- acquired conditions, effective for FY 2008.

C. 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 2007. 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, and payments for SCHs and MDHs. The changes being proposed would be effective for discharges occurring on or after October 1, 2006, unless otherwise noted.

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

In section II. of the preamble to this proposed rule, as required by section 1886(d)(4)(C) of the Act, we are proposing limited revisions to the DRG classifications structure. In this section, we respond to several recommendations made by MedPAC intended to improve the DRG system. We are also proposing to use, for FY 2007, hospital-specific relative values for 10 cost centers to compute DRG relative weights. In addition, we are proposing to use consolidated severity-adjusted DRGs or alternative severity adjustment methods in FY 2008 (if not earlier).

We also are presenting our reevaluation of certain FY 2006 applicants for add-on payments for high-cost new medical services and technologies, and our analysis of FY 2007 applicants (including public input,

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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 2007. 2. Proposed Changes to the Hospital Wage Index

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

The FY 2007 wage index update, using wage data from cost reporting periods that began during FY 2003.

The proposed FY 2007 occupational mix adjustment to the wage index.

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

The proposed adjustment to the wage index for FY 2007 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 2007 wage index.

The labor-related share for the FY 2007 wage index, including the labor-related share for Puerto Rico. 3. Other Decisions and Proposed Changes to the IPPS for Operating Costs, GME Costs, and Promoting Hospitals' Effective Use of Health Information Technology

In section IV. of the preamble to this proposed rule, we discuss a number of provisions of the regulations in 42 CFR Parts 412 and 413 including the following:

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

Proposed changes in payments to SCHs and MDHs.

Proposed updated national and regional case-mix values and discharges for purposes of determining rural referral center status.

The statutorily-required IME adjustment factor for FY 2007.

Proposed changes relating to hospitals' geographic classifications, including reclassifications under section 508 of Pub. L. 108-173, multicampus hospitals, urban group hospital reclassification and the effect of change in ownership on urban county group reclassifications.

Proposed changes and clarifications relating to GME that address determining the per resident amounts (PRAs) for merged hospitals and new teaching hospitals, counting and appropriate documentation of FTE residents, and counting of resident time spent in nonpatient care activities as part of approved residency programs.

Proposed changes relating to payment for costs of nursing and allied health education programs.

Proposed changes relating to requirements for emergency services for hospitals under EMTALA.

Discussion of the third year of implementation of the Rural Community Hospital Demonstration Program.

We also are inviting comments on promoting hospitals' effective use of health information technology. 4. Proposed Changes to the PPS for Capital-Related Costs

In section V. of the preamble to this proposed rule, we discuss the payment policy requirements for capital-related costs and capital payments to hospitals and propose several technical corrections to the regulations. 5. Proposed Changes for Hospitals and Hospital Units Excluded From the IPPS

In section VI. of the preamble to this proposed rule, we discuss payments to excluded hospitals and hospital units, proposed policy changes regarding increases or decreases in square footage or decreases in the number of beds of the ``grandfathering'' HwHs and satellite facilities, proposed changes to the methodology for determining LTCH CCRs and the reconciliation of high-cost and short-stay outlier payments under the LTCH PPS, and a proposed technical change relating to the designation of CAHs as necessary providers. 6. Payments for Services Furnished Outside the United States

In section VII. of the preamble to this proposed rule, we set forth proposed changes to clarify what is considered ``outside the United States'' for Medicare payment purposes. 7. Payment for Blood Clotting Factor Administered to Inpatients With Hemophilia

In section VIII. of the preamble to this proposed rule, we discuss the proposed changes in payment for blood clotting factor administered to Medicare beneficiaries with hemophilia for FY 2007. 8. Limitation on Payments to Skilled Nursing Facilities for Bad Debt

In section IX. of the preamble to this proposed rule, we propose to implement section 5004 of Pub. L. 109-171 relating to reduction in payments to SNFs for bad debt. 9. Determining Proposed Prospective Payment Operating and Capital Rates and Rate-of-Increase Limits

In the Addendum to this proposed rule, we set forth proposed changes to the amounts and factors for determining the FY 2007 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 2007 for hospitals and hospital units excluded from the PPS. 10. 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. 11. Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services

In Appendix B of this proposed rule, as required by sections 1886(e)(4) and (e)(5) of the Act, we provided our recommendations of the appropriate percentage changes for FY 2007 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. 12. Discussion of Medicare Payment Advisory Commission Recommendations

Under section 1805(b) of the Act, MedPAC is required to submit a report to Congress, no later than March 1 of each year, in which MedPAC reviews and makes recommendations on Medicare payment policies. MedPAC's March 2006 recommendation concerning hospital inpatient payment policies addressed the update factor for inpatient hospital operating costs and capital-related costs under the IPPS and for hospitals and distinct part hospital units excluded from the IPPS. This recommendation is addressed in Appendix B of this proposed rule. For further information relating specifically to the MedPAC March 2006 reports or to obtain a copy of the reports, contact MedPAC at (202) 220-3700 or visit

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MedPAC's Web site at: http://www.medpac.gov.

13. Appendix C and Appendix D

In Appendix C of this proposed rule, we list the combinations of the consolidated severity-adjusted DRGs that we are proposing to implement on FY 2008 (if not earlier), as discussed in section II.C. of the preamble of this proposed rule. In Appendix D of this proposed rule, we provide a crosswalk of the proposed consolidated severity- adjusted DRG system to the respective All Patient Related Diagnosis- Related Group (APR DRG) system.

II. Proposed Changes to DRG Classifications and Relative Weights

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

A. Background

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

Congress recognized that it would be necessary to recalculate the DRG relative weights periodically to account for changes in resource consumption. Accordingly, section 1886(d)(4)(C) of the Act requires that the Secretary adjust the DRG classifications and relative weights at least annually. These adjustments are made to reflect changes in treatment patterns, technology, and any other factors that may change the relative use of hospital resources.

B. DRG Reclassifications

1. General

For FY 2007, we are proposing only limited changes to the current DRG classifications, as discussed in section II.D. of the preamble to this proposed rule, that would be applicable to discharges occurring on or after October 1, 2006. We are limiting our proposed changes because, as discussed in detail in section II.C. of the preamble to this proposed rule, we are focusing our efforts on addressing the recommendations made last year by MedPAC to refine the entire CMS DRG system by taking into account severity of illness (if not earlier) and applying hospital-specific relative value (HSRV) weights to DRGs.

Currently, cases are classified into CMS DRGs for payment under the IPPS based on the principal diagnosis, up to eight additional diagnoses, and up to six procedures performed during the stay. In a small number of DRGs, classification is also based on the age, sex, and discharge status of the patient. The diagnosis and procedure information is reported by the hospital using codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).

The process of forming the DRGs was begun by dividing all possible principal diagnoses into mutually exclusive principal diagnosis areas, referred to as Major Diagnostic Categories (MDCs). The MDCs were formed by physician panels as the first step toward ensuring that the DRGs would be clinically coherent. The diagnoses in each MDC correspond to a single organ system or etiology and, in general, are associated with a particular medical specialty. Thus, in order to maintain the requirement of clinical coherence, no final DRG could contain patients in different MDCs. Most MDCs are based on a particular organ system of the body. For example, MDC 6 is Diseases and Disorders of the Digestive System. This approach is used because clinical care is generally organized in accordance with the organ system affected. However, some MDCs are not constructed on this basis because they involve multiple organ systems (for example, MDC 22 (Burns)). For FY 2006, cases are assigned to one of 526 DRGs in 25 MDCs. The table below lists the 25 MDCs.

Major Diagnostic Categories (MDCs)

1................................. Diseases and Disorders of the Nervous System. 2................................. Diseases and Disorders of the Eye. 3................................. Diseases and Disorders of the Ear, Nose, Mouth, and Throat. 4................................. Diseases and Disorders of the Respiratory System. 5................................. Diseases and Disorders of the Circulatory System. 6................................. Diseases and Disorders of the Digestive System. 7................................. Diseases and Disorders of the Hepatobiliary System and Pancreas. 8................................. Diseases and Disorders of the Musculoskeletal System and Connective Tissue. 9................................. Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast. 10................................ Endocrine, Nutritional and Metabolic Diseases and Disorders. 11................................ Diseases and Disorders of the Kidney and Urinary Tract. 12................................ Diseases and Disorders of the Male Reproductive System. 13................................ Diseases and Disorders of the Female Reproductive System. 14................................ Pregnancy, Childbirth, and the Puerperium. 15................................ Newborns and Other Neonates with Conditions Originating in the Perinatal Period. 16................................ Diseases and Disorders of the Blood and Blood Forming Organs and Immunological Disorders. 17................................ Myeloproliferative Diseases and Disorders and Poorly Differentiated Neoplasms. 18................................ Infectious and Parasitic Diseases (Systemic or Unspecified Sites). 19................................ Mental Diseases and Disorders. 20................................ Alcohol/Drug Use and Alcohol/Drug Induced Organic Mental Disorders. 21................................ Injuries, Poisonings, and Toxic Effects of Drugs. 22................................ Burns. 23................................ Factors Influencing Health Status and Other Contacts with Health Services. 24................................ Multiple Significant Trauma. 25................................ Human Immunodeficiency Virus Infections.

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In general, cases are assigned to an MDC based on the patient's principal diagnosis before assignment to a DRG. However, for FY 2006, 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 transplants, lung transplants, simultaneous pancreas/kidney transplants, and pancreas transplants, and for tracheostomies. Cases are assigned to these DRGs before they are classified to an MDC. The table below lists the nine current pre-MDCs.

Pre-Major Diagnostic Categories (Pre-MDCs)

DRG 103........................... Heart Transplant or Implant of Heart Assist System. DRG 480........................... Liver Transplant and/or Intestinal Transplant. DRG 481........................... Bone Marrow Transplant. DRG 482........................... Tracheostomy for Face, Mouth, and Neck Diagnoses. DRG 495........................... Lung Transplant. DRG 512........................... Simultaneous Pancreas/Kidney Transplant. DRG 513........................... Pancreas Transplant. DRG 541........................... ECMO or Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except for Face, Mouth, and Neck Diagnosis with Major O.R. DRG 542........................... Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except for Face, Mouth, and Neck Diagnosis without Major O.R.

Once the MDCs were defined, each MDC was evaluated to identify those additional patient characteristics that would have a consistent effect on the consumption of hospital resources. Because the presence of a surgical procedure that required the use of the operating room would have a significant effect on the type of hospital resources used by a patient, most MDCs were initially divided into surgical DRGs and medical DRGs. Surgical DRGs are based on a hierarchy that orders operating room (O.R.) procedures or groups of O.R. procedures by resource intensity. Medical DRGs generally are differentiated on the basis of diagnosis and age (0 to 17 years of age or greater than 17 years of age). Some surgical and medical DRGs are further differentiated based on the presence or absence of a complication or 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 diagnoses was evaluated to determine if complications, comorbidities, or the patient's age would consistently affect the consumption of hospital resources. Physician panels classified each diagnosis code based on whether the diagnosis, when present as a secondary condition, would be considered a substantial CC. A substantial CC was defined as a condition which, because of its presence with a specific principal diagnosis, would cause an increase in the length of stay by at least one day in at least 75 percent of the patients. Each medical and surgical class within an MDC was tested to determine if the presence of any substantial CC would consistently affect the consumption of hospital resources.

A patient's diagnosis, procedure, discharge status, and demographic information is 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 payment for each case covered by the IPPS based on the DRG relative weight and additional factors associated with each hospital, such as IME and DSH adjustments. These additional factors increase the payment amount to hospitals above the base DRG payment.

The records for all Medicare hospital inpatient discharges are maintained in the Medicare Provider Analysis and Review (MedPAR) file. The data in this file are used to evaluate possible DRG classification changes and to recalibrate the DRG weights. However, in the 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.

The limited changes that we are proposing to the DRG classification system for FY 2007 for the FY 2007 GROUPER, version 24.0 and to the methodology used to recalibrate the DRG weights are set forth under section II.E. of this proposed rule. Unless otherwise noted in this proposed rule, our DRG analysis is based on data from the December 2005 update of the FY 2005 MedPAR file, which contains hospital bills received through December 31, 2005, for discharges occurring in FY 2005. 2. Yearly Review for Making DRG Changes

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

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inclusion in the annual proposed rule and, if included, may be subjected to public review and comment. Therefore, similar to the timetable for interested parties to submit non-MedPAR data for consideration in the DRG recalibration process, concerns about DRG classification issues should be brought to our attention no later than early December in order to be considered and possibly included in the next annual proposed rule updating the IPPS.

The actual process of forming the DRGs was, and continues to be, highly iterative, involving a combination of statistical results from test data combined with clinical judgment. For purposes of this proposed rule, 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 existing DRG. We evaluate patient care costs using average charges and lengths of stay as proxies for costs and rely on the judgment of our medical officers to decide whether patients are clinically distinct or 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.

C. Proposals for Revisions to the DRG System Used Under the IPPS

1. MedPAC Recommendations

In the FY 2006 IPPS final rule, we discussed a number of recommendations made by MedPAC regarding revisions to the DRG system used under the IPPS (70 FR 47473 through 47482).

In Recommendation 1-3 in the 2005 Report to Congress on Physician- Owned Specialty Hospitals, MedPAC recommended that CMS:

Refine the current DRGs to more fully capture differences in severity of illness among patients, including--

Base the DRG relative weights on the estimated cost of providing care.

Base the weights on the national average of the hospital- specific relative values (HSRVs) for each DRG (using hospital-specific costs to derive the HSRVs).

Adjust the DRG relative weights to account for differences in the prevalence of high-cost outlier cases.

Implement the case-mix measurement and outlier policies over a transitional period.

As we noted in the FY 2006 IPPS final rule, we had insufficient time to complete a thorough evaluation of these recommendations for full implementation in FY 2006. However, we did adopt severity-weighted cardiac DRGs in FY 2006 to address public comments on this issue and the specific concerns of MedPAC regarding cardiac surgery DRGs. We also indicated that we planned to further consider all of MedPAC's recommendations and thoroughly analyze options and their impacts on the various types of hospitals in the FY 2007 IPPS proposed rule. Following the publication of the FY 2006 IPPS final rule, we contracted with 3M Health Information Systems to assist us in performing this analysis.

Beginning with MedPAC's relative weight recommendations, we analyzed MedPAC's recommendations to move to a cost-based HSRV weighting methodology. In performing this portion of the analysis, we studied hospital cost report data, departmental cost-to-charge ratios (CCRs), MedPAR claims data, and HSRV weighting methodology. Our intention in undertaking this portion of the analysis was to find an administratively feasible approach to improving the accuracy of the DRG weights. As we describe in detail below, we believe some changes can be made to MedPAC's methodology for determining the relative weights that will make it more feasible to replicate on an annual basis but will result in similar impacts.

In conjunction with analyzing MedPAC's relative weight recommendations, we looked at refining the current DRG system to better recognize severity of illness. Starting with the APR DRG GROUPER used by MedPAC in its analysis, we studied Medicare claims data. Based on this analysis, we developed a consolidated severity-adjusted DRG GROUPER that we believe could be a better alternative for recognizing severity of illness among the Medicare population. We note that MedPAC's recommendations with regard to revising the DRGs to better recognize severity of illness may have implications for the outlier threshold, the measurement of real case-mix versus apparent case-mix, and the IME and the DSH adjustments. We will discuss these implications in more detail in the following sections.

As we present below, we believe that the recommendations made by MedPAC, or some variants of them, have significant promise to improve the accuracy of the payment rates in the IPPS. For instance, the percent of DRGs with payment-to-cost ratios between 0.95 and 1.05 will increase substantially from adoption of these recommendations.\1\ We agree with MedPAC about exploring possible refinements to our payment methodology even in the absence of concerns about the proliferation of specialty hospitals. In the FY 2006 final rule, we indicated that until we had completed further analysis of the options and their effects, we could not predict the extent to which changing to APR DRGs would provide payment equity between specialty and general hospitals. In fact, we cautioned that any system that groups cases will always present some opportunities for providers to specialize in cases they believe to have higher margins. We believe that improving payment accuracy should reduce these opportunities, and potentially reduce the incentives that Medicare payments may provide for the further development of specialty hospitals.

\1\ Medicare Payment Advisory Commission: Report to the Congress; Physician-Owned Specialty Hospitals, March 2005, p. 37.

We considered MedPAC's recommendation to adjust the relative weights to account for differences in the prevalence of outlier cases. However, we placed most of our attention and resources on the recommendations related to refinement of the current DRGs to more fully capture differences in severity of illness among patients as we do not have the statutory authority to make the specific changes to our outlier policy that MedPAC recommended. While we have not made MedPAC's recommendation regarding outliers a central focus of our analysis, we do intend to examine this issue in more detail in the future. In the following sections II.C.2. through C.6. of this proposed rule, we present our analysis and discuss a number of issues related to the MedPAC recommendations. We also present the estimated impacts of implementing the recommendations and conclude with a specific proposal for FY 2007 and some proposed intended actions for implementation for FY 2008. We also are soliciting comments on other possible proposals or actions in FY 2007, FY 2008, or a combination of both.

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2. Refinement of the Relative Weight Calculation

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

MedPAC made two recommendations with respect to the DRG relative weight calculation. First, MedPAC recommended that CMS base the DRG relative weights on the estimated cost of providing care. Second, MedPAC recommended that CMS base the weights on the national average of the HSRVs in each DRG (using hospital-specific costs to derive the HSRVs). Because both of these recommendations address the relative weight calculation, we are addressing them together. The work we have done to address these recommendations is discussed below.

MedPAC recommended that CMS replace its charge-based relative weight methodology with cost-based HSRV weights as it believed that the charge-based relative weight methodology that CMS has utilized since 1983 has introduced bias into the weights due to differential markups for ancillary services among the DRGs. In analyzing claims data, it is evident to us that some hospital types (for example, teaching hospitals) are systematically more expensive overall than the average hospital and certain case types are more commonly treated at these more expensive facilities. This fact results in an upward bias in the weights for these types of cases. The HSRV methodology recommended by MedPAC would help reduce the bias that may be present in the national relative weights due to differences in case-mix adjusted costs.

Under the HSRV method recommended by MedPAC, charges are standardized for each provider by converting its charges for each case to hospital-specific relative charge values and then adjusting those values for the hospital's case-mix. The first step in this process involves dividing the charge for each case at the hospital by the average charge for all cases at the hospital in which the case was treated. The hospital-specific relative charge value, by definition, averages 1.0 for each hospital. The resulting ratio is then multiplied by the hospital's case-mix index (CMI). In this way, each hospital'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 hospitals.

Our analysis of departmental-level CCRs from the Medicare cost report data has shown that charges for routine days, intensive care days, and various ancillary services are not marked up by a consistent amount. For example, the markup amounts for cardiology services are higher than average. Because charges are the current basis for the DRG relative weights, the practice of differential markups can lead to bias in the DRG weights because various DRGs use, on average, more or less of particular ancillary services. MedPAC believes that the bias in the national DRG relative weights that may arise as a result of differential markups across various cost centers can be removed by moving from charge-based to cost-based weights.

Based on the analysis we have conducted, we agree that it may be appropriate to adjust the DRG relative weights to account for the differences in charge markups across cost centers and to adopt an HSRV methodology. However, we have several concerns about the methodology used by MedPAC. MedPAC's methodology to reduce hospital charges to cost is administratively burdensome, not only to develop, but also to maintain.

First, MedPAC developed CCRs for individual hospitals at the most detailed department level. Specifically, in calculating costs as the basis for the relative weights, MedPAC applied hospital-specific CCRs from each provider's cost report to the line item charges on the claims that the hospital submitted during the same time period. This methodology required matching cost report data to claims data, and because cost report data take longer to compile and file, the method necessitates using older claims data to set relative weights. The most recent complete set of Medicare cost reports available to us is from FY 2003. Thus, if we were to model the exact approach used by MedPAC and use claims data for a matching year, we would be using claims data from FY 2003. If we set DRG weights for FY 2007 using our current charge- based method, we would use FY 2005 hospital claims to set the proposed relative weights. In addition, MedPAC's hospital-specific approach required detailed cost center distinctions for each hospital that are difficult to define, map, and apply. This approach also required the use of the Standard Analytic File (SAF) because MedPAR data that we currently use to set DRG weights did not have the necessary level of detail. Using the SAF increases processing time and adds further complexity to the process of setting the relative weights.

Second, because MedPAC applied these CCRs at the individual claim level, missing or invalid data resulted in MedPAC deleting a large number of claims (approximately 10 percent) from the relative weight calculation. Lastly, MedPAC acknowledged that its method was too difficult to replicate on an annual basis and suggested that the weights be recalculated once every 5 years with other adjustments based on charges during the intervening years.

We have developed an alternative to MedPAC's approach that we believe would achieve similar results in a more administratively feasible manner. This method involves developing hospital-specific charge relative weights at the cost center level to remove the bias introduced by hospital characteristics (that is, teaching, disproportionate share, location, and size, among others) and then scaling the weights to costs using the national cost center charge ratios developed from the cost report data. After studying Medicare cost report data, we established 10 cost center categories based upon broad hospital accounting definitions. In our cost center categories, there are 8 ancillary cost groups in addition to routine day costs and intensive care day costs, and each category represents at least 5 percent of the charges in the claims data. The specific cost report lines that contribute to each category and the corresponding charge lines from the MedPAR claims data are itemized in Table A below.

We believe this alternative approach, which we are labeling as the HSRV cost center (HSRVcc) methodology, has several advantages. First, the use of national average rather than hospital-specific CCRs avoids the complexity encountered with cost center CCRs at the hospital level and allows us to retain more data for use in the relative weight calculation. In addition, the methodology eliminates the need to match claims to the time period of the CCRs, resulting in the ability to use more timely claims data. Furthermore, the alternative approach makes it more feasible to update the relative weights annually using a single methodology. We do not have to replicate the methodology once every 5 years and make adjustments based on changes in charges in the intervening years.

In developing an alternative method of calculating DRG weights, we utilized two data sources: claims data and cost report data. The claims data are taken from the FY 2004 MedPAR file. This file is based on fully coded diagnostic and procedure data for all Medicare inpatient hospital bills. The FY 2004 MedPAR data include discharges occurring between October 1, 2003, and September 30, 2004, based on bills received by CMS through March 30, 2005, from all hospitals subject to the IPPS. The full FY 2004 MedPAR file

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includes data for approximately 13,673,607 Medicare discharges. We excluded discharges for Medicare beneficiaries enrolled in a Medicare+Choice managed care plan from the analysis. In addition, we excluded data for any hospital that was paid under the IPPS during FY 2004 but became a CAH at any time before February 28, 2005; data from IPFs, IRFs, and LTCHs; data from Maryland hospitals; data from Indian Health Service hospitals; and data from all-inclusive rate providers. The Medicare cost report data used in the analysis were from FY 2003, the most recent full set of data available. Under our alternative methodology, we calculated DRG weights from MedPAR and cost report data as follows: a. Step One: Clean the Data

(1) All of the claims were grouped using Version 23.0 of the CMS DRGs.

The transplant cases that were used to establish the alternative relative weights for heart and heart-lung, liver and/or intestinal, and lung transplants (DRGs 103, 480, and 495 under the current Version 23.0 GROUPER) were limited to those Medicare-approved transplant centers that have cases in the FY 2004 MedPAR file. (Medicare coverage for heart, heart and lung, liver and/or intestinal, and lung transplants is limited to those facilities that have received approval from CMS as transplant centers.)

Organ acquisition 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 adjusting the charges under the HSRVcc methodology and before eliminating statistical outliers.

(2) The FY 2004 MedPAR data were edited to exclude claims for hospitals with no cost report data. Claims with total charges or total length of stay less than or equal to zero were eliminated. Claims that had an amount in the total charge field that differed by more or less than $10 from the sum of charges for routine days, intensive care, pharmacy, special equipment, therapy, operating room, cardiology, laboratory, radiology, and other services were deleted. In addition, we deleted claims for providers that had charges only in the routine days and intensive care days cost centers and had no charges in any of the eight ancillary cost centers. These claims were deleted because we believe the charges for the eight ancillary cost centers were included in the routine days and intensive care days cost centers. Had we included these claims, the charges for the routine days and intensive care days would have been inflated. After applying these edits, we identified 11,142,651 claims that we used in this analysis.

(3) Statistical outliers were eliminated by removing all cases that were beyond 3.0 standard deviations from the mean of the log distribution of both the charges per case and the charges per day for each DRG. b. Step Two: Compute HSRVs for Each Cost Center for Each DRG

Once the MedPAR data were edited, we sorted the data by provider so that charges could be standardized under the HSRVcc methodology. To do this, an average charge was computed for each provider for each of 10 proposed cost centers (see Table A). The average charge was computed by summing the charges for each cost center and dividing by the transfer- adjusted case count for each provider. A transfer case, identified by discharge code, DRG, and length of stay, was counted as a fraction of a case based on the ratio of its length of stay plus 1 day relative to the geometric mean length of stay for that DRG. That is, a transfer case with a length of stay of 2 days in a DRG with a geometric mean length of stay of 6 days would be counted as 3 (2 days plus 1 extra day) divided by 6 or 0.5 of a total case. This treatment of transfer cases is consistent with payment rules.

After computing the average charge for each provider for each cost center, the cost center charges on each claim were divided by the provider's average charge for the matching cost center across all services. For example, the routine day charges on each individual claim were divided by the average routine day charge for the provider across all services, the intensive care unit charges on the same claim were divided by the average intensive care unit charge for the provider across all services, and so on.

By using a hospital's relative charge structure, we found that the resulting weights did not reflect differences in charges among providers for factors such as location, size, wages, relative efficiency, average markup, IME adjustment, DSH adjustment, and the variety of cases treated. Therefore, once charge weights were computed at the hospital cost center level, they were multiplied by the provider's CMI. We made this adjustment for the CMI to rescale the hospital-specific relative charge values which, by definition, averaged to 1.0 for each cost center. We believed that the CMI was a reasonable scale factor to use to further adjust the relative charges to reflect the complexity of cases treated by the provider. We assigned a starting CMI of 1 to the cost center for each provider. However, an alternative starting CMI could have been assigned because the algorithm is not sensitive to starting values of CMI.

After the relative charges (cost center claim charge divided by the average cost center charge for the provider) were multiplied by the hospital's matching cost center CMI, they were summed by DRG. The transfer adjusted case count for each DRG was also summed. Average charges by DRG were calculated for each cost center by taking the sum of the relative CMI-adjusted charges for that DRG and dividing by the transfer-adjusted case count for that DRG. A national average charge for each cost center was calculated summing all relative CMI-adjusted charges in the trimmed MedPAR data set and dividing by the total transfer-adjusted case count. We then created a set of cost center DRG weights by dividing the national average charge for each DRG for each cost center by the national average charge for that cost center. The result was a set of 10 weights for each DRG. These 10 weights are then assigned to each claim, and a new CMI is created for each provider. Then the relative charges for each cost center on the claim (total charge for cost center is divided by the provider's average charge for that cost center) are multiplied by this new CMI and the weights are iterated until the national average CMI for each cost center stops changing between iterations. In preparing the proposed weights for their simulation, we used a transfer-adjusted CMI that was computed by taking the sum of the transfer-adjusted weights and dividing by a full case count, where the transfer-adjusted weight is computed by multiplying the transfer-adjusted case count (length of stay for the claim plus 1 day divided by geometric mean length of stay for the DRG) by the DRG weight.

Table A below illustrates the charge line items from MedPAR that were included in each cost center charge group. In addition, it shows the corresponding line items from Worksheet C, Part 1, columns 5, 6, and 7 of the Medicare cost reports. The name of each cost report line item appears as it is listed in the Hospital Cost Report Information System (HCRIS) cost report database record layout which is available for download via the Web site: http://www.cms.hhs.gov.

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c. Step Three: Compute CCRs From the Cost Reports for Each of the 10 Cost Center Groups Identified in Table A

After the iteration process was completed, we removed the effects of differential markups within cost centers. The first step in this process was to develop national cost center CCRs. Taking FY 2003 cost report data, we edited the data to remove data for CAHs, IPFs, IRFs, LTCHs, Maryland hospitals, Indian Health Service hospitals, and all inclusive rate hospitals, and cost reports that represented time periods of less than 1 year (365 days). We then created CCRs for each provider for each group of cost centers (see Table A for line items used in the calculations) while removing any cost center CCRs that were greater than 10 or less than .01, as we believe that these CCRs are outside of a reasonable range. We then took the logs of all of the cost center CCRs and removed any cost center CCRs where the log of the cost center CCR was greater or less than the mean log plus/minus 1.96 standard deviations of the log of that cost center CCR. We used 1.96 standard deviations as a trim factor because the logs of the cost center CCRs are normally distributed and 1.96 standard deviations represent the 95th percentile of the T-Distribution for large sample size, for which 2,000 to 3,000 hospitals qualify. Once the cost report data were trimmed, we calculated the geometric mean CCR for each cost center.

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d. Step Four: Sum the Average Charge for Each Cost Center From the MedPAR Data and Apply the National CCRs From the MedPAR File

Once the national average CCRs from Step Three were computed, they were multiplied by the total unadjusted charges for the matching cost centers in the MedPAR file. The estimated costs were then summed to derive a total cost for all cases across the Nation. The percentage that each cost center was contributing to the overall total costs is calculated by dividing the individual cost center cost by the total. For example, the total cost for routine days was divided by the total cost for all cases to arrive at 0.29, which indicated that routine costs were responsible for approximately 29 percent of total costs. The 10 scaling factors sum to 1.0. e. Step Five: Adjust Relative Weights From Step Two to Cost by Applying Scaling Factors From Step Four

For each DRG, the cost center weights are multiplied by these scaling factors (that is, the routine day weight is multiplied by the routine day scaling factor, the intensive care unit weight is multiplied by the intensive care unit scaling factor, and so on). After the weights are adjusted by the scaling factor, they are summed by DRG to create one final weight for each DRG. f. Step Six: Normalize the Weights

In order to compare the weights calculated in Step Five to the charge-based weights that are in effect in FY 2006, the weights were normalized by the FY 2006 normalization factor of 1.47462 (70 FR 47332). This factor was applied to the charge-based weights from FY 2006 to ensure that recalibration by itself neither increases nor decreases total payments under the IPPS. We used the same normalization factor that we applied for purposes of calculating the DRG relative weights in the FY 2006 IPPS final rule because we used the same FY 2004 MedPAR data and FY 2003 cost report data that we used to set the FY 2006 DRG relative weights. We note that we likely will have more recent data available when we determine the DRG relative weights for the FY 2007 IPPS final rule. 3. Refinement of DRGs Based on Severity of Illness

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

For purposes of the following discussions, the term ``CMS DRGs'' means the DRG system we currently use under the IPPS; the term ``APR DRGs'' means the severity DRG system designed by 3M Health Information Systems that currently is used by the State of Maryland; and the term ``consolidated severity-adjusted DRGs'' means the DRG system based on a consolidated version of the APR DRGs (as described in detail below). Although we discuss the consolidated severity-adjusted DRGs in this proposed rule, we are interested in public comments on whether there are alternative DRG systems that could result in better recognition of severity than the consolidated severity-adjusted DRGs we are proposing. We refer to adopting consolidated severity-adjusted DRGs numerous times in this proposed rule. As we make clear in the detailed discussion below, there are still further changes that we believe may be important to make to this proposed system before it is ready for adoption. In the remainder of this proposed rule, ``consolidated severity-adjusted DRGs'' refers to the DRG system we have analyzed. However, it is possible that the public comment process will present compelling evidence that there are potential alternatives to the consolidated severity-adjusted DRG system for us to consider that could more effectively recognize severity of illness.

In the FY 2006 IPPS final rule (70 FR 47474), we stated that we would consider making changes to the CMS DRGs to better reflect severity of illness among patients. We indicated that we would conduct a comprehensive review of the CC list as well as consider the possibility of using the APR DRGs for FY 2007. We did not adopt APR DRGs for FY 2006 because such an adoption would represent a significant undertaking that could have a substantial effect on all hospitals. There was insufficient time between the release of the MedPAC reports in March 2005 and the publication of the FY 2006 IPPS final rule for us to analyze fully a change of this magnitude. Instead, we adopted a more limited policy by implementing severity-adjusted cardiac DRGs.

After publication of the FY 2006 IPPS final rule, CMS contracted with 3M Health Information Systems to further analyze the MedPAC recommendations in support of our consideration of possible changes to the IPPS for FY 2007. Under one task of this contract, 3M Health Information Systems analyzed the feasibility of using a revised DRG system under the IPPS that is modeled on the APR DRGs Version 23 to better recognize severity of illness. The APR DRGs have been used successfully as the basis of Belgium's hospital prospective global budgeting system since 2002. The State of Maryland began using APR DRGs as the basis of its all-payer hospital payment system in July 2005. More than a third of the hospitals in the United States are already using APR DRG software to analyze comparative hospital performance. Many major health information system vendors have integrated this system into their products. Several State agencies utilize the APR DRGs for the public dissemination of comparative hospital performance reports. APR DRGs have been widely applied in policy and health services research. In addition to being used in research by MedPAC, the APR DRGs also contain a separate measure of risk of mortality that is used in the Quality Indicators of the Agency for Healthcare Research and Quality, the Premier Hospital Quality Incentive Demonstration discussed in section IV.B. of this preamble, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) hospital accreditation survey process (Shared Visions-New Pathways).

Below we present a comparison of the CMS DRG system and the APR DRG system. a. Comparison of the CMS DRG System and the APR DRG System

The CMS DRG and APR DRG systems have a similar basic structure. There are 25 MDCs in both systems. The DRG assignments for both systems are based on the reporting of ICD-9-CM diagnosis and procedure codes. Both DRG systems are composed of a base DRG that describes the reason for hospital admission and a subdivision of the base DRG based on other patient attributes that affect the care of the patient. For surgical patients, the base DRG is defined based on the type of procedure performed. For medical patients, the base DRG is defined based on the principal diagnosis. In Version 23.0 of the CMS DRG system, there are 367 base DRGs and 526 total DRGs. In Version 23 of the APR DRG system, there are 314 base DRGs and 1,258 total APR DRGs. Some of the base DRGs in the two systems are virtually identical. For example, there is no significant difference between the base DRG under both systems for medical treatment of congestive heart failure. For other base DRGs, there are substantial differences. For example, in the CMS DRG system, there are two base DRGs for appendectomy (simple and complex); in the APR DRG system, there is only one base DRG for appendectomy (the relative complexity of the patient is addressed in the subsequent subdivision

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of the base DRG into severity of illness subclasses).

The focus of the CMS DRGs is on complexity. Complexity is defined as the relative volume and types of diagnostic, therapeutic, and bed services required for the treatment of a particular illness. Thus, the focus of payment in the CMS DRG system reflects the relative resource use needed by the patient in one DRG group compared to another. Resource use is generally correlated with severity of illness but an intensive resource use does not necessarily indicate a high level of severity in every case. It is possible that some patients will be resource-intensive and require high-cost services even though they are less severely ill than other patients. The CMS DRG system subdivides the base DRGs using age and the presence of a secondary diagnosis that represents a CC. The age subdivisions primarily relate to pediatric patients (those who are less than 18 years of age). Patients are assigned to the CC subgroup if they have at least one secondary diagnosis that is considered a CC. The diagnoses that are designated as CCs are the same across all base DRGs. The subdivisions of the base CMS DRGs are not uniform: some base DRGs have no subdivision; some base DRGs have a two-way subdivision based on the presence of a CC; and other base DRGs have a three-way subdivision based on a pediatric subdivision followed by a CC subdivision of the adult patients. In addition, some base DRGs in MDC 5 (Diseases and Disorders of the Circulatory System) have a subdivision based on the presence of a major cardiovascular condition or complex diagnosis.

The APR DRG system subdivides the base DRGs by adding four severity of illness subclasses to each DRG. Under the APR DRG system, severity of illness is defined as the extent of physiologic decompensation or organ system loss of function. The underlying clinical principle of APR DRGs is that the severity of illness of a patient is highly dependent on the patient's underlying problem and that patients with high severity of illness are usually characterized by multiple serious diseases or illnesses. The assessment of the severity of illness of a patient is specific to the base APR DRG to which a patient is assigned. In other words, the determination of the severity of illness is disease-specific. High severity of illness is primarily determined by the interaction of multiple diseases. Patients with multiple comorbid conditions involving multiple organ systems are assigned to the higher severity of illness subclasses. The four severity of illness subclasses under the APR DRG system are numbered sequentially from 1 to 4, indicating minor (1), moderate (2), major (3), and extreme (4) severity of illness.

The APR DRG system does not subdivide base DRGs based on the age of the patient. Instead, patient age is used in the determination of the severity of illness subclass. In the CMS DRG system, the CC list is generally the same across all base DRGs. However, there are CC list exclusions for secondary diagnoses that are related to the principal diagnosis. In the APR DRG system, the significance of a secondary diagnosis is dependent on the base DRG. For example, an infection is considered more significant for an immune-suppressed patient than for a patient with a broken arm. The logic of the CC subdivision in the CMS DRG system is a simple binary split for the presence or absence of a CC. In the APR DRG system, the determination of the severity subclass is based on an 18-step process that takes into account secondary diagnoses, principal diagnosis, age, and procedures. The 18 steps are divided into three phases. There are six steps in Phase I, three steps in Phase II, and nine steps in Phase III.

The diagram below illustrates the three-phase process for determining patient severity of illness subclass. BILLING CODE 4120-01-P

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Under the CMS DRG system, a patient is assigned to the DRG with CC if there is at least one secondary diagnosis present that is a CC. There is no recognition of the impact of multiple CCs. Under the APR DRG system, high severity of illness is primarily determined by the interaction of multiple diseases. Under the CMS DRG system, patients are assigned to an MDC based on their principal diagnosis. While the principal diagnosis is generally used to assign the patient to an MDC in the APR DRG system, there is a rerouting step that assigns some patients to another MDC. For example, lower leg amputations can be performed for circulatory, endocrine, or musculoskeletal principal diagnoses. Instead of having three separate amputation base DRGs in different MDCs as is done in the CMS DRG system, the APR DRG system reroutes all of these amputation patients into a single base APR DRG in the musculoskeletal MDC. The CMS DRG system uses death as a variable in the DRG definitions but the APR DRG system does not. Both DRG systems are based on the information contained in the Medicare Uniform Bill. The APR DRG system requires the same information used by the current CMS DRG system. No changes to the claims form or the data reported would be necessary if CMS were to adopt APR DRGs or a variant of them.

The CMS DRG structure makes some DRG modifications difficult to accommodate. For example, high severity diseases that occur in low volume are difficult to accommodate because the only choice is to form a separate base DRG with relatively few patients. Such an approach would lead to a proliferation of low-volume DRGs. Alternatively, these cases may be included in DRGs with other patients that are dissimilar clinically or in costs. Requests for new base DRGs formed on the use of a specific technology may also be difficult to accommodate. Base DRGs formed based on the use of a specific technology would result in the payment weight for the DRG being dominated by the price set by the manufacturer for the technology.

The structure of the APR DRGs provides a means of addressing high severity cases that occur in low volume through assignment of the case to a severity of illness subclass. However, the APR DRG structure does not currently accommodate distinctions based on complexity. Technologies that represent increased complexity, but not necessarily greater severity of illness, are not explicitly recognized in the APR DRG system. For example, in the CMS DRGs, there are separate DRGs for coronary angioplasty with or without insertion of stents. The APR DRGs do not make such a differentiation. The insertion of the stent makes the patient's case more complex but does not mean the patient is more severely ill. However, the inability to insert a stent may be indicative of a patient's more advanced coronary artery disease. Although such conflicts are relatively few in number, they do represent an underlying difference between the two systems. If Medicare were to adopt a severity DRG system based on the APR DRG logic but assign cases based on complexity as well as severity as we do under the current Medicare DRG system, such a distinction would represent a departure from the exclusive focus on severity of illness that currently forms the basis of assigning cases in the APR DRG system.

Section 1886(d)(4) of the Act specifies that the Secretary must adjust the classifications and weighting factors at least annually to reflect changes in treatment patterns, technology, and other factors that may change the relative use of hospital resources. Therefore, we believe a method of recognizing technologies that represent increased complexity, but not necessarily greater severity of illness, should be included in the system. We plan to develop criteria for determining when it is appropriate to recognize increased complexity in the structure of the DRG system and how these criteria interact with the existing statutory provisions for new technology add-on payments. We invite public comments on this particular issue.

Another difference between the CMS DRG system and the APR DRG system is the assignment of diagnosis codes in category 996 (Complications peculiar to certain specified procedures). The CMS DRG system treats virtually all of these codes as CCs. With the exceptions of complications of organ transplant and limb reattachments, these complication codes do not contribute to the severity of illness subclass in the APR DRG system. While these codes could be added to the severity logic, the appropriateness of recognizing codes such as code 998.4 (Foreign body accidentally left during a procedure) as a factor in payment calculation could create the appearance of incentives for less than optimal quality. Although there is no direct recognition of the codes under the 996 category, the precise complication, in general, can be coded separately and could contribute to the severity of illness subclass assignment.

Table B below summarizes the differences between the two DRG systems:

Table B.--Comparison of the CMS DRG System and the APR DRG System

Element

CMS DRG system APR DRG system

Number of base DRGs............. 367............... 314. Total number of DRGs............ 526............... 1,258. Number of CC (severity)

2................. 4. subclasses. Multiple CCs recognized......... No................ Yes. CC assignment specific to base No................ Yes. DRG. Logic of CC subdivision......... Presence or

18-step process. absence. Logic of MDC assignment......... Principal

Principal diagnosis.

diagnosis with rerouting. Death used in DRG definitions... Yes............... No. Data requirements............... Hospital claims... Hospital claims.

To illustrate the differences between the two DRG systems, we compare in Table C below four cases that have been assigned to CMS DRGs and APR DRGs. In all four cases, the patient is a 67-year-old who is admitted for diverticulitis of the colon and who has a multiple segmental resection of the large intestine performed. ICD-9-CM diagnosis code 562.11 (Diverticulitis of colon (without mention of hemorrhage)) and ICD-9-CM procedure code 45.71 (Multiple segmental resection of large intestine) would be reported to capture this case. In both DRG systems, the patient would be assigned to the base DRG for major small and large bowel procedures. These four cases would fall

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into two different CMS DRGs and four different APR DRGs. We include Medicare average charges in the table to illustrate the differences in hospital resource use.

Case 1: The patient receives only a secondary diagnosis of an ulcer of anus and rectum (ICD-9-CM diagnosis code 569.41). Under the CMS DRG system, the patient is assigned to base DRG 149 (Major Small and Large Bowel Procedures Without CC). Under the APR DRG system, the patient is assigned to base DRG 221 (Major Small and Large Bowel Procedures) with a severity of illness subclass of 1 (minor).

Case 2: The patient receives a secondary diagnosis of an ulcer of anus and rectum and an additional secondary diagnosis of unspecified intestinal obstruction (ICD-9-CM diagnosis code 560.9). Under the CMS DRG system, the patient is assigned to DRG 148 (Major Small and Large Bowel Procedures With CC). Under the APR DRG system, the patient is assigned to base DRG 221 and the severity of illness subclass increases to 2 (moderate).

Case 3: The patient receives multiple secondary diagnoses of an ulcer of anus and rectum, unspecified intestinal obstruction, acute myocarditis (ICD-9-CM diagnosis code 422.99), and atrioventricular block, complete (ICD-9-CM diagnosis code 426.0). Under the CMS DRG system, the patient is assigned to DRG 148. Under the APR DRG system, the patient is assigned to base DRG 221 and the severity of illness subclass increases to 3 (major).

Case 4: The patient receives multiple secondary diagnoses of an ulcer of anus and rectum, unspecified intestinal obstruction, acute myocarditis, atrioventricular block, complete, and the additional diagnosis of acute renal failure, unspecified (ICD-9-CM diagnosis code 584.9). Under the CMS DRG system, the patient is assigned to DRG 148. Under the APR DRG system, the patient is assigned to base DRG 221 and the severity of illness subclass increases to 4 (extreme).

Table C.--Example of Sample Cases Assigned Under the CMS DRG System and Under the APR DRG System

CMS DRG system

APR DRG system Principal diagnosis code: 562.11 -------------------------------------------------------------------------- Procedure code: 45.71

Average

Average DRG assigned

charge

DRG assigned

charge

Case 1--Secondary Diagnosis: 569.41.. 149 without CC.......... $25,147 221 with severity of

$25,988 illness subclass 1. Case 2--Secondary Diagnoses: 569.41, 148 with CC............. 59,519 221 with severity of

38,209 560.9.

illness subclass 2. Case 3--Secondary Diagnoses: 569.41, 148 with CC............. 59,519 221 with severity of

66,597 560.9, 422.99, 426.0.

illness subclass 3. Case 4--Secondary Diagnoses: 569.41, 148 with CC............. 59,519 221 with severity of

130,750 560.9, 422.99, 426.0, 584.9.

illness subclass 4.

The largest significant difference in average charges is seen in case 4 where the average charge under the APR DRG assigned to the patient ($130,750) is more than double the average charge under the CMS DRG assigned to the patient ($59,519). b. Consolidated Severity-Adjusted DRGs for Use in the IPPS

APR DRGs were developed to encompass all-payer patient populations. As a result, we found that, for the Medicare population, some of the APR DRGs have very low volume. MedPAC noted that the larger number of DRGs under a severity-weighted system might mean that CMS would be faced with establishing weights in many categories that have few cases and, thus, potentially creating unstable estimates. While volume is an important consideration in evaluating any potential consolidation of APR DRGs for use under the IPPS, we believe that hospital resource use and clinical interpretability also need to be taken into consideration. For example, any consolidation of severity of illness subclasses within a base DRG should be restricted to contiguous severity of illness subclasses. Thus, it would not be reasonable clinically to combine severity of illness subclasses 1 and 4 solely because both consist of low-volume cases. We analyzed consolidating APR DRGs by either combining the base DRGs or the severity of illness subclasses within a base DRG. For consolidation across base APR DRGs, we considered patient volume, similarity of hospital charges across all four severity of illness subclasses and clinical similarity of the base APR DRGs. For consolidations of severity of illness subclasses within a base DRG, we considered patient volume and the similarity of hospital charges between severity of illness subclasses. In considering how to consolidate severity of illness subclasses, we believed it was important to use uniform criteria across all DRGs to avoid creating confusing and difficult to interpret results. That is, we were concerned about inconsistencies in the number of severity levels across different DRGs.

The objective to simultaneously take into consideration patient volume and average charges often produced conflict. Table D below contains the overall patient volume and average charge by APR DRG severity of illness subclass. While severity of illness subclass 4 (extreme) has had the lowest patient volume of 5.80 percent, we found that the dramatically different average charges between severity of illness subclass 3 (major) and subclass 4 (extreme) patients of approximately $32,426 and $81,952, respectively, would make it difficult to consolidate severity of illness subclass 3 and 4 patients. Conversely, we found that, while the average charge difference between severity of illness subclass 1 (minor) and 2 (moderate) patients was much smaller, of approximately $17,649 and $20,021, respectively, the majority of patient volume (68.08 percent) is in these two subclasses. Thus, low patient volume and small average charge differences rarely coincided.

[[Page 24016]]

Table D.--Overall Average Charges and Patient Volume by APR DRG Severity of Illness Subclass

APR DRG

APR DRG

APR DRG

APR DRG severity of severity of severity of severity of All cases

illness

illness

illness

illness subclass 1 subclass 2 subclass 3 subclass 4

Count........................... 11,142,651

21.47%

46.61%

26.12%

5.80% Average Charges.................

$26,342

$17,649

$20,021

$32,426

$81,952

There were also few opportunities to consolidate base DRGs. For base DRGs for which there was a clinical basis for considering a consolidation, there were usually significant differences in average charges for one or more of the severity of illness subclasses. APR DRGs already represented a considerable consolidation of base DRGs (314) compared to CMS DRGs (367). Thus, we expected that further base DRG consolidation would be difficult.

We reviewed the patient volume and average charges across APR DRGs and found that medical cases assigned severity of illness subclass 4 within an MDC have similar average charges. We observed the same pattern in average charges across severity of illness subclass 4 surgical patients within an MDC. The data suggest that, in cases with a severity of illness of subclass 4, the severity of the cases had more impact on hospital resource use than the reason for admission (that is, the base APR DRG within an MDC). Thus, we believe that, within each MDC, the severity of illness subclass 4 medical and surgical patients, respectively, could be consolidated into a single group.

In some MDCs, it was not possible to consolidate into a single medical and a single surgical severity of illness subclass 4 group. In these MDCs, more than one group was necessary. For instance, Table E below contains the patient volume and average charges for severity of illness subclass 4 cases in MDC 11 (Diseases and Disorders of the Kidney and Urinary Tract). Taking into consideration volume and average charges, except for APR DRG 440 (Kidney Transplant), surgical cases assigned severity of illness subclass 4 in MDC 11 could be consolidated into a single group having 5,492 patients and an average charge of $107,258. However, we decided not to include kidney transplant patients in this severity of illness 4 subclass due to their very high average charges (approximately $203,732 or more than $100,000 greater than other patients in MDC 11 having a severity of illness 4 subclass). Average charges within the consolidated severity of illness 4 surgical DRG in MDC 11 show some variation but are much higher than the corresponding average charges for the severity of illness subgroup 3 patients of $48,863. Thus, our analysis suggests that the data support maintaining three severity of illness levels for each base DRG in MDC 11; a separate severity of illness 4 subclass for all patients other than those having kidney transplant; and a separate DRG for kidney transplants.

Table E.--Summary Statistics for Surgical Cases With Severity of Illness Subclass 4 in MDC 11

Number of Average length Average total APR DRG

cases

of stay

charges

440 (Kidney Transplant).........................................

378

18.0

$203,732 441 (Major Bladder Procedures)..................................

528

21.5

128,729 442 (Kidney & Urinary Tract Procedure for Malignancy)...........

833

16.6

101,501 443 (Kidney & Urinary Tract Procedure for Non-Malignancy).......

966

18.4

103,905 444 (Renal Dialysis Access Device Procedure Only Severity of

935

18.3

104,249 Illness Subclass 4)............................................ 445 (Other Bladder Procedures)..................................

186

15.2

80,197 446 (Urethral & Transurethral Procedure--Severity of Illness

492

13.4

73,110 Subclass 4).................................................... 447 (Other Kidney, Urinary Tract & Related Procedures)..........

1,552

19.3

121,011

The consolidation of severity of illness 4 subclass APR DRG into fewer groups was done for all MDCs except MDC 15 (Newborn and Other Neonates With Conditions Originating in the Perinatal Period), MDC 19 (Mental Diseases and Disorders), and MDC 20 (Alcohol/Drug Use and Alcohol/Drug Induced Organic Mental Disorders). In the 22 MDCs in which the severity of illness subclass 4 consolidation was applied, the number of separate severity of illness subclass 4 groups was reduced from 262 to 69.

For MDC 14 (Pregnancy, Childbirth, and Puerperium), the base APR DRGs were consolidated from 12 to 6. Severity of illness subclass 1 through 3 were retained, and severity of illness subclass 4 was consolidated into a single APR DRG, except for cesarean section and vaginal deliveries, which were maintained as separate APR DRGs. This consolidation reduced the total number of obstetric APR DRGs from 48 to 22.

The Medicare patient volume in MDC 15 was very low, allowing for a more aggressive consolidation. For MDC 15, we consolidated 28 base APR DRGs into 7 base consolidated severity-adjusted DRGs. For each of the 7 consolidated base MDC 15 DRGs, we combined severity of illness subclasses 1 and 2 into one DRG and severity of illness subclass 3 and 4 into another one. This consolidation reduced the total number of MDC 15 DRGs from 112 in the APR DRG system to 14 consolidated severity- adjusted DRGs.

In MDC 19, we consolidated 12 base DRGs into 4 base DRGs. We retained the 4 severity of illness subclasses in MDC 19 for each of the 4 base DRGs. In MDC 20, the base APR DRG for patients who left against medical advice has severity of illness subclass 1 and 2 consolidated and severity of illness subclass 3 and 4 consolidated. The remaining 4 base DRGs were consolidated into 1 base DRG and retained in 4 severity of illness subclasses.

We did not consolidate any of the pre-MDC subclass 4 APR DRGs such as Heart Transplant. As explained earlier, pre-MDC DRGs are DRGs to which cases are directly assigned on the basis of ICD-9-CM procedure codes. These DRGs are for liver and/or intestinal transplants, heart and/or lung

[[Page 24017]]

transplants, bone marrow transplants, pancreas transplants, and tracheotomies. For the pre-MDC DRGs, except for Bone Marrow Transplant, we consolidated severity of illness subclasses 1 and 2 into one DRG. In addition, the three base APR DRGs for Human Immunodeficiency Virus (HIV) with multiple or major HIV-related conditions had severity of illness subclasses 1 and 2 consolidated.

In total, we reduced 1,258 APR DRGs to 861 consolidated severity- adjusted DRGs. In Appendix C of this proposed rule, we present the 861 unique combinations of consolidated severity-adjusted DRGs.

Table F below includes a description of the consolidations that we did within each individual MDC and includes information about the total number of DRGs that were eliminated from the APR DRGs to develop the consolidated severity-adjusted DRGs. BILLING CODE 4120-01-P

[[Page 24018]]

[GRAPHIC] [TIFF OMITTED] TP25AP06.003

BILLING CODE 4120-01-C

[[Page 24019]]

Appendix D of this proposed rule shows the crosswalk of each consolidated severity-adjusted DRG to its respective APR DRG. We numbered the DRGs sequentially and incorporated the severity of illness subclass into the DRG description. However, within the range of sequential numbers used for an MDC, we retained some unused numbers to allow for future DRG expansion. By using a three-digit number for the consolidated severity-adjusted DRGs, we also avoid the need for reprogramming of computer systems that would be necessary to accommodate a change from the current three-digit DRG number to separate fields for the base consolidated severity-adjusted DRG number and the severity of illness subclass.

Severity DRGs represent a significant change from our current DRG system. In addition to changing the way claims are grouped, severity DRGs introduce other issues requiring additional analysis, including possible increases in reported case-mix and changes to the outlier threshold. Our analysis of these issues is outlined below. c. Changes to CMI From a New DRG System

After the 1983 implementation of the IPPS DRG classification system, CMS observed unanticipated growth in inpatient hospital case- mix (the average relative weight of all inpatient hospital cases) that is used as proxy measurement for severity of illness. There are three factors that determine changes in a hospital's CMI:

(1) Admitting and treating a more resource intensive patient-mix (due, for example, to technical changes that allow treatment of previously untreatable conditions and/or an aging population);

(2) Providing services (such as higher cost surgical treatments, medical devices, and imaging services) on an inpatient basis that previously were more commonly furnished in an outpatient setting; and

(3) Changes in documentation (more complete medical records) and coding practice (more accurate and complete coding of the information contained in the medical record).

Changes in CMI as a result of improved documentation and coding do not represent real increases in underlying resource demands. For the implementation of the IPPS in 1983, improved documentation and coding were found to be the primary cause in the underprojection of CMI increases, accounting for as much as 2 percent in the annual rate of CMI growth observed post-PPS.\2\

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

We believe that adoption of consolidated severity-adjusted DRGs would create a risk of increased aggregate levels of payment as a result of increased documentation and coding. MedPAC notes that ``refinements in DRG definitions have sometimes led to substantial unwarranted increase in payments to hospitals, reflecting more complete reporting of patients' diagnoses and procedures.'' MedPAC further notes that ``refinements to the DRG definitions and weights would substantially strengthen providers' incentives to accurately report patients' comorbidities and complications.'' To address this issue, MedPAC recommended that the Secretary ``project the likely effect of reporting improvements on total payments and make an offsetting adjustment to the national average base payment amounts.'' \3\

\3\ Medicare Payment Advisory Commission: Report to Congress on Physician-Owned Specialty Hospitals, March 2005, p. 42.

The Secretary has broad discretion under section 1886(d)(3)(A)(vi) of the Act to adjust the standardized amount so as to eliminate the effect of changes in coding or classification of discharges that do not reflect real changes in case-mix. While we modeled the changes to the DRG system and relative weights to ensure budget neutrality, we are concerned that the large increase in the number of DRGs will provide opportunities for hospitals to do more accurate documentation and coding of information contained in the medical record. Coding that has no effect on payment under the current DRG system may result in a case being assigned to a higher paid DRG under the consolidated severity- adjusted system. Thus, more accurate and complete documentation and coding may occur under the consolidated severity-adjusted system because it will result in higher payments under the more sophisticated DRG system. We are soliciting comments on this issue. 4. Effect of Consolidated Severity-Adjusted DRGs on the Outlier Threshold

(If you choose to comment on issues in this section, please include the caption ``Cost-Based Weights: Outlier Threshold'' at the beginning of your comment.)

In its March 2005 Report to Congress on Physician-Owned Specialty Hospitals, MedPAC recommended that Congress amend the law to give the Secretary authority to adjust the DRG relative weights to account for the differences in the prevalence of high-cost outlier cases. MedPAC recommended DRG-specific outlier thresholds that are financed by each DRG rather than through an across-the-board adjustment to the standardized amounts. Furthermore, in comments that MedPAC submitted during the comment period for the FY 2006 IPPS proposed rule, MedPAC stated its belief that the current policy makes DRGs with a high prevalence of outliers profitable for two reasons: (1) These DRGs receive more in outlier payments than the 5.1 percent that is removed from the national standardized amount; and (2) the relative weight calculation results in these DRGs being overvalued because of the high standardized charges of outlier cases. MedPAC also noted that, under its recommendations, outlier thresholds in each DRG would reduce the distortion in the relative weights that comes from including the outlier cases in the calculation of the weight and would correct the differences in profitability that stem from using a uniform outlier offset for all cases. MedPAC added that its recommendation would help make relative profitability more uniform across all DRGs.

In the FY 2006 IPPS final rule (70 FR 47481), we responded to MedPAC's recommendation on outliers by noting that a change in policy to replace the 5.1 percent offset to the standardized amount would require a change in law. However, because the Secretary has broad discretion to consider all factors that change the relative use of hospital resources in the calculation of the DRG relative weights, we stated we would consider changes that would reduce or eliminate the effect of high-cost outliers on the DRG relative weights. At this time, we have not completed a detailed analysis of MedPAC's outlier recommendation because we do not have the authority to adopt such a change under current law. Instead, we have focused our resources on analyzing MedPAC's recommendations with respect to adopting severity DRGs and calculating cost-based HSRV weights that can be adopted without a change in law. While we intend to study MedPAC's recommendation in more detail at a future date, we note that the changes described above with respect to adopting a consolidated severity-adjusted DRG system would have important implications for the outlier threshold.

As noted above, we have completed a detailed analysis that would increase

[[Page 24020]]

the number of DRGs from 526 under the current CMS DRG system to 861 under a consolidated severity-adjusted DRG system. Using FY 2004 Medicare charge data, 3M Health Information Systems simulated the effect of adopting consolidated severity-adjusted DRGs in conjunction with cost-based HSRV weights (described below) on the FY 2006 outlier threshold using the same estimation parameters used by CMS in the FY 2006 final rule (that is, the charge inflation factor of 14.94 percent) (70 FR 47494). Under these assumptions, 3M Health Information Systems estimated that the outlier threshold would be reduced from $23,600 under the current system to $18,758 under a consolidated severity- adjusted DRG system. By increasing the number of DRGs to better recognize severity, the DRG system itself would provide better recognition for cases that are currently paid as outliers. That is, many cases that are high-cost outlier cases under the current DRG system would be paid using a severity of illness subclass 3 or 4 under the consolidated severity-adjusted DRGs and could potentially be paid as nonoutlier cases. 5. Impact of Refinement of DRG System on Payments

Using the FY 2004 MedPAR claims data, we simulated the payment impacts of moving to the consolidated severity-adjusted DRG GROUPER and the alternative HSRVcc method for developing HSRV weights. These payment simulations do not make any adjustments for changes in coding or case-mix. For purposes of this analysis, estimated payments were held budget neutral to the estimated FY 2006 payments because we have a statutory requirement to make any changes to the weights or GROUPER budget neutral. Based on the results of this impact analysis, we are proposing to adopt both the HSRVcc weighting methodology and the consolidated severity-adjusted DRGs. However, for reasons described in more detail below, we are proposing to implement the HSRVcc weighting methodology we described above for FY 2007 and future fiscal years and the consolidated severity-adjusted DRG GROUPER for implementation in FY 2008 (if not earlier). Although we are proposing to adopt each of these changes to the IPPS sequentially, the changes should be viewed as part of a unified effort to improve Medicare's inpatient hospital payment system. Our findings in support of these proposals are discussed below.

In examining the effects of moving to consolidated severity- adjusted DRGs with HSRVcc relative weights, the primary impact of the changes generally results from a redistribution of the relative weights from the surgical DRGs to the medical DRGs. In Table G below, we show an analysis of the total case-mix change for the medical and surgical DRGs. We are comparing the percent change in case-mix between the FY 2006 DRGs with HSRVcc relative weights and the FY 2006 GROUPER with the FY 2006 charge-based relative weights. We also show the percent change in case-mix between the consolidated severity-adjusted DRGs with HSRVcc relative weights and the FY 2006 GROUPER with the FY 2006 charge-based relative weights and the percent change between the consolidated severity-adjusted DRGs with HSRVcc relative weights and the FY 2006 DRGs with HSRVcc relative weights.

Table G.--Percent Change in Case-Mix Among Medical and Surgical DRGs by MDC

Percent change in case-mix Percent change due to Total impact MDC description

Cases

in case-mix consolidated all changes due to HSRVcc severity- (percent) adjusted DRGs

Medical......................................... 7,832,185

6.0

1.3

7.3 Surgical........................................ 3,301,570

-5.7

-1.3

-6.9

Surgical DRGs experience a decline of 5.7 percent in weights, while medical DRGs overall increase by approximately 6 percent when we apply the HSRVcc method to the FY6 DRGs. Adoption of the consolidated severity-adjusted DRGs also shows a redistribution of payment from the surgical to the medical DRGs, but to a much lesser extent. The redistribution of payments from adopting the HSRVcc weighting methodology can be explained by the much lower CCRs for ancillary cost centers that account for a higher proportion of total charges in the surgical DRGs than the medical DRGs. Table H below shows department charges as a percent of total charges and the CCRs for the two routine cost centers (routine days and intensive care unit) and eight ancillary cost centers that we used to develop the cost-based weights.

Table H.--Departmental Charges as Percent of Total Charges for Medical and Surgical DRGs and Departmental Cost-to-Charge Ratios (CCRs) [In percent]

Routine Intensive Supplies & days care unit equipment Therapy Lab Radiology Other O.R. Pharmacy Cardiac

Cost-to-Charge Ratio...................

85

72

34

35

25

24

51

37

26

20 Medical................................

24

12

5

7

14

10

7

1

16

5 Surgical...............................

10

10

23

4

8

5

4

17

13

6

As the above Table H shows, the routine cost centers account for 36 percent (24 percent for routine days and 12 percent for intensive care unit) and 20 percent (10 percent for routine days and 10 percent for intensive care unit) of total charges in the medical and surgical DRGs, respectively. These departments have CCRs that range from

[[Page 24021]]

85 (routine days) to 72 percent (intensive care unit). However, the markup over costs is much higher in the ancillary than in the routine cost centers. The CCRs in the ancillary departments range from 20 percent (cardiac) to 51 percent (other). Ancillary cost centers account for 64 percent of total charges in the medical and 80 percent of total charges in the surgical DRGs. Thus, because ancillary departments have higher markups and account for a larger proportion of total charges in the medical than the surgical DRGs, adopting HSRVcc redistributes payments to the more routine-intensive medical DRGs. Table H supports the hypothesis that the charge-based relative weight methodology results in high payments to surgical DRGs that use more ancillary services relative to medical DRGs that use more routine services. By changing the relative weight methodology from the charge-based to the HSRVcc method, the weights will more closely reflect actual relative costs.

In addition to examining the change in weights by MDC for the medical and surgical DRGs, we also looked at the percent change to the relative weights for several DRGs that account for the high Medicare spending. Again, the payment impacts illustrate that a change from the charge-based relative weights to the HSRVcc weighting methodology will result in significant payment redistribution for selected DRGs. Table I below also shows payment reductions from adopting HSRVcc for several DRGs where ancillary charges represent a high proportion of total charges and the ancillary department has a low CCR. For instance, Table I shows a 30-percent reduction in payment for DRG 558 from adopting HSRVcc weights. For this DRG, charges for the medical supplies and the cardiac care represent over 60 percent of average total hospital charges. These cost centers have low CCRs (34 and 20 percent for medical supplies and cardiology respectively). For this DRG, routine cost center charges account for only 7 percent of total hospital charges. Thus, similar to the MDC analysis presented above, payment for this DRG can be expected to decline because ancillary departments with higher markups account for a larger proportion of total charges.

The data are similar for many of the other DRGs presented in Table I that are showing large reductions in the relative weights from adopting the HSRVcc weighting methodology. Conversely, Table I shows payment increases from adopting HSRVcc for DRGs where routine charges represent a high proportion of total charges. These departments have high CCRs. Below we illustrate the charges by cost center as a percent of total charges for DRGs 558 and 089.

Illustration

Supplies Routine

and

Radiology days ICU equipment Therapy Laboratory

Other O.R. Pharmacy Cardiac (percent) (percent)

(percent) (percent) (percent) (percent) (percent) (percent) (percent) (percent)

CCRs.....................................

85

72

34

35

25

24

51

37

26

20 DRG 558..................................

2

5

39

0

3

2

1

2

8

29 DRG 089..................................

25

9

7

9

14

8

6

1

19

3

Table I below shows a 30-percent reduction in payment for DRG 558 from adopting HSRVcc weights. For this DRG, charges for the medical supplies and the cardiac care represent nearly 80 percent of average total hospital charges. These cost centers have low CCRs (34 percent and 20 percent for medical supplies and cardiology, respectively). For this DRG, routine cost center charges account for only 7 percent of total hospital charges. Thus, similar to the MDC analysis presented above, payment for this DRG can be expected to decline because ancillary departments with higher markups account for a larger proportion of total charges. The data are similar for many of the other DRGs presented in Table I that are showing large reductions in the relative weights from adopting HSRVcc. Conversely, routine charges account for a higher proportion of total charges for the DRGs that are showing large increases in payments. For instance, payment for DRG 089 is increasing nearly 10 percent from adoption of HSRVcc weights. Routine day charges account for 34 percent of total charges for DRG 089. Thus, because routine charges represent a high proportion of total charges and these cost centers have relatively low markups, the HSRVcc methodology will lead to higher payments for this DRG.

BILLING CODE 4120-01-P

[[Page 24022]]

[GRAPHIC] [TIFF OMITTED] TP25AP06.004

[[Page 24023]]

[GRAPHIC] [TIFF OMITTED] TP25AP06.005

BILLING CODE 4120-01-C

[[Page 24024]]

Our payment impacts were similar to MedPAC's in both magnitude and direction. Table J below compares our impact estimates to those simulated by MedPAC \4\ using our alternative HSRVcc weighting methodology and the consolidated severity-adjusted DRG GROUPER.

\4\ Medicare Payment Advisory Commission: Report to Congress on Physician-Owned Specialty Hospitals, March 2005, p. 39.

Table J.--Comparison of MedPAC's Table of Combined Payment Impact of Severity-Adjusted DRGs and Cost-Based, Hospital-Specific Relative Values (HSRVs) to the CMS/3M Analysis [The percent changes estimated by CMS/3M are shown in parenthesis.]

Decrease/ Decrease

Decrease

increase

Increase

Increase Type of hospital

greater than - between -5% between -1% between +1% greater than 5%

and -1%

and 1%

and +5%

+5%

Specialty:

Heart....................... 87% (95%)

13% (5%)

0% (0%)

0% (0%)

0% (0%)

Orthopedic.................. 76% (91%)

24% (2%)

0% (2%)

0% (2%)

0% (2%)

Surgical.................... N/A (67%) N/A (17%)

N/A (0%) N/A (17%)

N/A (0%) All Other IPPS:

Urban.......................

7% (8%) 22% (25%) 16% (19%) 33% (31%) 22% (17%)

Rural.......................

8% (11%) 25% (35%) 17% (20%) 33% (26%)

16% (9%)

High IME/DSH................

8% (10%) 28% (25%) 14% (15%) 25% (28%) 24% (23%)

**Numbers may not add to 100 percent due to rounding.

As shown in Table J above, the shifts in payment from MedPAC's method compared to the alternative approach that we developed are fairly similar. Both methods introduce refinements to the DRG GROUPER and relative weight methods that expand the DRG groups and create greater homogeneity among the cases within each DRG. These changes will significantly reduce payments to hospitals that specialize in certain DRGs experiencing a reduction in payment. There are also payment impacts across all other hospitals. Although some urban (17 percent) and rural (9 percent) providers are estimated to receive increases of greater than 5 percent from these combined changes, 8 percent of urban hospitals and 11 percent of rural hospitals are expected to experience decreases of greater than 5 percent in payment and an additional 25 percent of urban providers and 35 percent of rural providers are expected to experience a decrease of between 1 and 5 percent.

Table K below shows the impact on specific categories of hospitals of adopting HSRVcc weights and the consolidated severity-adjusted DRGs. As illustrated in Table K, cardiac specialty hospitals and orthopedic specialty hospitals may experience an 11.2 and 4.4 percent decline in payments, respectively, from the move to the HSRVcc weighting method alone. Urban hospitals experience a small decline of 0.3 but rural hospitals experience a gain of 2.7 percent. While urban hospitals as a group are not expected to experience a change in overall payments with the combined introduction of the consolidated severity-adjusted DRGs and the HSRVcc weighting methodology, rural hospitals would likely experience a 0.4 percent decline in payments.

Table K.--Payment Impact of Hospital-Specific Cost Weights and Consolidated Severity-Adjusted DRGs by Hospital Type

Percent change in case-mix Number of

Percent change due to Total impact hospitals

Cases

in case-mix consolidated all changes due to HSRVcc severity- adjusted DRGs

Specialty Hospital Type:

Cardiac.....................

19

44,203

-11.2

-0.5

-11.7

Orthopedic..................

43

11,097

-4.4

-5.2

-9.4

Surgery.....................

12

1,840

0.3

-7.4

-7.2 All Other IPPS:

Urban.......................

1,959 7,148,362

-0.3

0.3

0

Rural.......................

880 1,444,664

2.7

-3.1

-0.4

High IME/DSH................

734 2,492,485

0

0.4

0.4

In Table L, we provide a more detailed impact analysis by hospital type. Column 1 shows the estimated impact of moving from the current charge-based relative weight methodology to the HSRVcc method. Hospitals with more than 60 percent of Medicare patients are projected to receive the greatest benefit in payments with a 7.6 percent increase. Hospitals with less than 50 beds are estimated to experience an additional 4.1 percent increase, and hospitals with 50 to 100 beds are also projected to benefit with a 2.54 percent increase.

Payments to major and other teaching hospitals are estimated to decrease by 1.1 percent and 1 percent, respectively,

[[Page 24025]]

while payments to nonteaching hospitals are estimated to increase by 1.3 percent. Hospitals with less than 20 percent DSH payments will experience declines in payment from 0.48 to 1.45 percent, while hospitals with DSH payments greater than 50 percent will experience a 2.3 percent increase. Because we are proposing to implement the HSRVcc weighting methodology for FY 2007, we are also showing the impact of this proposal on FY 2007 payments in the impact section in the Addendum to this proposed rule. We note that the impact section models adopting the HSRVcc in isolation using FY 2005 Medicare charge data. The impacts shown here were simulated with FY 2004 Medicare charge data. Thus, the payment changes shown in this section from adopting HSRVcc may differ from those shown in the impact section in the Addendum to this proposed rule.

Column 2 shows the estimated incremental impacts of transitioning from the FY 2006 GROUPER with HSRVcc relative weights to the consolidated severity-adjusted DRG GROUPER with HSRVcc relative weights. Hospitals with high Medicare patient percentages experience the largest payment increases of 1.1 percent, followed by hospitals in the East North Central Region where increases are estimated at 0.9 percent. Hospitals with less than 50 beds, rural hospitals, and hospitals with 50 to 100 beds experience the greatest estimated decreases in payment of 5.2, 3.1, and 2.8 percent, respectively.

Column 3 shows the estimated total impact of moving from the FY 2006 GROUPER with the current charge-based relative weights to the consolidated severity-adjusted DRG GROUPER with HSRVcc relative weights. While large urban hospitals are expected to gain 0.7 percent from the combined changes, other urban hospitals and rural hospitals are projected to experience declines of 0.7 percent and 0.4 percent, respectively. Hospitals with high percentages of Medicare patients would see the greatest increase in payments, while hospitals with low DSH percentages, hospitals with under 50 beds, and hospitals in the West North Central Region are projected to experience the greatest decreases.

Table L.--Payment Impact of Hospital-Specific Cost Weights and Consolidated Severity-Adjusted DRGs by Hospital Category

Percent change in case-mix Percent change due to Total impact Number of

Cases

in case mix consolidated all changes hospitals

due to HSRVcc severity-

(3) (1)

adjusted DRGs (2)

Geographic Location:

Large Urban.................

1,454 5,159,405

-0.1

0.7

0.7

Other Urban.................

1,158 4,313,598

-0.7

0.0

-0.7

Rural.......................

1,035 1,669,648

2.8

-3.1

-0.4 Census:

New England.................

150

550,391

0.3

-0.5

-0.2

Middle Atlantic.............

473 1,750,452

0.1

-0.5

-0.4

South Atlantic..............

556 2,191,787

-0.2

0.4

0.2

East North Central..........

541 1,973,092

-0.1

0.9

0.8

East South Central..........

368

973,664

0.3

-1.3

-1.0

West North Central..........

314

846,046

-0.5

-0.8

-1.3

West South Central..........

572 1,332,819

-0.1

-0.1

-0.2

Mountain....................

234

502,128

-0.6

0.6

-0.1

Pacific.....................

439 1,022,272

0.6

0.3

0.9 Bed Size:

Less than 50 beds...........

761

423,096

4.1

-5.2

-1.3

50-100 beds.................

717 1,028,840

2.5

-2.8

-0.3

100-200 beds................

1,096 2,895,808

1.8

-0.6

1.2

200-300 beds................

509 2,396,739

0.0

0.5

0.5

300-400 beds................

269 1,666,872

-0.9

0.7

-0.2

400-500 beds................

138 1,017,724

-1.5

0.7

-0.8

Greater than 500 beds.......

157 1,713,572

-1.8

0.8

-1.0 Teaching Status:

Major Teaching..............

268 1,552,985

-1.1

0.5

-0.5

Other Teaching..............

760 3,856,302

-0.9

0.6

-0.3

Non Teaching................

2,619 5,733,364

1.3

-0.8

0.5 Disproportionate Share:

%DSH Less than 5%...........

202

339,171

-1.4

-0.8

-2.2

%DSH 5-10%..................

335 1,048,420

-0.6

-0.1

-0.7

%DSH 10-15%.................

460 1,429,319

-0.6

0.1

-0.4

%DSH 15-20%.................

582 2,061,387

-0.5

-0.1

-0.6

%DSH 20-25%.................

528 1,812,743

0.1

-0.1

0.0

%DSH 25-30%.................

455 1,497,940

0.0

0.2

0.2

%DSH 30-40%.................

516 1,586,376

0.0

0.0

-0.1

%DSH 40-50%.................

262

693,815

0.6

-0.1

0.4

%DSH Greater than 50%.......

307

673,480

2.3

0.5

2.9 Percent Medicare Discharges:

Less than 10% Medicare Cases

1,194 3,210,704

-0.7

-0.1

-0.8

10%-20% Medicare Cases......

1,471 5,109,042

0.1

0.0

0.0

20%-30% Medicare Cases......

617 1,934,947

-0.1

0.1

-0.1

30%-40% Medicare Cases......

226

617,518

0.9

0.1

1.0

40%-50% Medicare Cases......

86

197,882

2.0

0.8

2.8

[[Page 24026]]

50%-60% Medicare Cases......

39

55,346

5.2

1.1

6.4

Greater than 60% Medicare

14

17,212

7.6

-0.2

7.4 Cases......................

6. Conclusions

As we describe in more detail below, we believe that adopting HSRVcc weights and the consolidated severity-adjusted DRGs as recommended by MedPAC has the potential to result in significant improvements to Medicare's IPPS payments. This rule proposes the HSRVcc methodology effective for FY 2007.

Because we believe that accounting more appropriately for severity of illness may significantly improve the effectiveness of the IPPS, we are also proposing implementation of the consolidated severity-adjusted DRGs or alternative severity adjustment methods in FY 2008 (if not earlier). In developing this proposal, we considered a range of alternatives outlined below, and we are soliciting comments on both the proposal and the alternatives. We ask commenters to consider both the consolidated severity-adjusted DRGs and alternative severity adjustment methods for accounting for severity more comprehensively in the DRG payment system. For example, under one alternative, we would implement the consolidated severity-adjusted DRGs in FY 2007 along with the HSRVcc weighting methodology. In this event, as discussed above, to maintain budget neutrality, we would also implement in FY 2007 an adjustment to the standardized amounts to eliminate the effect of changes in coding or classification of discharges that do not reflect real changes in case-mix. Under another alternative, as proposed, we would adopt and implement consolidated severity-adjusted DRGs in FY 2008. Under yet another alternative, we would consider partially implementing the consolidated severity-adjusted DRGs in FY 2007 and complete implementation in FY 2008. However, there are practical difficulties associated with partial implementation of consolidated severity-adjusted DRGs because cases in a single DRG under the current CMS DRG system may group to multiple DRGs and MDCs under a consolidated severity-adjusted DRG system. Conversely, cases that group to multiple MDCs and DRGs under the current system may group to a single MDC and DRG under the current system. We welcome public comments on this issue.

One potential alternative to partially adopting consolidated severity-adjusted DRGs would involve applying a clinical severity concept to an expanded set of DRGs in FY 2007. For example, we have received correspondence that raised the concern that hospitals may have incentives under the current DRG system to avoid severely ill, resource-intensive back and spine surgical cases (as discussed in section II.D.3.b. of this proposed rule; the correspondence specifically requested that we apply a clinical severity concept to DRG 546). Other surgical DRGs may not accurately recognize case severity. Because of the frequency of DRG use and the potential for risk selection, certain DRGs may be particularly important in creating a financial incentive for hospitals to select a less severely ill patient whose case would be assigned to the same DRG as a more severely ill patient.

Therefore, while we are proposing to adopt the consolidated severity-adjusted DRGs in FY 2008, we are considering whether to make more limited changes to the current DRG system to better recognize severity of illness in FY 2007. In the FY 2006 IPPS final rule (70 FR 47474 through 47478), we took steps to better recognize severity of illness among cardiovascular patients. For all DRGs except cardiac DRGs, we currently distinguish between more complex and less complex cases based on the presence or absence of a CC. However, the diagnoses that we designate as CCs are the same across all base DRGs. Because the CC list is not dependent on the patient's underlying condition, CCs may not accurately recognize severity in a given case. The changes we made in FY 2006 to the cardiac DRGs significantly improved recognition of severity between patients by distinguishing between more and less severe cases based on the presence or absence of a major cardiovascular condition (MCV). We are considering whether a similar approach applied to other DRGs would improve payment.

Much like the approach we took last year to identify MCV conditions that represented higher severity in cardiovascular patients, we plan to examine which conditions identify more severely ill cases in selected MDCs and DRGs. We are soliciting comments as to whether it would be appropriate to adopt these types of limited changes in FY 2007 as an intermediate step to adopting consolidated severity-adjusted DRGs in FY 2008. We also encourage commenters to send suggestions regarding this method for modifying the DRGs. Under the final alternative, we would implement the consolidated severity-adjusted DRGs in FY 2007 and the HSRVcc methodology in FY 2008. As the impacts presented in this proposed rule are based on the latest and best available data, we believe the estimated yearly impacts due to implementing the HSRVcc methodology in FY 2007 described in the regulatory impact section of Appendix A of this proposed rule would be similar to the annual impact of adopting the HSRVcc methodology in FY 2008.

With respect to the relative weight calculations, we believe that adopting HSRVcc weights has the potential to significantly improve payment equity between DRGs. As MedPAC notes, ``a survey of hospitals' charging practices suggest that hospitals use diverse strategies for setting service charges and raising them over time.'' MedPAC found that data from the Medicare cost reports indicate that hospital markups for ancillary services (for example, operating room, radiology, and laboratory) are generally higher than for routine services (for example, intensive care unit and room and board).\5\ Thus, MedPAC has concluded that the relative weights for DRGs that use more ancillary services may be too high compared to other DRGs where the routine costs account for a higher proportion of hospital costs. We agree.

[[Page 24027]]

The CCRs that we are using to develop the HSRVccs support MedPAC's conclusion. As indicated above, we summarized hospital-level cost and charge information to 2 routine and 8 ancillary departmental cost centers and found that national average routine cost center CCRs ranged from 72 percent (intensive care unit days) to 85 percent (routine days), while ancillary cost center CCRs ranged from 20 percent (cardiology) to 37 percent (operating room).

\5\ Ibid., p. 26.

MedPAC also found that relative profitability ratios were higher among cardiovascular surgical DRGs than the medical DRGs.\6\ We believe the relative profitability of the surgical cardiovascular DRGs has been an important factor in the development of specialty heart hospitals. Our payment impact analysis indicates that this issue will be addressed by adopting HSRVccs. Moving from the current system of charge-based weights to HSRVcc weights increases payment in the medical DRGs relative to the surgical DRGs. We expected this result, given that routine costs will generally account for a higher proportion of total costs in the medical DRGs than in the surgical DRGs. Adopting HSRVcc weights would result in the most significant improvement in hospital payment-to-cost ratios among the changes to the IPPS recommended by MedPAC.\7\ For these reasons described above, we are proposing to adopt HSRVccs for FY 2007.

\6\ Ibid., p. 29.

\7\ Ibid., p. 37.

Based on our analysis, we concur with MedPAC that the modified version of the APR DRGs would account more completely for differences in severity of illness and associated costs among hospitals. MedPAC observed some modest improvements in hospitals' payment-to-cost ratios from adopting APR DRGs.\8\ We modeled the consolidated severity- adjusted DRGs discussed above and observed a 12-percent increase in the explanatory power (or R-square statistic) of the DRG system to explain total hospital charges. That is, we found more uniformity among hospital total charges within the consolidated severity-adjusted DRG system than we did with Medicare's current DRG system. While we believe the consolidated severity-adjusted DRG system that we described above has the potential to improve the IPPS, we have the following concerns about adopting these changes for FY 2007, which is why we have proposed not adopting the changes in FY 2007. However, we recognize that there may be countervailing views, and we specifically seek comment on the wisdom of adopting consolidated severity-adjusted DRGs in FY 2007. Below are our concerns with immediate implementation of consolidated severity-adjusted DRGs:

\8\ Ibid., p. 37.

These changes would represent a major change to how hospitals are paid for Medicare inpatient services. Given the number of new DRGs and logic for assigning cases in a consolidated severity- adjusted DRG system, we believe it may be appropriate to provide hospitals with additional time to plan for these changes. We also are considering whether hospitals should have more than the 60-day public comment period and the additional 60-day delay between the publication of the final rule and implementation on October 1, 2006, to fully understand and plan for the changes that we are proposing. Further, we welcome public comment on the changes we are proposing;

If, based on analysis of data and public comments received, we were to make significant revisions in the final rule to the consolidated severity-adjusted DRGs we describe above, hospitals would have only 60 total days between the publication of the final rule and the October 1, 2006 effective date of the IPPS rule to understand and plan for the new DRG system.

While we modeled the changes to the DRG system and relative weights to reflect budget neutrality, we believe the large increase in the number of DRGs would provide opportunities for hospitals to more accurately and completely code the information contained in the medical record. Coding that has no effect on payment under the current DRG system may result in a case being assigned to a higher paid DRG under the consolidated severity-adjusted DRG system. Thus, more accurate and complete coding may occur under the new system because the more sophisticated DRG system would mean that more comprehensive coding could result in higher payments. Section 1886(d)(3)(A)(vi) of the Act provides the Secretary with the authority to adjust the standardized amounts to account for the effect of coding or classification changes that do not reflect real changes in case-mix. We are interested in public comments on this issue.

As described above, adoption of a consolidated severity- adjusted DRG system could have implications for the outlier threshold.

As we indicated in the introduction to this section, adoption of a consolidated severity-adjusted DRG system also raises issues regarding the IME and DSH adjustments. It is possible that a consolidated severity-adjusted DRG system would have important implications for these payment adjustments. We believe further study of this issue is warranted.

To this point, we have only considered one alternative DRG system to better recognize severity of illness. It is possible that the public comment process will present compelling evidence that there are potential alternatives to the consolidated severity-adjusted DRG system that could also better recognize severity of illness.

Therefore, for the reasons indicated above, we are seeking comment on the most effective approach to address severity of illness in the IPPS. However, we reserve the option to adopt consolidated severity- adjusted DRGs in FY 2007, based upon the comments that we receive. Between now and the eventual implementation, we will carefully study the additional impact of these DRGs on payment accuracy after our proposed refinements in relative weights are implemented, as well as their impact on hospitals before reaching a final decision.

Given the changes we are proposing, we believe that hospitals would be interested in understanding how a given case would be assigned to a consolidated severity-adjusted DRG under the new system. In order to facilitate understanding of the underlying severity DRG concepts and logic, we are providing a link below to 3M's Web site for the duration of the comment period where users can access information related to the proposed consolidated severity-adjusted DRGs. Users will have access to a tool that allows them to build case examples using this proposed DRG classification system. The report produced by the tool will provide a detailed explanation of how the severity of illness was assigned and the diagnostic and demographic factors affecting that assignment. In addition, users will be able to view the APR DRG Definitions Manual, a report showing the mapping from the standard APR DRGs to the consolidated severity-adjusted DRGs, a report showing basic APR DRG statistics, and other APR DRG background and educational materials. This site can be accessed at http://www.aprdrgassign.com.

In addition to the above information, CMS makes available for purchase the Expanded Modified MedPAR data that were used in simulating the policies proposed in the IPPS rule. If readers have already ordered the proposed rule data, we are in the process of filling the orders and will be providing the FY

[[Page 24028]]

2005 MedPAR data that were used to model the proposed changes to the DRGs and relative weights for FY 2007 as well as the FY 2004 MedPAR data that we used to model the consolidated severity-adjusted DRGs that we are proposing to implement in FY 2008 (if not earlier). If readers have not ordered the proposed rule MedPAR data but are interested in receiving them, we encourage them to order the data as soon as possible by following the directions provided below. We will process orders in the order they are received. For information on how to order the Expanded Modified MedPAR, go to the following Web site: http://www.cms.hhs.gov/LimitedDataSets/ and click on MedPAR Limited Data Set

(LDS)--Hospital (National). This Web page will describe the file and provide directions to further detailed instructions for how to order. Persons placing orders must send the following: Letter of Request, LDS Data Use Agreement and Research Protocol (see Web site for further instructions), LDS Form, and a check for $3,655 to: Centers for Medicare & Medicaid Services, Public Use Files, Accounting Division, P.O. Box 7520, Baltimore, MD 21207-0520.

We are seeking public comments on both of these proposals and whether we should provide a transition to the HSRVcc weights. The proposed changes to the relative weights, in some cases, could result in significant changes to hospital payments. Using FY 2005 MedPAR data, we computed an estimated FY 2006 CMI (based on FY 2006 relative weights) and an estimated FY 2007 CMI (based on the FY 2007 weights that we are proposing in this proposed rule) and looked at the percent change from FY 2006 to FY 2007. Table M shows the number of hospitals in each category that can expect to experience increases or decreases in CMI of more than 5 percent and also shows the number of providers expected to experience smaller changes in case-mix.

Overall, we estimate that 134 providers may experience decreases in payment of greater than 5 percent, while 1,003 providers may expect increases of greater than 5 percent. Approximately 54 percent of rural hospitals may receive increases in their CMI of greater than 5 percent. However, as discussed in the previous section, the eventual implementation of a consolidated severity-adjusted DRG system in FY 2008 (if not earlier) would offset these increases for some types of cases or categories of hospitals. For this reason, we are considering whether to provide a transition to the HSRVcc weights. Under such a transition, we would blend the HSRVcc weights with the charge-based weights over a period of 2, 3, or 4 years. For instance, if we were to implement the HSRVcc methodology over 2 years, we would blend 1/2 of the HSRVcc weights with 1/2 of the charge-based weights. Such a transition would result in an impact of 50 percent of moving directly to the HSRVcc weights. If we were to establish a longer transition to the HSRVcc weights, we would blend charge-based with hospital-specific cost weights calculated under the consolidated severity-adjusted DRGs. As discussed in the previous sentences, we are presenting an example of a 2-year transition because the payment impact of consolidated severity-adjusted DRGs and the HSRVcc weights go in different directions for some types of cases or categories of hospitals. Thus, a 2-year transition provides the shortest time period for achieving the improvements to the IPPS we have analyzed. However, we welcome public comments on this issue.

TABLE M.--Percent Change in Case-Mix Index Between FY 2006 and FY 2007 Based on FY 2005 MedPAR Data

Number of Number of Number of Number of Number of providers Number of providers providers providers providers with hospitals with more with loss with 1% with gain greater than 5% between 1 loss to 1% between 1 than 5% loss

and 5%

gain

and 5%

gain (1)

(2)

(3)

(4)

(5)

(6)

All Hospitals.....................

3,522

134

581

394

1,410

1,003 By Geographic Location:

Urban hospitals...............

2,517

127

540

356

1,030

464

Large urban areas (populations

1,391

63

238

191

639

260 over 1 million)..............

Other urban areas (populations

1,126

64

302

165

391

204 of 1 million or fewer).......

Rural hospitals...............

1,005

7

41

38

380

539 Bed Size (Urban):

0-99 beds.....................

590

46

58

26

191

269

100-199 beds..................

865

22

103

87

490

163

200-299 beds..................

482

20

133

102

205

22

300-499 beds..................

414

28

164

93

120

9

500 or more beds..............

166

11

82

48

24

1 Bed Size (Rural):

0-49 beds.....................

349

2

5

3

67

272

50-99 beds....................

366

1

4

5

155

201

100-149 beds..................

179

1

14

10

92

62

150-199 beds..................

64

2

6

14

40

2

200 or more beds..............

47

1

12

6

26

2 Urban by Region:

New England...................

127

2

22

6

75

22

Middle Atlantic...............

353

15

50

39

194

55

South Atlantic................

381

19

86

39

179

58

East North Central............

388

14

100

68

145

61

East South Central............

163

8

36

19

51

49

West North Central............

156

15

49

28

39

25

West South Central............

350

27

85

68

99

71

Mountain......................

143

12

42

36

42

11

[[Page 24029]]

Pacific.......................

404

13

69

51

188

83

Puerto Rico...................

52

2

1

2

18

29 Rural by Region:

New England...................

19

0

1

0

15

3

Middle Atlantic...............

72

1

2

2

34

33

South Atlantic................

175

0

2

4

67

102

East North Central............

125

3

5

3

69

45

East South Central............

181

1

5

9

37

129

West North Central............

118

0

15

5

57

41

West South Central............

191

1

6

9

40

135

Mountain......................

80

1

5

4

35

35

Pacific.......................

44

0

0

2

26

16 By Payment Classification:

Urban hospitals...............

2,539

128

538

353

1,042

478

Large urban areas (populations

1,400

63

238

191

644

264 over 1 million)..............

Other urban areas (populations

1,139

65

300

162

398

214 of 1 million or fewer).......

Rural areas...................

983

6

43

41

368

525 Teaching Status:

Nonteaching...................

2,449

80

262

194

1,008

905

Fewer than 100 residents......

836

42

237

147

318

92

100 or more residents.........

237

12

82

53

84

6 Urban DSH:

Non-DSH.......................

854

71

165

95

364

159

100 or more beds..............

1,513

52

374

256

645

186

Less than 100 beds............

333

8

12

12

98

203 Rural DSH:

SCH...........................

383

0

6

5

106

266

RRC...........................

196

3

23

24

124

22 Other Rural:

100 or more beds..............

55

0

0

2

26

27

Less than 100 beds............

188

0

1

0

47

140 Urban teaching and DSH:

Both teaching and DSH.........

809

38

248

156

290

77

Teaching and no DSH...........

198

13

57

37

81

10

No teaching and DSH...........

1,037

22

138

112

453

312

No teaching and no DSH........

495

55

95

48

218

79 Rural Hospital Types:

Non special status hospitals..

288

1

6

5

88

188

RRC...........................

140

3

20

18

86

13

SCH...........................

341

0

6

7

113

215

MDH...........................

126

0

0

1

29

96

SCH and RRC...................

80

2

10

10

47

11

MDH and RRC...................

8

0

1

0

5

2 Type of Ownership:

Voluntary.....................

2,087

65

406

248

895

473

Proprietary...................

831

61

139

96

292

243

Government....................

604

8

36

50

223

287 Medicare Utilization as a Percent of Inpatient Days:

0-25..........................

252

8

26

23

130

65

25-50.........................

1,302

54

312

200

475

261

50-65.........................

1,490

45

210

147

669

419

Over 65.......................

459

25

33

24

129

248

Unknown.......................

19

2

0

0

7

10 Urban Hospitals Reclassified by the Medicare Geographic Classification Review Board:

First Half FY 2007

319

17

72

37

146

47 Reclassifications............

Urban Nonreclassified, First

2,119

109

444

312

846

408 Half FY 2007.................

All Urban Hospitals

339

17

75

37

160

50 Reclassified Second Half FY 2007.........................

Urban Nonreclassified

2,099

109

441

312

832

405 Hospitals Second Half FY 2007

All Rural Hospitals

385

5

30

34

210

106 Reclassified Full Year FY 2007.........................

Rural Nonreclassified

604

2

11

4

163

424 Hospitals Full Year FY 2007..

All Section 401 Reclassified

38

0

2

3

11

22 Hospitals....................

[[Page 24030]]

Other Reclassified Hospitals

54

1

0

0

24

29 (Section 1886(d)(8)(B))......

Section 508 Hospitals.........

95

1

24

7

45

18

We also recognize the change from the current Medicare DRGs to a consolidated severity-adjusted DRG system would represent significant changes for hospitals. While we have considered the possibility of blending the two DRG systems, we do not believe there is a practical and simple mechanism to transition from the CMS DRGs to a consolidated severity-adjusted DRG system. Our payments would be a blend of two different relative weights that would have to be determined using two different DRG systems. The systems and legal implications of such a transition could be significant. First, we believe that the use of two DRG systems would involve significant administrative complexity and expense for the Nation's hospitals, fiscal intermediaries, and CMS. Second, we would likely have to establish two sets of Medicare rates with one set specific to each DRG system. In addition to complicating the ratesetting process and making it unclear to hospitals how Medicare's IPPS rates for a year were determined, we are uncertain how we would:

Apply the budget neutrality requirement under section 1886(d)(4)(C)(iii) of the Act for changes to DRG classifications and weighting factors.

Determine the outlier threshold under section 1886(d)(5)(A)(iv) and the amounts removed for outliers from the IPPS standardized amounts under section 1886(d)(3)(B) of the Act.

While we believe there are significant administrative, technical, and legal difficulties associated with making a blended transition from one DRG system to another, we welcome public comments on this issue as well.

D. Proposed Changes to Specific DRG Classifications

1. Pre-MDCs: Pancreas Transplants

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

On July 1, 1999, we issued coverage policy which specified that pancreas transplants were only covered when performed simultaneously with or after a Medicare covered kidney transplant. A noncoverage policy for pancreas transplant remained in effect for patients who had not experienced end stage renal failure secondary to diabetes. On July 29, 2005, we opened a national coverage determination (NCD) to determine whether pancreas transplant alone, that is, without a kidney transplant, is a reasonable and necessary service for Medicare beneficiaries. On January 26, 2006, we published the proposed decision memorandum for pancreas transplants on our Web site at http://www.cms.hhs.gov.mcd/viewdraftdecisionmemo.asp?id=166 , stating that the

evidence is adequate to conclude that pancreas transplant alone is reasonable and necessary for Medicare beneficiaries under limited circumstances.

Medicare coverage of pancreas transplants alone is proposed to be limited to transplants in those facilities that are Medicare-approved for kidney transplantation. A listing of approved transplant centers can be found at http://www.cms.hhs.gov/AprovedTransplantCenters/. In

addition to other criteria listed in the draft decision memorandum, patients must have a diagnosis of Type I diabetes.

Because we have issued a proposed NCD and a final NCD is not expected to be completed until late April 2006, which is after the publication date of this proposed rule, we are using this proposed rule to indicate the coding changes that we would make to DRG 513 (Pancreas Transplant) in FY 2007 if limited coverage of pancreas transplants alone is established. If the final NCD indicates that a pancreas transplant alone is not a reasonable and necessary service, in the IPPS final rule, we will not adopt the changes we are currently proposing to make to DRG 513 to implement the NCD. In addition, we are also indicating the conforming changes that we would make to the MCE ``NonCovered Procedure'' edit if Medicare coverage is established for pancreas transplants alone. That discussion can be found in the section II.D.6. of this preamble, which describes proposed changes to the MCE.

Because of the potential decision to cover pancreas transplants alone, the logic for the determination of patient case assignment to DRG 513 would have to be modified to remove the requirement that patients also have kidney disease. Therefore, if the NDC is finalized, DRG 513 would consist of the following logic: List A (the diabetes codes) of the required principal or secondary diagnosis codes would remain the same, as would the required operating room procedures (codes 52.80 (Pancreatic transplant NOS), and 52.82, (Homotransplant of pancreas)). List B would be removed from the logic; the following codes would no longer be required as a principal or secondary diagnosis:

403.01, Hypertensive kidney disease, malignant, with chronic kidney disease.

403.11, Hypertensive kidney disease, benign, with chronic kidney disease.

403.91, Hypertensive kidney disease, unspecified, with chronic kidney disease.

404.02, Hypertensive heart and kidney disease, malignant, with chronic kidney disease.

404.03, Hypertensive heart and kidney disease, malignant, with heart failure and chronic kidney disease.

404.12, Hypertensive heart and kidney disease, benign, with chronic kidney disease.

404.13, Hypertensive heart and kidney disease, benign, with heart failure and chronic kidney disease.

404.92, Hypertensive heart and kidney disease, unspecified, with chronic kidney disease.

404.93, Hypertensive heart and kidney disease, unspecified, with heart failure and chronic kidney disease.

[[Page 24031]]

585.1, Chronic kidney disease, Stage I.

585.2, Chronic kidney disease, Stage II (mild).

585.3, Chronic kidney disease, Stage III (moderate).

585.4, Chronic kidney disease, Stage IV (severe).

585.5, Chronic kidney disease, Stage V.

585.6, End stage renal disease.

585.9, Chronic kidney disease, unspecified.

V42.0, Organ or tissue replaced by transplant, kidney.

V43.89, Organ or tissue replaced by other means, other organ or tissue, other.

We note that DRG 513 would remain in the Pre-MDC hierarchy. 2. MDC 1 (Diseases and Disorders of the Nervous System) a. Implantation of Intracranial Neurostimulator System for Deep Brain Stimulation (DBS)

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

Deep-brain stimulation (DBS) is designed to deliver electrical stimulation to the subthalamic nucleus or internal globus pallidus to ameliorate symptoms caused by abnormal neurotransmitter levels that lead to abnormal cell-to-cell electrical impulses in Parkinson's disease and essential tremor. DBS implants for essential tremor are unilateral, with neurostimulation leads on one side of the brain. DBS implants for Parkinson's disease are bilateral, requiring implantation of neurostimulation leads in both the left and right sides of the brain.

The implantation of a full DBS system requires two types of procedures. First, surgeons implant leads containing electrodes into the targeted sections of the brain where neurostimulation therapy is to be delivered. Second, a neurostimulator pulse generator is implanted in the pectoral region and extensions from the neurostimulator pulse generator are then tunneled under the skin along the neck and connected with the proximal ends of the leads implanted in the brain. Hospitals stage the two procedures required for a full-system DBS implant.

In FY 2005, to better account for these two types of procedures, we revised procedure code 02.93 (Implantation or replacement of intracranial neurostimulator lead(s)) for the lead placement and created three new procedures codes for the pulse generator: 86.94 (Insertion or replacement of single array neurostimulator pulse generator); 86.95 (Insertion or replacement of dual array neurostimulator pulse generator); and 86.96 (Insertion or replacement of other neurostimulator pulse generator). We published the new procedure codes and revised procedure code titles in Tables 6B and 6F of the FY 2005 IPPS final rule (69 FR 49627 and 49641).

In FY 2006, we made further refinements to the pulse generator codes to identify rechargeable pulse generators. We published the new procedure codes and revised procedure code titles in Tables 6B and 6F of the FY 2006 IPPS final rule (70 FR 47637 and 47639). The current list of pulse generators codes are:

86.94 (Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable);

86.95 (Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable);

86.96 (Insertion or replacement of other neurostimulator pulse generator);

86.97 (Insertion or replacement of single array neurostimulator rechargeable generator); and

86.98 (Insertion or replacement of dual array neurostimulator rechargeable generator).

Kinetra[supreg] is an implantable dual array neurostimulator pulse generator that is approved for a new technology add-on payment through FY 2006. For more information about the new technology add-on payment, please refer to section II.G.3.a. of this preamble.

Medtronic, the manufacturer of Kinetra[supreg], argues that the new technology add-on payment provision is designed to recognize the higher costs of new medical innovations for the initial period the technology is available on the market, and until the associated costs and charges related to the technology are available in the MedPAR database and can be used to recalibrate the DRG weights. Medtronic also argues that, once a technology is no longer eligible for new technology add-on payments, the new technology add-on payment provision is designed to support the reclassification of the technology to other clinically coherent DRGs with comparable resource costs.

With the conclusion of the new technology add-on payment, Medtronic is concerned that Kinetra[supreg] will be inadequately paid in DRG 1 (Craniotomy Age >17 With CC) or DRG 2 (Craniotomy Age >17 Without CC) under MDC 1. Medtronic recommended that CMS reassign the full-system Kinetra[supreg] implants to DRG 543 (Craniotomy with Implant of Chemo Agent or Acute Complex CNS Principal Diagnosis) under MDC 1. To accommodate this recommendation, procedure codes 02.93 and 86.95 would have to be reassigned to DRG 543 and the title for DRG 543 would have to be revised to ``Craniotomy with Implantation of Major Device or Acute Complex CNS Principal Diagnosis.'' Medtronic argued that DRG 543 would be a ``clinically-consistent DRG that more appropriately reflects the resource utilization associated with full-system [deep brain stimulation] procedures.'' Medtronic also emphasized that its proposal would only apply to full-system Kinetra[supreg] implants when both the leads and generators are implanted during a single inpatient stay or procedure codes 02.93 and 86.95 both appear on the claim. Medtronic believes the current DRG assignment is appropriate for partial system implants.

Medtronic provided an analysis of FY 2004 MedPAR data. Procedure code 86.95 was not created until FY 2005 so Medtronic used procedure codes 02.93 and 86.09 (Other incision of skin and subcutaneous tissue) to identify the full system. It identified 193 cases assigned to DRG 1 with average charges of approximately $69,155, and 532 cases assigned to DRG 2 with average charges of approximately $56,113.

We have reviewed the latest data for the full-system DBS implants assigned to DRG 1 or DRG 2 in the FY 2005 MedPAR file. We identified cases with procedure codes 02.93 and 86.95 for full-system dual array cases. We also identified cases with reported codes 02.93 and 86.96 for those full-system cases where the type of pulse generator was not specified. The following table displays our results:

Average length DRG

Number of cases of stay Average charges

DRG 1--All Cases.............................................

23,037

9.61

$55,494 DRG 1--Cases with 02.93 and 86.95 (Kinetra[supreg])..........

51

5.18

73,020 DRG 1--Cases with 02.93 and 86.96 (Unspecified)..............

101

4.86

53,356 DRG 2--All Cases.............................................

9,707

4.41

32,791

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DRG 2--Cases with 02.93 and 86.95 (Kinetra[supreg])..........

146

2.40

59,414 DRG 2--Cases with 02.93 and 86.96 (Unspecified)..............

249

2.12

47,047 DRG 543--All cases...........................................

5,192

11.71

71,138

The data show that approximately one-quarter of the full-system dual array neurostimulator pulse generator cases are assigned to DRG 1 and approximately three-quarters of these cases are assigned to DRG 2. In both DRGs, the average length of stay was shorter for the full- system array neurostimulator pulse generator cases than for all other cases. However, the average charges for the full-system dual array neurostimulator pulse generator cases are approximately $18,000 and $27,000 higher than the average charges for DRGs 1 and 2, respectively. The average charges for these cases in DRG 1 are comparable to those for DRG 543. However, the more commonly occurring cases in DRG 2 have average charges that are less than those in DRG 543 by nearly $12,000. We reviewed all of the procedures that will result in a case being assigned to DRGs 1 and 2. Unlike the full-system DBS implants, we believe for most of the cases assigned to these DRGs, there will be no device cost to the hospital. For this reason, we believe the higher average charges and lower length of stay for cases involving full- system dual array neurostimulator pulse generators are likely accounted for by the cost of the device. While it is possible that the cost of the device itself will make the full-system DBS implants more expensive than other cases in the DRG, the hospital's charge markup may also explain the higher charges but lower average length of stay. As indicated in section II.G.3.a.of this proposed rule, the national average CCR for medical equipment and supplies is approximately 34 percent. Thus, the actual cost to the hospital of the case including the full-system dual array neurostimulator pulse generator may be much lower than the charges would suggest.

With respect to whether the cost of the technology itself, absent a charge markup, makes the case more expensive, we intend to address this issue as we make further refinements to the severity DRG system we are proposing to implement in FY 2008 (if not earlier), as discussed in section II.C. of this preamble. As we indicate in section II.C. of this proposed rule, the consolidated severity-adjusted DRG system that we are proposing does not currently assign a case to a higher weighted DRG based on use of a technology that represents increased complexity but not necessarily greater severity of illness. The data above indicate that approximately three-quarters of the patients who receive a full- system dual array neurostimulator pulse generator do not have a CC. Thus, it appears that these patients would be more likely to be assigned to a lower severity of illness class based solely on diagnosis. However, the implant of a full-system dual array neurostimulator pulse generator may increase complexity and resource use even though the patient is not more severely ill. As we also explain in section II.C. of this proposed rule, we believe that the consolidated severity-adjusted DRG system we are proposing would need to be further refined to assign cases based on complexity as well as severity to account for technologies like the full-system dual array neurostimulator pulse generator implants that increase costs. We plan to further develop the consolidated severity-adjusted DRGs between now and its implementation to address this issue. b. Carotid Artery Stents

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

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 remained noncovered until the release of the October 12, 2004 NCD for PTA of the carotid artery in post-approval studies. This decision extended coverage of PTA in the carotid artery concurrent with placement of an FDA-approved carotid stent for an FDA- approved indication when furnished in accordance with the FDA-approved protocols governing post-approval studies. On March 17, 2005, CMS released the NCD extending coverage to patients at high risk for carotid endarterectomy (CEA) who also have symptomatic carotid artery stenosis >= 70 percent. Procedures must be performed in CMS-approved facilities and with FDA-approved carotid artery stenting with distal embolic protection. (Section 20.7 of the NCD manual, which may be viewed at the Web site: http://www.cms.hhs.gov/manuals/downloads/ncd103c1_Part1.pdf. )

We established codes for carotid artery stenting procedures for use with discharges occurring on or after October 1, 2004, for inpatients who are enrolled in an FDA-approved clinical trial and are using on- label FDA-approved stents and embolic protection devices. These codes are as follows:

00.61 (Percutaneous angioplasty or atherectomy of precerebral (extracranial vessel(s)); and

00.63 (Percutaneous insertion of carotid artery stent(s)).

We assigned procedure code 00.61 to four MDCs and seven DRGs. The most likely scenario is that in which cases are assigned to MDC 1 (Diseases and Disorders of the Nervous System) in DRGs 533 (Extracranial Procedures with CC) and 534 (Extracranial Procedures without CC). Other DRG assignments

[[Page 24033]]

can be found in Table 6B of the Addendum to the FY 2005 IPPS final rule (69 FR 49624).

As part of our annual DRG review, for the FY 2006 final rule (70 FR 47300), we used proxy codes to evaluate the costs and DRG assignments for carotid artery stenting because codes 00.61 and 00.63 were only approved for use beginning October 1, 2004, and MedPAR data for this period were not yet available. We used procedure code 39.50 (Angioplasty or atherectomy of other noncoronary vessel(s)) in combination with procedure code 39.90 (Insertion of nondrug-eluting peripheral vessel stent(s)) in DRGs 533 and 534 as the proxy codes for carotid artery stenting. For this evaluation, we used principal diagnosis code 433.10 (Occlusion and stenosis of carotid artery, without mention of cerebral infarction) to reflect the clinical trial criteria. Based on the results of our review, for FY 2006, we did not find sufficient evidence to warrant a DRG change at that time.

Manufacturer representatives have suggested that we assign all carotid stenting cases to DRG 533 only, bypassing DRG 534. We have reviewed the FY 2005 MedPAR data on all cases in DRGs 533 and 534 and on those cases containing code 00.61 in combination with 00.63. The following table displays our results:

Average length DRG

Number of cases of stay (days) Average charges

DRG 533--All cases...........................................

44,031

3.65

$26,376 DRG 533 with codes 00.61 and 00.63 reported..................

2,400

2.94

33,344 DRG 533 with code 00.61 and without 00.63....................

99

5.95

46,591 DRG 534--All cases...........................................

40,381

1.72

17,196 DRG 534 with codes 00.61 and 00.63 reported..................

2,056

1.52

25,000 DRG 534 with code 00.61 and without 00.63....................

55

2.31

27,895

We found that 5.5 and 5.1 percent of the cases in DRGs 533 and 534, respectively, involved placement of a carotid artery stent. In both DRGs, the average length of stay was shorter for the carotid stenting cases than for all other cases. However, the average charges for the carotid stent cases were higher by $6,968 in DRG 533 and $7,804 in DRG 534. We reviewed all of the procedures that would result in a case being assigned to DRGs 533 and 534. Unlike the carotid artery stent placements, we believe that, for most of the cases assigned to these DRGs, there will be no device cost to the hospital. For this reason, we believe the higher average charges and lower length of stay for the cases involving carotid artery stents are likely accounted for by the cost of the device. While it is possible that the cost of the device itself will make the stent cases more expensive than other cases in the DRG, the hospital's charge markup may also explain the higher charges but lower average length of stay. As indicated elsewhere in this proposed rule, the national average CCR for medical equipment and supplies is approximately 34 percent. Thus, the actual cost to the hospital of the case including the carotid stent may be much lower than the charges would suggest.

With respect to whether the cost of the technology itself, absent a charge markup, makes the case more expensive, we intend to address this issue as we make further refinements to the severity-adjusted DRG system we describe above. As we indicate in section II.C. of the preamble of this proposed rule, the consolidated severity-adjusted DRG system that we are proposing does not currently assign a case to a higher weighted DRG based on use of a technology that represents increased complexity but not necessarily greater severity of illness. The use of a carotid stent or stents may increase complexity and resource use even though the patient is not more severely ill. We believe that the consolidated severity-adjusted DRG system we are proposing would need to be further refined to assign cases based on complexity as well as severity to account for technologies such as carotid stents that increase costs. For this reason, we believe that this issue of assignment of carotid stent cases may be better addressed in the consolidated severity-adjusted DRG system that we are proposing in FY 2008 (if not earlier) than through a change to the current DRG assignment for these cases. 3. MDC 5 (Diseases and Disorders of the Circulatory System) a. Insertion of Epicardial Leads for Defibrillator Devices

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

We received a comment indicating that a change in coding advice for the insertion of epicardial leads for CRT-D defibrillator devices affects DRG assignment. The commenter noted that the Third Quarter 2005 issue of the American Hospital Association's publication Coding Clinic for ICD-9-CM instructs coders to assign code 37.74 (Insertion or replacement of epicardial lead [electrode] into atrium) for pacemaker or defibrillator leads inserted through use of a thoracotomy into the epicardium. While the use of code 37.74 is standard coding practice for pacemakers, the advice is new for defibrillators. This coding advice was discussed at the ICD-9-CM Coordination and Maintenance Committee meeting held on September 29 and 30, 2005. Participants at the Committee meeting proposed modifications for the code category 37.7 (insertion, revision, replacement, and removal of pacemaker leads; insertion of temporary pacemaker system; and revision of cardiac device pocket). These modifications involved expanding the category so that the codes for leads would no longer be restricted to pacemakers. This change would guide coders to use code 37.74 for the insertion of epicardial leads for both defibrillators and pacemakers. This change was adopted for the ICD-9-CM and will become effective on October 1, 2006.

The commenter pointed out that this coding advice would restrict some defibrillator cases from being assigned to the defibrillator DRGs. Specifically, the commenter expressed concerns about the DRG logic for the following DRGs:

DRG 515 (Cardiac Defibrillator Implant without Cardiac Catheter.

DRG 535 (Cardiac Defibrillator Implant with Cardiac Catheter with AMI/Heart Failure/Shock).

DRG 536 (Cardiac Defibrillator Implant with Cardiac Catheter without AMI/Heart Failure/Shock).

Cases are assigned to one of these three DRGs when a total defibrillator system, including both the device and one or more leads, is implanted. The implant could be represented by the ICD-9-CM codes for the total system, that is, code 00.51 (Implantation of cardiac resynchronization defibrillator,

[[Page 24034]]

total system [CRT-D]) or code 37.94 (Implantation or replacement of automatic cardioverter/defibrillator, total system [AICD]). Cases can also be assigned to DRGs 515, 535, and 536 when a combination of a device and a lead code is reported. The following combinations of defibrillator device and lead codes are present in the current DRG logic:

00.52 (Implantation or replacement of transvenous lead

[electrode] into left ventricular coronary venous system) and 00.54 (Implantation or replacement of cardiac resynchronization defibrillator, pulse generator device only [CRT-D]).

37.95 (Implantation of automatic cardioverter/ defibrillator lead(s) only) and 00.54 (Implantation or replacement of cardiac resynchronization defibrillator, pulse generator device only

[CRT-D] ).

37.95 (Implantation of automatic cardioverter/ defibrillator lead(s) only) and 37.96 (Implantation of automatic cardioverter/defibrillator pulse generator only).

37.97 (Replacement of automatic cardioverter/defibrillator lead(s) only) and 00.54 (Implantation or replacement of cardiac resynchronization defibrillator, pulse generator device only [CRT-D]).

37.97 (Replacement of automatic cardioverter/defibrillator lead(s) only) and 37.98 (Replacement of automatic cardioverter/ defibrillator pulse generator only).

A DRG logic issue has arisen concerning the instruction to use code 37.74 to capture epicardial leads inserted with CRT-D defibrillators. The new combination of a defibrillator device with an epicardial lead (code 37.74) is not included in DRGs 515, 535, and 536. The commenter recommended that the following combinations be added to DRGs 515, 535, and 536 so that all types of defibrillator device and lead combinations would be included: code 37.74 and code 00.54; code 37.74 and code 37.96; and code 37.74 and code 37.98.

We agree that these three combinations should be added to the list of combination codes included in DRGs 515, 535, and 536. This would result in all combinations of defibrillator devices and leads being assigned to one of the defibrillator DRGs. Therefore, we are proposing to add these three combinations to the list of procedure combinations under DRGs 515, 535, and 536. b. Application of Major Cardiovascular Diagnoses (MCVs) List to Defibrillator DRGs

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

In the FY 2006 IPPS final rule (70 FR 47289 and 47474 through 47479), we addressed a comment we had received in response to the FY 2006 proposed rule which noted that section 507(c) of Pub. L. 108-173 required MedPAC to conduct a study to determine how the DRG system should be updated to better reflect the cost of delivering care in a hospital setting. The commenter noted that MedPAC reported that the ``cardiac surgery DRGs have high relative profitability ratios.'' While the commenter acknowledged that it may take time to conduct and complete a thorough evaluation of the MedPAC payment recommendations for all DRGs, the commenter strongly encouraged CMS to revise the cardiac DRGs through patient severity refinement as part of the IPPS final rule effective for FY 2006.

In response to this comment, we performed an extensive review of the cardiovascular DRGs in MDC 5, particularly those DRGs that were commonly billed by specialty hospitals. We observed that there was some overlap between the lists of cardiovascular complications and complex diagnoses and that these lists were already used to segregate patients into DRGs that use greater resources. Because the hospital industry already was familiar with the major complication and complex diagnosis lists used within the cardiovascular DRGs, we began our analysis with these two overlapping lists.

The two lists were originally developed for the current DRG system because they contained conditions that could have an impact on the resources needed to treat a patient with cardiovascular complications. Many of the conditions were cardiovascular diagnoses and, therefore, would be classified to MDC 5. However, we determined that some of the diagnoses were not cardiovascular, but would still have an impact on a patient with cardiovascular complications. The conditions that were not cardiovascular diagnoses were not assigned to MDC 5 if they were the principal diagnosis.

We reviewed the conditions on the two overlapping lists and identified conditions that we believed would lead to a more complicated patient stay requiring greater resource use. We referred to these conditions as ``major cardiovascular conditions (MCVs).'' The MCVs could be present as either a principal diagnosis or a secondary diagnosis and lead to greater resource consumption. The complete list of MCVs was published in the FY 2006 IPPS final rule (70 FR 47477 and 47478).

In the FY 2006 IPPS final rule, we also adopted new DRGs 547 through 558, effective October 1, 2006 (70 FR 47475 and 47476). However, we emphasized that the refinements to the DRGs were being taken as an interim step to better recognize severity in the DRG system for FY 2006 until we could complete a more comprehensive analysis of the APR DRG system and the CC list as part of a complete analysis of the MedPAC recommendations that we planned to perform for FY 2007 (and which is addressed in section II.C. of the preamble of this proposed rule).

Since publication of the FY 2006 IPPS final rule, we have received a question from a commenter as to why we did not apply the MCV list to the following defibrillator DRGs: 515, 535, and 536. The commenter noted that the pacemaker DRGs were revised using the MCV list, but the defibrillator DRGs were not.

As noted above, for FY 2006, we created new DRGs 546 through 558 to identify cases with more costly and severely ill patients as an interim step to evaluating severity DRGs. We analyzed for the first time past year data on cases within MDC 5 and presented data that showed significant difference for patients in certain DRGs based on the presence of absence of an MCV. This split did not work for the defibrillator DRGs, as we could not identify groups with significantly different resource use. For instance, splitting DRG 515 based on the presence of an MCV would lead to two groups with differences in charges of only $3,430 ($89,341 for those with an MCV and $85,911 for those without an MCV). In the data we displayed in the FY 2006 IPPS final rule, the differences for DRGs selected for an MCV split ranged from $10,319 to $21,035. Splitting DRG 515 based on an MCV would produce a difference in charges of only 10.1 percent as compared to differences of 28.7 to 47.7 percent for DRGs 547 through 558. Therefore, the data did not support including DRG 515 among those split based on the presence or absence of an MCV. Similar results were found when DRG 536 was split by an MCV. There was only an 8.1 percent difference in charges between the two groups. We also identified other problems with splitting DRG 535 based on the presence or absence of an MCV. Some of the codes a claim must include for the case

[[Page 24035]]

to be grouped to DRG 535 under our current system are also codes on the MCV list. Therefore, applying the MCV list to DRG 535 would result in all cases being assigned to the DRG with an MCV and none to the DRG without an MCV. For these reasons, we did not subdivide DRGs 515, 535, and 536 based on the presence or absence of an MCV.

We have decided not to propose additional refinements of the DRGs based on MCVs for FY 2007 because of our efforts to propose a broader refinement of the DRG system that would focus on consolidated severity- adjusted DRGs, as discussed in detail in section II.C. of this proposed rule. However, as discussed further in section II.C. of this preamble, we are soliciting comments on whether it would be appropriate in FY 2007 to apply a clinical severity concept to an expanded set of DRGs, similar to the approach we used in FY 2006 to refine cardiac DRGs based on the presence or absence of an MCV. 4. MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue) a. Hip and Knee Replacements

(If you choose to comment on issues in this section, please include the caption ``DRGs: Hip and Knee Replacements'' at the beginning of your comment.)

In the FY 2006 final rule (70 FR 47303), we deleted DRG 209 (Major Joint and Limb Reattachment Procedures of Lower Extremity) and created new DRGs 544 (Major Joint Replacement or Reattachment of Lower Extremity) and 545 (Revision of Hip or Knee Replacement) to help resolve payment issues for hospitals that perform revisions of joint replacements because we found revisions of joint replacements to be significantly more resource intensive than original hip and knee replacements. DRG 544 includes the following code assignments:

81.51, Total hip replacement.

81.52, Partial hip replacement.

81.54, Total knee replacement.

81.56, Total ankle replacement.

84.26, Foot reattachment.

84.27, Lower leg or ankle reattachment.

84.28, Thigh reattachment.

DRG 545 includes the following procedure code assignments:

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

00.71, Revision of hip replacement, acetabular component.

00.72, Revision of hip replacement, femoral component.

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

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

00.81, Revision of knee replacement, tibial component.

00.82, Revision of knee replacement, femoral component.

00.83, Revision of knee replacement, patellar component.

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

81.53, Revision of hip replacement, not otherwise specified.

81.55, Revision of knee replacement, not otherwise specified.

In the FY 2006 IPPS final rule (70 FR 47305), we indicated that the American Association of Orthopaedic Surgeons had requested that, once we receive claims data using the two DRG procedure code assignments, we closely examine data from the use of the codes under the two DRGs to determine if future additional DRG modifications are needed.

After publication of the FY 2006 IPPS final rule, a number of hospitals and coding personnel advised us that the DRG logic for DRG 471 (Bilateral or Multiple Major Joint Procedures of Lower Extremity), which utilizes the new and revised hip and knee procedure codes under DRGs 544 and 545, also includes codes that describe procedures that are not bilateral or that do not involve multiple major joints. DRG 471 was developed to include cases where major joint procedures such as revisions or replacements were performed either bilaterally or on two joints of one lower extremity. We changed the logic for DRG 471 last year for the first time when we added the new and revised codes. The commenters indicated that, by adding the more detailed codes that do not include total revisions or replacements to the list of major joint procedures to DRG 471, we are assigning cases to DRG 471 that do not have bilateral or multiple joint procedures. For example, when a hospital reports a code for revision of the tibial component (code 00.81) and patellar component of the right knee (code 00.83), the current DRG logic assigns the case to DRG 471. The commenters indicated that this code assignment is incorrect because only one joint has undergone surgery, but two components were used. One commenter indicated that ICD-9-CM does not identify left/right laterality. Therefore, it is difficult to use the current coding structure to determine if procedures are performed on the same leg or on both legs. The commenters raised concern about whether CMS intended to pay hospitals using DRG 471 for procedures performed on one joint. The commenters indicated that the DRG assignments for these codes would also make future data analysis misleading. The commenters recommended removing codes from DRG 471 that do not specifically identify bilateral or multiple joint procedures so that DRG 471 will only include cases involving the more resource intensive cases of bilateral or multiple total joint replacements and revisions.

We agree that the new and revised joint procedure codes should not be assigned to DRG 471 unless they include bilateral and multiple joints. Therefore, we are proposing to remove the following codes from DRG 471 that do not capture bilateral and multiple joint revisions or replacements:

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.

00.81, 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 total knee replacement, tibial insert (liner).

81.53, Revision of hip replacement, not otherwise specified.

81.55, Revision of knee replacement, not otherwise specified.

The proposed revised DRG 471 would then contain only the following codes:

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

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

81.51, Total hip replacement.

81.52, Partial hip replacement.

81.54, Total knee replacement.

81.56, Total ankle replacement.

As a result of the proposed removal of the identified codes from DRG 471, we are proposing that one or more of the following hip or knee revision codes would be assigned to DRG 545: 00.71, 00.72, 00.73, 00.81, 00.82, 00.83, 00.84, 81.53, and 81.55. This list includes partial revisions of the knee and hip as well as unspecified joint procedures such as code 81.55 where it is not clear if the revision is total or partial.

We plan to perform extensive data analysis on the new and revised joint procedure codes as we receive billing data to determine if future refinements of these DRGs are needed. In addition, as indicated in section II.C. of this

[[Page 24036]]

preamble, we are proposing to adopt a consolidated severity-adjusted DRG system for the IPPS. We encourage commenters to evaluate how the new and revised joint procedures are addressed in the consolidated severity-adjusted DRG system. If changes to these procedures are warranted based on public comments and our continuing analysis, we will evaluate them as we further develop our plans for adopting the consolidated severity-adjusted DRGs. b. Spinal Fusion

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

In the FY 2006 IPPS final rule (70 FR 47307), we created new DRG 546 (Spinal Fusions Except Cervical with Curvature of the Spine or Malignancy). DRG 546 is composed of all noncervical spinal fusions previously assigned to DRGs 497 (Spinal Fusion Except Cervical with CC) and 498 (Spinal Fusion Except Cervical without CC) that have a principal or secondary diagnosis of curvature of the spine or a principal diagnosis of a malignancy. The principal diagnosis codes that lead to DRG 546 assignment are the following:

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

198.5, Secondary malignant neoplasm of bone and bone marrow.

213.2, Benign neoplasm of bone and articular cartilage; vertebral column, excluding sacrum and coccyx.

238.0, Neoplasm of uncertain behavior of other and unspecified sites and tissues; Bone and articular cartilage.

239.2, Neoplasms of unspecified nature; bone, soft tissue, and skin.

732.0, Juvenile osteochondrosis of spine.

733.13, Pathologic fracture of vertebrae.

737.0, Adolescent postural kyphosis.

737.10, Kyphosis (acquired) (postural).

737.11, Kyphosis due to radiation.

737.12, Kyphosis, postlaminectomy.

737.19, Kyphosis (acquired), other.

737.20, Lordosis (acquired) (postural).

737.21, Lordosis, postlaminectomy.

737.22, Other postsurgical lordosis.

737.29, Lordosis (acquired), other.

737.30, Scoliosis [and kyphoscoliosis], idiopathic.

737.31, Resolving infantile idiopathic scoliosis.

737.32, Progressive infantile idiopathic scoliosis.

737.33, Scoliosis due to radiation.

737.34, Thoracogenic scoliosis.

737.39, Other kyphoscoliosis and scoliosis.

737.8, Other curvatures of spine.

737.9, Unspecified curvature of spine.

754.2, Congenital scoliosis.

756.51, Osteogenesis imperfecta.

The secondary diagnoses that will lead to DRG 546 assignment are:

737.40, Curvature of spine, unspecified.

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

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

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

After publication of the FY 2006 IPPS final rule, we received a comment stating that creating new DRG 546 was insufficient to address clinical severity and resource differences among spinal fusion cases that involve fusing multiple levels of the spine. Specifically, the commenter suggested that the spinal fusion DRGs be further modified to incorporate Bone Morphogenic Protein (BMP), code 84.52 (Insertion of recombinant bone morphogenetic protein). The commenter also suggested that CMS apply a clinical severity concept to all back and spine surgical cases similar to the approach that we used for the MCVs to refine the cardiac DRGs in the final rule for FY 2006. The commenter recommended recognizing additional conditions that reflect higher resource needs, regardless of whether they are principal or secondary diagnoses. The commenter also suggested that the spine DRGs be further subdivided based on the use of specific spinal devices such as artificial discs. These changes would entail the creation of 10 new spine DRGs in addition to other changes requested.

We agree that it is important to recognize severity when classifying patients into specific DRGs. In response to recommendations made by MedPAC last year that are discussed in section II.C. of this proposed rule, we are conducting a comprehensive analysis of the entire DRG system to determine whether to undertake significant reform to better recognize severity of illness. At this time, we believe it is premature to develop a severity adjustment for spine surgeries while we are considering a more systematic approach to capturing severity of illness across all DRGs. We also believe it would be premature to propose revisions to DRG 546 because this DRG was created on October 1, 2005, and we do not yet have data to analyze its impact. Given the number of innovations occurring in spinal surgery over the last several years (for example, artificial spinal disc prostheses, kyphoplasty, and vertebroplasty), we agree that additional analysis of the spine DRGs would be warranted if we were to continue with the current DRG system and not adopt consolidated severity-adjusted DRGs. However, as discussed above, we are proposing to develop a severity-adjusted DRG system. For this reason, we are not further researching this issue for FY 2007. However, we encourage commenters to examine the proposed consolidated severity-adjusted DRG system described in section II.C. of the preamble of this proposed rule to determine whether there is a better recognition of severity of illness and resource use in that system. c. Charite\TM\ Spinal Disc Replacement Device

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

CHARITE\TM\ is a prosthetic intervertebral disc. On October 26, 2004, the FDA approved the CHARITE\TM\ Artificial Disc for single level spinal arthroplasty in skeletally mature patients with degenerative disc disease between L4 and S1. On October 1, 2004, we created new procedure codes for the insertion of spinal disc prostheses (codes 84.60 through 84.69). We provided the DRG assignments for these new codes in Table 6B of the FY 2005 IPPS proposed rule (69 FR 28673). We received a number of comments on the proposed rule recommending that we change the assignments for these codes from DRG 499 (Back and Neck Procedures Except Spinal Fusion With CC) and DRG 500 (Back and Neck Procedures Except Spinal Fusion Without CC) to the DRGs for spinal fusion, DRG 497 (Spinal Fusion Except Cervical With CC) and DRG 498 (Spinal Fusion Except Cervical Without CC) for procedures on the lumbar spine and to DRGs 519 and 520 for procedures on the cervical spine. In the FY 2005 IPPS final rule (69 FR 48938), we indicated that DRGs 497 and 498 are limited to spinal fusion procedures. Because the surgery involving the CHARITE\TM\ is not a spinal fusion, we decided not to include this procedure in these DRGs. However, we stated that we would continue to analyze this issue and solicited further public comments on the DRG assignment for spinal disc prostheses.

In the FY 2006 final rule (70 FR 47353), we noted that, if a product

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meets all of the criteria for Medicare to pay for the product as a new technology under section 1886(d)(5)(K) of the Act, there is a clear preference expressed in the statute for us to assign the technology to a DRG based on similar clinical or anatomical characteristics or costs. However, for FY 2006, we did not find that CHARITE\TM\ met the substantial clinical improvement criterion and, thus, did not qualify as a new technology. Consequently, we did not address the DRG classification request made under the authority of this provision of the Act.

However, we did evaluate whether to reassign CHARITE\TM\ to different DRGs using the Secretary's authority under section 1886(d)(4) of the Act (70 FR 47308). We indicated that we did not have Medicare charge information to evaluate DRG changes for cases involving an implant of a prosthetic intervertebral disc like CHARITE\TM\ and did not make a change in its DRG assignments. We stated that we would consider whether changes to the DRG assignments for CHARITE\TM\ were warranted for FY 2007, once we had information from Medicare's data system that would assist us in evaluating the costs of these patients.

For the FY 2007 IPPS update, we received a comment regarding the DRG assignments for the CHARITETMArtificial Disc, code 84.65 (Insertion of total spinal disc prosthesis, lumbosacral). The commenter had previously submitted an application for the CHARITETMArtificial Disc for new technology add-on payments for FY 2006 and had requested a reassignment of cases involving CHARITETMimplantation to DRGs 497 and 498. The commenter asked that we examine claims data for FY 2005 and reassign procedure code 84.65 from DRGs 499 and 500 into DRGs 497 and 498. The commenter again stated the view that cases with the CHARITETM Artificial Disc reflect comparable resource use and similar clinical indications as do those in DRGs 497 and 498. If CMS were to reject reassignment of the CHARITETMArtificial Disc to DRGs 497 and 498, the commenter suggested creating two separate DRGs for lumbar disc replacements.

On February 16, 2006, we posted a proposed NCD memorandum regarding lumber artificial disc replacement with a focus of the CHARITETMLumber Artificial Disc for public comment on the CMS Web site. This is part of the process for issuing an NCD. In this memorandum, we proposed to issue an NCD. We are seeking public comment on our proposed determination that the evidence is not adequate to conclude that lumbar artificial disc replacement with the CHARITETMLumber Artificial Disc is reasonable and necessary. This proposed decision memorandum can be found at: http://www.cms.hhs.gov/mcd/ viewnca.asp?where=index& nca--id=170&

basket=nca:00292N:170: Lumbar+Artificial+Disc+Replacement: Open:New:5. After considering the public comments and any additional evidence, we will make a final determination and issue a final NCD.

The proposed NCD states that lumber artificial disc replacement with the CHARITETMLumber Artificial Disc is generally not indicated in patients over 65 years old. Further, it states that there is insufficient evidence among either the aged or disabled Medicare population to make a reasonable and necessary determination for coverage. With an NCD pending to make spinal arthroplasty with CHARITETMnoncovered, we do not believe it is appropriate at this time to reassign procedure code 84.65 from DRGs 499 and 500 to DRGs 497 and 498. 5. MDC 18 (Infectious and Parasitic Diseases (Systemic or Unspecified Sites)): Severe Sepsis

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

In FYs 2005 and 2006, we considered requests for the creation of a separate DRG for the diagnosis of severe sepsis. Severe sepsis is described by ICD-9-CM code 995.92 (Systemic inflammatory response syndrome due to infection with organ dysfunction). Patients admitted with sepsis as a principal diagnosis currently are assigned to DRG 416 (Septicemia Age > 17) and DRG 417 (Septicemia Age 0-17) in MDC 18 (Infectious and Parasitic Diseases (Systemic or Unspecified Sites)). The commenter requested that all cases in which severe sepsis is present on admission, as well as those cases in which it develops after admission (which are currently classified elsewhere), be included in this new DRG. In both FY 2005 and FY 2006 (69 FR 48975 and 70 FR 47309), we did not believe the current clinical definition of severe sepsis was 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, in the past we have not found that they can be identified adequately to justify removing them from all of the other DRGs in which they appear. For this reason, we did not create a new DRG for severe sepsis for FY 2005 or FY 2006. We indicated that we would continue to work with National Center for Health Statistics (NCHS) to improve the codes so that our data on these patients improve. We also indicated that we would continue to examine data on these patients as we consider future modifications.

For this FY 2007 proposed rule, we again received a request to consider creating a separate DRG for patients diagnosed with severe sepsis. The information and data available to us from hospital bills with respect to identifying patients with severe sepsis have not changed since last year. However, the NCHS discussed modifications to the current ICD-9-CM diagnosis codes for systemic inflammatory response syndrome (SIRS), codes 995.91 through 995.94 (which include severe sepsis) at the September 29-30, 2005 ICD-9-CM Coordination and Maintenance Committee meeting. During the meeting, it became clear that there is still confusion surrounding the use of these codes. As a result of the meeting and the comments received, the Committee made modifications to the set of SIRS codes. These modifications are reflected in Table 6E, Revised Diagnosis Code Titles, of the Addendum to this proposed rule.

We believe that implementation of the modified SIRS diagnosis codes and the updated coding guidelines over the next year could begin the process of improving data for this group of patients. The desired outcome is to be able to better evaluate Medicare beneficiaries with severe sepsis with regard to their clinical coherence, resource utilization, and charges. Therefore, at this time, we are not proposing to create a new DRG for severe sepsis for FY 2007. We also note that we are proposing to adopt a consolidated severity-adjusted DRG system, as discussed in section II.C. of this preamble. The underlying clinical principle of the proposed consolidated severity-adjusted DRG system is that the severity of illness of a patient is highly dependent on the patient's underlying problem and that patients with high severity of illness are usually characterized by multiple serious diseases or illnesses. The assessment of the severity of illness of a patient is specific to the base DRG to which a patient is assigned. In other words, the determination of the severity of illness is disease- specific. High severity of

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illness is primarily determined by the interaction of multiple diseases. Patients with multiple comorbid conditions involving multiple organ systems are assigned to the higher severity of illness subclasses. Thus, patients with severe sepsis and organ dysfunction are likely to be classified as severity of illness subclass 3 or 4 under the proposed DRG system, depending on the other comorbid conditions or underlying problems the patient may have at that time. It is possible that the consolidated severity-adjusted DRG system that we are planning to adopt would better recognize the extensive resources that hospitals use to treat patients with severe sepsis. We encourage commenters to examine the consolidated severity-adjusted DRGs described in section II.C. of this proposed rule to determine whether there is a better recognition of severity of illness and resource use in that proposed system. 6. Medicare Code Editor (MCE) Changes

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

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

For FY 2007, we are proposing to make the following changes to the MCE edits: a. Newborn Diagnoses Edit

We are proposing to add code 780.92 (Excessive crying of infant (baby)) to the ``Newborn Diagnoses'' edit in the MCE. This edit is structured for patients with an age of ``0''. In the Tabular portion of the ICD-9-CM diagnosis codes, the ``excludes'' note at code 780.92 states that this code ``excludes excessive crying of child, adolescent or adult'' and sends the coder to code 780.95 (Other excessive crying. (The new title of this code, shown on Table 6E of the Addendum to this proposed rule is ``Excessive crying of child, adolescent, or adult).) To make a conforming change, we also are proposing that code 780.92 be removed from the ``Pediatric Diagnoses--Age 0 Through 17'' edit. b. Diagnoses Allowed for Females Only Edit

The following codes are now invalid codes, as shown in Table 6C of the Addendum to this proposed rule. Therefore, we are proposing to remove them from the ``Diagnosis Allowed for Females Only'' edit in the MCE.

616.8, Other specified inflammatory diseases of cervix, vagina, and vulva.

629.8, Other specified disorders of female genital organs.

Codes 616.8 and 629.8 have been expanded to the fifth-digit level. Therefore, we are proposing to place the following expanded codes in the ``Diagnoses Allowed for Females Only'' edit.

616.81, Mucositis (ulcerative) of cervix, vagina, and vulva.

616.89, Other inflammatory disease of cervix, vagina, and vulva.

629.81, Habitual aborter without current pregnancy.

629.89, Other specified disorders of female genital organs.

The following two codes have revised descriptions (as shown in Table 6E of the Addendum to this proposed rule) which specify gender. Therefore, we are proposing to add them to ``Diagnoses Allowed for Females Only'' edit.

V26.31, Testing of female for genetic disease carrier status.

V26.32, Other genetic testing of female. c. Diagnoses Allowed for Males Only Edit

Code 608.2 (Torsion of testis) is now an invalid code (as shown in Table 6C of the Addendum to this proposed rule). Therefore, we are proposing to remove it from the ``Diagnoses Allowed for Males Only'' edit. This code has been expanded to the fifth-digit level. Therefore, we are proposing to place the following expanded codes in the ``Diagnoses Allowed for Males Only'' edit:

608.20, Torsion of testis, unspecified.

608.21, Extravaginal torsion of spermatic cord.

608.22 Intravaginal torsion of spermatic cord.

608.23, Torsion of appendix testis.

608.24, Torsion of appendix epididymis.

The following codes have been created effective for FY 2007 and are gender specific. Therefore, we are proposing to add them to the ``Diagnosis Allowed for Males Only'' edit.

V26.34, Testing of male for genetic disease carrier status.

V26.35, Encounter for testing of male partner of habitual aborter.

V26.39, Other genetic testing of male. d. Manifestations Not Allowed as Principal Diagnosis Edit

We are proposing to add the following codes to the ``Manifestations Not Allowed as Principal Diagnosis'' edit in the MCE:

362.03, Nonproliferative diabetic retinopathy, NOS.

362.04, Mild nonproliferative diabetic retinopathy.

362.05, Moderate nonproliferative diabetic retinopathy.

362.06, Severe nonproliferative diabetic retinopathy.

362.07, Diabetic macular edema.

In addition, we are proposing to remove code 525.10 (Acquired absence of teeth, unspecified) from this edit in the MCE. e. Nonspecific Principal Diagnosis Edit

We are proposing to add the following codes to the ``Nonspecific Principal Diagnosis'' edit in the MCE:

255.10, Hyperaldosteronism, unspecified.

323.9, Unspecified causes of encephalitis, myelitis, and encephalomyelitis.

770.10, Fetal and newborn aspiration, unspecified.

780.31, Febrile convulsions (simple), unspecified.

Codes 255.10, 323.9, and 780.31 appear on Table 6E, Revised Diagnosis Codes, and are being included in this edit because of their revised descriptions. Code 770.10 was inadvertently left off this list for FY 2006 when the code was created. f. Unacceptable Principal Diagnosis Edit

Most V-codes describe an individual's health status, but these codes are not usually a current illness or injury. Therefore, most V- codes are included in the ``Unacceptable Principal Diagnosis'' edit. The following codes became invalid (as shown in Table 6C of the Addendum to this proposed rule) for FY 2007, and we are proposing to remove them from this edit:

V18.5, Family history, digestive disorders.

V58.3, Attention to surgical dressings and sutures.

V72.1, Examination of ears and hearing.

The following V-codes represent either fifth-digit extensions of the above codes, or new codes that were created effective October 1, 2006 (Table 6A of the Addendum to this proposed rule). Therefore, we are proposing to add the following codes to the ``Unacceptable Principal Diagnosis'' edit:

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V18.51, Family history, colonic polyps.

V18.59, Family history, other digestive disorders.

V26.34, Testing of male for genetic disease carrier status.

V26.35, Encounter for testing of male partner of habitual aborter.

V26.39, Other genetic testing of male.

V45.86, Bariatric surgery status.

V58.30, Encounter for change or removal of nonsurgical wound dressing.

V58.31, Encounter for change or removal of surgical wound dressing.

V58.32, Encounter for removal of sutures.

V72.11, Encounter for hearing examination following failed hearing screening.

V72.19, Other examination of ears and hearing.

V82.71, Screening for genetic disease carrier status.

V82.79, Other genetic screening.

V85.51, Body mass index, pediatric, less than 5th percentile for age.

V85.52, Body mass index, pediatric, 5th percentile to less than 85th percentile for age.

V85.53, Body mass index, pediatric, 85th percentile to less than 95th percentile for age.

V85.54, Body mass index, pediatric, greater than or equal to 95th percentile for age.

V86.0, Estrogen receptor positive status [ER+].

V86.1, Estrogen receptor negative status [ER-]. g. Nonspecific O.R. Procedures Edit

We are proposing to remove code 00.29 (Intravascular imaging unspecified vessel(s)) from the ``Nonspecific O.R. Procedure'' edit in the MCE. This code was erroneously placed in this edit; it is not considered an O.R. procedure. h. Noncovered Procedures Edit

Under the proposed changes to DRG 513 (Pancreas Transplant) under the Pre-MDCs described in section II.D.1. of this preamble, a patient must have a history of medically uncontrollable, insulin-dependent diabetes mellitus, that is, Type I diabetes mellitus. Therefore, to conform the ``Noncovered Procedures'' Edit in the MCE to these proposed changes, we are proposing to revise Diagnosis List 1 in this edit to include only the following codes:

250.01, Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled.

250.03, Diabetes mellitus without mention of complication, type I [juvenile type], uncontrolled.

250.11, Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled.

250.13, Diabetes with ketoacidosis, type I [juvenile type], uncontrolled.

250.21, Diabetes with hyperosmolarity, type I [juvenile type], not stated as uncontrolled.

250.23, Diabetes with hyperosmolarity, type I [juvenile type], uncontrolled.

250.31, Diabetes with other coma, type I [juvenile type], not stated as uncontrolled.

250.33, Diabetes with other coma, type I [juvenile type], uncontrolled.

250.41, Diabetes with renal manifestations, type I

[juvenile type] , not stated as uncontrolled.

250.43, Diabetes with renal manifestations, type I

[juvenile type] , uncontrolled.

250.51, Diabetes with ophthalmic manifestations, type I

[juvenile type] , not stated as uncontrolled.

250.53, Diabetes with ophthalmic manifestations, type I

[juvenile type] , uncontrolled.

250.61, Diabetes with neurological manifestations, type I

[juvenile type] , not stated as uncontrolled.

250.63, Diabetes with neurological manifestations, type I

[juvenile type] , uncontrolled.

250.71, Diabetes with peripheral circulatory disorders, type I [juvenile type], not stated as uncontrolled.

250.73, Diabetes with peripheral circulatory disorders, type I [juvenile type], uncontrolled.

250.81, Diabetes with other specified manifestations, type I [juvenile type], not stated as uncontrolled.

250.83, Diabetes with other specified manifestations, type I [juvenile type], uncontrolled.

250.91, Diabetes with unspecified complication, type I

[juvenile type] , not stated as uncontrolled.

250.93, Diabetes with unspecified complication, type I

[juvenile type] , uncontrolled.

In addition, we are proposing to remove Diagnosis List 2 from the ``Noncovered Procedures'' edit, which is comprised of the following codes:

403.01, Hypertensive kidney disease, malignant, with chronic kidney disease.

403.11, Hypertensive kidney disease, benign, with chronic kidney disease.

403.91, Hypertensive kidney disease, unspecified, with chronic kidney disease.

404.02, Hypertensive heart and kidney disease, malignant, with chronic kidney disease.

404.03, Hypertensive heart and kidney disease, malignant, with heart failure and chronic kidney disease.

404.12, Hypertensive heart and kidney disease, benign, with chronic kidney disease.

404.13, Hypertensive heart and kidney disease, benign, with heart failure and chronic kidney disease.

404.92, Hypertensive heart and kidney disease, unspecified, with chronic kidney disease.

404.93, Hypertensive heart and kidney disease, unspecified, with heart failure and chronic kidney disease.

585.1, Chronic kidney disease, Stage I.

585.2, Chronic kidney disease, Stage II (mild).

585.3, Chronic kidney disease, Stage III (moderate).

585.4, Chronic kidney disease, Stage IV (severe).

585.5, Chronic kidney disease, Stage V.

585.6, End stage renal disease.

585.9, Chronic kidney disease, unspecified.

V42.0, Organ or tissue replaced by transplant, kidney.

V43.89, Organ or tissue replaced by other means, other organ or tissue, other. i. Bilateral Procedure Edit

We are proposing to remove the following codes from the ``Bilateral Procedure'' edit, as these are adjunct codes. They are not O.R. codes recognized by the GROUPER as procedures, and the edit was created in error last year.

00.74, Hip replacement bearing surface, metal on polyethylene.

00.75, Hip replacement bearing surface, metal-on-metal.

00.76, Hip replacement bearing surface, ceramic-on- ceramic. 7. Surgical Hierarchies

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

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

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procedures are assigned to the DRG associated with the most resource- intensive surgical class.

Because the relative resource intensity of surgical classes can shift as a function of DRG reclassification and recalibrations, we reviewed the surgical hierarchy of each MDC, as we have for previous reclassifications and recalibrations, to determine if the ordering of classes coincides with the intensity of resource utilization.

A surgical class can be composed of one or more DRGs. For example, in MDC 11, the surgical class ``kidney transplant'' consists of a single DRG (DRG 302) and the class ``kidney, ureter and major bladder procedures'' consists of three DRGs (DRGs 303, 304, and 305). Consequently, in many cases, the surgical hierarchy has an impact on more than one DRG. The methodology for determining the most resource- intensive surgical class involves weighting the average resources for each 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 changes under the HSVRcc weighting methodology that we are proposing for FY 2007, as discussed in section II.C.2. of this preamble, we are proposing to revise the surgical hierarchy for Pre- MDCs, MDC 1 (Diseases and Disorders of the Nervous System), MDC 2 (Diseases and Disorders of the Eye), MDC 3 (Diseases and Disorders of the Ear, Nose, Mouth and Throat), MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue), MDC 10 (Endocrine, Nutritional and Metabolic Diseases and Disorders), and MDC 13 (Diseases and Disorders of the Female Reproductive System) as follows. In our analysis, we looked at the number of cases and the arithmetic mean.

In Pre-MDCs, we are proposing to reorder DRG 481 (Bone Marrow Transplant) above DRG 513 (Pancreas Transplant).

In MDC 1, we are proposing to reorder DRGs 531-532 (Spinal Procedures, with CC and without CC, respectively) above DRGs 529-530 (Ventricular Shunt Procedures, with CC and without CC, respectively).

In MDC 2, we are proposing to reorder DRG 42 (Intraocular Procedures Except Retina, Iris and Lens) above DRG 36 (Retinal Procedures).

In MDC 3, we are proposing to reorder DRGs 168-169 (Mouth Procedures, with CC and without CC, respectively) above DRG 57 (T&A Procedures, Except Tonsillectomy and/or Adenoidectomy Only, Age > 17) and DRG 58 (T&A Procedures, Except Tonsillectomy and/or Adenoidectomy Only, Age 0-17).

In MDC 8, we are proposing to reorder DRG 213 (Amputation for Musculoskeletal System and Connective Tissue Disorders) above DRG 216 (Biopsies of Musculoskeletal System and Connective Tissue).

In MDC 10, we are proposing to reorder DRG 285 (Amputation of Lower Limb for Endocrine, Nutritional and Metabolic Diseases and Disorders) above DRG 288 (O.R. Procedures for Obesity).

In MDC 13, we are proposing to reorder DRG 363 (D&C, Conization and Radio-Implant, for Malignancy) and DRG 364 (D&C, Conization and Radio- Implant, Except for Malignancy) above DRG 360 (Vagina, Cervix, and Vulva Procedures). 8. 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. Given the long period of time that had elapsed since the original CC list was developed, the incremental nature of changes to it, and changes in the way inpatient care is delivered, and in partial response to recommendations in MedPAC's March 2005 Report to Congress on Physician- Owned Specialty Hospitals, for the FY 2006 IPPS final rule, we reviewed the 121-paired DRGs that were split on the presence or absence of a CC among the 3,285 diagnosis codes on the CC list. We presented the results of that review and summarized public comments that we received in the FY 2006 proposed rule on the review results in the FY 2006 IPPS final rule (70 FR 47313 through 47315). Further analysis of the CC list

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and refinement to recognize the effects of differences in severity of illness among patients is discussed in section II.C. of this preamble as part of our efforts to develop a consolidated severity-adjusted DRG system for use in the IPPS. However, as further discussed in section II.C. of the preamble to this proposed rule, we are soliciting comments on whether it would be appropriate in FY 2007 to apply to an expanded set of DRGs a clinical severity concept similar to the approach we used in FY 2006 to refine cardiac DRGs based on the presence or absence of an MCV. c. CC Exclusions List Proposed for FY 2007

In the September 1, 1987 final notice (52 FR 33143) concerning changes to the DRG classification system, we modified the GROUPER logic so that certain diagnoses included on the standard list of CCs would not be considered valid CCs in combination with a particular principal diagnosis. We created the CC Exclusions List for the following reasons: (1) To preclude coding of CCs for closely related conditions; (2) to preclude duplicative or inconsistent coding from being treated as CCs; and (3) to ensure that cases are appropriately classified between the complicated and uncomplicated DRGs in a pair. As we indicated above, we developed a list of diagnoses, using physician panels, to include those diagnoses that, when present as a secondary condition, would be considered a substantial complication or comorbidity. In previous years, we have made changes to the list of CCs, either by adding new CCs or deleting CCs already on the list. At this time, we are not proposing to delete any of the diagnosis codes on the CC list for FY 2007.

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.\9\

\9\ See the FY 1989 final rule (53 FR 38485, September 30, 1988), for the revision made for the discharges occurring in FY 1989; the FY 1990 final rule (54 FR 36552, September 1, 1989), for the FY 1990 revision; the FY 1991 final rule (55 FR 36126, September 4, 1990), for the FY 1991 revision; the FY 1992 final rule (56 FR 43209, August 30, 1991) for the FY 1992 revision; the FY 1993 final rule (57 FR 39753),September 1, 1992), for the FY 1993 revision; the FY 1994 final rule (58 FR 46278, September 1, 1993), for the FY 1994 revisions; the FY 1995 final rule (59 FR 45334, September 1, 1994), for the FY 1995 revisions; the FY 1996 final rule (60 FR 45782, September 1, 1995), for the FY 1996 revisions; the FY 1997 final rule (61 FR 46171, August 30, 1996), for the FY 1997 revisions; the FY 1998 final rule (62 FR 45966, August 29, 1997) for the FY 1998 revisions; the FY 1999 final rule (63 FR 40954, July 31, 1998), for the FY 1999 revisions; the FY 2001 final rule (65 FR 47064, August 1, 2000), for the FY 2001 revisions; the FY 2002 final rule (66 FR 39851, August 1, 2001), for the FY 2002 revisions; the FY 2003 final rule (67 FR 49998, August 1, 2002), for the FY 2003 revisions; the FY 2004 final rule (68 FR 45364, August 1, 2003), for the FY 2004 revisions; the FY 2005 final rule (69 FR 49848, August 11, 2004), for the FY 2005 revisions; and the FY 2006 final rule (70 FR 47640, August 12, 2005), for the FY 2006 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 to make limited revisions to the CC Exclusions List to take into account the changes that will be made in the ICD-9-CM diagnosis coding system effective October 1, 2006. (See section II.D.10. 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, 2006. 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, 2006, the indented diagnoses will not be recognized by the GROUPER as valid CCs for the asterisked principal diagnosis.

CCs that are deleted from the list are in Table 6H--Deletions from the CC Exclusions List. Beginning with discharges on or after October 1, 2006, the indented diagnoses will be recognized by the GROUPER as valid CCs for the asterisked principal diagnosis.

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

Users should be aware of the fact that all revisions to the CC Exclusions List (FYs 1989, 1990, 1991, 1992, 1993, 1994, 1995, 1996, 1997, 1998, 1999, 2001, 2002, 2003, 2004, 2005, and 2006) and those in Tables 6G and 6H of this proposed rule for FY 2007 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, 2006.

(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 23.0, is available for $225.00, which includes $15.00 for shipping and handling. Version 24.0 of this manual, which will include the final FY 2007 DRG changes, will be available in hard copy for $250.00. Version 24.0 of the manual is also available on a CD for $200.00; a combination hard copy and CD is available for $400.00. These manuals may be obtained by writing 3M/HIS at the following address: 100 Barnes Road, Wallingford, CT 06492; or by calling (203) 949-0303. Please specify the revision or revisions requested. 9. Review of Procedure Codes in DRGs 468, 476, and 477

Each year, we review cases assigned to DRG 468 (Extensive O.R. Procedure Unrelated to Principal Diagnosis), DRG 476 (Prostatic O.R. Procedure Unrelated

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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.\10\

\10\ 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. In the FY 2006 (70 FR 47317), we moved one procedure from DRG 468 and assigned it to DRG 477.

For FY 2007, we are not proposing to change the procedures assigned among these DRGs. 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 are not proposing to remove any procedures in DRGs 468 or 477 to one of the surgical DRGs for FY 2007. 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.

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 for FY 2007. c. Adding Diagnosis or Procedure Codes to MDCs

Based on our review this year, we are not proposing to add any diagnosis codes to MDCs for FY 2007. 10. Changes to the ICD-9-CM Coding System

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

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

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

The Committee encourages participation in the above process by health-related organizations. In this regard, the Committee holds public meetings for discussion of educational issues and proposed coding changes. These meetings provide an opportunity for representatives of recognized organizations in the coding field, such as the American Health Information Management Association (AHIMA), the American Hospital Association (AHA),

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and various physician specialty groups, as well as individual physicians, health information management professionals, and other members of the public, to contribute ideas on coding matters. After considering the opinions expressed at the public meetings and in writing, the Committee formulates recommendations, which then must be approved by the agencies.

The Committee presented proposals for coding changes for implementation in FY 2007 at a public meeting held on September 29-30, 2005, and finalized the coding changes after consideration of comments received at the meetings and in writing by December 2, 2005. Those coding changes are announced in Tables 6A through 6F in the Addendum to this proposed rule. The Committee held its 2006 meeting on March 23-24, 2006. Proposed new codes for which there was a consensus of public support and for which complete tabular and indexing changes can be made by May 2006 will be included in the October 1, 2006 update to ICD-9-CM. Code revisions that were discussed at the March 23-24, 2006 Committee meeting could not be finalized in time to include them in this FY 2007 IPPS proposed rule. These additional codes will be included in Tables 6A through 6F of the final rule and will be marked with an asterisk (*).

Copies of the minutes of the procedure codes discussions at the Committee's September 29-30, 2005 meeting can be obtained from the CMS Web site: http://new.cms.hhs.gov/ICD9ProviderDiagnosticCodes/03_meetings.asp. The minutes of the diagnosis codes discussions at the

September 29-30, 2005 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, 2006. 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, 2006. 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, 2006. 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 2007.

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 23-24, 2006 Committee meeting that received consensus and that can be finalized by May 2006, will be included in Tables 6A through 6F of the Addendum to the final rule.

Section 503(a) of Pub. L. 108-173 included a requirement for updating ICD-9-CM codes twice a year instead of a single update on October 1 of each year. This requirement was included as part of the amendments to the Act relating to recognition of new technology under the IPPS. Section 503(a) amended section 1886(d)(5)(K) of the Act by adding a clause (vii) which states that the ``Secretary shall provide for the addition of new diagnosis and procedure codes 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 1886(d)(5)(K)(vii) of the Act states that the addition of new diagnosis and procedure codes on April 1 of each year shall not require the Secretary to adjust the payment, or DRG classification under section 1886(d) of the Act until the fiscal year that begins after such date, we have to update the DRG software and other systems in order to recognize and accept the new codes. We also publicize the code changes and the need for a mid-year systems update by providers to capture the new codes. Hospitals also have to obtain the new code books and encoder updates, and make other system changes in order to capture and report the new codes.

The ICD-9-CM Coordination and Maintenance Committee holds its meetings in the Spring and Fall in order to update the codes and the applicable payment and reporting systems by October 1 of each year. Items are placed on the agenda for the ICD-9-CM Coordination and Maintenance Committee meeting if the request is received at least 2 months prior to the meeting. This requirement allows time for staff to review and research the coding issues and prepare material for discussion at the meeting. It also allows time for the topic to be publicized in meeting announcements in the Federal Register as well as on the CMS Web site. The public decides whether or not to attend the meeting based on the topics listed on the agenda. Final decisions on code title revisions are currently made by March 1 so that these titles can be included in the IPPS proposed rule. A complete addendum describing details of all changes to ICD-9-CM, both tabular and index, are publicized on CMS and NCHS Web pages in May of each year. Publishers of coding books and software use this information to modify their products that are used by health care providers. This 5-month time period has proved to be necessary

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for hospitals and other providers to update their systems.

A discussion of this timeline and the need for changes are included in the December 4-5, 2005 ICD-9-CM Coordination and Maintenance Committee minutes. The public agreed that there was a need to hold the fall meetings earlier, in September or October, in order to meet the new implementation dates. The public provided comment that additional time would be needed to update hospital systems and obtain new code books and coding software. There was considerable concern expressed about the impact this new April update would have on providers.

In the FY 2005 IPPS final rule, we implemented section 1886(d)(5)(K)(vii) of the Act, as added by section 503(a) of Public Law 108-173, by developing a mechanism for approving, in time for the April update, diagnosis and procedure code revisions needed to describe new technologies and medical services for purposes of the new technology add-on payment process. We also established the following process for making these determinations. Topics considered during the Fall ICD-9-CM Coordination and Maintenance Committee meeting are considered for an April 1 update if a strong and convincing case is made by the requester at the Committee's public meeting. The request must identify the reason why a new code is needed in April for purposes of the new technology process. The participants at the meeting and those reviewing the Committee meeting summary report are provided the opportunity to comment on this expedited request. All other topics are considered for the October 1 update. Participants at the Committee meeting are encouraged to comment on all such requests. There were no requests for an expedited April l, 2006 implementation of an ICD-9-CM code at the September 29-30, 2005 Committee meeting. Therefore, there were no new ICD-9-CM codes implemented on April 1, 2006.

We believe that this process captures the intent of section 1886(d)(5)(K)(vii) of the Act. This requirement was included in the provision revising the standards and process for recognizing new technology under the IPPS. In addition, the need for approval of new codes outside the existing cycle (October 1) arises most frequently and most acutely where the new codes will 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/icd9ProviderDiagnosticCodes.

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

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

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

These same means of disseminating information on new, revised, and deleted ICD-9-CM codes will be used to notify providers, publishers, software vendors, contractors, and others of any changes to the ICD-9- CM codes that are implemented in April. The code titles are adopted as part of the ICD-9-CM Coordination and Maintenance Committee process. Thus, although we publish the code titles in the IPPS proposed and final rules, they are not subject to comment in the proposed or final rules. We will continue to publish the October code updates in this manner within the IPPS proposed and final rules. For codes that are implemented in April, we will assign the new procedure code to the same DRG in which its predecessor code was assigned so there will be no DRG impact as far as DRG assignment. This mapping was specified by section 1886(d)(5)(K)(vii) of the Act as added by section 503(a) of Pub. L. 108-173. Any midyear coding updates will be available through the 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 Web sites 5 months prior to implementation (that is, early November of the previous year), as is the case for the October 1 updates. Codebook publishers are evaluating how they will provide any code updates to their subscribers. Some publishers may decide to publish mid-year book updates. Others may decide to sell an addendum that lists the changes to the October 1 code book. Coding personnel should contact publishers to determine how they will update their books. CMS and its contractors will also consider developing provider education articles concerning this change to the effective date of certain ICD-9-CM codes.

E. 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 change the DRG recalibration process methodology for FY 2007 to move to an HSRV weighting method as discussed in section II.C.2. of the preamble to this proposed rule. For FY 2006 and years prior, we have recalibrated the DRG weights based on charge data for Medicare discharges using the most current charge information available (for example, the FY 2005 MedPAR file would have been used for FY 2007). Our thorough analysis of the March 2005 MedPAC recommendations regarding refinement of the DRG system used for the IPPS (see discussion of the MedPAC recommendations in section II.C.2. of this preamble) has shown that using gross charges as a basis for setting the DRG weights has introduced bias into the weighting process. Specifically, hospitals that are systematically more expensive than others (that is, teaching hospitals and specialty hospitals) tend to treat certain cases more commonly than others, causing the weights for these cases to be artificially high. In addition, hospitals may mark up their charges for routine days, intensive care days, and various ancillary services by different percentages. This practice of differential markups among hospital cost centers may also introduce bias into the weights. For instance, we have observed that ancillary service cost centers generally have higher charge markups than routine services. Thus, the charge-based relative weight methodology may result in high weights for DRGs that use more ancillary services relative to DRGs that use more routine services than would occur under a system where the weights are based on costs.

As discussed in section II.C.2. of this preamble, based on our study of the MedPAC recommendations, we have developed an alternative methodology for recalibrating the DRG weights. This method involves applying the HSRV methodology at the cost center level (HSRVcc) to remove the bias introduced by hospital characteristics (that is, teaching, disproportionate share, location, and size, among others) and then scaling the weights to costs using national cost center CCRs derived from cost report data.

In developing this proposed system of weights, we used two data sources:

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

[[pp. 24045-24094]] Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2007 Rates

[[Continued from page 24044]]

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Claims data and cost report data. As in previous years, the claims data source is the MedPAR file. This file is based on fully coded diagnostic and procedure data for all Medicare inpatient hospital bills. The FY 2005 MedPAR data used in this proposed rule include discharges occurring between October 1, 2004 and September 30, 2005, based on bills received by CMS through December 31, 2005, from all hospitals subject to the IPPS and short-term acute care hospitals in Maryland (which are under a waiver from the IPPS under section 1814(b)(3) of the Act). The FY 2005 MedPAR file used in calculating the relative weights includes data for approximately 12,137,358 Medicare discharges. Discharges for Medicare beneficiaries enrolled in a Medicare+Choice managed care plan are excluded from this analysis. The data exclude CAHs, including hospitals that subsequently became CAHs after the period from which the data were taken. The second data source used in the new HSRVcc weight methodology are the FY 2003 Medicare cost report data files from HCRIS, which represents the most recent full set of cost report data available. We used the December 31, 2005 update of the HCRIS cost report files for FY 2003 in setting the proposed relative weights.

Previously, the charge-based methodology used to calculate the DRG relative weights from the MedPAR data was as follows:

To the extent possible, all the claims were regrouped using the DRG classification revisions that we would have proposed.

The transplant cases that were used to establish the proposed relative weight for heart and heart-lung, liver and/or intestinal, and lung transplants (DRGs 103, 480, and 495) were limited to those Medicare-approved transplant centers that have cases in the FY 2005 MedPAR file. (Medicare coverage for heart, heart-lung, liver and/ or intestinal, and lung transplants is limited to those facilities that have received approval from CMS as transplant centers.)

Organ acquisition costs for kidney, heart, heart-lung, liver, lung, pancreas, and intestinal (or multivisceral organs) transplants continue to be paid on a reasonable cost basis. Because these acquisition costs are paid separately from the prospective payment rate, it would have been 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 would have been 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 would have been 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 non-transfer cases. That is, a transfer case receiving payment under the transfer methodology equal to half of what the case would receive as a non-transfer would be counted as 0.5 of a total case.

Statistical outliers were eliminated by removing all cases that were beyond 3.0 standard deviations from the mean of the log distribution of both the 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.

These charge-based weights were then normalized by an adjustment factor so that the average case weight after recalibration is equal to the average case weight before recalibration. We will continue to apply this normalization adjustment as it is intended to ensure that recalibration by itself neither increases nor decreases total payments under the IPPS as required by section 1886(d)(4)(C)(iii) of the Act.

The methodology we are proposing to calculate the DRG weights from the FY 2005 MedPAR and FY 2003 cost report data is as follows:

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

The transplant cases that were used to establish the proposed relative weight for heart and heart-lung, liver and/or intestinal, and lung transplants (DRGs 103, 480, and 495) were limited to those Medicare-approved transplant centers that have cases in the FY 2005 MedPAR file. (Medicare coverage for heart, heart-lung, liver and/ or intestinal, and lung transplants is limited to those facilities that have received approval from CMS as transplant centers.)

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

Claims for IPPS hospitals were used in this analysis (claims for IPFs, IRFs, LTCHs, cancer and children's hospitals, and RNHCIs were dropped). Claims with total charges or total length of stay less than or equal to zero were dropped. Claims that had an amount in the total charge field that differed by more than $10.00 from the sum of the routine day charges, intensive care charges, pharmacy charges, special equipment charges, therapy services charges, operating room charges, cardiology charges, laboratory charges, radiology charges, and other service charges were also dropped. At least 96 percent of the providers in the MedPAR file had charges for 8 of the 10 cost centers. Claims for providers that did not have charges greater than zero for at least 8 of the 10 cost centers were dropped.

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

Once the MedPAR data were trimmed, the data were sorted by provider so that charges could be standardized under the HSRVcc methodology (discussed in section II.C.2. of this preamble). To do this, an average charge was computed for each provider for each of 10 proposed cost centers. The average charge was computed by summing the charges for each cost center and dividing by the transfer adjusted case count for each provider. A transfer case, identified by discharge code, DRG, and length of stay, was counted as a fraction of a case based on the ratio of its length of stay plus 1 day relative to the geometric mean length of stay for that DRG. That is, a transfer case with a length of stay of 2 days in a DRG with a geometric mean length of stay of 6 days would be counted as 3 (2 days plus 1 extra day) divided by 6 or 0.5 of a total case as this reflects current payment policy.

The 10 cost centers that we are proposing to use in the HSRV weight calculation are shown in the following table. In addition, the table shows the lines on the cost report that we are proposing to use to create the national cost center CCRs that will be discussed later in this section:

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[GRAPHIC] [TIFF OMITTED] TP25AP06.006

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[GRAPHIC] [TIFF OMITTED] TP25AP06.007

BILLING CODE 4120-01-C

After computing the average charge for each provider for each cost center, the cost center charges on each claim are divided by the provider's average charge for the matching cost center. For example, the routine day charges on the claim are divided by the average routine day charge for the provider, the intensive care unit charges on the claim are divided by the average intensive care unit charge for the provider, and so on. By using a hospital's relative charge structure, the resulting weights from this step do not reflect differences in charges among providers for factors such as location, size, wages, relative efficiency, average markup, IME, DSH and the variety of cases treated. Once these charges are adjusted by the average charge for the cost center, they are then multiplied by the provider's CMI.

This adjustment for CMI is needed to rescale the hospital-specific relative charge values which, by definition, will average to 1.0 for each cost center. Because the average relative weight for a provider is that provider's CMI, we believe CMI is a reasonable scale factor to use to further adjust the relative charges to reflect the complexity of cases treated by the provider. A starting CMI of one was assigned to each cost center for each provider.

After the relative charges (cost center claim charge divided by the average cost center charge for the provider) are multiplied by the hospital's matching cost center CMI, they are summed by DRG. The transfer adjusted case count for each DRG is also summed. Average charges by DRG are calculated for each cost center by taking the sum of the relative, CMI adjusted charges for that DRG and dividing by the transfer adjusted case count for that DRG.

A national average charge is calculated for each cost center by summing all relative CMI adjusted charges in the trimmed MedPAR data set and dividing by the total transfer-adjusted case count. The first set of DRG weights is created by dividing the average charge for each DRG for each cost center by the national average charge for that cost center. The result is a set of 10 weights for each DRG. These 10 weights are then assigned to each claim, a new CMI is created for each provider, the relative charges for each cost center on the claim (total charge for cost center is divided by the provider's

[[Page 24048]]

average charge for that cost center) are multiplied by the new CMI and the weights are iterated until the national average CMI for each cost center stops changing between iterations. In preparing the proposed weights for this proposed rule, we used a straight CMI calculation where each case was given a full weight and counted as a full case regardless of transfer status.

Alternatively, we could use the method we applied in our study of the MedPAC recommendations (see section II.C. of this preamble) where we used a CMI that was computed by taking the sum of the transfer- adjusted weights and dividing by a full case count, where the transfer- adjusted weight is computed by multiplying the transfer-adjusted case count (length of stay for claim plus one day divided by geometric mean length of stay for the DRG) by the DRG weight. We are soliciting public comment on which CMI calculation would be the most appropriate to use in this weighting methodology.

After the iteration process is completed, we remove the effects of differential markups within cost centers. To do this, we are proposing to use national average departmental CCRs in conjunction with the total charges from the trimmed MedPAR file to create scaling factors for each cost center. The first step in this process is to develop national cost center CCRs.

Taking the FY 2003 cost report data, we removed CAHs, Maryland hospitals, Indian Health Service hospitals, all-inclusive rate hospitals, and cost reports that represented time periods of less than 1 year (365 days). We then created CCRs for each provider for each cost center (see prior table for line items used in the calculations) and removed any cost CCRs that were greater than 10 or less than .01. We then took the logs of all of the cost center CCRs and removed any cost center CCRs where the log of the cost center CCR was greater or less than the mean log plus/minus 1.96 times the standard deviation for the log of that cost center CCR. We are proposing to use 1.96 times the standard deviation as a trim factor because the logs of the cost center CCRs are normally distributed and 1.96 times the standard deviation represents the 95 percentile of the T-Distribution for large sample size, for which 2,000 to 3,000 hospitals should qualify. Once the cost report data was trimmed, we calculated the geometric mean CCR for each cost center.

We are proposing to use these geometric mean CCRs to create cost scaling factors to apply to the DRG weights. Once the national average CCRs are computed, they are multiplied by the total unadjusted charges for the matching group of cost centers in MedPAR. The resulting costs for each group of cost centers are then summed to derive a total cost for all cases across the Nation. The percentage that each cost center is contributing to the overall total costs is calculated by dividing the individual cost center cost by the total amount. For example, the total cost for routine days is divided by the total cost for all cases to arrive at 0.29, which indicates that routine costs are responsible for approximately 29 percent of total cost. We are proposing to use these percentages as scaling factors to apply to the relative weights. For each DRG, the cost center weights are multiplied by these scaling factors (that is, routine day weight is multiplied by the routine day scaling factor, intensive care unit weight is multiplied by the intensive care unit scaling factor, and so on). After the weights are adjusted by the scaling factor, they are summed by DRG to create one final weight for each DRG. Following that, they are normalized by a factor of 1.49216 so that the weights so that the average case weight after recalibration is equal to the average case weight before recalibration. This normalization adjustment was 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 are proposing to use that same case threshold in recalibrating the DRG weights for FY 2007. Using the FY 2005 MedPAR data set, there are 40 DRGs that contain fewer than 10 cases. Because we believe that we do not have sufficient MedPAR data to set accurate and stable HSRVcc weights for these low-volume DRGs, we are proposing to assign them the weights of similar DRGs for which we have more complete data. The crosswalk we are proposing to use is shown below. We are soliciting comment on this crosswalk.

Low volume DRG

DRG title

Crosswalk to DRG

3......................... Craniotomy Age 0-17.. 2 (Craniotomy Age >17 Without CC). 30........................ Traumatic Stupor & 29 (Traumatic Stupor Coma, Coma 17 Without CC). 33........................ Concussion Age 0-17.. 32 (Concussion Age >17 Without CC). 41........................ Extraocular

40 (Extraocular Procedures Except Procedures Except Orbit Age 0-17.

Orbit Age >17). 48........................ Other Disorders Of 47 (Other Disorders The Eye Age 0-17. of The Eye Age >17 Without CC). 54........................ Sinus and Mastoid 53 (Sinus and Mastoid Procedures Age 0-17. Procedures Age >17). 58........................ T&A Proc, Except 57 (T&A Proc, Except Tonsillectomy &/or Tonsillectomy &/or Adenoidectomy Only, Adenoidectomy Only, Age 0-17.

Age >17). 60........................ Tonsillectomy and/or 59 (Tonsillectomy and/ Adenoidectomy Only, or Adenoidectomy Age 0-17.

Only, Age >17). 62........................ Myringotomy W Tube 61 (Myringotomy With Insertion Age 0-17. Tube Insertion Age >17). 74........................ Other Ear, Nose, 73 (Other Ear, Nose, Mouth & Throat

Mouth & Throat Diagnoses Age 0-17. Diagnoses Age >17). 81........................ Respiratory

79 (Respiratory Infections &

Infections & Inflammations Age 0- Inflammations Age 17.

>17 With CC). 137....................... Cardiac Congental & 135 (Cardiac Valvular Disorders Congental & Valvular Age 0-17.

Disorders Age >17 With CC). 156....................... Stomach, Esophageal & 155 (Stomach, Duodenal Procedures Esophageal & Age 0-17.

Duodenal Procedures Age >17 Without CC). 163....................... Hernia Procedures Age 162 (Inguinal & 0-17.

Femoral Hernia Procedures Age >17 Without CC). 186....................... Dental & Oral Disease 185 (Dental & Oral Except Extractions & Disease Except Restorations Age 0- Extractions & 17.

Restorations, Age >17). 220....................... Lower Extrem & Humer 219 (Lower Extrem & Proc Except Hip, Humer Proc Except Foot, Femur Age 0-17. Hip, Foot, Femur Age >17 Without CC). 252....................... Fx, Sprn, Strn & Disl 251 (Fx, Sprn, Strn & Of Foreman, Hand, Disl of Foreman, Foot Age 0-17.

Hand, Foot Age >17 Without CC).

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255....................... Fx, Sprn, Strn & Disl 254 Fx, Sprn, Strn & Of Uparm, Lowleg Ex Disl of Uparm, Foot Age 0-17.

Lowleg Ex Foot Age >17 Without CC). 279....................... Cellulitis Age 0-17.. 278 (Cellulitis Age >17 Without CC). 282....................... Trauma To The Skin, 281 (Trauma To The Subcut Tiss & Breast Skin, Subcut Tiss & Age 0-17.

Breast Age >17 Without CC). 314....................... Urethral Procedures, 313 (Urethral Age 0-17.

Procedures, Age >17 Without CC). 330....................... Urethral Stricture 329 (Urethral Age 0-17.

Stricture Age >17 Without CC). 340....................... Testes Procedures, 339 (Testes Non-Malignancy Age 0- Procedures, Non- 17.

Malignancy Age >17). 343....................... Circumcism Age 0-17.. 342 (Circumcism Age >17). 351....................... Sterilization, Male.. 352 (Other Male Reproductive System Diagnoses). 362....................... Endoscopic Tubal 361 (Laparoscopy & Interruption.

Incisional Tubal Interruption). 385....................... Neonates, Died Or FY 2006 FR weight Transferred To

(adjusted by percent Another Acute Care change in average Facility.

weight of the cases in other DRGs). 386....................... Extreme Immaturity Or FY 2006 FR weight Respiratory Distress (adjusted by percent Syndrome, Neonate. change in average weight of the cases in other DRGs). 387....................... Prematurity With FY 2006 FR weight Major Problems.

(adjusted by percent change in average weight of the cases in other DRGs). 388....................... Prematurity Without FY 2006 FR weight Major Problems.

(adjusted by percent change in average weight of the cases in other DRGs). 389....................... Full Term Neonate FY 2006 FR weight With Major Problems. (adjusted by percent change in average weight of the cases in other DRGs). 390....................... Neonate With Other FY 2006 FR weight Significant Problems. (adjusted by percent change in average weight of the cases in other DRGs). 391....................... Normal Newborn....... FY 2006 FR weight (adjusted by percent change in average weight of the cases in other DRGs). 393....................... Splenectomy Age 0-17. 392 (Splenectomy Age >17). 405....................... Acute Leukemia

473 (Acute Leukemia Without Major O.R. Without Major O.R. Procedure Age 0-17. Procedure Age >17). 411....................... History Of Malignancy 465 (Aftercare With Without Endoscopy. History of Malignancy As Secondary Diagnosis). 412....................... History Of Malignancy 465 (Aftercare With With Endoscopy.

History of Malignancy As Secondary Diagnosis). 446....................... Traumatic Injury Age 445 (Traumatic Injury 0-17.

Age >17 Without CC). 448....................... Allergic Reactions 447 (Allergic Age 0-17.

Reactions Age >17). 451....................... Poisoning and Toxic 450 (Poisoning and Effects Of Drugs Age Toxic Effects of 0-17.

Drugs Age >17 Without CC).

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.

F. Proposed LTC-DRG Reclassifications and Relative Weights for LTCHs for FY 2007

(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 uses the same DRGs as those currently used under the IPPS for acute care hospitals, in that same final rule, we explained that the annual update of the long-term care diagnosis-related group (LTC-DRG) classifications and relative weights will continue to remain linked to the annual reclassification and recalibration of the 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 2006 IPPS final rule (70 FR 47323 through 47341) and in the Rate Year (RY) 2007 LTCH PPS proposed rule (71 FR 4652 through 4658), with the implementation of section 503(a) of Pub. L. 108-173, there is the possibility that one feature of the GROUPER software program may be updated twice during a Federal fiscal year (October 1 and April 1) as required by the statute for the IPPS. Specifically, ICD-9-CM diagnosis and procedure codes for new medical technology may be created and added to existing DRGs in the middle of the Federal fiscal year on April 1. However, this policy change will have no effect on the LTC-DRG relative weights, which will continue to be updated only once a year (October 1), nor will there be any impact on Medicare payments under the LTCH PPS. The use of the ICD-9-CM code set is also compliant with the current requirements of the Transactions and Code Sets Standards regulations at 45 CFR Parts 160 and 162, promulgated in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub. L. 104-191.

As we explained in the RY 2007 LTCH PPS proposed rule (71 FR 4654

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through 4658), 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 also mentioned above, the ICD-9-CM coding update process was revised as a result of implementing section 503(a) of Pub. L. 108-173, which 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 (as discussed in greater detail in section II.D.10. of the preamble of this proposed rule). 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 improves 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 most recently in the RY 2007 LTCH PPS proposed rule (71 FR 4654 through 4655), 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 RY 2007 LTCH PPS proposed rule (71 FR 4655), 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 also explained that because we do not publish a midyear IPPS rule, any April 1 code updates will not be published in a midyear IPPS rule. Rather, we will assign any new diagnosis or procedure codes to the same DRG in which its predecessor code was assigned, so that there will be no impact on the DRG assignments (as also discussed in section II.D.10. of this preamble). Any coding updates will be available through the Web sites provided in section II.D.10. of this preamble and through the Coding Clinic for ICD-9-CM. Publishers and software vendors currently obtain code changes through these sources in order to update their code books and software system. If new codes are implemented on April 1, revised code books and software systems, including the GROUPER software program, will be necessary because we must use current ICD-9-CM codes. Therefore, for purposes of the LTCH PPS, because each ICD-9-CM code must be included in the GROUPER algorithm to classify each case into a LTC-DRG, the GROUPER software program used under the LTCH PPS would need to be revised to accommodate any new codes.

In implementing section 503(a) of Pub. L. 108-173, there will only be an April 1 update if new technology codes are requested and approved. We note that any new codes created for April 1 implementation will be limited to those diagnosis and procedure code revisions primarily needed to describe new technologies and medical services. However, we reiterate that the process of discussing updates to the ICD-9-CM has been an open process through the ICD-9-CM Coordination and Maintenance Committee since 1995. Requestors will be given the opportunity to present the merits for a new code and make a clear and convincing case for the need to update ICD-9-CM codes for purposes of the IPPS new technology add-on payment process through an April 1 update (as also discussed in section II.D.10. of this preamble).

However, as we discussed in the RY 2007 LTCH PPS proposed rule (71 FR 4655), at the September 29-30, 2005 ICD-9-CM Coordination and Maintenance Committee meeting, there were no requests for an April 1, 2006 implementation of ICD-9-CM codes, and, therefore, the next update to the ICD-9-CM coding system would not occur until October 1, 2006 (FY 2007). Presently, as there were no coding changes suggested for an April 1, 2006 update, the ICD-9-CM coding set implemented on October 1, 2005, will continue through September 30, 2006 (FY 2006). The proposed update to the ICD-9-CM coding system for FY 2007 is discussed above in section II.D.10. of this preamble. Accordingly, in this proposed rule, as discussed in greater detail below, 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, 2006 through September 30, 2007 (FY 2007). Furthermore, we would notify LTCHs of any revisions to the GROUPER software used under the IPPS and the LTCH PPS that would be implemented April 1, 2007. The proposed LTC-DRGs and relative weights for FY 2007 in this proposed rule are based on the proposed IPPS DRGs (GROUPER Version 24.0) discussed in section II.B. of the preamble to this proposed rule. 2. Proposed Changes in the LTC-DRG Classifications a. Background

Section 123 of Pub. L. 106-113 specifically requires that the agency implement a PPS for LTCHs 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 24.0 for FY 2007 to process LTCH PPS claims for LTCH discharges occurring from October 1, 2006 through September 30, 2007. The proposed changes to the CMS-DRG classification system used under the IPPS for FY 2007

[[Page 24051]]

(GROUPER Version 24.0) are discussed in section II.D. of the preamble to this proposed rule.

We note that, as we discuss in section II.C.6. of the preamble to this proposed rule, MedPAC, in its 2005 Report to Congress on Physician-Owned Specialty Hospitals, recommended that CMS, among other things, refine the current DRGs under the IPPS to more fully capture differences in severity of illness among patients. As we also discuss in that same section, in evaluating the MedPAC recommendation for the IPPS, we are evaluating the APR DRG GROUPER used by MedPAC in its analysis. Based on this analysis, we concur with MedPAC that the modified version of the APR DRGs would account more completely for differences in severity of illness and associated costs among hospitals. Therefore, as discussed in greater detail in section II.C.6. of the preamble of this proposed rule, we are proposing to adopt the consolidated severity adjusted DRGs for implementation in the IPPS in FY 2008 (if not earlier). As discussed above in this section, the LTCH PPS uses the same patient classification system (DRGs). In response to MedPAC's recommendation that severity adjusted DRGs, such as the APR DRGs or a modified version of the APR DRGs, be adopted under the IPPS (as discussed in greater detail in section II.C. of this preamble), we are proposing to adopt consolidated severity-adjusted DRGs under the IPPS in FY 2008 (if not earlier). At that time, we would need to consider whether to propose revisions to the patient classification system under the LTCH PPS. Any proposed changes to the patient classification system would be done through notice and comment rulemaking.

Under the LTCH PPS, we determine relative weights for each of the DRGs to account for the difference in resource use by patients exhibiting the case complexity and multiple medical problems 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 2006 IPPS final rule (70 FR 47324), we use low-volume quintiles in determining the LTC-DRG relative weights for LTC-DRGs with less than 25 LTCH cases, because LTCHs do not typically treat the full range of diagnoses as do acute care hospitals. Specifically, we group those low-volume LTC-DRGs (that is, 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 2006 LTC-DRGs (based on FY 2004 MedPAR data) appears in section II.G.3. of the FY 2006 IPPS final rule (70 FR 47325 through 47332).) 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.F.4. of this preamble. b. Patient Classifications Into DRGs

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

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

Because the assignment of a case to a particular LTC-DRG will 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 acute care hospitals to ensure accuracy and consistency in coding practices. There will be only one LTC-DRG assigned per long-term care hospitalization; it will be assigned at the time of discharge of the patient. Therefore, it is mandatory that the coders continue to report the same principal diagnosis on all claims and include all diagnosis codes for conditions that coexist at the time of admission, for conditions that are subsequently developed, or for conditions that affect the treatment received. Similarly, all procedures performed in a LTCH, or paid for under arrangements by a LTCH, during that stay are to be reported on each claim.

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

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

The LTCH GROUPER is used both to classify past cases in order to measure relative hospital resource consumption to establish the LTC-DRG weights and to classify current cases for purposes of determining payment. The records for all Medicare hospital inpatient

[[Page 24052]]

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.E. 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 2007 LTC-DRG Relative Weights a. General Overview of Development of the LTC-DRG Relative Weights

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

To calculate the proposed LTC-DRG relative weights for FY 2007 in this proposed rule, we obtained total Medicare allowable charges from FY 2005 Medicare LTCH bill data from the December 2005 update of the MedPAR file, which are the best available data at this time, and we used the proposed Version 24.0 of the CMS GROUPER used under the IPPS (as discussed in section II.B. of this preamble) to classify cases. To calculate the final LTC-DRG relative weights for FY 2007, we are proposing that, if more recent data are available (that is, data from the March 2006 update of the MedPAR file, for example), we would use that data and use the finalized Version 24.0 of the CMS GROUPER used under the IPPS.

As we discussed in the FY 2006 IPPS final rule (70 FR 47325), 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 2007 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 2005 MedPAR file. c. Hospital-Specific Relative Value Methodology

By nature, LTCHs often specialize in certain areas, such as ventilator-dependent patients and rehabilitation and wound care. Some case types (DRGs) may be treated, to a large extent, in hospitals that have, from a perspective of charges, relatively high (or low) charges. This nonarbitrary distribution of cases with relatively high (or low) charges in specific 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 in section II.E. of this preamble. We believe this method will remove this hospital-specific source of bias in measuring LTCH average charges. Specifically, we reduce the impact of the variation in charges across providers on any particular LTC-DRG relative weight by converting each LTCH's charge for a case to a relative value based on that LTCH's average charge.

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

In accordance with the methodology established under Sec. 412.523, as implemented in the August 30, 2002 LTCH PPS final rule (67 FR 55989 through 55991), we standardize charges for each case by first dividing the adjusted charge for the case (adjusted for short-stay outliers under Sec. 412.529 as described in section II.F.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 at a LTCH with higher average costs than they would at a LTCH with low average costs, which is needed to adjust each LTCH's relative charge value to reflect its case-mix relative to the average case-mix for all LTCHs. Because we standardize charges in this manner, we count charges for a Medicare patient at a LTCH with high average charges as less resource intensive than they would be at a LTCH with low average charges. For example, a $10,000 charge for a case at a LTCH with an average adjusted charge of $17,500 reflects a higher level of relative resource use than a $10,000 charge for a case at a LTCH with the same case-mix, but an average adjusted charge of $35,000. We believe that the adjusted charge of an individual case more accurately reflects actual resource use for an individual LTCH because the variation in charges due to systematic differences in the markup of charges among LTCHs is taken into account. d. Proposed Low-Volume LTC-DRGs

In order to account for LTC-DRGs with low-volume (that is, with fewer than 25 LTCH cases), in accordance with the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55984), we group those ``low-volume LTC-DRGs'' (that is, DRGs that contained between 1 and 24 cases annually) into one of five categories (quintiles) based on average charges, for the purposes of determining relative weights. For this FY 2007 IPPS

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proposed rule, we are proposing to continue to employ this treatment of low-volume LTC-DRGs in determining the FY 2007 LTC-DRG relative weights using the best available LTCH data. In this proposed rule, using LTCH cases from the December 2005 update of the FY 2005 MedPAR file, we identified 173 LTC-DRGs that contained between 1 and 24 cases. This list of LTC-DRGs was then divided into one of the 5 low-volume quintiles, each containing a minimum of 34 LTC-DRGs (173/5 = 34 with 3 LTC-DRGs as the remainder). In accordance with our established methodology, we are proposing to make an assignment to a specific low- volume quintile by sorting the low-volume 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 173 low- volume LTC-DRGs by ascending order by average charge. Because the number of LTC-DRGs with less than 25 LTCH cases is not evenly divisible by five, the average charge of the low-volume LTC-DRG was used to determine which low-volume quintile received the additional LTC-DRG. After sorting the 173 low-volume LTC-DRGs in ascending order, we are proposing to group the first fifth of low-volume LTC-DRGs with the lowest average charge into Quintile 1. The highest average charge cases would be grouped into Quintile 5. Because the average charge of the 35th LTC-DRG in the sorted list is closer to the 34th proposed 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 proposed low-volume LTC-DRGs so that 3 proposed low-volume quintile contain 35 proposed LTC-DRGs and 2 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 2007, in accordance with the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55984), we are proposing to use the five low-volume quintiles described above. The composition of each of the proposed five low- volume quintiles shown in the chart below was used in determining the proposed LTC-DRG relative weights for FY 2007. We would determine a proposed relative weight and (geometric) average length of stay for each of the five proposed 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.F.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. BILLING CODE 4120-01-P

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We note that we will continue to monitor the volume (that is, the number of LTCH cases) in these low-volume quintiles to ensure that our proposed quintile assignment results in appropriate payment for such cases and does not result in an unintended financial incentive for LTCHs to inappropriately admit these types of cases. 4. Steps for Determining the Proposed FY 2007 LTC-DRG Relative Weights

As we noted previously, the proposed FY 2007 LTC-DRG relative weights are determined in accordance with the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55989 through 55991). In summary, LTCH cases must be grouped in the appropriate LTD-DRG, while taking into account the proposed low-volume LTD-DRGs as described above, before the proposed FY 2007 LTD-DRG relative weights can be determined. After grouping the cases in the appropriate proposed LTD- DRG, we are proposing to calculate the relative weights for FY 2007 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 LTD-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 LTD-DRG using the hospital-specific relative value method described above.

Below we discuss in detail the steps for calculating the proposed FY 2007 LTD-DRG relative weights. We note that, as we stated above in section II.F.3.b. of this preamble, we have excluded the data of all- inclusive rate LTCHs and LTCHs that are paid in accordance with demonstration projects that had claims in the FY 2005 MedPAR file.

Step 1--Remove statistical outliers.

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The first step in the calculation of the proposed FY 2007 LTD-DRG relative weights is to remove statistical outlier cases. We define statistical outliers as cases that are outside of 3.0 standard deviations from the mean of the log distribution of both charges per case and the charges per day for each proposed LTD-DRG. These statistical outliers are removed prior to calculating the proposed relative weights. As noted above, we believe that they may represent aberrations in the data that distort the measure of average resource use. Including those LTCH cases in the calculation of the proposed relative weights could result in an inaccurate proposed relative weight that does not truly reflect relative resource use among the proposed LTD-DRGs.

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

The proposed FY 2007 LTD-DRG relative weights reflect the average of resources used on representative cases of a specific type. Generally, cases with a length of stay 7 days or less do not belong in a LTCH because these stays do not fully receive or benefit from treatment that is typical in a LTCH stay, and full resources are often not used in the earlier stages of admission to a LTCH. As explained above, if we were to include stays of 7 days or less in the computation of the proposed FY 2007 LTD-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, as explained above, in determining the proposed FY 2007 LTD- 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 2007 LTD-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 LTD-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 LTD-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 LTD-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 LTD-DRG.

As we explained in the FY 2006 IPPS final rule (70 FR 47336), counting short-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'' for nonshort-stay outlier cases and an ``overpayment'' for 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 2007 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 2007 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 LTCH's average relative weight for all of its cases (case-mix) is calculated by dividing the sum of all the LTCH's proposed 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 2007 LTC-DRG relative weights to account for nonmonotonically increasing relative weights.

As explained in section II.B. of this preamble, the proposed FY 2007 CMS DRGs, on which the proposed FY 2007 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 2006 IPPS final rule (70 FR 47336), 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'' when only the principal diagnosis was coded. Since the LTCH PPS was only implemented

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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 2006 IPPS final rule (70 FR 47336 through 47337), based on FY 2004 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 2006 LTC-DRG relative weights.

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

There are three types of ``with CC'' and ``without CC'' pairs that could be nonmonotonic; that is, where the ``without CC'' LTC-DRG would have a higher average charge than the ``with CC'' proposed LTC-DRG. For this proposed rule, using the LTCH cases in the December 2005 update of the FY 2005 MedPAR file (the most recent and complete data available at this time), we identified one of the three types of nonmonotonic LTC- DRG pairs. As we stated in the August 30, 2002 LTCH PPS final rule (67 FR 55990), we believe this anomaly may be due to coding inaccuracies and expect that, as was the case when we first implemented the acute care hospital IPPS, this problem will be self-correcting, as LTCHs submit more completely coded data in the future.

The first category of nonmonotonically increasing relative weights for LTC-DRG pairs ``with and without CCs'' contains one pair of 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 LTC-DRG pairs, based on our established methodology (67 FR 55983 through 55990), we would combine the LTCH cases and compute a new relative weight based on the case-weighted average of the combined LTCH cases of the LTC-DRGs. The case-weighted average charge is determined by dividing the total charges for all LTCH cases by the total number of LTCH cases for the combined LTC-DRG. This new relative weight would then be assigned to both of the LTC-DRGs in the pair. In this proposed rule, for FY 2007, there were no LTC-DRGs that fell into this category.

The second category of nonmonotonically increasing relative weights for LTC-DRG pairs ``with and without CCs'' consists of one pair of LTC- DRGs that has fewer than 25 cases, and each LTC-DRG would be grouped to different low-volume quintiles in which the ``without CC'' LTC-DRG is in a higher-weighted low-volume quintile than the ``with CC'' LTC-DRG. For those pairs, based on our established methodology, 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 LTC-DRGs in the pair are then grouped into the same low-volume quintile, thus have the same relative weight. In this proposed rule, for FY 2007, there are no LTC-DRGs that fell into this category.

The third category of nonmonotonically increasing proposed relative weights for proposed LTC-DRG pairs ``with and without CCs'' consists of one pair of proposed LTC-DRGs where one of the proposed LTC-DRGs has fewer than 25 LTCH cases and is grouped to a 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 proposed higher relative weight. Based on our established methodology, we removed the proposed low-volume LTC-DRG from the proposed low-volume quintile and combined it with the other proposed LTC-DRG for the computation of a proposed new relative weight for each of these proposed LTC-DRGs. This proposed new relative weight is assigned to both proposed LTC-DRGs, so they each have the same proposed relative weight. In this proposed rule, for FY 2007, 4 ``pairs'' of proposed LTC-DRGs fall into this category: LTC-DRGs 94 and 95; LTC-DRGs 96 and 97; LTC-DRGs 141 and 142; and LTC-DRGs 292 and 293.

Step 6--Determine a proposed FY 2007 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 2005 update of the FY 2005 MedPAR file. Of the 526 proposed LTC-DRGs for FY 2007, we identified 191 proposed LTC-DRGs for which there were no LTCH cases in the database. That is, based on data from the FY 2005 MedPAR file used in this proposed rule, no patients who would have been classified to those proposed LTC-DRGs were treated in LTCHs during FY 2005 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 191 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 2007, we are proposing to assign proposed relative weights to each of the 191 proposed ``no volume'' LTC-DRGs based on clinical similarity and relative costliness to one of the remaining 335 (526-191 = 335) proposed LTC-DRGs for which we are able to determine proposed relative weights, based on FY 2005 LTCH claims data.

As there are currently no LTCH cases in these proposed ``no volume'' LTC-

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DRGs, we determined proposed relative weights for the 191 proposed LTC- DRGs with no LTCH cases in the FY 2005 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 the 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 2005 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 proposed five quintiles and we assign the proposed no volume LTC-DRG the relative weight of the proposed low-volume quintile with the closest weight. For this proposed rule, a list of the proposed no volume FY 2007 LTC-DRGs and the proposed FY 2007 LTC-DRG to which it is crosswalked in order to determine the appropriate proposed low-volume quintile for the assignment of a proposed relative weight for FY 2007 is shown in the chart below. BILLING CODE 4120-01-P

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To illustrate this methodology for determining the proposed relative weights for the proposed 191 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 2007 provided in the chart above.

Example 1: There were no cases in the FY 2005 MedPAR file used for this proposed rule for proposed LTC-DRG 3 (Craniotomy 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 1 (Craniotomy Age >17 with CC), which is assigned to proposed low-volume Quintile 1 for the purpose of determining the proposed FY 2007 relative weights, would display similar clinical and resource use. Therefore, we assign the same proposed relative weight of proposed LTC-DRG 1 of 1.6479 (Quintile 5) for FY 2007 (Table 11 in the Addendum to this proposed rule) to LTC-DRG 3.

Example 2: There were no LTCH cases in the FY 2005 MedPAR file used in this proposed rule for LTC-DRG 91 (Simple Pneumonia and Pleurisy Age 0-17). Since the severity of illness in patients with bronchitis and asthma is similar in patients regardless of age, we determined that 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 proposed 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 (0.4981) (refer to Table 11 in the Addendum to this proposed rule) would be proposed low-volume Quintile 2 (0.5655) (refer to Table 11 in the Addendum to this proposed rule). Therefore, we assign proposed LTC-DRG 91 a proposed relative weight of 0.5655 for FY 2007. We note that we will continue to monitor the volume (that is, the number of LTCH cases) that have few or no LTCH cases to ensure that our proposed no volume LTC-DRG crosswalking and relative weight assignment results in appropriate payments for such cases and does not result in an unintended financial incentive for LTCHs to inappropriately admit these types of cases.

Furthermore, we are proposing to establish proposed 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 2007 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

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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 2007.

We also wish to point out that in section VI.A.5. of the preamble of this proposed rule, we discuss our proposal to revise the regulations for grandfathered HwHs, grandfathered hospital satellite facilities, and grandfathered satellite units at Sec. Sec. 412.22(f), 412.22(h)(3); and 412.25(e)(3), respectively. In addition, in section VI.A.6. of the preamble of this proposed rule, we discuss our proposal to revise and clarify the existing policies governing the determination of LTCHs' CCRs and the reconciliation of high-cost and short-stay outlier payments under the LTCH PPS. (We note that these proposed changes concerning the determination of LTCHs' CCRs and the reconciliation of LTCH PPS high-cost and short-stay outlier payments are the same as the changes proposed in the RY 2007 LTCH PPS proposed rule (71 FR 674 through 4676 and 4690 through 4692). As discussed in greater detail in that section, in response to comments and requests, in this IPPS proposed rule, we are presenting the same proposed changes to the policies governing the determination of LTCHs' CCRs and the reconciliation of high-cost and short-stay outlier payments, and providing additional information on the values of the proposed LTCH CCR ceiling and the proposed statewide average LTCH CCRs that would be effective October 1, 2006, rather than responding to comments or finalizing any policy changes in the RY 2007 LTCH PPS final rule.)

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

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

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

The regulations implementing this provision establish three criteria for new medical services and technologies to receive an additional payment. First, Sec. 412.87(b)(2) defines when a specific medical service or technology will be considered new for purposes of new medical service or technology add-on payments. The statutory provision contemplated the special payment treatment for new medical services or technologies until such time as data are available to reflect the cost of the technology in the DRG weights through recalibration. There is a lag of 2 to 3 years from the point a new medical service or technology is first introduced on the market and when data reflecting the use of the medical service or technology are used to calculate the DRG weights. For example, data from discharges occurring during FY 2005 are used to calculate the proposed FY 2007 DRG weights in this proposed rule. Section 412.87(b)(2) provides that a ``medical service or technology may be considered new within 2 or 3 years after the point at which data begin to become available reflecting the ICD-9-CM code assigned to the new medical service or technology (depending on when a new code is assigned and data on the new medical service or technology become available for DRG recalibration). After CMS has recalibrated the DRGs, based on available data, to reflect the costs of an otherwise new medical service or technology, the medical service or technology will no longer be considered `new' under the criterion for this section.''

The 2-year to 3-year period during which a medical service or technology can be considered new would ordinarily begin with FDA approval, unless there was some documented delay in bringing the product onto the market after that approval (for instance, component production or drug production 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 2005 and entered the market at that time may be eligible to receive add-on payments as a new technology until FY 2008 (discharges occurring before October 1, 2007), when data reflecting the costs of the technology would be used to recalibrate the DRG weights. Because the FY 2008 DRG weights will be calculated using FY 2006 MedPAR data, the costs of such a new technology would likely be reflected in the FY 2008 DRG weights.

Section 412.87(b)(3) further provides that, to receive special payment treatment, new medical services or technologies must be inadequately paid otherwise under the DRG system. To assess whether technologies would be inadequately paid under the DRGs, we establish thresholds to evaluate applicants for new technology add-on payments. In the FY 2004 IPPS final rule (68 FR 45385, August 1, 2003), we established the threshold at the geometric mean standardized charge for all cases in the DRG plus 75 percent of 1 standard deviation above the geometric mean standardized charge (based on the logarithmic values of the charges and transformed back to charges) for all cases in the DRG to which the new medical service or technology is assigned (or the case-weighted average of all relevant DRGs, if the new medical service or technology occurs in many different DRGs). Table 10 in the Addendum to the FY 2004 IPPS final rule (68 FR 45648) listed the qualifying threshold by DRG, based on the discharge data that we used to calculate the FY 2004 DRG weights.

However, section 503(b)(1) of Pub. L. 108-173 amended section 1886(d)(5)(K)(ii)(I) of the Act to provide for ``applying a threshold * * * that is the lesser of 75 percent of the standardized amount (increased to reflect the difference between cost and charges) or 75 percent of 1 standard deviation for the diagnosis-related group involved.'' The provisions of section 503(b)(1) apply to classification for fiscal years beginning with FY 2005. We updated Table 10 from the Federal Register document that corrected the FY 2004 final rule (68 FR 57753, October 6, 2003), which contained 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/AcuteInpatientPPS/08_newtech.asp. In the FY 2005 IPPS final rule (in

Table 10 of the Addendum), we included the final thresholds that were being used to evaluate applicants for new technology add-on payments for FY 2006. (Refer to

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section IV.D. of the preamble to the FY 2005 IPPS final rule (69 FR 49084, August 11, 2004) for a discussion of a revision of the regulations to incorporate the change made by section 503(b)(1) of Pub. L. 108-173.) Table 10 of the Addendum to the FY 2006 final rule (70 FR 47680) contained the final thresholds that are being used to evaluate applications for new technology add-on payments for FY 2007.

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

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

The report language accompanying section 533 of Pub. L. 106-554 indicated Congressional intent that the Secretary implement the new mechanism on a budget neutral basis (H.R. Conf. Rep. No. 106-1033, 106th Cong., 2nd Sess. at 897 (2000)). Section 1886(d)(4)(C)(iii) of the Act requires that the adjustments to annual DRG classifications and relative weights must be made in a manner that ensures that aggregate payments to hospitals are not affected. Therefore, in the past, we accounted for projected payments under the new medical service and technology provision during the upcoming fiscal year at the same time we estimated the payment effect of changes to the DRG classifications and recalibration. The impact of additional payments under this provision was then included in the budget neutrality factor, which was applied to the standardized amounts and the hospital-specific amounts.

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

Applicants for add-on payments for new medical services or technologies for FY 2008 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, 2006. Applicants must submit a complete database no later than December 30, 2006. Complete application information, along with final deadlines for submitting a full application, will be available at our Web site: http://www.cms.hhs.gov/AcuteInpatientPPS/08_newtech.asp. To allow interested parties to

identify the new medical services or technologies under review before the publication of the proposed rule for FY 2008, the Web site 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 1886(d)(5)(K)(viii) of the Act, as amended by section 503(b)(2) of Pub. L. 108-173, provides for a mechanism for public input before publication of a notice of proposed rulemaking regarding whether a medical service or technology represents a substantial clinical improvement or advancement. The process for evaluating new medical service and technology applications requires the Secretary to--

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

Make public and periodically update a list of the services and technologies for which applications for add-on payments are pending.

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

Provide, before publication of a proposed rule, for a meeting at which organizations representing hospitals, physicians, manufacturers, and any other interested party may present comments, recommendations, and data regarding whether a new 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 2007 before publication of this FY 2007 IPPS proposed rule, we published a notice in the Federal Register on December 23, 2005 (70 FR 76315) and held a town hall meeting at the CMS Headquarters Office in Baltimore, MD, on February 16, 2006. 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 criterion for each of the FY 2007 new medical service and technology add-on payment applications before the publication of this FY 2007 IPPS proposed rule.

Approximately 35 participants registered and attended the town hall meeting in person, while additional participants listened over an open telephone line. The participants focused on presenting data on the substantial clinical improvement aspect of their products, as well as the need for additional payments to ensure access to Medicare beneficiaries. In addition, we received written comments regarding the substantial clinical improvement criterion for the applicants. We considered these comments in our evaluation of each new application for FY 2007 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. We received two general comments about application of the newness and substantial clinical improvement criteria.

Comment: AdvaMed encouraged CMS to amend the definition of substantial clinical improvement for the IPPS new technology provision to conform with the outpatient definition of substantial clinical improvement used in 2001. Specifically, AdvaMed requests that

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after ``decreased pain, bleeding, or other quantifiable symptom,'' CMS should insert, the following language: ``such as convenience, durability, ease of operation or make other improvements in quality of life.''

Response: We believe we addressed this concern in the FY 2006 IPPS final rule (70 FR 47360). We use similar standards to evaluate substantial clinical improvement in the IPPS and OPPS and, in both systems, we employ identical language to explain and elaborate on the kinds of considerations that are taken into account in determining whether a new technology represents a substantial clinical improvement. We do not believe a change to the regulations text is necessary.

Comment: AdvaMed commented that CMS should not use ``substantial similarity'' to evaluate newness without also determining whether the product is a substantial clinical improvement. AdvaMed argues that CMS is applying a concept that is not defined in regulations. If CMS applies the concept as part of determining whether a product is new without evaluating substantial clinical improvement, AdvaMed commented that we should define substantial similarity through notice and comment rulemaking.

Response: We addressed this comment in the FY 2006 IPPS final rule (70 FR 47350 through 47351). We refer readers to that final rule for a detailed response to this comment.

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

At the time an application for new technology add-on payments is submitted, the DRGs associated with the new technology are identified. We only determine that a new DRG assignment is necessary or a new technology add-on payment is appropriate when the payment under these currently assigned DRGs is not adequate and the technology otherwise meets the newness, cost, and substantial clinical improvement criteria.

In this proposed rule, we evaluate whether new technology add-on payments will continue in FY 2007 for the three technologies that currently receive such payments. In addition, we present our evaluations of three applications for add-on payments in FY 2007. 3. FY 2007 Status of Technologies Approved for FY 2006 Add-On Payments a. 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. In the IPPS final rule for FY 2005 (69 FR 49019, August 11, 2004), we approved Kinetra[supreg] for new technology add-on payments.

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. This technology received FDA approval on December 16, 2003. Therefore, the technology will be beyond the 2- to 3-year period during which it can be considered new during FY 2007. Therefore, we are proposing to discontinue add-on payments for the Kinetra[supreg] rechargeable, implantable neurostimulator device for FY 2007.

The manufacturer has submitted a request that we consider a higher paying DRG assignment for dual array neurostimulator pulse generator cases. We have taken this request into consideration and have reviewed the FY 2005 Medicare charge data for cases that use implantable neurostimulator for deep brain stimulation. Our findings and a full discussion of this issue can be found in Section II.D.2.a. of the preamble of this proposed rule. b. Endovascular Graft Repair of the Thoracic Aorta

W. L. Gore & Associates, Inc. submitted an application for consideration of its Endovascular Graft Repair of the Thoracic Aorta (GORE TAG) for new technology add-on payments for FY 2006. The manufacturer argued that endovascular stent-grafting of the descending thoracic aorta provides a less invasive alternative to the traditional open surgical approach required for the management of descending thoracic aortic aneurysms. The GORE TAG device is a tubular stent-graft mounted on a catheter-based delivery system, and it replaces the synthetic graft normally sutured in place during open surgery. The device was initially identified using ICD-9-CM procedure code 39.79 (Other endovascular repair (of aneurysm) of other vessels). The applicant also requested a unique ICD-9-CM procedure code. As noted in Table 6B of the FY 2006 IPPS final rule (70 FR 47637), new procedure code 39.73 (Endovascular implantation of graft in thoracic aorta) was assigned to this technology.

In the FY 2006 IPPS final rule (70 FR 47356), we approved the GORE TAG device for new technology add-on payment for FY 2006. We noted that any substantially similar device that is FDA-approved before or during FY 2006 that uses the same ICD-9-CM procedure code as GORE TAG and falls into the same DRGs as those approved for new technology add-on payments may also receive the new technology add-on payment associated with this technology in FY 2006.

FDA approved GORE TAG on March 23, 2005. The technology 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 the endovascular graft repair of the thoracic aorta for FY 2007. c. Restore[supreg] Rechargeable Implantable Neurostimulator

Medtronic Neurological submitted an application for new technology add-on payments for its Restore[supreg] Rechargeable Implantable Neurostimulator for FY 2006. The Restore[supreg] Rechargeable Implantable Neurostimulator is designed to deliver electrical stimulation to the spinal cord to block the sensation of pain. The technology standard for neurostimulators uses internal sealed batteries as the power source to generate the electrical current. These internal batteries have finite lives, and require replacement when their power has been completely discharged. According to the manufacturer, the Restore[supreg] Rechargeable Implantable Neurostimulator ``represents the next generation of neurostimulator technology, allowing the physician to set the voltage parameters in such a way that fully meets the patient's requirements to achieve adequate pain relief without fear of premature depletion of the battery.'' The applicant stated that the expected life of the Restore rechargeable battery is 9 years, compared to an average life of 3 years for conventional neurostimulator batteries. We approved new technology add-on payments for all rechargeable, implantable neurostimulators for FY

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2006. Cases involving these devices, made by any manufacturer, are identified by the presence of newly created ICD-9-CM code 86.98 (Insertion or replacement of dual array rechargeable neurostimulator pulse generator).

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 the Restore[supreg] Rechargeable Implantable Neurostimulator in 2005. However, as noted above and in the FY 2006 IPPS final rule (70 FR 47357), at least one similar product was approved by the FDA as early as April 2004. Nevertheless, consistent with current policy (70 FR 47362) and decisions for prior products (that is, bone morphogenetic products and CRT-D devices), we are proposing to continue new technology add-on payments for rechargeable, implantable neurostimulators in FY 2007 because the product will be beyond the 3- year period only in the latter 6 months of the fiscal year. 4. FY 2007 Applications for New Technology Add-On Payments a. C-Port[supreg] Distal Anastomosis System

Cardica, Inc. submitted an application for new technology add-on payments for FY 2007 for its Cardica C-Port[supreg] Distal Anastomosis System. The manufacturer states that the C-Port[supreg] System is indicated for all patients requiring a vein as a conduit during a coronary bypass operation for bypassing a coronary artery stenosis or occlusion. The manufacturer contends that the C-Port[supreg] System is specifically designed to create a reliable and consistent end-to-side anastomosis between a conduit, such as a venous graft, and a small arterial vessel during the bypass surgery. The device consists of eight stainless steel clips and a delivery system. Once the vein graft has been loaded into the device and the device positioned against the target vessel, the anastomosis is created by pushing a single button. Cardica, Inc. states the main purpose of the device is to replace a conventional hand-sewn, distal anastomosis with an automated, compliant, mechanical anastomosis.

The C-Port[supreg] System was granted section 510(K) approval from the FDA on November 10, 2005. While the device appears to meet the criteria for being considered new based on its FDA approval date, we are concerned that various forms of surgical staples and clips have been used for more than a decade in a wide range of surgical procedures. In fact, the FDA found that the C-Port[supreg] System ``is substantially equivalent to the predicate devices with regard to indications, device characteristics, method of use, labeling and materials.'' Thus, given its similarity to other devices currently on the market, we are concerned that the C-Port[supreg] System may not qualify as new. We welcome comments on whether this device is new and how it can be distinguished from predicate devices that perform the same or a similar function.

We also note that there is currently no ICD-9-CM code used to identify how the anastomosis is performed. The surgical technique used to graft the bypass to the arterial vessel is part of the surgical procedure itself and is not separately identified in our current coding structure. Thus, if a new code is created, we would be creating a code that is a subset of the surgical procedure that identifies whether the graft was performed by hand-sewing or using a device like the C- Port[supreg] System, a distinction that has been unnecessary to date for inpatient hospital payments. Furthermore, we note that such a coding distinction would only be necessary for the new technology add- on payment period if the device met all of the criteria. Once the new technology add-on payments are completed, the surgical technique used for the anasotomosis would not need to be identified because the code that describes the grafting procedure would be the same whether or not this technology is used.

The applicant made several arguments in support of the device meeting the cost criterion. Cardica, Inc. estimates that the cost of each device will be approximately $1,200. The applicant assumes a hospital markup of 100 percent, with an average use of 2.5 C-Port devices per case. Therefore it estimates that the total average charge per patient will be $6,000. The C-Port[supreg] System would be used when a coronary artery bypass graft is performed. Thus, we are assessing whether it meets the cost criterion in relation to the threshold for DRGs 106 (Coronary Bypass with Percutaneous Transluminal Coronary Angioplasty), 547 (Coronary Bypass with Cardiac Catheter with Major CV Diagnosis), 548 (Coronary Bypass with Cardiac Catheter without Major CV Diagnosis), 549 (Coronary Bypass without Cardiac Catheter with Major CV Diagnosis), and 550 (Coronary Bypass without Cardiac Catheter without Major CV Diagnosis). We note that the data analysis for this technology is slightly unusual, as the DRGs to which the technology would have been assigned in FY 2005 (the MedPAR data we are currently using) are DRGs 107 and 109. These DRGs were terminated in FY 2006, and 4 new coronary bypass DRGs were created for these cases (DRGs 547, 548, 549, and 550). The manufacturer provided estimates showing a case- weighted threshold for DRGs 106, 547, 548, 549 and 550 of $75,373. The applicant projects a 20-percent market penetration for the device in FY 2007 or its use in approximately 23,000 cases across the 5 DRGs. The applicant submitted data showing average standardized charges for cases using the C-Port[supreg] System of $80,887. Therefore, the applicant argued that the device meets the cost threshold for a new technology add-on payment. Our internal data analysis of the technology, using the FY 2005 MedPAR data and Table 10 thresholds for FY 2005, shows a case- weighted threshold of $68,416. We identified cases using coronary bypass procedure codes 36.10, 36.11, 36.12, 36.13 and 36.14, and concluded that the case-weighted average standardized charge for these bypass cases was $79,394. Thus, our internal data also suggest that the device may meet the cost threshold.

The applicant made several arguments in support of the device meeting the substantial clinical improvement criterion. The manufacturer argues that the C-Port[supreg] creates a reliable and fully compliant end-to-side anastomosis between a vein graft and a coronary artery, in less time than is required to create a hand-sewn distal anastomosis. The applicant also states that the C-Port[supreg] System integrates deployment of the anastomotic clips and creation of the arteriotomy, thus enabling deployment to occur without occlusion of blood flow through the target vessel. However, we note that the applicant submitted evidence suggesting that the device does not always produce reliable anastomoses; specifically, a study of 130 patients receiving 132 devices reported 13 incomplete anastomoses in 12 patients, and the study also noted that additional manual stitches were required in the majority of the patients studied. Therefore, we are concerned that these studies suggest that the C-Port[supreg] System may not represent a substantial clinical improvement over the traditional hand-sewn technique. At the town hall meeting, the applicant noted that these results were associated with inexperience preparing the target vessel, vein thickness assessment, proper device alignment and anastomosis site selection rather than problems with the

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device itself. The applicant believes that these problems will become infrequent as surgeons have more experience with the device. We welcome further information from commenters that would suggest how the product meets the substantial clinical improvement criterion.

We received the following public comments at the new technology town hall meeting regarding whether this technology meets the substantial clinical improvement criteria:

Comment: The manufacturer argued that this technology meets the substantial clinical improvement criterion because:

It achieves higher patency rates at 6 months compared to conventional hand-sown anastomoses.

Use of the device will result in less surgeon-to-surgeon variability in the quality of the anastomosis compared to hand sewing.

The device leads to reduced operative time.

The product allows for the creation of an anastomosis during minimally invasive surgery.

In addition, we received written comments expressing support for approval of new technology add-on payments for the C-Port[supreg] System. These commenters noted that:

The device allows the anastomosis to be completed quickly, reducing patient complications during surgery from ischemia.

The device will allow for smaller incisions during heart surgery and physicians will not have to position their hands in the chest cavity in order to hand-sew the anastomosis.

The rapidly deployed anastomosis clamp provides patients with a surgical alternative where one would otherwise not be available due to the comorbidities associated with the more invasive CABG procedures.

Response: We appreciate the time and effort the applicant took to present at the town hall meeting. We will consider the information presented in the written comments and at the town hall meeting, and welcome objective data that will support the assertions presented above by the commenters. b. NovoSeven[supreg] for Intracerebral Hemorrhage

The Pinnacle Health Group in conjunction with Novo Nordisk Inc. (the manufacturer) submitted an application for new technology add-on payments for FY 2007 for NovoSeven[supreg] for Intracerebral Hemorrhage. The technology is a drug that promotes hemostasis by activating clotting factors. The applicant is seeking new technology add-on payments for the use of its product in the treatment of intracerebral hemorrhage (ICH) using ICD-9-CM diagnosis code 431 (Intracerebral hemorrhage).

On March 25, 1999, the FDA approved NovoSeven[supreg] for the treatment of bleeding episodes in patients with hemophilia A or B with inhibitors to Factor VIII or Factor IX. The applicant is now seeking FDA approval for the additional indication of ICH in patients without hemophilia or other clotting abnormalities. The applicant noted that it expects FDA approval sometime in the first quarter of 2007. Because the technology is not currently FDA approved, we are not presenting our full analysis on whether the technology meets the criteria for the new technology add-on payment in this proposed rule. However, we note that the applicant did submit the information below on the cost and substantial clinical improvement criteria.

Cases using the NovoSeven[supreg] are assigned to DRG 14 (Intracranial Hemorrhage or Cerebral Infraction). The applicant expects NovoSeven[supreg] to be used in 20 to 35 percent of patients with ICH diagnosis code 431 in FY 2007. The applicant searched the FY 2004 MedPAR and found a total of 31,407 cases with a principal diagnosis code of ICH. The condition was present as a secondary diagnosis in 32,730 cases. The average standardized charge per case was $18,752.12 when ICH was the principal diagnosis and $19,045.58 when ICH was the secondary diagnosis. The applicant submitted data demonstrating that the technology costs a total of $7,265, including the costs for the drug, sterile water, IV supplies, nursing services, pharmaceuticals, and followup CT scan. However, some of these costs (for example, nursing and pharmacy) are not part of the drug or technology itself and are normal operating costs included in the Medicare DRG payment for the inpatient stay and cannot be considered ``new.'' Therefore, based on data from the applicant, the total cost for this technology is $5,997. We then added the revised cost of the technology to determine a total average standardized charge per case of $24,749.12 when ICH was the principal diagnosis and $25,455.58 when it was the secondary diagnosis. The threshold for DRG 14 is $23,807. Based on the analysis above, the applicant maintains that NovoSeven[supreg] meets the cost criterion because the average standardized charge per case exceeds the threshold for DRG 14.

The applicant also maintained that the technology meets the substantial clinical improvement criterion. The applicant explained that several studies have shown a correlation between the size of the intracranial hematoma and the mortality rate of patients with ICH within 30 days. As a result, Recombinant Coagulation Factors VIIa (rFVIIa), such as NovoSeven[supreg], are being explored as a treatment option for ICH.

The applicant further explained that NovoSeven[supreg] activates prothrombin to thrombin by binding factor VIIa to exposed tissue factor, which then activates Factor IX into IXa and Factor X into Xa. The applicant noted that use of rFVIIa for hemophilia patients showed an 84-percent efficacy rate, with only one fatality and no major adverse events or evidence of disseminated intravascular coagulation. The applicant stated that the use of rFVIIa in a nonhemophilia population was safe across a wide range of doses.

In addition, a recent randomized trial published in the New England Journal of Medicine \11\ researched 399 patients with ICH diagnosed by CT within 3 hours after onset who received either placebo or one of three doses of NovoSeven[supreg] (40[mu]g, 80[mu]g, or 160[mu]g). Some of the outcomes reported from the study for those patients treated with NovoSeven[supreg] compared to placebo include: Mortality was reduced by 38 percent; the odds of improving by one level on the modified Rankin Scale at 90 days doubled; and the proportion of patients who died or were severely disabled declined from 69 percent in the placebo group to 53 percent in the treatment group (combined for all three levels of doses). The applicant noted that the study concluded that ultra early hemostatic therapy within 4 hours after the onset of ICH with rFVIIa significantly reduced the growth of the hemorrhage, reduced mortality, and improved the functional outcomes at 3 months, thus demonstrating substantial clinical improvement.

\11\ Mayer, S.A., et al. ``Recombinant Activated Factor VII for Acute Intracerebral Hemorrhage.'' New England Journal of Medicine, Vol. 352, No. 8, pp. 777-785, 2005.

We received no public comments regarding this application for new technology add-on payments at the town hall meeting. c. X STOP Interspinous Process Decompression System

St. Francis Medical Technologies submitted an application for new technology add-on payments for the X STOP Interspinous Process Decompression System for FY 2007.

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Lumbar spinal stenosis describes a condition that occurs when the spaces between bones in the spine become narrowed due to arthritis and other age-related conditions. This narrowing, or stenosis, causes nerves coming from the spinal cord to be compressed, thereby causing symptoms including pain, numbness, and weakness. It particularly causes symptoms when the spine is in extension, as occurs when a patient stands fully upright or leans back. The X STOP device is inserted between the spinous processes of adjacent vertebrae in order to provide a minimally invasive alternative to conservative treatment (exercise and physical therapy) and invasive surgery (spinal fusion). It works by limiting the spine extension that compresses the nerve roots while still preserving as much motion as possible. The device is inserted in a relatively simple, primarily outpatient procedure using local anesthesia. However, in some circumstances, the physician may prefer to admit the patient for an inpatient stay. The manufacturer has described the device as providing ``a new minimally invasive, stand-alone alternative treatment for lumbar spinal stenosis.''

The X STOP Interspinous Process Decompression system received premarket approval from the FDA on November 21, 2005. The device is currently described by ICD-9-CM code 84.58 (Implantation of Interspinous process decompression device) (excluding: fusion of spine (codes 81.00 through 81.08, and 81.30 through 81.39)). This ICD-9-CM code went into effect on October 1, 2005.

The manufacturer provided data in support of the device meeting the cost threshold criterion. The applicant stated that there would be an average of 1.6 units used per case. Each unit costs $5,500; therefore, the technology is expected to cost $8,800 per case. The device is currently assigned to DRGs 499 (Back and Neck Procedures Except Spinal Fusion with CC) and 500 (Back and Neck Procedures Except Spinal Fusion without CC). The manufacturer projected that there would be approximately 424 patients eligible to receive the device in DRG 499 in FY 2007, while there may be approximately 1,700 patients who receive the device in DRG 500. The manufacturer also provided data for cases involved in the clinical trials. The average standardized charge for the cases in FY 2004 was $24,065. The weighted threshold for DRGs 499 and 500 is $20,096. However, the manufacturer argued that because significantly less than 20 percent of patients receiving the X STOP experienced complications or had comorbidities, the threshold should be calculated by estimating that 20 percent of patients would be assigned to DRG 499 and 80 percent would to DRG 500. The manufacturer stated in its application that, using this methodology, the applicable threshold should be $19,796. Using either calculation, it appears that the technology meets the cost threshold for new technology add-on payments.

The applicant also submitted information in support of its claim of substantial clinical improvement. The manufacturer stated that the X STOP device is placed between the spinous processes to limit extension of the symptomatic level(s), yet allowing flexion, axial rotation, and lateral bending (that is, the device limits pressure on the spinal nerves and the resulting pain symptoms when the patient is in an upright position or leans backward while also preserving the patient's ability to turn side-to-side, bend forward, and to turn to either side). The applicant contends that this technology provides an alternative with improved clinical outcomes to conservative and surgical treatments. The manufacturer further stated that the device may offer a new alternative to lumbar spinal decompression procedures such as laminectomy and laminotomy. Additional information included in the application suggests that the device preserves spinal motion and is superior to a spinal decompression procedure that requires concomitant fusion (with or without instrumentation). The applicant argued that the advantages over spinal decompression include reduced risk, shorter hospital stay, and earlier improvement in pain and function. The manufacturer further contends that disease progression at adjacent levels is minimal following X STOP implantation compared to the known risk associated with surgical decompression and concomitant fusion. The applicant stated that the X STOP is comparable to traditional surgical decompression of lumbar spinal stenosis with respect to improved quality of life postoperatively. According to the applicant, the device provides advantages over nonoperative care, including better symptom relief, improved function, and increased patient satisfaction.

We believe that the device satisfies the newness and cost threshold criteria for new technology add-on payments. However, we are concerned that the information included with the application may raise issues about substantial clinical improvement. During the FDA approval process, the Center for Devices and Radiological Health (CDRH) Advisory Panel voted against premarket approval (PMA) in August 2004 because of concerns about proper patient selection as well as the lack of objective endpoints, especially radiographic endpoints. The Panel also mentioned the overall low clinical efficacy rate in the study population. The device subsequently received PMA approval, but only on the condition that it be used in the context of a long term (5 year) follow-up study. We welcome information from commenters that addresses the concerns raised by the CDRH Advisory Panel or other information bearing on the issue of whether this product meets the substantial clinical improvement criterion.

We received the following public comments through the new technology town hall meeting process regarding this application for add-on payments.

Comment: The applicant asserted that the X STOP Interspinous Process Decompression system has the following advantages:

It retains spinal anatomy and all spinal structures.

The device allows for increased function and less pain after implantation as evidenced by radiographic measures that showed increases in the spinal canal area by 18 percent, diameter by 9 percent, and subarticular diameter (the route that the nerves exit the spine) by 50 percent. In lateral view: area increased by 25 percent and width by 41 percent.

The X STOP is a reversible procedure that causes no damage to facets or disks.

The device allows for a treatment option for patients that cannot undergo surgeries with general anesthesia.

The rate of complications associated with implantation of the device is below 1 percent.

Response: We will evaluate these assertions as we further consider this application for new technology add-on payments for the final rule. We also note that the study that the applicant summarized at the town hall meeting for the X STOP used a randomized study that targeted lumbar spinal stenosis patients with mild to moderate symptoms. The control group did not require operative care. We welcome information from the comments that demonstrates how the study populations showed substantial clinical improvement compared to the control group.

We note that the town hall meeting produced contradictory information regarding whether this procedure is generally performed in inpatient or

[[Page 24074]]

outpatient settings. The presenter indicated that over 90 percent of his patients were treated as outpatients. The manufacturer noted 90 percent of non-U.S. patients and approximately two-thirds of U.S. patients since FDA approval have been treated in inpatient settings. While the setting where the procedure is typically performed has no bearing on whether the product represents a substantial clinical improvement, we note that we believe the physician should select the most appropriate site to perform the procedure based on the clinical needs of the patient.

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 2007 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 2007 is discussed in section II.B. of the Addendum to this proposed rule.

As discussed below in section III.H. of this preamble, we also take into account the geographic reclassification of hospitals in accordance with sections 1886(d)(8)(B) and 1886(d)(10) of the Act when calculating the wage index. Under section 1886(d)(8)(D) of the Act, the Secretary is required to adjust the standardized amounts so as to ensure that aggregate payments under the IPPS after implementation of the provisions of sections 1886(d)(8)(B) and (C) and 1886(d)(10) of the Act are equal to the aggregate prospective payments that would have been made absent these provisions. The proposed budget neutrality adjustment for FY 2007 is discussed in section II.A.4.b. of the Addendum to this proposed rule.

Section 1886(d)(3)(E) of the Act also provides for the collection of data every 3 years on the occupational mix of employees for short- term, acute care hospitals participating in the Medicare program, in order to construct an occupational mix adjustment to the wage index. A discussion of the occupational mix adjustment that we propose to apply beginning October 1, 2006 (the proposed FY 2007 wage index) appears under section III.C. of this preamble.

B. Core-Based Statistical Areas 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 revised CBSAs established by OMB comprised MSAs and 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 revised

definitions recognize 49 MSAs and 565 Micropolitan Areas, and extensively changed the composition of many of the MSAs that existed prior to the revisions.

The revised area designations resulted in a higher wage index for some areas and a lower wage index for others. Further, some hospitals that were previously classified as urban 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 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 the wage index computation, the wage data of these hospitals remained assigned to the statewide rural area in which they are located.) The hospitals receiving this transition will not be considered urban hospitals; rather, they will maintain their status as rural hospitals. Thus, the hospital would not be eligible, for example, for a large urban add-on payment under the capital PPS. In other words, it is the wage index, but not the urban or rural status, of these hospitals that is being affected by this transition. The higher wage indices that these hospitals are receiving are also being taken into consideration in determining whether they qualify for the out-migration adjustment discussed in section III.I. of this preamble and the amount of any adjustment.

[[Page 24075]]

FY 2007 will be the third 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 and in subsequent years. These hospitals will be considered rural for reclassification purposes.

Consistent with the FY 2005 and FY 2006 IPPS final rules, as we did beginning in FY 2006, for FY 2007 we are proposing to provide that hospitals receive 100 percent of their wage index based upon the CBSA configurations. Specifically, we will determine for each hospital a proposed wage index for FY 2007 employing wage index data from FY 2003 hospital cost reports and using the CBSA labor market definitions.

C. Proposed Occupational Mix Adjustment to the Proposed FY 2007 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 proposed FY 2007 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 FYs 2005 and 2006 wage indices, 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, pharmacy, dietary and medical and clinical laboratory. These services each include several standard occupational classifications (SOCs), as defined by the BLS' Occupational Employment Statistics (OES) survey. For the proposed FY 2007 wage index, we are using revised survey data for 16 hospitals that took advantage of the opportunity we afforded hospitals to submit changes to their occupational mix data during the FY 2007 wage index data collection process (see the 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 for hospitals for which there are no corresponding cost report data for the FY 2007 wage index. The proposed FY 2007 wage index includes occupational mix data from 3,362 out of 3,580 hospitals (93.9 percent response rate). The results of the occupational mix survey are included in the chart below. BILLING CODE 4120-01-P

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[GRAPHIC] [TIFF OMITTED] TP25AP06.019

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[GRAPHIC] [TIFF OMITTED] TP25AP06.020

BILLING CODE 4120-01-C 2. Calculation of the Proposed FY 2007 Occupational Mix Adjustment Factor and the Proposed FY 2007 Occupational Mix Adjusted Wage Index

For the proposed FY 2007 wage index, we are proposing to use the same methodology that we used to calculate the occupational mix adjustment to the FY 2005 and FY 2006 wage indices (69 FR 49042 and 70 FR 47367). We are proposing to use the following steps for calculating the proposed FY 2007 occupational mix adjustment factor and the proposed FY 2007 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.

[[Page 24078]]

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

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

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

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

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

Step 8--To compute the national occupational mix adjusted average hourly wage, sum the total occupational mix adjusted salaries and wage- related costs for all hospitals in the Nation, then sum the total hours for all hospitals in the Nation. Next, divide the national occupational mix adjusted salaries and wage-related costs by the national hours. The proposed national occupational mix adjusted average hourly wage for FY 2007 is $29.6213. (This figure represents a 100 percent adjustment for occupational mix.)

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

Step 10--To compute the Puerto Rico specific occupational mix adjusted wage index, follow Steps 1 through 9 above. The proposed Puerto Rico occupational mix adjusted average hourly wage for FY 2007 is $12.9490. (This figure represents a 100 percent adjustment for occupational mix.)

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

For the FY 2006 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 FYs 2005 and 2006 IPPS final rule (69 FR 49035 and 70 FR 47368), 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 2007 occupational mix adjustment that we used for FYs 2005 and 2006, with the only exceptions as stated in section III.C.1. of this preamble, we are treating the wage data for hospitals that did not respond to the survey in this same manner for the proposed FY 2007 wage index.

In implementing an occupational mix adjusted wage index based on the above calculation, the proposed wage index values for 17 rural areas (36.2 percent) and 204 urban areas (52.8 percent) would decrease as a result of the adjustment. Five rural areas (10.6 percent) and 106 urban areas (27.5 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 1.8 percent and for an urban area, 4.2 percent. Meanwhile, 30 rural areas (63.8 percent) and 178 urban areas (46.1 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 approximately 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 2006 IPPS final rule (70 FR 47368), we indicated that, for future data collections, we would revise the occupational mix survey to allow hospitals to provide both salaries and hours data for each of the employment categories that are included on the survey. We also indicated that we would assess whether future occupational mix surveys should be based on the calendar year or if the data should be collected on a fiscal year basis as part of the Medicare cost report. (One logistical problem is that cost report data are collected yearly, but occupational mix survey data are collected only every 3 years.)

In a document published in the Federal Register on October 14, 2005 (70 FR 60092), we proposed a new survey, the 2006 Medicare Wage Index Occupational Mix Survey. The 2006 survey provides for the collection of data on hospital-specific wages and hours for a 6-month reporting period (January 1, 2006 through June 30, 2006), as well as additional clarification of the definitions for the occupational categories, an expansion of the registered nurse category to include functional subcategories, the exclusion of average hourly rate data associated with advance practice nurses, and the transfer of each general service category that comprised less than 4 percent of total hospital employees in the 2003 survey to the ``all other occupations'' category. The results of the 2006 occupational mix survey will be used to adjust the IPPS wage index beginning with FY 2008. On February 10, 2006, we

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published in the Federal Register a notice with a 30-day comment period for the 2006 survey (71 FR 7047). We will provide a full discussion of the 2006 survey design, the survey results, and the methodology for calculating and applying the new occupational mix adjustment in the FY 2008 IPPS proposed rule.

In our continuing efforts to meet the information needs of the public, we are providing via the Internet three additional public use files (PUFs) for the proposed occupational mix adjusted wage index concurrently with the publication of this proposed rule: (1) A file including each hospital's unadjusted and adjusted average hourly wage (FY 2007 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 2007 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 posted on the Internet at http://www.cms.hhs.gov/AcuteInpatientPPS. We also plan to post these files via the Internet

with future applications of the occupational mix adjustment.

D. Worksheet S-3 Wage Data for the Proposed FY 2007 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 2007 wage index values (effective for hospital discharges occurring on or after October 1, 2006 and before October 1, 2007) in section II.B. of the Addendum to this proposed rule are based on the data collected from the Medicare cost reports submitted by hospitals for cost reporting periods beginning in FY 2003 (the FY 2006 wage index was based on FY 2002 wage data).

The proposed FY 2007 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.

Consistent with the wage index methodology for FY 2006, the proposed wage index for FY 2007 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 2007 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 IRFs, IPFs, and LTCHs, and for hospital outpatient services. We note that, in the IPPS rules, we do not address comments pertaining to the wage indices for non-IPPS providers. Such comments should be made in response to separate proposed rules for those providers.

E. Verification of Worksheet S-3 Wage Data

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

The wage data for the proposed FY 2007 wage index were obtained from Worksheet S-3, Parts II and III of the FY 2003 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 2003 data submitted to us as of March 1, 2006. 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 2007 wage 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 14, 2006. 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 215 hospitals from our database: 178 hospitals designated as CAHs between February 18, 2005, the cutoff date for exclusion of CAHs from the FY 2006 wage index, and February 17, 2006, the cutoff date for CAH exclusion for the FY 2007 wage index (that is, 7 or more days prior to the posting of the preliminary February 24, 2006 PUF), and 30 hospitals were low Medicare utilization hospitals or failed edits that could not be corrected because the hospitals terminated the program or changed ownership. In addition, we removed the wage data for 7 hospitals with incomplete or inaccurate data resulting in zero or negative, or otherwise aberrant, average hourly wages. 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 pass our edits. As a result, the proposed FY 2007 wage index is calculated based on FY 2003 wage data from 3,580 hospitals.

In constructing the proposed FY 2007 wage index, we include the wage data for facilities that were IPPS hospitals in FY 2003, 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.

Section 4410 of Pub. L. 105-33 provides that, for the purposes of section 1886(d)(3)(E) of the Act, for discharges occurring 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 the State. This provision is commonly referred to as the ``rural floor.'' In the August 11, 2004 IPPS final rule (69 FR 49109), we discussed situations where a State has only urban areas and no geographically rural areas, or a State has geographically rural areas but no IPPS hospitals are located in those rural

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areas. As a result, these States did not have rural IPPS hospitals from which to compute and apply a ``rural floor.'' In that final rule, we developed a policy for imputing a ``rural floor'' for these States, effective for the FYs 2005, 2006, and 2007 wage indices, so that a ``rural floor'' could be applicable to IPPS urban hospitals in those States in the same manner that a ``rural floor'' is applicable to IPPS urban hospitals in States that have IPPS rural hospitals. We revised the regulations at Sec. 412.64(h) to describe the methodology for computing the imputed ``rural floors'' for these States and to define an all-urban State. Specifically, Sec. 412.64(h)(5) defines an all- urban State as ``a State with no rural areas * * * or a State in which there are no hospitals classified as rural. A State with rural areas and with hospitals reclassified as rural under Sec. 412.103 is not an all-urban State.''

We have received questions as to what area wage index CMS would apply in the instance where a new rural IPPS hospital opens in a State that has an imputed ``rural floor'' because it has rural areas but had no hospitals classified as rural. In addition, we have been asked whether a new IPPS hospital could submit its wages and hours data to be used in computing the wage index, even though the hospital did not file a cost report as an IPPS provider for the cost report base year that is used in calculating that wage index.

A new hospital can be an entirely new facility that did not exist before, or it can be a hospital that participated in Medicare under a previous provider number, but has acquired a new Medicare provider number (such as when a CAH converts to IPPS status, or vice versa). As a new IPPS hospital (in this case, rural), the hospital would not yet have filed any wages and hours data on a Medicare cost report. Even in the situation where a new IPPS hospital previously participated in Medicare as another provider type (such as a CAH) and was able to develop its wages and hours data for the wage index base year, consistent with section 1886(d)(3)(E) of the Act which specifies that the wage index must be based on data from short-term, acute care hospitals, CMS could not include the hospital's wages and hours from a period during which the hospital was not an IPPS provider. Furthermore, even once the hospital files its first Medicare cost report under the new IPPS provider number, that first cost report is not used in computing the wage index for the hospital's geographic area until 4 years later. This is because a current fiscal year's wage index is computed from cost reports that are 4 years prior to that current fiscal year. Consequently, the only wage index that would be available for such a new IPPS rural hospital in the first 3 years of the hospital's existence is the imputed ``rural floor.'' Therefore, if a new rural IPPS hospital opens in a State that has an imputed ``rural floor'' and has rural areas, the hospital would receive the imputed ``rural floor'' as its wage index until its first cost report is contemporaneous with the cost reporting period being used to develop a given fiscal year's wage index.

F. Computation of the Proposed FY 2007 Unadjusted Wage Index

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

The method used to compute the proposed FY 2007 wage index without an occupational mix adjustment follows:

Step 1--As noted above, we based the proposed FY 2007 wage index on wage data reported on the FY 2003 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, 2002 and before October 1, 2003. In addition, we included data from some hospitals that had cost reporting periods beginning before October 2002 and reported a cost reporting period covering all of FY 2003. 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 2003 data. We note that, if a hospital had more than one cost reporting period beginning during FY 2003 (for example, a hospital had two short cost reporting periods beginning on or after October 1, 2002 and before October 1, 2003), we included wage data from only one of the cost reporting periods, the longer, in the wage index calculation. If there was more than one cost reporting period and the periods were equal in length, we included the wage data from the later period in the wage index calculation.

Step 2--Salaries--The method used to compute a hospital's average hourly wage excludes certain costs that are not paid under the IPPS. In calculating a hospital's average salaries plus wage-related costs, we subtracted from Line 1 (total salaries) the GME and CRNA costs reported on Lines 2, 4.01, 6, and 6.01, the Part B salaries reported on Lines 3, 5 and 5.01, home office salaries reported on Line 7, and excluded salaries reported on Lines 8 and 8.01 (that is, direct salaries attributable to SNF services, home health services, and other subprovider components not subject to the IPPS). We also subtracted from Line 1 the salaries for which no hours were reported. To determine total salaries plus wage-related costs, we added to the net hospital salaries the costs of contract labor for direct patient care, certain top management, pharmacy, laboratory, and nonteaching physician Part A services (Lines 9 and 10), home office salaries and wage-related costs reported by the hospital on Lines 11 and 12, and nonexcluded area wage- related costs (Lines 13, 14, and 18).

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

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

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

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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, 2002, through April 15, 2004, for private industry hospital workers from the BLS' Compensation and Working Conditions. We use the ECI because it reflects the price increase associated with total compensation (salaries plus fringes) rather than just the increase in salaries. In addition, the ECI includes managers as well as other hospital workers. This methodology to compute the monthly update factors uses actual quarterly ECI data and assures that the update factors match the actual quarterly and annual percent changes. The factors used to adjust the hospital's data were based on the midpoint of the cost reporting period, as indicated below.

Midpoint of Cost Reporting Period

Adjustment After

Before

factor

10/14/2002.................................. 11/15/2002 1.06058 11/14/2002.................................. 12/15/2002 1.05679 12/14/2002.................................. 01/15/2003 1.05304 01/14/2003.................................. 02/15/2003 1.04915 02/14/2003.................................. 03/15/2003 1.04513 03/14/2003.................................. 04/15/2003 1.04108 04/14/2003.................................. 05/15/2003 1.03713 05/14/2003.................................. 06/15/2003 1.03325 06/14/2003.................................. 07/15/2003 1.02948 07/14/2003.................................. 08/15/2003 1.02584 08/14/2003.................................. 09/15/2003 1.02231 09/14/2003.................................. 10/15/2003 1.01878 10/14/2003.................................. 11/15/2003 1.01510 11/14/2003.................................. 12/15/2003 1.01127 12/14/2003.................................. 01/15/2004 1.00743 01/14/2004.................................. 02/15/2004 1.00367 02/14/2004.................................. 03/15/2004 1.00000 03/14/2004.................................. 04/15/2004 0.99644

For example, the midpoint of a cost reporting period beginning January 1, 2003 and ending December 31, 2003 is June 30, 2003. An adjustment factor of 1.02948 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 2003 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 $29.6008.

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 $12.9564 for Puerto Rico. For each labor market area in Puerto Rico, we calculated the Puerto Rico-specific wage index value by dividing the area average hourly wage (as calculated in Step 7) by the overall Puerto Rico average hourly wage.

Step 11--Section 4410 of Pub. L. 105-33 provides that, for discharges on or after October 1, 1997, the area wage index applicable to any hospital that is located in an urban area of a State may not be less than the area wage index applicable to hospitals located in rural areas in that State. (For all-urban States, we established an imputed floor (69 FR 49109). Furthermore, this wage index floor is to be implemented in such a manner as to ensure that aggregate IPPS payments are not greater or less than those that would have been made in the year if this section did not apply. For FY 2007, this change affects 187 hospitals in 62 urban areas. The areas affected by this provision are identified by a footnote in Tables 4A-1 and 4A-2 in the Addendum of this proposed rule.

G. Computation of the Proposed FY 2007 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 comment.)

For the final FY 2005 and FY 2006 wage indices, 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 and FY 2006 wage index adjustment factor by a factor reflecting occupational mix. We refer readers to the FY 2005 IPPS final rule at 69 FR 49052 and the FY 2006 IPPS final rule at 70 FR 47376 for a detailed discussion of the blended wage index. For FY 2007, we are proposing to apply the same blended wage index as we did in FYs 2005 and 2006, so that 10 percent of the wage index is adjusted by a factor reflecting occupational mix. We believe this is prudent policy because we are relying on the same survey data used in FYs 2005 and 2006.

In computing the occupational mix adjustment for the proposed FY 2007 wage index, we used the occupational mix survey data that we collected for the FY 2006 wage index, replacing the survey data for 16 hospitals that submitted revised data, and excluding the survey data for hospitals with no corresponding Worksheet S-3 wage data for the FY 2007 wage index.

With 10 percent of the proposed FY 2007 wage index adjusted for occupational mix, the proposed national average hourly wage is $29.6029 and the Puerto Rico-specific average hourly wage is $12.9557. The wage index values for 17 rural areas (36.2 percent) and 200 urban areas (51.8 percent) would decrease as a result of the adjustment. These decreases would be minimal; the largest negative impact for a rural area would be 0.18 percent and for an urban area, 0.42 percent. Conversely, 29 rural areas (61.7 percent) and 173 urban areas (44.8 percent) would benefit from this adjustment, with 1 urban area increasing 2.2 percent and 2 rural areas increasing 0.38 percent. As there are no significant differences between the FY 2006 and the FY 2007 occupational mix survey data and results, we believe it is appropriate to again apply the occupational mix to 10 percent of the proposed FY 2007 wage index. (See Appendix A to this proposed rule for

[[Page 24082]]

further analysis of the impact of the occupational mix adjustment on the proposed FY 2007 wage index.)

The proposed wage index values for FY 2007 (except those for hospitals receiving wage index adjustments under section 505 of Pub. L. 108-173) are shown in Tables 4A-1, 4A-2, 4B, 4C-1, 4C-2, and 4F in the Addendum to this proposed rule.

Tables 3A and 3B in the Addendum to this proposed rule list the 3- year average hourly wage for each labor market area before the redesignation of hospitals, based on FYs 2005, 2006, 2007 cost reporting periods. Table 3A lists these data for urban areas and Table 3B lists these data for rural areas. In addition, Table 2 in the Addendum to this proposed rule includes the adjusted average hourly wage for each hospital from the FY 2001 and FY 2002 cost reporting periods, as well as the FY 2003 period used to calculate the proposed FY 2007 wage index. The 3-year averages are calculated by dividing the sum of the dollars (adjusted to a common reporting period using the method described previously) across all 3 years, by the sum of the hours. If a hospital is missing data for any of the previous years, its average hourly wage for the 3-year period is calculated based on the data available during that period.

The proposed wage index values in Tables 4A-1, 4A-2, 4B, 4C-1, 4C- 2, and 4F and the average hourly wages in Tables 2, 3A, and 3B in the Addendum to this proposed rule include the proposed occupational mix adjustment.

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

(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 and if the commuting rates used in determining outlying counties were determined on the basis of the aggregate number of resident workers who commute to (and, if applicable under the standards, from) the central county or counties of all contiguous MSAs. In light of the new CBSA definitions and the Census 2000 data that we implemented for FY 2005 (69 FR 49027), we undertook to identify those counties meeting these criteria. The eligible counties are identified under section III.H.4. 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,\12\ the wage index values were determined by considering the following:

\12\ Although section 1886(d)(8)(C)(iv)(I) of the Act also provides that the wage index for an urban area may not decrease as a result of redesignated hospitals if the urban area wage index is already below the wage index for rural areas in the State in which the urban area is located, the provision was effectively made moot by section 4410 of Pub. L. 105-33, which provides that the area wage index applicable to any hospital that is located in an urban area of a State may not be less than the area wage index applicable to hospitals located in rural areas in that State. For all-urban States, CMS established an imputed floor (69 FR 49109). Also, section 1886(d)(8)(C)(iv)(II) of the Act provides that an urban area's wage index may not decrease as a result of redesignated hospitals if the urban area is located in a State that is composed of a single urban area.

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

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

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

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

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

The wage index value for a redesignated rural hospital cannot be reduced below the wage index value for the rural areas of the State in which the hospital is located.

In cases where urban hospitals have reclassified to rural areas under 42 CFR

[[Page 24083]]

412.103, the urban hospital wage data are: (a) Included in the rural wage index calculation, unless doing so would reduce the rural wage index; and (b) included in the urban area where the hospital is physically located. 3. FY 2007 MGCRB Reclassifications

At the time this proposed rule was constructed, the MGCRB had completed its review of FY 2007 reclassification requests. There are 214 hospitals approved by the MGCRB for wage index reclassifications for FY 2007. Because MGCRB wage index reclassifications are effective for 3 years, hospitals reclassified during FY 2005 or FY 2006 are eligible to continue to be reclassified based on prior reclassifications to current MSAs during FY 2007. There were 299 hospitals reclassified for wage index for FY 2006, and 395 hospitals reclassified for wage index for FY 2005. Some of the hospitals that reclassified for FY 2005 and FY 2006 have elected not to continue their reclassifications in FY 2007 because, under the revised labor market area definitions, they are now physically located in the areas to which they previously reclassified. Of all of the hospitals approved for reclassification for FY 2005, FY 2006, and FY 2007, 766 hospitals are in a reclassification status for FY 2007.

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 and, effective for discharges occurring on or after October 1, 2006, MDHs have no cap). (A detailed discussion of this application appears in section IV.I. of the preamble of the FY 2005 IPPS final rule (69 FR 49085). The exclusion of MDHs from the 12 percent DSH cap under Pub. L. 109-171 is discussed under Section IV.F.4. of this preamble.)

Under Sec. 412.273, hospitals that have been reclassified by the MGCRB are permitted to withdraw their applications within 45 days of the publication of a proposed rule. The request for withdrawal of an application for reclassification or termination of an existing 3-year reclassification that would be effective in FY 2007 must be received by the MGCRB within 45 days of the publication of this proposed rule. If a hospital elects to withdraw its wage index application after the MGCRB has issued its decision, but within 45 days of the publication of the proposed rule, it may later cancel its withdrawal in a subsequent year and request the MGCRB to reinstate its wage index reclassification for the remaining fiscal year(s) of the 3-year period (Sec. 412.273(b)(2)(i)). The request to cancel a prior withdrawal must be in writing to the MGCRB no later than the deadline for submitting reclassification applications for the following fiscal year (Sec. 412.273(d)). For further information about withdrawing, terminating, or canceling a previous withdrawal or termination of a 3-year reclassification for wage index purposes, we refer the reader to Sec. 412.273, as well as the August 1, 2002 IPPS final rule (67 FR 50065) and the August 1, 2001 IPPS final rule (66 FR 39887).

Changes to the wage index that result from withdrawals of requests for reclassification, wage index corrections, appeals, and the Administrator's review process will be incorporated into the wage index values published in the final rule. These changes may affect not only the wage index value for specific geographic areas, but also the wage index value redesignated hospitals receive; that is, whether they receive the wage index that includes the data for both the hospitals already in the area and the redesignated hospitals. Further, the wage index value for the area from which the hospitals are redesignated may be affected.

Applications for FY 2008 reclassifications are due to the MGCRB by September 1, 2006. We note that this is also the deadline for canceling a previous wage index reclassification withdrawal or termination under Sec. 412.273(d). Applications and other information about MGCRB reclassifications may be obtained, beginning in mid-July 2006, via the CMS Internet Web site at: http://www.cms.hhs.gov/mgcrb/, or by calling

the MGCRB at (410) 786-1174. The mailing address of the MGCRB is: 2520 Lord Baltimore Drive, Suite L, Baltimore, MD 21244-2670. 4. Proposed FY 2007 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 New England County Metropolitan Areas (NECMAs)), and if the commuting rates used in determining outlying counties (or, for New England, similar recognized areas) were determined on the basis of the aggregate number of resident workers who commute to (and, if applicable under the standards, from) the central county or counties of all contiguous MSAs (or NECMAs). Hospitals that met the criteria using the January 3, 1980 version of these OMB standards were deemed urban for purposes of the standardized amounts and for purposes of assigning the wage data index.

Effective beginning FY 2005, we use OMB's 2000 CBSA standards and the Census 2000 data to identify counties qualifying for redesignation under section 1886(d)(8)(B) for the purpose of assigning the wage index to the urban area. The chart below contains the listing of the rural counties designated as urban under section 1886(d)(8)(B) of the Act that we are proposing to use for FY 2007. For discharges occurring on or after October 1, 2006, hospitals located in the first column of this chart will be redesignated for purposes of using the wage index of the urban area listed in the second column.

Rural Counties Redesignated as Urban Under Section 1886(d)(8)(B) of the Act [Based on CBSAs and Census 2000 Data]

Rural county

CBSA

Cherokee, AL........................... Rome, GA. Macon, AL.............................. Auburn-Opelika, AL.

[[Page 24084]]

Talladega, AL.......................... Anniston-Oxford, AL. Hot Springs, AR........................ Hot Springs, AR. Windham, CT............................ Hartford-West Hartford-East Hartford, CT. Bradford, FL........................... Gainesville, FL. Flagler, FL............................ Deltona-Daytona Beach-Ormond Beach, FL. Hendry, FL............................. West Palm Beach-Boca Raton- Boynton, FL. Levy, FL............................... Gainesville, FL. Walton, FL............................. Fort Walton Beach-Crestview- Destin, FL. Banks, GA.............................. Gainesville, GA. Chattooga, GA.......................... Chattanooga, TN-GA. Jackson, GA............................ Atlanta-Sandy Springs-Marietta, GA. Lumpkin, GA............................ Atlanta-Sandy Springs-Marietta, GA. Morgan, GA............................. Atlanta-Sandy Springs-Marietta, GA. Peach, GA.............................. Macon, GA. Polk, GA............................... Atlanta-Sandy Springs-Marietta, GA. Talbot, GA............................. Columbus, GA-AL. Bingham, ID............................ Idaho Falls, ID. Christian, IL.......................... Springfield, IL. DeWitt, IL............................. Bloomington-Normal, IL. Iroquois, IL........................... Kankakee-Bradley, IL. Logan, IL.............................. Springfield, IL. Mason, IL.............................. Peoria, IL. Ogle, IL............................... Rockford, IL. Clinton, IN............................ Lafayette, IN. Henry, IN.............................. Indianapolis, IN. Spencer, IN............................ Evansville, IN-KY. Starke, IN............................. Gary, IN. Warren, IN............................. Lafayette, IN. Boone, IA.............................. Ames, IA. Buchanan, IA........................... Waterloo-Cedar Falls, IA. Cedar, IA.............................. Iowa City, IA. Allen, KY.............................. Bowling Green, KY. Assumption Parish, LA.................. Baton Rouge, LA. St. James Parish, LA................... Baton Rouge, LA. Allegan, MI............................ Holland-Grand Haven, MI. Montcalm, MI........................... Grand Rapids-Wyoming, MI. Oceana, MI............................. Muskegon-Norton Shores, MI. Shiawassee, MI......................... Lansing-East Lansing, MI. Tuscola, MI............................ Saginaw-Saginaw Township North, MI. Fillmore, MN........................... Rochester, MN. Dade, MO............................... Springfield, MO. Pearl River, MS........................ Gulfport-Biloxi, MS. Caswell, NC............................ Burlington, NC. Granville, NC.......................... Durham, NC. Harnett, NC............................ Raleigh-Cary, NC. Lincoln, NC............................ Charlotte-Gastonia-Concord, NC- SC. Polk, NC............................... Spartanburg, NC. Los Alamos, NM......................... Santa Fe, NM. Lyon, NV............................... Carson City, NV. Cayuga, NY............................. Syracuse, NY. Columbia, NY........................... Albany-Schenectady-Troy, NY. Genesee, NY............................ Rochester, NY. Greene, NY............................. Albany-Schenectady-Troy, NY. Schuyler, NY........................... Ithaca, NY. Sullivan, NY........................... Poughkeepsie-Newburgh- Middletown, NY. Wyoming, NY............................ Buffalo-Niagara Falls, NY. Ashtabula, OH.......................... Cleveland-Elyria-Mentor, OH. Champaign, OH.......................... Springfield, OH. Columbiana, OH......................... Youngstown-Warren-Boardman, OH- PA. Cotton, OK............................. Lawton, OK. Linn, OR............................... Corvallis, OR. Adams, PA.............................. York-Hanover, PA. Clinton, PA............................ Williamsport, PA. Greene, PA............................. Pittsburgh, PA. Monroe, PA............................. Allentown-Bethlehem-Easton, PA- NJ. Schuylkill, PA......................... Reading, PA. Susquehanna, PA........................ Binghamton, NY. Clarendon, SC.......................... Sumter, SC. Lee, SC................................ Sumter, SC. Oconee, SC............................. Greenville, SC. Union, SC.............................. Spartanburg, SC.

[[Page 24085]]

Meigs, TN.............................. Cleveland, TN. Bosque, TX............................. Waco, TX. Falls, TX.............................. Waco, TX. Fannin, TX............................. Dallas-Plano-Irving, TX. Grimes, TX............................. College Station-Bryan, TX. Harrison, TX........................... Longview, TX. Henderson, TX.......................... Dallas-Plano-Irving, TX. Milam, TX.............................. Austin-Round Rock, TX. Van Zandt, TX.......................... Dallas-Plano-Irving, TX. Willacy, TX............................ Brownsville-Harlingen, TX. Buckingham, VA......................... Charlottesville, VA. Floyd, VA.............................. Blacksburg-Christiansburg- Radford, VA. Middlesex, VA.......................... Virginia Beach-Norfolk-Newport News, VA. Page, VA............................... Harrisonburg, VA. Shenandoah, VA......................... Winchester, VA-WV. Island, WA............................. Seattle-Bellevue-Everett, WA. Mason, WA.............................. Olympia, WA. Wahkiakum, WA.......................... Longview, WA. Jackson, WV............................ Charleston, WV. Roane, WV.............................. Charleston, WV. Green, WI.............................. Madison, WI. Green Lake, WI......................... Fond du Lac, WI. Jefferson, WI.......................... Milwaukee-Waukesha-West Allis, WI. Walworth, WI........................... Milwaukee-Waukesha-West Allis, WI.

As in the past, hospitals redesignated under section 1886(d)(8)(B) of the Act are also eligible to be reclassified to a different area by the MGCRB. Affected hospitals are permitted to compare the reclassified wage index for the labor market area in Tables 4C-1 and 4C-2 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. 5. 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.

Some hospitals currently receiving a section 508 reclassification are eligible to reclassify to that same area under the standard reclassification process as a result of the new labor market definitions that we adopted for FY 2005. The governing regulations indicate that ``if a hospital is already reclassified to a given geographic area for wage index purposes for a 3-year period, and submits an application to the same area for either the second or third year of the 3-year period, that application will not be approved.'' However in the FY 2006 IPPS final rule (70 FR 47382), we stated that hospitals that indicated in their FY 2007 MGCRB applications that they agreed to waive their section 508 reclassification for the first 6 months of FY 2007 if they were granted a 3-year reclassification under the traditional MGCRB process will not be subject to the rule cited above. Thus, in applying for a 3-year MGCRB reclassification beginning in FY 2007, hospitals that are already reclassified to the same area under section 508 should have indicated in their MGCRB reclassification requests that if they receive the MGCRB reclassification, they would forfeit the section 508 reclassification for the first 6 months of FY 2007.

Under 1886(d)(10)(D)(v) of the Act, CMS has the authority to ``establish procedures'' under which a hospital may elect to terminate a reclassification before the end of a 3-year period. In the FY 2006 IPPS final rule (70 FR 47382), we discussed our decision to exercise this authority to establish a procedural rule for section 508 hospitals to retain their section 508 reclassification through its expiration on March 31, 2007, and reclassify under the regulations at 42 CFR Part 412, Subpart L, for the second half of FY 2007. The following procedural rules will apply for section 508 hospitals that wish to reclassify for the second half of FY 2007 (April 1, 2007, through September 30, 2007):

For section 508 hospitals applying for individual reclassification under Sec. 412.230--

(a) Hospitals must have applied for reclassification through the MGCRB by the September 1, 2005 deadline.

(b) Section 508 hospitals that are approved by the MGCRB for reclassification will have 45 days from the date this FY 2007 IPPS proposed rule is published to cancel their section 1886(d)(10) reclassification for either the first 6 months of FY 2007 or for the entire fiscal year. Hospitals should note that if they fail to cancel their section 1886(d)(10) reclassification by the deadline, they will not receive their section 508 wage adjustment in FY 2007. To further clarify--

Hospitals that cancel their section 1886(d)(10) reclassification for the first 6 months receive their section 508 reclassification for October 1, 2006, through March 31, 2007, and their section 1886(d)(10) reclassification for

[[Page 24086]]

April 1, 2007, through September 30, 2009.

Hospitals that cancel their section 1886(d)(10) reclassification for the entire year will receive their section 508 reclassification for October 1, 2006, through March 31, 2007 and their home area wage index for April 1, 2007, through September 30, 2007.

Hospitals that do not cancel their section 1886(d)(10) reclassification will receive their section 1886(d)(10) reclassification, not their section 508 reclassification, for the entire fiscal year.

Hospital groups that include a section 508 hospital were also permitted to submit section 1886(d)(10) reclassification applications by the September 1, 2005 deadline. However, in order for a group reclassification to be approved, either of the following conditions needed to be met:

(a) The section 508 hospital that is part of the group waived its section 508 reclassification for the first half of FY 2007. This is necessary because the regulations at Sec. Sec. 412.232 and 412.234 state that all hospitals in a county must apply for reclassification as a group. The hospitals either agreed to receive the same reclassification or failed to qualify as a group. The Administrator upheld this policy in an MGCRB appeal for FY 2006.

(b) Each member of the group agreed, in writing, at the time the application was submitted September 1, 2005, that they cancelled the group reclassification if granted for the first 6 months of FY 2007. The section 1886(d)(10) reclassification then is effective only from April 1, 2007, through September 30, 2007. In the FY 2006 final rule, we stated that, under this scenario, the section 508 hospital receives its section 508 reclassification from October 1, 2006, through March 31, 2007, and the remainder of the group receives the home wage index for that time period. For April 1, 2007, through September 30, 2009, the section 508 hospital and the remainder of the group receive the group reclassification. The group may also cancel the April 1, 2007 through September 30, 2009 group reclassification within 45 days of publication of this proposed rule.

We will apply a similar rule for purposes of the out-migration adjustment for FY 2007 discussed in section III.I. of this preamble. The statute states that a hospital cannot receive an out-migration adjustment if it is reclassified under section 1886(d)(10) of the Act. Therefore, eligible hospitals that are not reclassified during any part of FY 2007 will, by default, receive an out-migration adjustment during that time period. If the hospital is reclassified for all of FY 2007, the hospital will be ineligible for the out-migration adjustment. If a hospital has a half fiscal year reclassification, the hospital will be eligible for the out-migration adjustment for the portion of the fiscal year that it is not reclassified.

The procedural rules described in the FY 2006 IPPS final rule were intended to address specific circumstances where individual and group reclassifications involve a section 508 hospital. The rules were designed to recognize the special circumstances of section 508 hospital reclassifications ending mid-year during FY 2007 and were intended to provide flexibility in our regulations that would allow previously approved reclassifications to continue through March 31, 2007, and new reclassifications to begin April 1, 2007, upon the conclusion of the section 508 reclassifications. We have received questions about the application of these special procedural rules to non-section 508 hospitals that are part of group applications that previously were awarded an individual reclassification that continues into FY 2007. These hospitals are concerned that the procedural rules imply that such prior reclassification would be terminated beginning October 1, 2006, because the rules specify that ``the remainder of the group receives the home wage index'' for the period October 1, 2006, through March 31, 2007, if the group reclassification application specified that the section 1886(d)(10) group reclassification would not begin until April 1, 2007. We did not specifically contemplate preexisting individual reclassifications when we drafted the special procedural rules for group reclassifications that involve section 508 hospitals. However, we did not intend to adopt a less favorable policy for non-section 508 hospitals in a group with a pending individual geographic reclassification than we did for section 508 hospitals. Thus, we are clarifying our procedural rule with respect to non-section 508 hospitals with preexisting individual reclassifications that are part of group reclassifications that include a section 508 hospital.

For the first half of FY 2007, we intend to either apply (a) the area wage index where the hospital is physically located if there is no reclassification pending, or (b) the hospital's individual reclassification wage index if the hospital was part of a group awarded a group reclassification and the group followed the procedural rules for postponing reclassification until April 1, 2007. However, once the hospital begins its new section 1886(d)(10) reclassification for the period April 1, 2007, through September 30, 2009, any prior reclassifications are permanently terminated, consistent with 42 CFR 412.274(b)(2)(ii). In fact, because any withdrawal of the group reclassification must be received within 45 days of the publication of this proposed rule, failure to meet this deadline would effectively permanently terminate any remaining years of the individual reclassification. Further, a non-section 508 hospital that is part of a group reclassification that includes a section 508 hospital that will not begin until April 1, 2007, will have the option of canceling its preexisting reclassification for the entire year consistent with section 412.274(b)(1)(ii) within 45 days of publication of this proposed rule. Under this scenario, the hospital would receive its home wage index for the first half of the year and the approved group reclassification wage index for the second half of the year. We are also reiterating that the special procedural rules that we have adopted for half fiscal year reclassifications and terminations are intended only to address the special circumstances created by section 508 of Pub. L. 108-173 with respect to reclassifications beginning and ending mid-way through a fiscal year. These special procedural rules do not change any of the permanent provisions currently in effect with respect to reclassifications under subpart L of 42 CFR Part 412.

As an example: Suppose Hospital A is a non-section 508 hospital that was part of a group reclassification application for FYs 2007 through 2009 and such group contained a section 508 hospital. In accordance with our special section 508 procedural rule, the entire group would be considered to have agreed it would waive its group reclassification for the first half of FY 2007. Hospital A also is currently (for FY 2006) reclassified from Area X to Area Y for FYs 2006 through 2008. For the first half of FY 2007, Hospital A will continue to receive its individual reclassification to Area Y; for the second half of FY 2007, it will receive the group reclassification.

Hospital A may terminate its individual reclassification (termination must be received within 45 days of publication of this proposed rule), in which case it will receive its home wage index for the first half of FY 2007 and the group reclassification for the second half. Acceptance of the group reclassification effectively permanently terminates the individual reclassification to Area Y.

Hospital A's group also has the option of withdrawing its group reclassification (withdrawal must be received within 45 days of publication of this proposed rule

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and all members of the group must agree). If such withdrawal occurs, the default rule is that Hospital A receives its FYs 2006 through 2008 individual reclassification for all of FY 2007.

If Hospital A wishes to receive its home wage index (plus any out- migration adjustment, if applicable), it must also terminate the individual reclassification for all of FY 2007 (termination must be received within 45 days of publication of this proposed rule).

We show the reclassifications effective under the one-time appeal process in Table 9B in the Addendum to this proposed rule. All section 1886(d)(10) reclassifications are listed in Table 9A in the Addendum to this proposed rule. 6. Proposed Wage Indices for Reclassified Hospitals and Proposed Reclassification Budget Neutrality Factor

Under the procedural rules described under section III.H.5. of this preamble, different wage indices may be in effect for the first 6 months and the second 6 months of FY 2007. Specifically, section 508 hospitals that were approved for individual reclassification under Sec. 412.230 have the opportunity to cancel their section 1886(d)(10) reclassification for the first 6 months within 45 days of the publication of this proposed rule and receive their section 508 reclassifications for October 1, 2006, through March 31, 2007, and their section 1886(d)(10) reclassifications for April 1, 2007, through September 30, 2009. The special procedural rule also applied to urban county group applications including a section 508 hospital. In order for the hospital to retain its section 508 reclassification for the first 6 months, each member of the group must have agreed in writing, at the time the application was submitted, that they cancel the group reclassification if granted for the first 6 months of FY 2007. Under this scenario, the section 508 hospital receives its section 508 reclassification from October 1, 2006, through March 31, 2007, and the remainder of the group receives their preexisting individual reclassification or home wage index for that time period. For April 1, 2007, through September 30, 2009, the section 508 hospital and the remainder of the group receive the group reclassification.

The half fiscal year section 1886(d)(10) reclassifications permitted under these procedural rules present issues related to the calculation of the reclassified wage indices and reclassification budget neutrality factor. Section 1886(d)(8)(C) of the Act provides requirements for determining the wage index values for both 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. As provided in the statute, we are required to calculate a separate wage index for hospitals reclassified to an area if including the wage data for the reclassified hospitals would reduce the area wage index by more than 1 percent. Conceivably, we could calculate one reclassified wage index for FY 2007 that would include the wage data of hospitals that are reclassified to the area for any part of FY 2007. However, we are aware of situations in which including the wage data from hospitals only reclassifying for the second half of the fiscal year would change the wage index for reclassified hospitals for the entire fiscal year, even though the reclassification would only be in effect during the second half of the fiscal year. We believe it would be unfair to have wage indices affected for the first half of the fiscal year by including the wage data for hospital reclassifications in effect only for the second half of the fiscal year. We believe that the most equitable approach to this issue would be to calculate separate wage indices for reclassified hospitals for the first and second half of FY 2007. Therefore, we are proposing to issue two separate reclassified wage indices for affected areas (one effective from October 1, 2006, through March 31, 2007, and a second reclassified wage index effective April 1, 2007, through September 30, 2007). The reclassified wage indices would be calculated based on the wage data for hospitals reclassified to the area in the respective half of the fiscal year.

The half fiscal year reclassifications also have implications for budget neutrality. The overall effect of geographic reclassification is required by section 1886(d)(8)(D) of the Act to be budget neutral. We apply an adjustment to the IPPS standardized amounts to ensure that the effects of geographic reclassification are budget neutral. Because we are proposing to calculate two separate reclassification wage indices for the first half and the second half of FY 2007, it is conceivable that we could apply budget neutrality separately for first and second half fiscal year reclassifications. Under this scenario, we would issue two separate IPPS standardized amounts for FY 2007. However, we believe this approach would be administratively burdensome and perhaps cause confusion in the provider community. For this reason, we are proposing an alternative approach. We are proposing to calculate one budget neutrality adjustment that reflects the average of the adjustments required for first and second half fiscal year reclassifications, respectively, as discussed in section II.A.4.b. of the Addendum to this proposed rule.

I. Proposed FY 2007 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 under 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 indices of the labor market area(s) with higher wage indices and the wage index of the resident county, weighted by the overall percentage of hospital workers residing in the qualifying county who are employed in any labor market area with a higher wage index. We have employed the prereclassified wage indices in making these calculations.

We are proposing that hospitals located in the qualifying counties

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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 will receive the wage index adjustment listed in the table for FY 2007. 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 obtained in Step 1.

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

Step 4. Multiply the result from Step 3 by the percentage of hospital employees who are residing in the qualifying county and who are employed in any higher wage index area.

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

As previously noted, hospitals receiving the wage index adjustment under section 1886(d)(13)(F) of the Act are not eligible for reclassification under sections 1886(d)(8) or (d)(10) of the Act, or under section 508 of Pub. L. 108-173, unless they waive such out- migration adjustment. As announced in the FYs 2005 and 2006 final rules, hospitals redesignated under section 1886(d)(8) of the Act or reclassified under section 1886(d)(10) of the Act or under section 508 of Pub. L. 108-173 will be deemed to have chosen to retain their redesignation or reclassification, unless they explicitly notify CMS that they elect to receive the out-migration adjustment instead within 45 days from the publication of this proposed rule. 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.

In addition, under Sec. 412.273, hospitals that have been reclassified by the MGCRB are permitted to terminate existing 3-year reclassifications within 45 days of publication of this proposed rule. Hospitals that are eligible to receive the out-migration wage index adjustment and that withdraw their application for reclassification automatically receive the wage index adjustment listed in Table 4J in the Addendum to this proposed rule. Requests for withdrawal of an application for reclassification or termination of an existing 3-year reclassification will be effective in FY 2007 and must be received by the MGCRB within 45 days of the publication of this proposed rule. Requests to waive section 1886(d)(8) redesignations for FY 2007 must be received by CMS within 45 days of the publication of this proposed rule. In addition, hospitals that wished to retain their redesignation/ reclassification under section 1886(d)(8), section 1886(d)(10), or section 508 (instead of receiving the out-migration adjustment) for FY 2007 do not need to submit a formal request to CMS; they will automatically retain their redesignation/reclassification status for FY 2007. 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 for FY 2007 were made available on October 7, 2005, through the Internet on the CMS Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS. In a

memorandum dated October 7, 2005, 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 7, 2005 wage and occupational mix data files, the hospital was to submit corrections along with complete, detailed supporting documentation to its fiscal intermediary by December 5, 2005. 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 7, 2005 memorandum referenced above.

In the October 7, 2005 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 2007 wage index.

The fiscal intermediaries notified the hospitals by mid-February 2006 of any changes to the wage index data as a result of the desk reviews and the resolution of the hospitals' early December 2005 change requests. The fiscal intermediaries also submitted the revised data to CMS by mid-February 2006. CMS published the proposed wage index PUFs that included hospitals' revised wage data on February 24, 2006. Also, in a memorandum dated February 14, 2006, we instructed fiscal intermediaries to notify all hospitals regarding the availability of the proposed wage index PUFs and the criteria and process for requesting corrections and revisions to the wage index data. Hospitals had until March 13, 2006, 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

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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 transmit any additional revisions resulting from the hospitals' reconsideration requests by April 14, 2006. The deadline for a hospital to request CMS intervention in cases where the hospital disagreed with the fiscal intermediary's policy interpretations is April 21, 2006.

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 2003 data used to construct the proposed FY 2007 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 March 1, 2006.

We will release a final wage data PUF in early May 2006 to hospital associations and the public on the Internet at http://www.cms.hhs.gov/AcuteInpatientPPS. The May 2006 PUF 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 14, 2006). If, after reviewing the May 2006 final file, a hospital believes that its wage data are 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 outlining why the hospital believes an error exists and to provide all supporting information, including relevant dates (for example, when it first became aware of the error). CMS and the fiscal intermediaries must receive these requests no later than June 12, 2006. (We note that the June 12, 2006 date is revised from the June 9, 2006 date originally specified in the October 7, 2005 letter to hospitals.) 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 2006 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 14, 2006.

Requests for correction of errors that were not, but could have been, identified during the hospital's review of the February 24, 2006 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 12, 2006) will be incorporated into the final wage index to be published by August 1, 2006, to be effective October 1, 2006.

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 2007 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) and Palisades General Hospital v. Thompson, No. 99-1230 (D.D.C. 2003.) We refer the reader also to the FY 2000 final rule (64 FR 41513) for a discussion of the parameters for appealing to the Provider Reimbursement Review Board for wage index data corrections.

Again, we believe the wage index data correction process described above provides hospitals with sufficient opportunity to bring errors in their wage index data to the fiscal intermediaries' attention. Moreover, because hospitals will have access to the final wage index data by early May 2006, 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 2007 wage index by August 1, 2006, and the implementation of the FY 2007 wage index on October 1, 2006. 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 12, 2006, we retain the right to make midyear changes to the wage index under very limited circumstances.

Specifically, in accordance with Sec. 412.64(k)(1) of our existing regulations, we make midyear corrections to the wage index for an area only if a hospital can show that: (1) The fiscal intermediary or CMS made an error in tabulating its data; and (2) the requesting hospital could not have known about the error or did not have an opportunity to correct the error, before the beginning of the fiscal year. For purposes of this provision, ``before the beginning of the fiscal year'' means by the June deadline for making corrections to the wage data for the following fiscal year's wage index. This provision is not available to a hospital seeking to revise another hospital's data that may be affecting the requesting hospital's wage index for the labor market area. As indicated earlier, since CMS makes the wage data available to a hospital on the CMS Web site prior to publishing both the proposed and final IPPS rules, and the fiscal intermediaries notify hospitals directly of any wage data changes after completing their desk reviews, we do not expect that midyear corrections would be necessary. However, under our current policy, if the correction of a data error changes the wage index value for an area, the revised wage index value will be effective prospectively from the date the correction is made.

In the FY 2006 IPPS final rule (70 FR 47385), we revised Sec. 412.64(k)(2) to specify that, effective on October 1, 2005, that is beginning with the FY 2006 wage index, a change to the wage index can be made retroactive to the beginning of the Federal fiscal year only when: (1) The fiscal intermediary or 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 12, 2006 deadline for the FY 2007 wage index); and (3) CMS agreed

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that the fiscal intermediary or CMS made an error in tabulating the hospital's wage data and the wage index should be corrected.

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 was caused by CMS's or the fiscal intermediary's mishandling of the data, we believe that the hospital should not be penalized by our delay in publishing or implementing the correction. As with our current policy, we indicated that the provision is not available to a hospital seeking to revise another hospital's data. In addition, the provision cannot be used to correct prior years' wage data; it can 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 note that, as with prospective changes to the wage index, the final retroactive correction will be made irrespective of whether the change increases or decreases a hospital's payment rate. In addition, we note that the policy of retroactive adjustment will still apply in those instances where a judicial decision reverses a CMS denial of a hospital's wage data revision request.

K. Labor-Related Share for the Wage Index for FY 2007

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

Section 1886(d)(3)(E) of the Act directs the Secretary to adjust the proportion of the national prospective payment system base payment rates that are attributable to wages and wage-related costs by a factor that reflects the relative differences in labor costs among geographic areas. It also directs the Secretary to estimate from time to time the proportion of hospital costs that are labor-related: ``The Secretary shall adjust the proportion (as estimated by the Secretary from time to time) of hospitals' costs which are attributable to wages and wage- related costs of the DRG prospective payment rates * * *'' We refer to the portion of hospital costs attributable to wages and wage-related costs as the labor-related share. The labor-related share of the prospective payment rate is adjusted by an index of relative labor costs, which is referred to as the wage index.

In its June 2001 Report to Congress, MedPAC recommended that the Secretary ``should reevaluate current assumptions about the proportion of providers' costs that reflect resources purchased in local and national markets.'' (Report to the Congress: Medicare in Rural America, Recommendation 4D, page 80.) MedPAC recommended that the labor-related share include the weights for wages and salaries, fringe benefits, contract labor, and other labor-related costs for locally purchased inputs only. MedPAC noted that this would likely result in a lower labor-related share, which would decrease the amount of the national base payment amount adjusted by the wage index. As a result, hospitals located in low-wage markets (those with a wage index less than 1.0) would receive higher payments, while those located in high-wage labor markets would receive lower payments.

In our proposed and final rules updating the IPPS for FY 2003 (67 FR 31447, May 9, 2002 and 67 FR 50041, August 1, 2002), we discussed the methodology that we have used to determine the labor-related share. We noted that, at that time, the results of employing that methodology suggested that an increase in the labor-related share (from 71.066 percent to 72.495 percent) was warranted. However, we decided not to propose such an increase in the labor-related share until we conducted further research to determine whether a different methodology for determining the labor-related share should be adopted.

Section 403 of Pub. L. 108-173 amended section 1886(d)(3)(E) of the Act to provide that the Secretary must employ 62 percent as the labor- related share unless this ``would result in lower payments to a hospital than would otherwise be made.'' However, this provision of Pub. L. 108-173 did not change the legal requirement that the Secretary estimate ``from time to time'' the proportion of hospitals' costs that are ``attributable to wages and wage-related costs.'' In fact, section 404 of Pub. L. 108-173 required the Secretary to develop a frequency for revising the weights used in the hospital market basket, including the labor-related share, to reflect the most current data more frequently than once every 5 years. We believe that this reflected Congressional intent that hospitals receive payment based on either a 62-percent labor-related share, or the labor-related share estimated from time to time by the Secretary, depending on which labor-related share resulted in a higher payment.

Section 404 further required us to include in the final IPPS rule for FY 2006 an explanation of the reasons for, and options considered, in determining the frequency for revising the weights used in the hospital market basket, including the labor-related share. In addition, we have continued our research into the assumptions employed in calculating the labor-related share. Our research involves analyzing the compensation share separately for urban and rural hospitals, using regression analysis to determine the proportion of costs influenced by the area wage index, and exploring alternative methodologies to determine whether all or only a portion of professional fees and nonlabor intensive services should be considered labor-related.

In the FY 2006 IPPS final rule (70 FR 47392), we presented our analysis and conclusions regarding the frequency and methodology for updating the labor-related share for FY 2006. We also recalculated a labor-related share of 69.731 percent, using the FY 2002-based PPS market basket for discharges occurring on or after October 1, 2005. In addition, we implemented this revised and rebased labor-related share in a budget neutral manner, but consistent with section 1886(d)(3)(E) of the Act, we did not take into account the additional payments that would be made as a result of hospitals with a wage index less than or equal to 1.0 being paid using a labor-related share lower than the labor-related share of hospitals with a wage index greater than 1.0.

The labor-related share is used to determine the proportion of the national PPS base payment rate to which the area wage index is applied. In this proposed rule, we are not making any changes to the national average proportion of operating costs that are attributable to wages and salaries, fringe benefits, professional fees, contract labor, and labor intensive services. Therefore, we are continuing to use a labor- related share of 69.731 percent for discharges occurring on or after October 1, 2006, as reflected in Tables 1A and 1B in the Addendum to this proposed rule. We note that section 403 of Pub. L. 108-173 amended sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act to provide that the Secretary must employ 62 percent as the labor-related share unless this employment ``would result in lower payments to a hospital than would otherwise be made.''

We also are continuing to use a labor-related share for the Puerto Rico-specific standardized amounts of 58.7 percent for discharges occurring on or after

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October 1, 2006. Consistent with our methodology for determining the national labor-related share, we added the Puerto Rico-specific relative weights for wages and salaries, fringe benefits, contract labor, nonmedical professional fees, and other labor-intensive services to determine the labor-related share. Puerto Rico hospitals are paid based on 75 percent of the national standardized amounts and 25 percent of the Puerto Rico-specific standardized amounts. For Puerto Rico hospitals, the national labor-related share will always be 62 percent because the wage index for all Puerto Rico hospitals is less than 1.0. A Puerto Rico-specific wage index is applied to the Puerto Rico- specific portion of payments to the hospitals. The labor-related share of a hospital's Puerto Rico-specific rate will be either 62 percent or the Puerto Rico-specific labor-related share depending on which results in higher payments to the hospital. If the hospital has a Puerto Rico- specific wage index of greater than 1.0, we will set the hospital's rates using a labor-related share of 62 percent for the 25 percent portion of the hospital's payment determined by the Puerto Rico standardized amounts because this amount will result in higher payments. Conversely, a hospital with a Puerto Rico-specific wage index of less than 1.0 will be paid using the Puerto Rico-specific labor- related share of 58.7 percent of the Puerto Rico-specific rates because the lower labor-related share will result in higher payments. The Puerto Rico labor-related share of 58.7 percent for FY 2007 is reflected in the Table 1C of the Addendum of this proposed rule.

L. Proxy for the Hospital Market Basket

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

In the FY 2006 IPPS final rule (70 FR 47387), we changed the base year cost structure for the IPPS hospital index for the hospital market basket for operating costs from FY 1997 to FY 2002. As discussed in that final rule, the IPPS hospital index primarily uses the BLS data as price proxies, which are grouped in one of the three BLS categories. The categories are Producer Price Indexes (PPIs), Consumer Price Indexes (CPIs), and Employment Cost Indexes (ECIs), discussed in detail in the FY 2006 IPPS final rule (70 FR 47388 through 47391). We evaluate the price proxies using the criteria of reliability, timeliness, availability, and relevance. The PPIs, CPIs, and ECIs selected by us and used for this proposed rule meet these criteria as described in the FY 2006 IPPS final rule. We believe they continue to be the best measures of price changes for the cost categories.

Beginning April 2006 with the publication of March 2006 data, the BLS' ECI will use a different classification system, the North American Industrial Classification System (NAICS), instead of the Standard Industrial Codes (SIC), which will no longer exist. We have consistently used the ECI as the data source for our wages and salaries and other price proxies in the IPPS market basket and are not making any changes to the usage at this time. However, we are soliciting comments on our continued use of the BLS ECI data in light of the BLS change in system usage to the NAICS-based ECI.

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

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

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

Section 5001(a) of Public Law 109-171 (DRA of 2005) sets out new requirements for the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program. The RHQDAPU program was established to implement section 501(b) of Public Law 108-173 (MMA). It builds on our ongoing voluntary Hospital Quality Initiative which is intended to empower consumers with quality of care information to make more informed decisions about their health care while also encouraging hospitals and clinicians to improve the quality of care.

Section 5001(a) of Public Law 109-171 revises the mechanism used to update the standardized amount for payment for hospital inpatient operating costs. New sections 1886(b)(3)(B)(viii)(I) and (II) of the Act provide that the payment update for FY 2007 and each subsequent fiscal year will be reduced by 2.0 percentage points for any ``subsection (d) hospital'' that does not submit certain quality data in a form and manner, and at a time, specified by the Secretary.

New sections 1886(b)(3)(B)(viii)(III) and (IV) of the Act require that we expand the ``starter set'' of 10 quality measures that we have used since 2003. In expanding these measures, we must begin to adopt the baseline set of performance measures as set forth in a 2005 report issued by the Institute of Medicine (IOM) of the National Academy of Sciences under section 238(b) of Public Law 108-173, effective for payments beginning with FY 2007. The IOM measures include the Hospital Quality Alliance (HQA) measures, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS[reg]) patient perspective survey, and three structural measures. We discuss the IOM report more fully in section IV.B. of the preamble to this proposed rule.

New sections 1886(b)(3)(B)(viii)(V) and (VI) of the Act require that, effective for payments beginning with FY 2008, we add other quality measures that reflect consensus among affected parties, and provide the Secretary with the discretion to replace any quality measures or indicators in appropriate cases, such as where all hospitals are effectively in compliance with a measure, or the measures or indicators have been subsequently shown to not represent the best clinical practice. Thus, the Secretary has broad discretion to replace measures on the basis that they are not appropriate.

New section 1886(b)(3)(B)(viii)(VII) of the Act requires that we establish procedures for making quality data available to the public after ensuring that a hospital has the opportunity to review, in advance, its data that are to be made public. In addition, this section requires that we report quality measures of process, structure, outcome, patients' perspective on care, efficiency, and costs of care that relate to services furnished in inpatient settings on the CMS Web site.

Like the provisions of section 501(b) of Public Law 108-173, the provisions of section 5001(a) of Public Law 109-171 do not apply to hospitals and hospital units excluded from the IPPS, or to payments to hospitals under other prospective payment systems such as the hospital outpatient PPS. New section 1886(b)(3)(B(viii)(I) of the Act also provides that any reduction will apply only with respect to the fiscal year involved, and will not be taken into account for computing the applicable percentage increase for a subsequent fiscal year.

Initially, section 1886(b)(3)(B)(vii) of the Act provided for a reduction of 0.4 percentage points to the update percentage increase for each of FYs 2005 through 2007 for any ``subsection (d) hospital'' that did not submit data on the starter set of 10 quality measures established by the Secretary of Health and Human Services as of November 1, 2003. Section 5001(a) of Public Law 109-171 limits the 0.4 percentage point reduction to FY 2005 and FY 2006, and

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establishes a 2.0 percentage point reduction for FY 2007 and subsequent fiscal years.

The starter set of 10 quality measures we established 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 (HF)

Did the patient get an assessment of his or her heart function?

Was an ACE inhibitor given to the patient?

Pneumonia (PNE)

Was an antibiotic given to the patient in a timely way?

Had the patient received a pneumococcal vaccination?

Was the patient's oxygen level assessed?

We adopted these measures after the Secretary of HHS initiated a partnership with several collaborators intended to promote hospital quality improvement and 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 (NQF), 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.

This collaboration, originally known as the National Voluntary Hospital Reporting Initiative, is now known as the HQA. Hospital data are submitted through the QualityNet Exchange secure Web site (http://www.qnetexchange.org). This Web site meets or exceeds all current

Health Insurance Portability and Accountability Act requirements. Data from this initiative were initially used to populate the Hospital Compare Web site, http://www.hospitalcompare.hhs.gov. This Web site assists

beneficiaries and the general public by providing information on hospital quality of care for consumers who need to select a hospital. It further serves to encourage consumers to work with their doctors and hospitals to discuss the quality of care they provide to patients, thereby providing an additional incentive to improve the quality of that care.

This starter set of 10 quality measures has been endorsed by the NQF and is a subset of measures currently collected for the JCAHO as part of its certification program. We chose these 10 quality measures in order to collect data that will: (1) Provide useful and valid information about hospital quality to the public; (2) provide hospitals with a sense of predictability about public reporting expectations; (3) begin to standardize data and data collection mechanisms; and (4) foster hospital quality improvement. Many hospitals have participated in the HQA, and are continuing to submit data to the QIO Clinical Warehouse. Since the HQA released the starter set of 10 quality measures, it has continued to release additional quality measures, and has released 11 additional NQF-endorsed quality measures to date. Many HQA-participating hospitals have been voluntarily reporting on these additional quality measures, although only the starter set of 10 quality measures were subject to potential reductions in hospitals' annual payment update percentages under section 501(b) of Public Law 108-173.

To implement section 501(b) of Public Law 108-173, we created the RHQDAPU program. Originally, the program set out the form, manner, and timeframes for hospitals to submit data regarding the starter set of 10 quality measures. For the FY 2005 payment update, we permitted hospitals to withdraw from the RHQDAPU program at any time up to August 1, 2004. Hospitals that withdrew from the program did not receive the full payment update and, instead, received a reduction of 0.4 percentage points in their payment update. We did not establish a deadline for withdrawal for the FY 2006 payment update.

For FY 2006, in order to receive a full payment update, hospitals were required to continuously submit to the QIO Clinical Warehouse abstracted data regarding the starter set of 10 quality measures each calendar quarter according to the schedule found on the QualityNet Exchange Web site. New participants were required to submit these data using the same schedule, starting with the quarter they began discharging patients. The data for each quarter had to be submitted on time and pass all of the edits and consistency checks required in the QIO Clinical Warehouse. Hospitals that did not treat a condition or that had very few discharges were not penalized, and they received the full payment update if they submitted appropriate data on each of the 10 quality measures that they treated for patients who were discharged during the reporting periods. 2. New Procedures for Hospital Reporting of Quality Data

We are proposing to amend our regulations at Sec. 412.64(d)(2) to reflect the 2.0 percentage point reduction in the payment update for FY 2007 and subsequent fiscal years for hospitals that do not comply with requirements for reporting quality data as provided for under section 5001(a) of Public Law 109-171. We are also revising the RHQDAPU program's procedures to reflect our experience with this program and to implement section 5001(a) of Public Law 109-171, including the new requirement for reporting of an expanded set of quality measures.

In addition to publication in this proposed rule, all revised procedures will be added to the ``Reporting Hospital Quality Data for Annual Payment Update Reference Checklist'' section of the QualityNet Exchange Web site. This checklist also contains all of the forms to be completed by hospitals participating in the program. In order to participate in the hospital reporting initiative, hospitals must follow these steps:

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.

Complete the revised ``Reporting Hospital Quality Data for Annual Payment Update Notice of Participation'' form. All hospitals must send this form to their QIO, no later than August 1, 2006. In addition, before participating hospitals initially begin reporting data, they must register with the QualityNet Exchange, regardless of the method used for submitting data.

Continue to collect data for all 10 ``starter set'' quality measures (or begin collecting such data, if newly participating in the program), and submit the data to the QIO Clinical Warehouse either using the CMS Abstraction & Reporting Tool (CART), the JCAHO ORYX[supreg] Core Measures Performance Measurement System, or another third-party vendor tool that has met the measurement specification requirements for data transmission to QualityNet Exchange. The QIO Clinical

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Warehouse will submit the data to CMS on behalf of the hospitals. The submission will be done through QualityNet Exchange. Because the information in the QIO Clinical Warehouse is considered QIO information, it is subject to the stringent QIO confidentiality regulations in 42 CFR part 480. We are proposing that hospitals continue to submit data regarding the starter set of 10 quality measures because the existing data submission schedule that we will use for the FY 2007 update relies on discharges that occurred in calendar year (CY) 2005. Because the first three quarters of CY 2005 data already have been submitted, we are not proposing to require hospitals to submit any additional CY 2005 data to address the new quality measures in the anticipated expanded 21 quality measures discussed below. However, we again note that many hospitals have been providing data on these additional measures since they were first included in the HQA set, although these measures did not affect hospitals' annual payment adjustment under the RHQDAPU program implementing section 501(b) of Public Law 108-173.

For the FY 2007 update, hospitals also will be required to complete and return a written form on which they pledge to submit data on the following set of expanded quality measures (anticipated 21 clinical quality measures), starting with discharges that occur in CY 2006. These expanded quality measures are the HQA-released measures that the 2005 IOM report recommended we use as expanded ``starter'' measures. As discussed above, new section 1886(b)(3)(B)(viii)(IV) of the Act requires us to begin to adopt the baseline set of performance measures set forth in the 2005 IOM report effective for payments beginning with FY 2007. Hospitals will be required to submit data on the expanded measures to the QIO Clinical Warehouse beginning with discharges that occur in the first calendar quarter of 2006 (January through March discharges). The deadline for hospitals to submit their data for first quarter 2006 is August 15, 2006.

The expanded measures are:

Heart Attack (Acute Myocardial Infarction)

Aspirin at arrival

Aspirin prescribed at discharge

ACE inhibitor (ACE-I) or Angiotensin Receptor Blocker (ARBs) for left ventricular systolic dysfunction

Beta blocker at arrival

Beta blocker prescribed at discharge

Thrombolytic agent received within 30 minutes of hospital arrival

Percutaneous Coronary Intervention (PCI) received within 120 minutes of hospital arrival

Adult smoking cessation advice/counseling

Heart Failure (HF)

Left ventricular function assessment

ACE inhibitor (ACE-I) or Angiotensin Receptor Blocker (ARBs) for left ventricular systolic dysfunction

Discharge instructions

Adult smoking cessation advice/counseling

Pneumonia (PNE)

Initial antibiotic received within 4 hours of hospital arrival

Oxygenation assessment

Pneumococcal vaccination status

Blood culture performed before first antibiotic received in hospital

Adult smoking cessation advice/counseling

Appropriate initial antibiotic selection

Influenza vaccination (collected but not publicly reported--subject to change)

Surgical Infection Prevention (SIP)

Prophylactic antibiotic received within 1 hour prior to surgical incision

Prophylactic antibiotics discontinued within 24 hours after surgery end time

Further, as recommended in the IOM report, we will be implementing the HCAHPS[supreg] patient survey in October 2006, to measure patients' perspectives of care. HCAHPS[supreg] is designed to make ``apples to apples'' comparisons of patients' perspectives on hospital care including communications with doctors, communications with nurses, responsiveness of hospital staff, cleanliness and quietness of the hospital, pain control, communication about medicines, and discharge information. More information on this survey can be found on our Web site: http://www. cms. hhs.gov/Hospital QualityInits/ downloads/Hospital

HCAHPSFactSheet 200512.pdf. We intend to report the first three quarters of these survey data in late 2007 on the Web site: http://www.hospitalcompare.hhs.gov. HCAHPS[supreg] was endorsed by the NQF in

May 2005. However, at this time, we do not anticipate including HCAHPS[supreg] as a part of the revised FY 2007 ``Reporting Hospital Quality Data for Annual Payment Update Notice of Participation'' form. We believe that our proposed procedure will meet the requirement of section 1886(b)(3)(B)(viii)(IV) of the Act that, ``for payments beginning with fiscal year 2007, in expanding the number of measures, under subclause (III), the Secretary shall begin to adopt'' the IOM report's set of baseline measures. Section 1886(b)(3)(B)(viii)(III) of the Act states that we must expand, for FY 2007 and each subsequent fiscal year, the set of measures that the Secretary determines to be ``appropriate'' for the measurement of the quality of care furnished by hospitals in inpatient settings beyond the original quality measures that applied in FY 2005 and FY 2006.

We believe that the statute gives the Secretary the discretion to choose what ``begin to adopt'' should involve in FY 2007 and the number of additional measures, if any, that would be ``appropriate'' during that time. In proposing our revised procedures, designing the methods that hospitals will use to report during FY 2007, establishing an anticipated set of expanded measures based on the IOM report, and revising RHQDAPU materials, we believe that we have met the statutory requirements. We will continue to explore the feasibility of adopting additional measures for purpose of the FY 2008 update, including the HCAHPS[supreg] and structure measures described in the IOM report and other measures that reflect consensus among affected parties, as required by new section 1886(b)(3)(B)(viii)(III) through (V) of the Act.

For the FY 2007 update, we specify that hospitals must submit these complete data in accordance with the joint CMS/JCAHO sampling requirements located on the QualityNet Exchange Web site. These requirements specify that hospitals are required to submit a random sample or complete population of cases for each of three topics (acute myocardial infarction, heart failure, and pneumonia) covered by the starter set of 10 quality measures. These requirements include all Medicare and non-Medicare patients discharged from hospitals. Hospitals are expected to continuously meet these sampling requirements for the starter set of 10 quality measures for discharges in each quarter.

We do not anticipate significant additional burden on hospitals regarding the starter set of 10 quality measures or the anticipated 21 clinical quality measures because all JCAHO-accredited hospitals are currently required to adhere to these sampling requirements in acute myocardial infarction, heart failure, pneumonia, and surgical infection prevention for

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accreditation and core measure reporting purposes.

For the FY 2007 update, hospitals may withdraw from the revised RHQDAPU program at any time up to August 1, 2006. If a hospital withdraws from the program, it will receive a 2.0 percentage point reduction in its payment update.

For the FY 2007 update, we will continue to require that hospitals meet the chart validation requirements that we implemented in the FY 2006 IPPS final rule. There were no chart-audit validation criteria in place for FY 2005. Based upon our experience with the FY 2005 submissions and our requirement for reliable and valid data, in the FY 2006 IPPS final rule, we established additional requirements for the data that hospitals were required to submit in order to receive the full FY 2006 payment update (70 FR 47421 and 47422). These requirements, as well as additional information on validation requirements, will continue and are being placed on the QualityNet Exchange Web site.

For the FY 2007 payment update, hospitals must pass our validation requirement of a minimum of 80 percent reliability, based upon our chart-audit validation process, for the first three quarters of data from CY 2005. These data were due to the QIO Clinical Warehouse by July 15, 2005 (first quarter CY 2005 discharges), November 15, 2005 (second quarter CY 2005 discharges), and February 15, 2006 (third quarter CY 2005 discharges).

We use confidence intervals to determine if a hospital has achieved an 80-percent reliability aggregated over the three quarters. The use of confidence intervals allows us to establish an appropriate range below the 80-percent reliability threshold that demonstrates a sufficient level of validity to allow the data to still be considered valid.

We estimate the percent reliability based upon a review of five charts, and then calculate the upper 95-percent confidence limit for that estimate. If this upper limit is above the required 80-percent reliability, the hospital data are considered validated. We are using the design-specific estimate of the variance for the confidence interval calculation, which, in this case, is a stratified single stage cluster sample, with unequal cluster sizes. (For reference, see Cochran, William G.: Sampling Techniques, John Wiley & Sons, New York, chapter 3, section 3.12 (1977); and Kish, Leslie: Survey Sampling, John Wiley & Sons, New York, chapter 3, section 3.3 (1964).) Each quarter is treated as a stratum for variance estimation purposes.

We use a two-step process to determine if a hospital is submitting valid data. In the first step, we calculate the percent agreement for all of the variables submitted in all of the charts. If a hospital falls below the 80-percent cutoff, we restrict the comparison to those variables associated with the starter set of 10 quality measures. We recalculate the percent agreement and the estimated 95-percent confidence interval and again compare to the 80-percent cutoff point. If a hospital passes under this restricted set of variables, the hospital is considered to be submitting valid data for purposes of the revised RHQDAPU program.

Under the standard appeal process, all hospitals are given the detailed results of the Clinical Data Abstraction Center (CDAC) reabstraction along with their estimated percent reliability and the upper bound of the 95-percent confidence interval. If a hospital does not meet the required 80-percent threshold, the hospital has 10 working days to appeal these results to their QIO. The QIO will review the appeal with the hospital and make a final determination on the appeal. The QIO receives from the hospital the element or elements that are to be evaluated during the appeal process, along with the hospital's rationale for the difference between the hospital's abstraction and the CDAC abstraction. In this validation appeal process, the QIO reviews the appeal using the medical record to evaluate the data elements that are being appealed. This process allows for an independent review and is designed to find coding errors on the part of abstractors. QIO appeal decisions are based on the data that the hospital submitted to the QIO Clinical Warehouse. The QIO has 20 calendar days to make a final decision. The QIO can either uphold or reverse the CDAC validation decision. If the QIO does not agree with the hospital's appeal, the original results stand. However, if the QIO agrees with the hospital, new validation results are calculated and provided to the hospital through the usual processes. This validation appeal process is described in detail at the QualityNet Exchange Web site.

In reviewing the hospital data, we plan to combine the samples for first quarter, second quarter, and third quarter (15 cases) into a single stratified 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 five charts pulled each quarter and for the entire year around the overall hospital mean score (on all individual data elements compared). The closer each case's reliability score is to the hospital mean score, the tighter the confidence interval established for that hospital. A hospital may code each chart equally inaccurately, achieve a tight confidence interval, and not pass, even though its overall score is just below the passing threshold (75 percent, for example). A hospital with more variation among charts will achieve a broader confidence interval, which may allow it to pass, even though some charts score very low and others score very high.

We believe we have adopted the most suitable statistical tests for the hospital data we are trying to validate. We are particularly interested in comments from hospitals on this passing threshold, the confidence interval, and the sampling approach. Based on analytical results from FY 2006, we found confidence intervals using only five charts widely varied in size. As a result of these findings, we decided to combine multiple quarters of validation samples into a single stratified sample to shrink and/or decrease the variation and produce a more reliable estimate of abstraction reliability 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 CMS Quality Improvement Group will continue to study methods for improving the validation process for hospital submission in regard to completeness and adherence to sampling requirements. Current validation sampling assesses abstraction accuracy, but submission completeness and adherence to sampling requirements are critical prerequisites to produce accurate hospital quality measures.

For the FY 2007 update, we plan to revise and post up-to-date confidence interval information on the QualityNet Exchange Web site explaining the application of the confidence interval to the overall validation results. The data are being validated at several levels. There are consistency and internal edit checks to ensure the integrity of the submitted data; there are external edit checks to verify expectations about the volume of the data received.

We are proposing that hospitals attest to the completeness and accuracy of the data submitted to the QIO Clinical Warehouse in order to improve aspects of the validation checks. In order to

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meet this requirement, for each quarter, hospitals will have to sign off on the volume of the data submitted. We plan to provide additional information to explain the data completeness requirement and as well as a form to be completed on the QualityNet Exchange Web site.

We will continue to display quality information for public viewing as required by new section 1886(b)(3)(B)(viii)(VII) of the Act. Before we display this information, hospitals will be permitted to review their information as we have it recorded.

For hospitals that CMS has determined do not meet the RHQDAPU program requirements for the applicable fiscal year who wish to appeal this determination, the appeals process set forth in 42 CFR Part 405, Subpart R (a Provider Reimbursement Review Board (PRRB) appeal) applies. However, we believe it may be appropriate to establish a structured reconsideration process to precede the PRRB appeal. Currently, hospitals submit letters detailing their reasons for requesting that CMS reconsider its decision that the hospital did not meet the RHQDAPU program requirements. We are proposing to continue this process for FY 2007 RHQDAPU program decisions. However, we are proposing to establish a deadline of November 1, 2006, for hospitals to make such requests related to the FY 2007 RHQDAPU decisions, which will give hospitals a minimum of 30 days to submit reconsideration requests from the dates that the decisions are made public. Further, we are proposing that the November 1, 2006 deadline also would apply to FY 2005 and FY 2006 RHQDAPU program decisions and that a November 1 deadline would apply in all future fiscal years. CMS will officially respond to the letters submitted by hospitals.

Further, we are seeking public comment specifically on the need for a more structured reconsideration process to precede any PRRB appeal for FY 2008 and subsequent fiscal years. We also are seeking comment on what such a process would entail. For example, we would expect that such a process, if established, would include--

A limited time, such as 30 days from the public release of the decision, for requesting a reconsideration;

Who in a hospital organization can request such a reconsideration and be notified of its outcome;

The specific factors that CMS will consider in such a reconsideration, such as an inability to submit data timely due to CMS systems failures;

Specific requirements for submitting a reconsideration request, such as a written request for reconsideration specifically stating all reasons and factors, including specific data elements, why the hospital believes it did meet the RHQDAPU program requirements;

Specific CMS components that would participate in the reconsideration process; and

The timeframe, such as 60 days, for CMS to provide its reconsideration decision to the hospital.

We are also soliciting comments on the reasons for not establishing such a reconsideration process. 3. Electronic Medical Records

In the FY 2006 IPPS final rule, we encouraged hospitals to take steps toward the adoption of electronic medical records (EMRs) that will allow for reporting of clinical quality data from the EMRs directly to a CMS data repository (70 FR 47420). We intend to begin working toward creating measures specifications and a system or mechanism, or both, that will accept the data directly without requiring the transfer of the raw data into an XML file as is currently done. The Department continues to work cooperatively with other Federal agencies in the development of Federal health architecture data standards. We encourage hospitals that are developing systems to conform them to both industry standards and, when developed, the Federal Health Architecture Data standards, and to ensure that the data necessary for quality measures are captured. Ideally, such systems will also provide point-of-care decision support that enables high levels of performance on the measures. Hospitals using EMRs to produce data on quality measures will be held to the same performance expectations as hospitals not using EMRs.

Due to the low volume of comments we received on this issue in response to the FY 2006 IPPS rule, in this proposed rule for FY 2007, we again are inviting comments on these requirements and options. In section IV.B.6. of the preamble to this proposed rule, we are also inviting comments on the potential role of effective, interoperable, health information on technology in value-based purchasing.

B. Value-Based Purchasing

(If you choose to comment on issues in this section, please include the caption ``Value-Based Purchasing'' at the beginning of your comment.) 1. Introduction

CMS has undertaken a number of activities to improve the quality and efficiency of care delivered to Medicare beneficiaries. Currently, there are several different fee-for-service payment systems under Medicare that are used to pay health professionals and other providers based on the number and complexity of services provided to patients. In general, all providers to which a specific Medicare payment system applies receive the same amount for a service, regardless of its quality or efficiency. As a result, Medicare's payment systems can direct more resources to hospitals that deliver care that is not of the highest quality or include unnecessary services (for example, duplicative tests and services or services to treat avoidable complications). Therefore, we are examining the concept of ``value- based purchasing,'' which may use a range of incentives to achieve identified quality and efficiency goals, as a means of promoting better quality of care and more effective resource use in the Medicare payment systems. In considering the concept of value-based purchasing, we are working closely with stakeholder partners, including health professionals and providers. In this proposed rule, we are seeking public comment on value-based purchasing as related specifically to hospitals.

In this section, we discuss CMS' and Congress' initial steps toward hospital value-based purchasing, which include the Premier Hospital Quality Incentive Demonstration, the RHQDAPU program authorized by section 501(b) of Public Law 108-173 (MMA), and the extended and expanded RHQDAPU program authorized by section 5001(a) of Public Law 109-171 (DRA). (The RHQDAPU program is also discussed in section IV.A. of the preamble to this proposed rule.) In addition, we discuss the issues that must be considered in developing a plan to implement a value-based purchasing plan beginning with FY 2009 for Medicare payments for subsection (d) hospitals. This plan is required by section 5001(b) of the DRA. For each of the required planning issues (measures, data infrastructure, payment methodology, and public reporting), we discuss CMS' activities to date and solicit comments on outstanding policy questions. Next, we discuss options for implementation of section 5001(c) of Public Law 109-171, which authorizes quality adjustment to DRG payments for certain conditions that were not present on hospital admission. We are soliciting input about detailed design considerations related to each of these issues and the advantages and disadvantages of possible approaches to

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planning and implementing hospital value-based purchasing.

Finally, we discuss and invite comments on how to encourage hospitals to effectively use health information technology to improve efficiency, processes, and health care outcomes, through, for example, adopting interoperable health information technology. 2. Premier Hospital Quality Incentive Demonstration

One of the ways in which CMS is testing innovative potential approaches to improving quality is through demonstrations and pilot projects. The demonstration most relevant to hospitals is the Premier Hospital Quality Incentive Demonstration. Premier, Inc., a nationwide alliance of not-for-profit hospitals, submitted an unsolicited proposal for consideration by CMS.\13\ We have partnered with Premier to conduct a demonstration that is designed to test whether the quality of inpatient care for Medicare beneficiaries improves when financial incentives are provided. Under the demonstration, about 270 hospitals are voluntarily providing data on 34 quality measures related to 5 clinical conditions: Heart attack, heart failure, pneumonia, coronary artery bypass graft, and hip and knee replacements.

\13\ The Premier Hospital Quality Incentive Demonstration was authorized under section 402 of Public Law 90-248, Social Security Amendments of 1967 (42 U.S.C. 1395b-1). This section authorizes certain types of demonstration projects that waive compliance with the regular payment methods used in the Medicare program.

Using the quality measures, CMS identifies hospitals with the highest quality performance in each of the five clinical areas. Hospitals scoring in the top 10 percent in each clinical area receive a 2-percent bonus payment in addition to the regular Medicare DRG payment for the measured condition. Hospitals in the second highest 10 percent receive a 1-percent bonus payment. In the third year of the demonstration, hospitals that do not achieve absolute improvements above the demonstration's first year composite score baseline (the lowest 20 percent) for that condition will have their DRG payments reduced by 1 or 2 percent, depending on how far their performance is below the baseline.

Following the first year of the demonstration (FY 2004), CMS awarded a total of $8.85 million to participating hospitals in the top two deciles for each clinical area. In the aggregate, quality of care improved in all five clinical areas that were measured. Preliminary information from the second year of the demonstration indicates that quality is continuing to improve, particularly for the poorest performing hospitals. Additional information on the Premier Hospital Quality Incentive Demonstration is available on the CMS Web site at: http://www. cms.hhs.gov/ HospitalQuality Inits/35--HospitalPremier.asp.

3. RHQDAPU Program

We believe that the acts of collecting and submitting performance data and of publicly reporting comparative information about hospital performance seems to be a strong incentive to encourage hospital accountability. Measurement and reporting can help focus the attention of hospitals and consumers on specific goals and on hospitals' performance relative to those goals. a. Section 501(b) of Public Law 108-173 (MMA)

Since 2003, we have operated the Hospital Quality Initiative,\14\ which is designed to stimulate improvements in hospital care by standardizing hospital performance measures and data transmission to ensure that all payers, hospitals, and oversight and accrediting entities use the same measures when publicly reporting on hospital performance. Section 501(b) of Public Law 108-173 authorized us to link the collection of data for an initial starter set of 10 quality measures to the Medicare annual update of the standardized payment amount for hospital inpatient operating costs (also known as the RHQDAPU program). For FYs 2005 and 2006, hospitals that met the RHQDAPU program's requirements received the full annual payment update to their inpatient operating costs, while hospitals that did not comply received an update that was reduced by 0.4 percentage points. For FY 2005, virtually every hospital in the country that was eligible to participate submitted data (98.3 percent), and approximately 96 percent of all participating hospitals met the requirements to receive the full update. The data regarding the starter set of 10 quality measures as well as additional, voluntarily-reported data on other quality measures, are available to the public through the Hospital Compare Web site at: http://www.hospitalcompare.hhs.gov.

\14\ For more information about CMS' Hospital Quality Initiative, see http://www. cms.hhs.gov/ HospitalQuality Inits/.

b. Section 5001(a) of Public Law 109-171 (DRA)

As discussed in section IV.A. of this preamble, for FY 2007 and each subsequent year, section 5001(a) of Public Law 109-171 amended section 1886(b)(3)(B) of the Act and made changes to the program established under section 501(b) of Public Law 108-173. These changes require us to expand the number of measures for which data must be submitted, and to change the percentage point reduction in the annual payment update from 0.4 percentage points to 2.0 percentage points for subsection (d) hospitals that do not report the required quality measures in a form and manner, and at a time, specified by the Secretary. Effective for payments beginning with FY 2007, new section 1886(b)(3)(B)(viii)(IV) of the Act requires the Secretary to begin to adopt the expanded set of performance measures set forth in the IOM's 2005 report entitled, ``Performance Measurement: Accelerating Improvement.'' \15\ Those measures include the HQA measures, the HCAHPS[supreg] patient perspective survey, and three structural measures.\16\ Effective for payments beginning with FY 2008, the Secretary must add other measures that reflect consensus among affected parties and may replace existing measures as appropriate. New section 1886(b)(3)(B)(viii)(VII) of the Act requires the Secretary to post hospital quality data on these measures on the CMS Web site. Additional information on the Hospital Quality Initiative is available on the CMS Web site at: http://www.cms. hhs.gov/Hospital QualityInits.

\15\ Institute of Medicine, ``Performance Measurement: Accelerating Improvement,'' December 1, 2005, available at http://www.iom.edu/CMS/3809/19805/31310.aspx .

\16\ The three structural measures are: (1) Computerized provider order entry; (2) intensive care intensivists; and (3) evidence-based hospital referrals.

4. Plan for Implementing Hospital Value-Based Purchasing Beginning with FY 2009

Section 5001(b) of Public Law 109-171 requires us to develop a plan to implement hospital value-based purchasing beginning with FY 2009. The plan must consider the following issues: (a) The ongoing development, selection, and modification process for measures of quality and efficiency in hospital inpatient settings; (b) the reporting, collection, and validation of quality data; (c) the structure of payment adjustments, including the determination of thresholds of improvements in quality that would

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substantiate a payment adjustment, the size of such payments, and the sources of funding for the payments; and (d) the disclosure of information on hospital performance. Section 5001(b) of Public Law 109- 171 also calls for us to consult with affected parties and to consider relevant demonstrations in developing the plan. Each of these issues (measure development and refinement, data infrastructure, incentives, and public reporting) is discussed below, along with our activities to date and outstanding policy questions. We are seeking comments on these issue areas and outstanding policy questions. a. Measure Development and Refinement

As we explore the potential connections between performance measurement and incentives, we would like to better understand how to develop valid, meaningful, current performance measures that are aligned with other hospital measurement activities, and an enterprise for development, validation, consensus building, and maintenance of these measures. In addition, before measures could be used to compare the relative quality or cost of care provided by hospitals, we believe that the information would need to be appropriately adjusted to account for relevant differences among hospitals and among their patients. The availability of appropriate measures on which consensus might be achieved depends on the state of the art of research on measure development.

We believe that it is desirable for performance measures to be based on appropriate evidence, effectively related to desired outcomes, derived in a transparent fashion involving consultation with experts and affected hospitals, and routinely updated. MedPAC's 2005 Report to Congress \17\ stated that measures should be evidence-based; that collecting and analyzing data should not be unduly burdensome for the provider or for CMS; that risk adjustment should be sufficient to deter providers from avoiding patients who might lower performance scores; that most providers should be able to improve on the measures; that measures should apply to a broad range of care and providers; that measures should capture aspects of care that are under the control of the providers being measured; and that areas of care being measured should be those needing improvement.

\17\ Medicare Payment Advisory Commission: Report to Congress: Medicare Payment Policy, March 2005, pp. 186-187, available at: http://www. medpac.gov/ publications/generic --report-- display.cfm?

report--type --id=1& sid=2 & subid=0.

The IOM's December 2005 report, ``Performance Measurement: Accelerating Improvement'' (previously cited under footnote 15) recommended that measure sets should build on the work of key public- and private-sector organizations; that national performance measures that have been approved through ongoing consensus processes led by major stakeholder groups are an appropriate starting point; that the limited scope of current measures should be broadened to address efficiency, equity, and patient-centeredness; that quality, costs, and outcomes of care should be measured over longer time intervals; and that measures be applicable to more than one setting so that providers can share accountability for a patient's care (pp. 8-11).

The plan for hospital value-based purchasing mandated by Pub. L. 109-171 must address the ongoing development, selection, and modification process for measures of quality and efficiency in hospital inpatient settings. We have worked collaboratively in defining consistent, meaningful performance measures for hospitals and other providers for a number of years. The efforts of CMS and its stakeholder partners to develop standardized performance measures increase the likelihood that the measures will be valid, reliable, and widely accepted as viable indicators of performance. Standardized measures also reduce the burden for hospitals that would otherwise have to report different measures to multiple entities, such as accrediting bodies and State agencies.

CMS and the HQA (which includes representatives from consumers, hospitals, health professionals, purchasers, and accreditation organizations) collectively selected a starter set of 10 consensus- derived quality measures for public reporting, which was incorporated into the RHQDAPU program authorized by section 501(b) of Pub. L. 108- 173. (See section IV.A. of this preamble for a detailed discussion of the RHQDAPU program.) The measures were endorsed by the NQF, a nonprofit voluntary organization that represents a broad range of health care stakeholders and endorses consensus-based national performance standards. CMS has also worked with the JCAHO to align hospital performance measures that we share in common, thereby reducing hospitals' reporting burden.

In April and September 2005, CMS and the HQA identified additional NQF-endorsed measures of hospital performance. In section IV.A. of the preamble to this proposed rule, we list these measures and propose to require hospital reporting on these measures under an expanded version of the RHQDAPU program authorized by section 5001(a) of Pub. L. 109- 171. These measures are discussed in more detail on the CMS Web site at: http://www.cms.hhs.gov/HospitalQualityInits/downloads/HospitalHQA2004_2007200512.pdf .

An additional two outcome measures of 30-day mortality for heart attack and heart failure have been endorsed by the NQF for public reporting. Further, in October 2006, we will be implementing the HCAHPS[reg] survey of inpatient perceptions of their hospital care experiences, with the intention that an aggregate HCAHPS[reg] measure will become a publicly reported performance measure. HCAHPS[reg] was endorsed by the NQF in May 2005. Beyond these, we could also consider including measures from the Surgical Care Improvement Project, measures relating to a hospital's use of information technology that result in improved patient outcomes, implementation of data standards, and preventable readmissions as quality reporting measures under the RHQDAPU program or the hospital value-based purchasing program. b. Data Infrastructure

Implementing measures on which to base a value-based purchasing system would require an infrastructure that could collect appropriate information from hospitals, store and aggregate it as necessary, and prepare it for use in determining appropriate incentives. Hospitals would likely need to be able to generate appropriate data as input for calculation of the measures. For some measures, data that hospitals already submit with claims for payment or for some other administrative purpose may be sufficient. For other measures, hospitals might need to provide information regarding their structure and resources or about the specifics of medical care provided to patients or the outcomes of that care. For that information, hospitals may need special software to assist with data collection and secure channels by which they can transmit data. We are interested in receiving comments on how to develop an infrastructure that would facilitate the efficient transmission and storage of data, and especially, as discussed in sections IV.A.3. and IV.B.6. of the preamble to this proposed rule, in comments on how electronic medical and health record systems could help improve care and be integrated into or facilitate the data collection process.

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Implementation would require communication channels and data warehouses with sufficient capacity and flexibility to acquire and store data from hospitals. We are considering how we might validate the submitted data, determine incentives based on that data, and transmit these values to Medicare's fiscal intermediaries. The potential infrastructure would need to be extremely secure and afford the most privacy protection permitted by law. It would also need to minimize the burden of data collection and transmission on providers. It would need to be accurate, efficient, and cost-effective for CMS to administer.

The plan for hospital value-based purchasing mandated by Pub. L. 109-171 must address the reporting, collection, and validation of quality data. Over the past few years, we have developed a data collection and reporting infrastructure for the RHQDAPU program that can transmit performance measurement data via secure channels for its submission, storage, analysis, validation and reporting. Specifically, to facilitate data collection, we have developed the CART software to assist hospitals in the collection of clinical and administrative data used to measure performance improvement. CART, which is provided to hospitals free of charge, is a powerful application that hospitals and their designees can use to abstract clinical data needed for performance measurement from medical records. This tool was designed and developed by CMS with input from the JCAHO and the Medicare QIOs. We have also developed the QualityNet Exchange system for secure transmission of data to the QIO Clinical Warehouse. QNetExchange.org is the CMS-approved Web site for secure communications and data exchange between two or more of the following: Hospitals, performance measurement system vendors, end stage renal disease networks and facilities, QIOs, and CMS.

For data warehousing, we have a claims warehouse for Medicare Part A data, which maintains the claims for the most recent 42 months. We also have a QIO Clinical Warehouse that currently contains information on the starter set of 10 quality measures collected under the RHQDAPU program, as well as additional voluntarily reported measures. We must assess the validity of the RHQDAPU information because of its use for quality improvement, public reporting, and determining hospitals' annual payment updates under the RHQDAPU program. Validation activities assess the reliability of the data that a hospital has submitted, as evidenced by the consistency between a hospital's abstraction and reabstraction by an independent party.

We are currently using a contractor, the CDAC, to carry out the validation process under the RHQDAPU program. Hospitals are required to submit certain quality data to the QIO Clinical Warehouse within 4.5 months of the end of each quarterly reporting period. The steps in the validation process are: (1) Check for duplicates; (2) draw a sample; (3) obtain copies of medical records; (4) request and complete CDAC abstraction; (5) post results on QualityNet Exchange for hospitals' review; and (6) resolve validation appeals. We are seeking comments on how the data submission and validation processes that we currently use for the RHQDAPU program might be adaptable to a hospital value-based purchasing program.

One of the key challenges we face in considering implementation of hospital value-based purchasing is minimizing the length of time between our receipt of data and our ability to provide feedback to hospitals on the data. Some of the hospitals that are participating in the RHQDAPU program and the Premier Hospital Quality Incentive Demonstration have asked for more timely feedback on their performance. We recognize that a long delay between the provision of services and feedback about the quality of those services may impede both improvement efforts and a hospital's motivation to improve. The current lag time between the end of the quarterly reporting period and the availability of performance feedback under the RHQDAPU program is approximately 9 months. Hospitals have 4.5 months to complete their paper medical records and to submit information to the QIO Clinical Warehouse, which roughly coincides with JCAHO's timeline for submission of data to their ORYX Core Measure Performance Measurement System. Another 4.5 months are required to accomplish the steps in the validation process.

We are considering options to decrease the overall length of time between our receipt of data and our ability to provide feedback to hospitals, and we are interested in comments on these options. First, we are considering whether more frequent data submissions, such as monthly submissions, would decrease the time between the provision of services and feedback about the quality of those services. We are aware that some hospitals and their vendors already submit quality data on a monthly basis to JCAHO. However, unless we reduced the sample size per reporting period, the process of validating each month the same number of records that are currently validated each quarter would increase costs significantly. On the other hand, if we reduced the sample size per reporting period, the monthly numbers might be too small to provide for adequate validation. Second, we could shorten the data submission period, which is a significant source of lag time. This option would require hospitals to submit information to the data warehouse more quickly, which could increase the possibility that hospitals would submit less complete data. In addition, this option would require coordination with JCAHO to keep submission timelines congruent, which reduces hospitals' reporting burden. Third, we could eliminate the validation appeals process, which would reduce the lag time by up to 2 months. Fourth, we could create an expanded role for the third party vendors that assist hospitals with submitting quality data to CMS and JCAHO. For example, CMS could certify third party vendors to also provide standardized validation services and quick performance feedback to their hospital customers. c. Incentive Methodology

While measurement of the quality of care and of resources use may be advantageous in itself, we are considering whether and what kind of incentives can further improve outcomes. The potential design of incentives in a value-based purchasing system presents many choices. The implementation plan for hospital value-based purchasing mandated by Pub. L. 109-171 must address the structure of payment adjustments, including the determination of thresholds of improvements in quality that would substantiate a payment adjustment, the size of such payments, and the sources of funding for the value-based payments. We are interested in comments on the merits of and alternatives to all of the approaches to the design of a value-based purchasing methodology that are discussed below. (1) How Should Incentives Be Structured?

A number of options exist for the structure of potential incentives. The incentive methodology could include differential incentives depending on whether hospitals exceed a particular standard of performance. To reflect expectations of continued improvement among hospitals, the standard could be raised in predictable steps over time. Alternatively, incentives could be structured to reward hospitals that

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improve from a baseline level of performance. These approaches could be combined to develop an incentive methodology that includes both attaining benchmarks and improving care. (2) What Level of Incentive Is Needed?

Value-based purchasing incentives should be targeted to that needed to achieve a desired level of performance. Our experience with implementing section 501(b) of Pub. L. 108-173 (discussed in section IV.A. of this preamble) indicates that a targeted incentive, coupled with active management by CMS, can encourage reporting on quality measures. Nearly every eligible hospital has been willing and able to submit the required data in order to receive the full payment update under the RHQDAPU program. Similarly, our experience with the Premier Hospital Quality Incentive Demonstration indicates that a 1 or 2 percent bonus, coupled with potential reductions for poor performance, may stimulate improvement. Further experience in ascertaining how hospitals respond to incentives will be important for examining incentives over time. (3) What Should Be the Source of Incentives?

The President's FY 2007 Budget indicates support for identifying and testing ``budget-neutral incentives that will stimulate Medicare providers to improve performance on quality and efficiency measures.'' \18\ We do not believe that providing additional aggregate funding to finance performance-based incentives is either supportable or necessary. One approach might be to examine how we could identify and apply measurable savings achieved by reducing care that is unnecessary or otherwise inappropriate. For example, we may examine possibilities of improving care coordination, whether this could produce measurable savings, and whether some of the savings generated in one payment system could be used for incentives in another, as long as these reforms do not provide inappropriate incentives to stop providing necessary care. For instance, appropriate quality of care and effective resource use in hospitals and other institutional providers might generate savings that could be used for incentives for both physicians and facilities.

\18\ Budget of the United States Government, Fiscal year 2007, available at: http://www. whitehouse.gov/ omb/budget/ fy2007/.

(4) What Should The Form Of Incentives Be?

Potential approaches for incentives include making an add-on payment to the base payment for individual inpatient hospital services or providing periodic, lump-sum payments on a monthly, quarterly, or annual basis. Under the RHQDAPU program, hospitals that do not submit the required data receive a decrease in the standardized payment amount made for all inpatient operating costs for the applicable fiscal year. In a hospital value-based purchasing system, per-service payments might be made only in connection with the services directly associated with the particular measure for which the hospital achieved a good result. Alternatively, lump-sum payments might be made on a periodic basis to hospitals that achieve particular performance targets. The preferable approach may depend on operational concerns, the strength of incentive effects, and other aspects of the design. We welcome comments on this issue. (5) What Should the Timing of Incentives Be in Relation to Performance?

Any value-based purchasing system should seek a balance between rewarding desired performance close to when it occurs and ensuring the accuracy of both performance measurement and incentives. Given the lag times for collecting and reviewing different types of data, some measures may be calculated quickly after the period of performance, while data lag times for other measures may be longer. For instance, structural measures could affect incentives soon after they are collected. Other measures that are based on experience over a time interval may require some time for measured events to manifest. An example of this type of measure would be the rate of mortality within 30 days of hospitalization. (6) How Should We Develop Composite Scores?

Encouraging improved performance could be facilitated by valid and reliable methods to aggregate performance data into single composite scores. Composite scoring may also improve consumer understanding of complex performance indicators by combining measures of many dimensions of care into a single score. One example of a composite scoring methodology that we used for the Premier Hospital Quality Incentive Demonstration (discussed in detail above) is a modification of the ``opportunity model,'' which can be used to address individual weighting, missing data, and sensitivity to case volumes. For example, a hospital that has few or no cases for a particular dimension of care could receive a low score, yet that measure is equally weighted with others in the composite. Under the opportunity model, a composite may be developed for a disease category by dividing the total number of successful interventions by the total number of opportunities for the same targeted interventions. Some of the advantages of the opportunity model are that individual measures are weighted by the volume of opportunities for the associated intervention for a particular hospital; missing values for a particular aspect of care provided by an individual hospital would not prevent that hospital from being represented in a public report; and composite measures may easily accommodate the addition of individual measures.

The ``appropriate care measure'' (ACM) is another composite scoring methodology, which we used in connection with the QIOs. The ACM scoring methodology is patient-centric. For a hospital to receive credit for treating a patient well, the hospital must have met the standard for every measure applicable to that patient's condition. There are also a number of proprietary composite measures, such as those used by Solucient, Healthgrades, CareScience, and U.S. News & World Report. We are interested in comments on the use of composite scoring for hospital value-based purchasing and on the various composite scoring methodologies.

Value-based purchasing methods are still under development, and anticipating their potential effects on the health care system is difficult. We understand that unintended consequences may result from the implementation of these methods. We believe that we will need to assess incentives and evaluate their effects so that we can revise them quickly as we learn more about their impact on hospitals and on inpatient hospital services provided to Medicare beneficiaries. d. Public Reporting

The plan for hospital value-based purchasing mandated by Pub. L. 109-171 must address the public disclosure of information on hospital performance. CMS currently provides public reporting of quality information through the ``Compare'' Web sites for hospitals, nursing homes, home health agencies,

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and dialysis facilities.\19\ The Compare Web sites provide comparative quality information to consumers and others to help guide choices and drive improvements in the quality of care delivered in these settings. Besides providing Medicare beneficiaries and their health professionals with information to assist them in making informed health care decisions, public reporting of comparative performance data also provides information that is useful to health care consumers who are not Medicare beneficiaries. For example, a consumer who has a Health Savings Account can access CMS' Hospital Compare Web site to gather comparative quality information to assist in choosing a high quality hospital. CMS is contributing to the Administration's Consumer-Directed Health Care Initiative by working with our private- and public-sector partners to make health care information more transparent and available to consumers than ever before. (Refer to section IV.M. of this preamble for more information.) We are interested in comments on how we can further stimulate public reporting to increase the transparency and meaningfulness of healthcare performance information.

\19\ See CMS' Hospital Compare Web site, available at: http://www.hospitalcompare.hhs.gov/ ; Nursing Home Compare Web site,

available at: http://www.medicare.gov/NHCompare; Home Health Compare Web site, available at: http://www.medicare.gov/HHCompare/Home.asp; e/Home.asp; Dialysis Facility Compare Web site, available at: http://www.medicare.gov/Dialysis .

5. Considerations Related to Certain Conditions, Including Hospital- Acquired Infections

Medicare's IPPS encourages hospitals to treat patients efficiently. Hospitals receive the same DRG payment for stays that vary in length. In many cases, complications acquired in the hospital do not generate higher payments than the hospital would otherwise receive for other cases in the same DRG. To this extent, the IPPS does encourage hospitals to manage their patients well and to avoid complications, when possible. However, complications, such as infections, acquired in the hospital can trigger higher payments in two ways. First, the treatment of complications can increase the cost of hospital stays enough to generate outlier payments. However, the outlier payment methodology requires that hospitals experience large losses on outlier cases (in FY 2006, hospitals must lose $23,600 before a case qualifies for outlier payments, and the hospital would then only receive 80 percent of its costs above the outlier threshold). Second, there are about 121 sets of DRGs that split based on the presence or absence of a complication or comorbidity (CC). The CC DRG in each pair would generate a higher Medicare payment. If an infection acquired during the beneficiary's hospital stay is one of the conditions on the CC list, the result may be a higher payment to the hospital under a CC DRG. (See section II.C. of this preamble for a detailed discussion of proposed DRG reforms.)

Section 5001(c) of Pub. L. 109-171 requires the Secretary to identify, by October 1, 2007, at least two conditions that are (a) high cost or high volume or both, (b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. For discharges occurring on or after October 1, 2008, hospitals would not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis was not present. Section 5001(c) provides that we can revise the list of conditions from time to time, as long as it contains at least two conditions. Section 5001(c) also requires hospitals to submit the secondary diagnoses that are present at admission when reporting payment information for discharges on or after October 1, 2007. We are interested in input about which conditions and which evidence-based guidelines should be selected. 6. Promoting Effective Use of Health Information Technology

We recognize the potential for health information technology (HIT) to facilitate improvements in the quality and efficiency of health care services. One recent RAND study found that broad adoption of electronic health records could save more than $81 billion annually and, at the same time, improve quality of care.\20\ The largest potential savings that the study identified was in the hospital setting because of shorter hospital stays promoted by better coordinated care; less nursing time spent on administrative tasks; better use of medications in hospitals; and better utilization of drugs, laboratory services, and radiology services in hospital outpatient settings. The study also identified potential quality gains through enhanced patient safety, decision support tools for evidence-based medicine, and reminder mechanisms for screening and preventive care. Despite such large potential benefits, the study found that only about 20 to 25 percent of hospitals have adopted HIT systems.

\20\ RAND News Release: Rand Study Says Computerizing Medical Records Could Save $81 Billion Annually and Improve the Quality of Medical Care, September 14, 2005, available at: http://rand.org/news/press.05/09.14.html .

It is important to note the caveats to the RAND study. The projected savings are across the health care sector, and any Federal savings would be a reduced percentage. In addition, there are significant assumptions made in the RAND study. National savings are projected in some cases based on one or two small studies. Also, the study assumes patient compliance, in the form of participation in disease management programs and following medical advice. For these reasons, extreme caution should be used in interpreting these results.

In summary, there are mixed signals about the potential of HIT to reduce costs. Some studies have indicated that HIT adoption does not necessarily lead to lower costs and improved quality. In addition, some industry experts have stated that factors such as an aging population, medical advances, and increasing provider expenses would make any projected savings impossible.

In his 2004 State of the Union Address, President Bush announced a plan to ensure that most Americans have electronic health records within 10 years.\21\ One part of this plan involves developing voluntary standards and promoting the adoption of interoperable HIT systems that use these standards. The 2007 Budget states that ``The Administration supports the adoption of health information technology (IT) as a normal cost of doing business to ensure patients receive high quality care.''

\21\ Transforming Health Care: The President's Health Information Technology Plan, available at: http://www.whitehouse.gov/infocus/technology/economic_policy200404/chap3.html .

Over the past several years, CMS has undertaken several activities to promote the adoption and effective use of HIT in coordination with other Federal agencies and with the Office of the National Coordinator for Health Information Technology. One of those activities is promotion of data standards for clinical information, as well as for claims and administrative data. In addition, through our 8th Scope of Work contract with the QIOs, we are offering assistance to hospitals on how to adopt and redesign care processes to effectively use HIT to improve the quality of care for Medicare beneficiaries, including computerized physician order entry (CPOE) and bar coding systems. In section IV.A.3. of the

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preamble to this proposed rule, we again invite comments on streamlining the submission of clinical quality data by using standards-based electronic medical records. (We use the term ``electronic medical records'' in section IV.A.3. of the preamble to this proposed rule instead of the term ``electronic health records'' that is used in this section in order to maintain consistency with our request for comments in the FY 2006 IPPS final rule.) Finally, our Premier Hospital Quality Incentive Demonstration provides additional financial payments for hospitals that achieve improvements in quality, which effective HIT systems can facilitate.

We are considering the role of interoperable HIT systems in increasing the quality of hospital services while avoiding unnecessary costs. As noted above, the Administration supports the adoption of HIT as a normal cost of doing business. While payments under the IPPS do not vary depending on the adoption and use of HIT, hospitals that leverage HIT to provide better quality services may more efficiently reap the reward of any resulting cost savings. In addition, the adoption and use of HIT may contribute to improved processes and outcomes of care, including shortened hospital stays and the avoidance of adverse drug reactions. We are seeking comments on our statutory authority to encourage the adoption and use of HIT. We also are seeking comments on the appropriate role of HIT in any value-based purchasing program, beyond the intrinsic incentives of the IPPS, to provide efficient care, encourage the avoidance of unnecessary costs, and increase quality of care. In addition, we are seeking comments on promotion of the use of effective HIT through hospital conditions of participation, perhaps by adding a requirement that hospitals use HIT that is compliant with and certified in its use of the HIT standards adopted by the Secretary. We anticipate that the American Health Information Community will provide advice to the Secretary on these issues.

C. Sole Community Hospitals (SCHs) (Sec. 412.92) and Medicare- Dependent, Small Rural Hospitals (MDHs) (Sec. 412.108)

1. Background

Under the IPPS, special payment protections are provided to a sole community hospital (SCH). Section 1886(d)(5)(D)(iii) of the Act defines an SCH as a hospital that, by reason of factors such as isolated location, weather conditions, travel conditions, absence of other like hospitals (as determined by the Secretary), or historical designation by the Secretary as an essential access community hospital, is the sole source of inpatient hospital services reasonably available to Medicare beneficiaries. The regulations that set forth the criteria that a hospital must meet to be classified as an SCH are located in Sec. 412.92.

Under the IPPS, separate special payment protections also are provided to a Medicare-dependent, small rural hospital (MDH). Section 1886(d)(5)(G)(iv) of the Act defines an MDH as a hospital that is located in a rural area, has not more than 100 beds, is not an SCH, and that has a high percentage of Medicare discharges (not less than 60 percent in its 1987 cost reporting year or in 2 of its most recent 3 audited and settled Medicare cost reporting years). The regulations that set forth the criteria that a hospital must meet to be classified as an MDH are located in Sec. 412.108.

Although SCHs and MDHs are paid under special payment methodologies, they are section 1886(d) hospitals. Like all section 1886(d) IPPS hospitals, SCHs and MDHs are paid for their discharges based on the DRG weights calculated under section 1886(d)(4) of the Act.

Effective with hospital cost reporting periods beginning on or after October 1, 2000, section 1886(d)(5)(D)(i) of the Act (as amended by section 6003(e) of Pub. L. 101-239) and section 1886(b)(3)(I) of the Act (as added by section 405 of Pub. L. 106-113 and further amended by section 213 of Pub. L. 106-554), provide that SCHs are paid based on whichever of the following rates yields the greatest aggregate payment to the hospital for the cost reporting period:

The Federal rate applicable to the hospital;

The updated hospital-specific rate based on FY 1982 costs per discharge;

The updated hospital-specific rate based on FY 1987 costs per discharge; or

The updated hospital-specific rate based on FY 1996 costs per discharge.

For purposes of payment to SCHs for which the FY 1996 hospital- specific rate yields the greatest aggregate payment, payments for discharges during FYs 2001, 2002, and 2003 were based on a blend of the FY 1996 hospital-specific rate and the greater of the Federal rate or the updated FY 1982 or FY 1987 hospital-specific rate. For discharges during FY 2004 and subsequent fiscal years, payments based on the FY 1996 hospital-specific rate are 100 percent of the updated FY 1996 hospital-specific rate.

For each cost reporting period, the fiscal intermediary determines which of the payment options will yield the highest rate of payment to the SCH. 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 after it determines precisely which of the payment rates would yield the highest payment to the hospital.

If an SCH disagrees with the fiscal intermediary's determination regarding the final amount of program payment to which it is entitled, it has the right to appeal the fiscal intermediary's decision in accordance with the procedures set forth in Subpart R of Part 405, which concern provider payment determinations and appeals.

Through and including FY 2006, 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. However, section 5003 of Pub. L. 109-171 (DRA) modified these rules for discharges occurring on or after October 1, 2006. Section 5003(c) changed the 50-percent adjustment to 75 percent. Section 5003(b) requires that an MDH use the 2002 cost reporting year as its base year (that is, the FY 2002 hospital-specific rate), if that use results in a higher payment. An MDH does not have the option to use its FY 1996 hospital-specific rate. We discuss our proposed changes to implement section 5003 of the DRA in section IV.C.4 of this preamble. 2. Volume Decrease Adjustment for SCHs and MDHs

(If you choose to comment on the issues in this section, please include the caption (``SCH/MDH Volume Decrease Adjustment'' at the beginning of your comment.)

Section 1886(d)(5)(D)(ii) of the Act requires that the Secretary make a payment adjustment to an SCH that experiences a decrease of more than 5 percent in its total number of inpatient discharges from one cost reporting period to the next, if the circumstances

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leading to the decline in discharges were beyond the SCH's control. Section 1886(d)(5)(G)(iii) of the Act requires that the Secretary make a payment adjustment to an MDH that experiences a decrease of more than 5 percent in its total number of inpatient discharges from one cost reporting period to the next, if the circumstances leading to the decline in discharges were beyond the MDH's control. These adjustments were designed to compensate an SCH or MDH for the fixed costs it incurs in the year following the reduction in discharges (this is, the second year), which it may be unable to reduce. Such costs include the maintenance of necessary core staff and services.

However, we believe that not all staff costs can be considered fixed costs. Using a standardized formula specified by us, the SCH or MDH must demonstrate that it appropriately adjusted the number of staff in inpatient areas of the hospital based on the decrease in the number of inpatient days. This formula examines nursing staff in particular. If an SCH or MDH has an excess number of nursing staff, the cost of maintaining those staff members is deducted from the total adjustment. One exception to this policy is that no SCH or MDH may reduce its number of staff to a level below what is required by State or local law. In other words, an SCH or MDH will not be penalized for maintaining a level of staff that is consistent with State or local requirements.

The process for determining the amount of the volume decrease adjustment can be found in section 2810.1 of the Provider Reimbursement Manual. Fiscal intermediaries are responsible for establishing whether an SCH or MDH is eligible for a volume decrease adjustment and, if so, the amount of the adjustment. To qualify for this adjustment, the SCH or MDH must demonstrate that: (a) A 5 percent or more decrease of total discharges has occurred; and (b) the circumstance that caused the decrease in discharges was beyond the control of the hospital. Once the fiscal intermediary has established that the SCH or MDH satisfies these two requirements, it will calculate the adjustment. The adjustment amount is determined by subtracting the second year's DRG payment from the lesser of: (a) The second year's costs minus any adjustment for excess staff; or (b) the previous year's costs multiplied by the appropriate IPPS update factor minus any adjustment for excess staff. The SCH or MDH receives the difference in a lump-sum payment.

The adjustment for excess staff is currently broken into two parts: The routine acute care area (excluding intensive care unit areas) excess staff adjustment and the intensive care unit excess staff adjustment. (For purposes of this section of the preamble, any subsequent references to the routine acute care area of an SCH or MDH refer to the routine acute care area excluding any intensive care unit areas.) In order to determine whether or not the hospital is appropriately staffing its routine acute care and its intensive care unit area, the fiscal intermediary compares the hospital's actual number of nursing staff in each area with the staffing of like-size hospitals in the same census region.

Currently, fiscal intermediaries obtain average nurse staffing data from the American Hospital Association's HAS/Monitrend Data Book. (More information on the HAS/Monitrend Data Book follows.) If a hospital employs more than the reported average number of nurses in the routine acute care or intensive care unit area for hospitals of its size and census region, the fiscal intermediary reduces the amount of the adjustment by the cost of maintaining the additional staff. The amount of the reduction is calculated by multiplying the actual number of nursing staff above the reported average by the average nurse salary for that hospital as reported on the Medicare cost report. The complete process for determining the amount of the adjustment can be found at section 2810.1 of the Provider Reimbursement Manual.

Representatives from several SCH and MDH hospitals have contacted CMS with concerns regarding the current use of the HAS/Monitrend data for determining the volume decrease adjustment for SCHs and MDHs. Because the most recent HAS/Monitrend Data Book was published in 1989 and is no longer updated, the hospitals expressed concern that the information in the publication is too outdated for current use. Therefore, in this proposed rule, we are presenting for public comment a new methodology for calculating the adjustment for excess staff under section IV.C.2.b. of this preamble. a. HAS/Monitrend Data

From the mid-1960's to 1989, the Healthcare Administrative Services Division of the American Hospital Association (AHA) published biannually the HAS/Monitrend Data Book, a collection of aggregate hospital statistics. Hospitals completed surveys based on 6 months of data; these data were categorized into one of five bed-size groups and into one of nine census regions. The bed size groups were 0-49, 50-99, 100-199, 200-399, and 400 or more beds. The census regions include: (1) New England (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont); (2) Middle Atlantic (New Jersey, New York, and Pennsylvania); (3) South Atlantic (Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, and West Virginia); (4) East North Central (Illinois, Indiana, Michigan, Ohio, and Wisconsin); (5) East South Central (Alabama, Kentucky, Mississippi, and Tennessee); (6) West North Central (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota); (7) West South Central (Arkansas, Louisiana, Oklahoma, and Texas); (8) Mountain (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, and Wyoming); and (9) Pacific (Alaska, California, Hawaii, Oregon, and Washington).

The survey collected data on nearly 400 items pertaining to utilization, resource allocation, departmental productivity, departmental direct expenses, and staffing. In order for aggregate data to be published for a category, at least three hospitals in the same census region and bed-size group had to have responded to the survey. For the final 1989 publication, 996 acute care hospitals completed the survey. CMS has used the HAS/Monitrend Data Book since 1984 to determine the volume decrease adjustment for SCHs; the data also have been used for the volume decrease adjustment for MDHs since 1990. In particular, CMS has used the HAS/Monitrend data on the number of paid nursing hours per patient day (``paid hours/patient day'') in both the general acute care area (``Medical and Surgical Units'') and the intensive care unit (``Med & Surg Intensive Care Unit''). More information on the HAS/Monitrend Data Book is available from the American Hospital Association, 840 North Lake Shore Drive, Chicago, Illinois 60611. b. HAS/Monitrend Data Book Replacement Alternative

Below, we are proposing an alternative method for determining an SCH's or MDH's target number of core staff using data from the Medicare cost report and the occupational mix survey. However, this methodology would only establish one combined average number of nursing hours per patient day for both the inpatient routine care and the intensive care unit areas. We are proposing to use the Medicare cost report and occupational mix survey data beginning with requests for adjustments for FY 2008 cost reports. We welcome

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comments from the public on this proposal. (1) Occupational Mix Survey

As discussed in section III.C. of the preamble to this proposed rule, the CMS occupational mix survey collects from each hospital data on the mix of employees in the areas of the hospital payable under the IPPS for a limited number of hospital occupational categories. These categories (nursing, therapy, medical and clinical laboratory, dietary, and pharmacy) each include several SOCs, as defined by the BLS, that may be used by hospitals with different mixes to provide specific aspects of patient care. For example, hospitals may choose to employ different combinations of registered nurses, licensed practical nurses, and nurses' aides 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. The data collected on the survey are used to adjust hospitals' wage data to account for each hospital's SOC mix within the general occupational categories. Hospitals completed the first occupational mix survey using FY 2003 data. A second survey will be completed this year (FY 2006).

Under this proposed method, we would calculate the nursing hours per inpatient day for each SCH or MDH by dividing the number of paid nursing hours (for registered nurses, licensed practical nurses, and nursing aides) reported on the occupational mix survey by the number of inpatient days reported on the Medicare cost report. The results would be grouped into the same bed-size groups and census regions as the HAS/ Monitrend Data Book. CMS would publish the mean number of nursing hours per patient day for each census region and bed-size group in the Federal Register. (We are proposing to include licensed practical nurse and nursing aide hours as well as registered nurse hours to reflect the various levels of nursing staff employed by hospitals to provide direct patient care.)

The results that would be published in the Federal Register would be the target number of core nursing hours per patient day. For purposes of the volume decrease adjustment, the published data would be utilized in the same way as the HAS/Monitrend data: the fiscal intermediary would multiply the SCH's or MDH's number of inpatient days by the applicable published hours per patient day. This figure would be divided by the average number of worked hours per year per nurse (for example, 2,080 for a standard 40-hour week). The result would be the target number of core nursing staff for the particular SCH or MDH. If necessary, the cost of any excess staff (number of FTEs that exceed the published number) would be removed from the second year's costs or, if applicable, the previous year's costs multiplied by the IPPS update factor when determining the volume decrease adjustment. Because we are considering registered nurses, licensed practical nurses, and nursing aides, the fiscal intermediary would calculate the excess staff adjustment by multiplying the number of excess staff by the average salary among the three groups, taking into account how many registered nurses, licensed practical nurses, and nursing aides work at the facility. (For instance, if the hospital's average salary for a registered nurse is $50,000 and the hospital's average salary for a licensed practical nurse is $30,000 and the hospital employs 5 registered nurses, 3 licensed practical nurses, and no nursing aides, the calculated average salary would be $42,500 for one FTE (((5 x $50,000) + (3 x $30,000))/8 = $42,500).

We are proposing to use the results of the FY 2006 occupational mix survey and begin applying the proposed methodology for adjustments resulting from a decrease in discharges between FYs 2007 to 2008. Because the occupational mix survey is conducted once every 3 years, we would update the data set every 3 years. We are proposing to use the FY 2006 survey results and not to utilize the FY 2003 survey results to take into account comments we received in response to the first set of results from the occupational mix survey, and to ensure that hospitals have had some experience with the occupational mix survey before it is used in determining these adjustments. Because we have used the HAS/ Monitrend data for so many years, we believe it is appropriate to continue to use these data for one more year and wait for the results of the FY 2006 survey. This will give hospitals an opportunity to have some experience with the occupational mix survey before it is used in these adjustments, and will allow us to compare the data from the FY 2006 occupational mix survey with the data reported in the 2003 survey, if necessary. However, for purposes of describing how we would implement this methodology, we have applied the proposed calculation to the FY 2003 occupational mix survey data. While we are not proposing to use the FY 2003 data, we believe that it is the best data available at this time to help explain our proposed methodology.

To calculate the results below, we merged the FY 2003 occupational mix survey results into the FY 2003 cost report file. We eliminated all observations for non-IPPS providers, providers who failed to complete the occupational mix survey, and providers for which provider numbers, bed counts and/or day counts were missing. We also only included providers with 12 months' worth of data. This resulted in a pool of approximately 3,541 providers.

For each provider in this pool, we calculated the number of nursing hours by adding the number of registered nurse, license practical nurse, and nursing aide hours reported on the occupational mix survey. We divided the result of this calculation by the total number of inpatient days reported on the cost report to determine the number of nursing hours per patient day.

For purposes of calculating the census regional averages for the various bed-size groups, we are proposing to only include observations that fall within 3 standard deviations of the mean of all observations, thus removing potential outliers in the data. Below are the results of this calculation.

We realize that, in the chart, some results may appear to be anomalous (for example, 0-49 beds for census regions 4, 6, and 8). We believe a small number of outlier data may have skewed the mean, which was the basis for identifying data within 3 standard deviations to include in the calculations. Therefore, we are soliciting comments on whether we should consider another method for determining the appropriateness of using available data in calculating the average number of nursing hours per patient day. For instance, in this case, the results are based on the inclusion of data within 3 standard deviations of the mean. Alternatively, we could use another measure of central tendency.

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Paid Nursing Hours per Patient Day

Census region Number of beds

1

2

3

4

5

6

7

8

9

0-49................................................. 16.38 8.33 19.26 30.76 11.72 26.70 20.50 31.00 17.39 50-99................................................ 13.71 11.07 15.66 17.37 13.69 15.53 12.51 16.63 16.11 100-199.............................................. 11.98 10.99 14.38 13.44 11.93 17.03 13.91 14.33 13.32 200-399.............................................. 12.40 12.19 14.19 13.00 10.57 16.20 11.35 14.06 15.33 400 or more.......................................... 13.32 9.42 12.77 15.39 9.51 19.70 12.36 17.64 13.32

(2) American Hospital Association Annual Hospital Survey

In the process of evaluating different sources of data to replace the HAS/Monitrend Data Book, we considered using the results of the AHA's Annual Hospital Survey. This survey includes over 700 data fields that cover facilities and services, utilization, finances, and staffing. On average, 6,000 hospitals complete the survey each year. Section E of the Annual Survey Database includes total facility staffing data. FTE counts are available for registered nurses, practical and vocational nurses, nursing assistive personnel, and other personnel. However, FTEs in outpatient areas, excluded units, and nursing home units within the hospital are also included in the aggregated FTE counts. It is not possible to separately identify how many of the total reported nursing FTEs are attributable to the general acute care facility and how many to a distinct part unit or outpatient facility. Due to varying staffing needs in distinct part units and outpatient areas, we believe that any calculation of average staffing for the inpatient acute care area should consist of data solely from this area of the hospital. Nevertheless, we are requesting comments on this alternative, and possible means for addressing the issue of staffing outside the inpatient acute care area. 3. Mandatory Reporting Requirements for Any Changes in the Circumstances Under Which a Hospital Was Designated as an SCH or MDH

(If you choose to comment on the issues in this section, please include the caption (``SCH/MDH Changes in Qualification Status'' at the beginning of your comment.)

Under Sec. 412.92(b)(3) and Sec. 412.108(b)(4) respectively, once a facility has been designated as an SCH or MDH, the classification remains in effect without need for reapproval unless there is a change in the hospital's circumstances. Currently, the regulations do not contain an explicit requirement that an SCH report to CMS a change in circumstances that would affect its status as an SCH. Likewise, the current regulations for MDHs do not contain an explicit requirement that an MDH report to CMS a change in the circumstances affecting its MDH status. However, the fiscal intermediary is required to evaluate on an ongoing basis whether a hospital continues to qualify for MDH status.

We have become aware of several hospitals that have maintained SCH or MDH status after the original circumstances that led to the respective classification changed. We are proposing to amend Sec. 412.92(b)(3) for SCHs and Sec. 412.108(b)(4) for MDHs to require an SCH or MDH to report to its appropriate CMS Regional Office when the circumstances under which the hospital was approved for SCH or MDH status have changed. At that time, the CMS Regional Office will determine whether the SCH or MDH continues to meet the criteria for classification under Sec. 412.92 or Sec. 412.108. If an SCH or MDH no longer meets these criteria, the CMS Regional Office will issue a letter canceling the classification within 30 days of its determination. If the circumstances affecting a hospital's SCH or MDH classification change and the hospital does not disclose the information to the CMS Regional Office, CMS will cancel the hospital's SCH or MDH designation effective on the earliest discernable date on which the fiscal intermediary can determine that the hospital no longer met the criteria for classification.

For MDHs, this reporting requirement is in addition to the fiscal intermediary's ongoing evaluations of whether a hospital continues to qualify for MDH status as set out in our existing regulations at Sec. 412.108(b)(5). 4. Proposed Payment Changes for MDHs Under the DRA of 2005 (Proposed Sec. 412.79 and Existing Sec. Sec. 412.90(j) and 412.108)

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

Under Sec. 412.108(a) of our regulations, in order to be classified as an MDH, a hospital must: (1) Be located in a rural area (as defined in 42 CFR Part 412, Subpart D); (2) have 100 or fewer beds (as defined at Sec. 412.105(b)) during the cost reporting period; (3) must not be classified as an SCH (as defined in Sec. 412.92); and (4) have no less than 60 percent of its inpatient days or discharges attributable to inpatients receiving Medicare Part A benefits during either its cost reporting period beginning in FY 1987, or in two of the last three of its audited cost reports that have been settled.

MDHs have been eligible for a series of special payment rates under the IPPS. Section 6003(f) of Pub. L. 101-239 created the first IPPS special payment methodology for MDHs. Effective for cost reporting periods beginning on or after April 1, 1990, and ending on or before March 31, 1993, an MDH was paid based on whichever of the following rates yielded the greatest aggregate payment for the cost reporting period:

The Federal payment rate applicable to the MDH;

The MDH's updated hospital-specific rate based on its FY 1982 base period costs per discharge; or

The MDH's updated hospital-specific rate based on its FY 1987 base period costs per discharge.

Section 13501(e)(1) Pub. L. 103-66 extended the MDH payment provisions through 1994 and provided that, for discharges occurring after March 31, 1993, if an MDH's applicable hospital-specific rate exceeded the Federal payment rate, the additional payment was limited to 50 percent of the amount by which the applicable updated hospital- specific rate exceeded the Federal rate. These provisions expired effective for cost reporting periods beginning on or after October 1, 1994.

Section 4204(a)(3) of Pub. L. 105-33 amended sections 1886(d)(5)(G)(i) and (d)(5)(G)(ii)(II) of the Act to reinstate these special MDH payment provisions, including the 50-percent limitation, for cost reporting periods ``beginning on or after October 1, 1997, and before October 1, 2001.'' Section 321(b)(1) of Pub. L. 106-113 made a technical

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amendment to these provisions of the Act (which describes the time periods for which some of the special payment provisions apply and the time periods during which a hospital may be considered an MDH under section 1886(d)(1)(G)(iv) of the Act) by striking the language ``beginning on or after October 1, 1997, and before October 1, 2001'' and replacing it with ``discharges occurring on or after October 1, 1997, and before October 1, 2001''. This change was made effective as if included in Pub. L. 105-33. Pub. L. 106-113 also provided for a 5- year extension of the MDH special payment provisions. Section 404(a) of that law further amended sections 1886(d)(1)(G)(i) and (d)(1)(G)(ii)(II) of the Act by striking the phrase ``and before October 1, 2001'' and inserting the phrase ``and before October 1, 2006''.

Section 5003(a) of Pub. L. 109-171 (DRA of 2005) amended the MDH special payment provisions in the Act. It amended section 1886(d)(5)(G) of the Act and made a conforming amendment under section 1886(b)(3)(D) of the Act to provide for another 5-year extension of the special MDH payment methodology. Under this extension, a revised special MDH payment methodology will apply for discharges occurring on or after October 1, 2006, and before October 1, 2011.

As stated earlier, currently, MDHs are paid using whichever rate yields the greatest aggregate payment: The Federal payment rate or, if higher, the Federal payment rate plus 50 percent of the difference between the Federal payment rate and the updated hospital-specific rate based on FY 1982 or FY 1987 base period costs per discharge.

Section 5003(b) of Pub. L. 109-171 provides that, for discharges occurring on or after October 1, 2006, and before October 1, 2011, an MDH's updated hospital-specific rate will be the FY 2002 base period costs per discharges if the FY 2002 based hospital-specific rate results in a payment increase. In cases where no payment increase results from using FY 2002 hospital-specific rate, an MDH will continue to be paid based on the higher of its updated FY 1982 or FY 1987 hospital-specific rates, if using one of those rates results in a payment higher than that under the Federal payment rate. (Unlike an SCH, an MDH does not have the option of using its updated FY 1996 hospital-specific rate.)

Under section 5003(c) of Pub. L. 109-171, for discharges occurring on or after October 1, 2006, and before October 1, 2011, if an MDH's applicable hospital-specific rate exceeded the Federal payment rate, the additional payment is limited to 75 percent (as opposed to the previous 50 percent) of the amount by which the applicable updated hospital-specific rate exceeded the Federal rate.

Section 5003(d) of Pub. L. 109-171 enhances the DSH adjustment for MDHs for discharges occurring on or after October 1, 2006. We discuss our proposals to implement this provision in section IV.F.4. of this preamble. b. Proposed Regulation Changes

We are proposing to amend our regulations to implement section 5003(a) through (c) of Pub. L. 109-171. We are proposing to add a new Sec. 412.79 that describes how we would compute and update the MDH hospital-specific rate based on its FY 2002 base period. In addition, we are proposing to revise Sec. 412.90(j) to reflect the extension of the MDH special payment provisions to discharges occurring before October 1, 2011. We also are proposing to amend Sec. 412.108 by revising paragraph (a) and adding a new paragraph (c)(2)(iii) to reflect the changes to the special payment methodology effective for discharges occurring on or after October 1, 2006, and before October 1, 2011.

As a part of our proposed amendments to Sec. 412.90(j) and Sec. 412.108(a), we are making two technical corrections. Section 412.90(j) describes when an MDH may receive a special payment adjustments, while Sec. 412.108(a) discusses the definition of an MDH. Each of these sections now refers to ``cost reporting periods beginning on or after April 1, 1990 and before October 1, 1994, or beginning on or after October 1, 1997 and before October 1, 2006''. However, as noted above, sections 1886(d)(5)(G)(i) and (d)(5)(G)(ii)(II) of the Act, the provisions of the Act from which these time periods were drawn, were amended by Pub. L. 106-113. Sections 321(b)(1) and 404(a) of Pub. L. 106-113 amended sections 1886(d)(5)(G)(i) and (d)(5)(ii)(II) of the Act so that the phrase in each section ``beginning on or after October 1, 1997, and before October 1, 2001'' was replaced with the phrase ``discharges occurring on or after October 1, 1997, and before October 1, 2006''. (Section 5003(a)(1) of Pub. L. 109-171 changed the ending date in these provisions from ``before October 1, 2006'' to ``before October 1, 2011''.)

Therefore, we are removing the incorrect phrase ``beginning on or after October 1, 1997'' from each of these regulations and inserting the phrase, ``discharges occurring on or after October 1, 1997'', to conform the regulations to the statute. 5. Proposed Technical Change

In paragraph (b)(2)(iv) of Sec. 412.92, we are proposing to correct the spelling of the word ``adjustment'' by changing it to ``adjustment''.

D. Rural Referral Centers (Sec. 412.96)

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

Under the authority of section 1886(d)(5)(C)(i) of the Act, the regulations at Sec. 412.96 set forth the criteria that a hospital must meet in order to qualify under the IPPS as 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 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

[[Page 24106]]

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. We used the definitions of ``urban'' and ``rural'' specified in Subpart D of 42 CFR Part 412.

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 CMI and a minimum number of discharges) and at least one of three optional criteria (relating to specialty composition of medical staff, source of inpatients, or referral volume) (Sec. 412.96(c)(1) through (c)(5)). (See also the September 30, 1988 Federal Register (53 FR 38513).) With respect to the two mandatory prerequisites, a hospital may be classified as a rural referral center if--

The hospital's CMI is at least equal to the lower of the median CMI for urban hospitals in its census region, excluding hospitals with approved teaching programs, or the median CMI for all urban hospitals nationally; and

The hospital's number of discharges is at least 5,000 per year, or, if fewer, the median number of discharges for urban hospitals in the census region in which the hospital is located. (The number of discharges criterion for an osteopathic hospital is at least 3,000 discharges per year, as specified in section 1886(d)(5)(C)(i) of the Act.) 1. Case-Mix Index

Section 412.96(c)(1) provides that CMS will establish updated national and regional CMI values in each year's annual notice of prospective payment rates for purposes of determining rural referral center status. The methodology we use to determine the national and regional CMI values is set forth in regulations at Sec. 412.96(c)(1)(ii). The proposed national median CMI value for FY 2007 includes all urban hospitals nationwide, and the proposed regional values for FY 2007 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 2005 (October 1, 2004 through September 30, 2005) and include bills posted to CMS' records through December 2005.

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, 2006, rural hospitals with fewer than 275 beds must have a CMI value for FY 2005 that is at least--

1.3365; or

The median CMI 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 CMI values by region are set forth in the following table:

Case-mix index Region

value

1. New England (CT, ME, MA, NH, RI, VT)..............

1.2678 2. Middle Atlantic (PA, NJ, NY)......................

1.2701 3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA,

1.1781 WV)................................................. 4. East North Central (IL, IN, MI, OH, WI)...........

1.3156 5. East South Central (AL, KY, MS, TN)...............

1.2009 6. West North Central (IA, KS, MN, MO, NE, ND, SD)...

1.2856 7. West South Central (AR, LA, OK, TX)...............

1.2445 8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY).........

1.3024 9. Pacific (AK, CA, HI, OR, WA)......................

1.3620

The preceding numbers will be revised in the final rule to the extent required to reflect the updated FY 2005 MedPAR file, which will contain data from additional bills received through March 2006.

Hospitals seeking to qualify as rural referral centers or those wishing to know how their CMI value compares to the criteria should obtain hospital-specific CMI values (not transfer-adjusted) from their fiscal intermediaries. Data are available on the Provider Statistical and Reimbursement (PS&R) System. In keeping with our policy on discharges, these CMI values are computed based on all Medicare patient discharges subject to 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 2003 (that is, October 1, 2002 through September 30, 2003), which is the latest available cost report data we had at that 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, 2006, must have as the number of discharges for its cost reporting period that began during FY 2003 a figure that is at least--

5,000 (3,000 for an osteopathic hospital); or

The median number of discharges for urban hospitals in the census region in which the hospital is located, as indicated in the following table:

Number of Region

discharges

1. New England (CT, ME, MA, NH, RI, VT)..............

7,360 2. Middle Atlantic (PA, NJ, NY)......................

10,170

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3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA,

10,117 WV)................................................. 4. East North Central (IL, IN, MI, OH, WI)...........

8,983 5. East South Central (AL, KY, MS, TN)...............

7,427 6. West North Central (IA, KS, MN, MO, NE, ND, SD)...

7,346 7. West South Central (AR, LA, OK, TX)...............

7,060 8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY).........

9,832 9. Pacific (AK, CA, HI, OR, WA)......................

7,680

These numbers will be revised in the final rule based on the latest available cost report data.

We note that the median number of discharges for hospitals in each census region is greater than the national standard of 5,000 discharges. Therefore, 5,000 discharges is the minimum criterion for all hospitals.

We reiterate that if an osteopathic hospital is to qualify for rural referral center status for cost reporting periods beginning on or after October 1, 2006, the hospital would be required to have at least 3,000 discharges for its cost reporting period that began during FY 2003.

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

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

Section 1886(d)(5)(B) of the Act provides that prospective payment hospitals that have residents in an approved graduate medical education (GME) program receive an additional payment to reflect the higher indirect patient care costs of teaching hospitals relative to nonteaching hospitals. The regulations regarding the calculation of this additional payment, known as the indirect medical education (IME) adjustment, are located at Sec. 412.105.

The Balanced Budget Act of 1997 (Pub. L. 105-33) established a limit on the number of allopathic and osteopathic residents that a hospital may include in its full-time equivalent (FTE) resident count for direct GME and IME payment purposes. Under section 1886(h)(4)(F) of the Act, a hospital's unweighted FTE count of residents may not exceed the hospital's unweighted FTE count for its most recent cost reporting period ending on or before December 31, 1996. Under section 1886(d)(5)(B)(v) of the Act, the limit on the FTE resident count for IME purposes is effective for discharges occurring on or after October 1, 1997. A similar limit is effective for direct GME purposes for cost reporting periods beginning on or after October 1, 1997. 2. IME Adjustment Factor for FY 2007

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.

Section 502(a) of Public Law 108-173 modified the formula multiplier (c) to be used in the calculation of the IME adjustment. Prior to the enactment of Public Law 108-173, the formula multiplier was fixed at 1.35 for discharges occurring during FY 2003 and thereafter. Section 502(a) modified the formula multiplier beginning midway through FY 2004 and provided for a new schedule of formula multipliers for FY 2005 and thereafter. In the FY 2005 IPPS rule, we announced the schedule of formula multiplier to be used in the calculation of the IME adjustment and incorporated the schedule in our regulations at Sec. 412.105(d)(3)(viii) through (d)(3)(xii).

In this proposed rule, we are specifying that for any discharges occurring during FY 2007, the formula multiplier is 1.32. We estimate that application of the mandated formula multiplier for FY 2007 will result in an increase of 5.38 percent in IME payment for every approximately 10-percent increase in the resident-to-bed ratio from FY 2006 to FY 2007. 3. Technical Change To Revise Cross-Reference

We are proposing to revise the cross-references included in paragraph (f)(1)(ii)(C) of Sec. 412.105 that specify the criteria for counting FTE residents who spend time in nonprovider settings for IME payment adjustment purposes. Currently, this paragraph only cites the criteria set forth in Sec. Sec. 413.78(c) or 413.78(d). We should have also cited the provisions of Sec. 413.78(e), which state that the time residents spend in nonprovider settings such as freestanding clinics, nursing homes, and physicians' offices in connection with approved programs may be included in determining the number of FTE residents in the calculation of a hospital's resident count if other applicable conditions specified in paragraph (e) are met.

We note that in sections IV.H.2., 3., 4., and 5. of the preamble of this proposed rule, we discuss other proposed policy changes and clarifications to the methodology for counting FTE residents for the purposes of direct GME payments, which would be applicable to IME payments also.

F. Payment Adjustment for Disproportionate Share Hospitals (DSHs) (Sec. 412.106)

(If you choose to comment on issues in this section, please include the caption ``DSH Adjustment'' 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

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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] TP25AP06.022

2. Technical Corrections

We are proposing to make a technical correction to Sec. 412.106(a)(1)(iii) to reflect the statutory requirement at section 1886(d)(8)(E) of the Act that hospitals reclassified under Sec. 412.103 are considered rural for purposes of this DSH regulation. We are also proposing to correct the regulation to eliminate the reference to Sec. 412.62(f). These corrections reflect current policy and already-existing statutory requirements. 3. Proposed Reinstatement of Inadvertently Deleted Provisions on DSH Payment Adjustment Factors

In an interim final rule published in the Federal Register on June 13, 2001 (66 FR 32174 and 32194) (which was finalized in the Federal Register on August 1, 2001 (66 FR 39827)), we incorporated into our regulations at Sec. 412.106(d)(2) the provisions of section 211(b) of Public Law 106-554. Section 211(b) amended section 1886(d)(5)(F) of the Act to revise the calculation of the disproportionate share percentage adjustment for hospitals affected by the revised DSH qualifying threshold percentages specified in section 211(a) of Public Law 106- 554. When the section 211 changes were incorporated into the Code of Federal Regulations at Sec. 412.106(d)(2), the regulation text at Sec. 412.106(d)(2)(v) was inadvertently deleted during the transcribing of the new text into the existing regulations. Section 412.106(d)(2)(v) specifies the payment adjustment factors for hospitals that meet the following criteria under Sec. 412.106(c)(2) for discharges occurring on or after April 1, 1990, and before October 1, 1991, and on or after October 1, 1991: Hospitals located in an urban area, that have 100 or more beds, and that can demonstrate that, during their cost reporting period, more than 30 percent of their net inpatient care revenues are derived from State and local government payments for care furnished to indigent patients.

We are proposing to reinstate the inadvertently deleted text of Sec. 412.106(d)(2)(v). We note that this is a correction to the regulations; we are not proposing to change the payment adjustment factors for hospitals that meet the criteria under Sec. 412.106(c)(2). 4. Enhanced DSH Adjustment for MDHs

The DSH adjustment factor for most categories of hospitals is capped at 12 percent. Urban hospitals with more than 100 beds, rural hospitals with more than 500 beds, and rural referral centers, are exempt from this cap.

Section 5003(d) of Public Law 109-171 (DRA of 2005) amended section 1886(d)(5)(F) of the Act to revise the DSH payment adjustment factor for MDHs, effective for discharges occurring on or after October 1, 2006. Specifically, section 5003(d) amended section 1886(d)(5)(F)(xiv)(II) of the Act to exclude MDHs from the 12-percent DSH adjustment factor cap.

For all discharges occurring on or after October 1, 2006, the fiscal intermediary will not apply the cap when calculating the DSH payments. These payments will be subject to revision upon final settlement of the cost reporting period. We note that this change will not affect the calculation of the disproportionate patient percentage.

We are proposing to amend the regulations at Sec. 412.106 to include this provision under proposed new paragraph (d)(2)(iv)(D).

G. Geographic Reclassifications (Sec. Sec. 412.103, 412.230, and 412.234)

(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 Public Law 108-7, section 402 of Public Law 108-89, and section 401 of Public Law 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. We implemented this policy 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 42 CFR 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 2007, the MGCRB used the 3-year average hourly wages published in Table 2 of the August 12, 2005 IPPS final rule (70 FR 47508). These average hourly wages are taken from data used to calculate the wage indexes for FY 2004, FY 2005, and FY 2006, based on cost reporting periods beginning during FY 2000, FY 2001, and FY 2002, respectively. 2. Reclassifications Under Section 508 of Public Law 108-173

As we discuss in section III.H.5. of the preamble of this proposed rule, under section 508 of Public Law 108-173, a

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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). 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 achieved in a budget neutral manner.

Some hospitals currently receiving a section 508 reclassification are eligible to reclassify to that same area under the standard reclassification process as a result of the new labor market definitions that we adopted for FY 2005. In applying for a 3-year MGCRB reclassification beginning in FY 2007, hospitals that are already reclassified to the same area under section 508 should have indicated in their MGCRB reclassification requests that if they receive the MGCRB reclassification, they would forfeit the section 508 reclassification for the first 6 months of FY 2007.

We refer readers to section III.H.5. of the preamble of this proposed rule for a discussion of our updated procedural rules established under section 1886(d)(10)(D)(v) of the Act in which a section 508 hospital may retain its section 508 reclassification through its expiration on March 31, 2007, and accept a reclassification approved by the MGCRB for the second half of FY 2007 (April 1, 2007, through September 30, 2007). We also clarify the procedural rules for an already individually reclassified hospital that is part of a group that includes a section 508 hospital. 3. Multicampus Hospitals (Sec. 412.230(d)(2)(iii))

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 implemented in FY 2005 for the IPPS, a multicampus hospital previously located in a single MSA is now located in more than one CBSA. Under our existing 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 Divisions, where applicable) in which the campus of the hospital is located. Prior to FY 2006, the criteria for a hospital being reclassified to another wage area by the MGCRB did not address the circumstances under which a single campus of a multicampus hospital may seek reclassification. The regulations require that a hospital provide data from the CMS hospital wage survey for the average hourly wage comparison that is used to support a request for reclassification. Because a multicampus hospital is required to report data for the entire hospital 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 the FY 2006 IPPS final rule (70 FR 47444 through 47446 and 47487), we modified the reclassification rules at Sec. 412.230(d)(2)(iii) to allow campuses of multicampus hospitals located in separate wage index areas to support a reclassification application to an area where another campus is located using the average hourly (composite) wage data submitted on the cost report for the entire multicampus hospital as its hospital-specific data. This special rule applies for reclassification applications for FY 2006, FY 2007, and FY 2008 and will not be in effect for FY 2009 reclassification requests. Because reclassification applications to the MGCRB for FY 2009 must be filed in September 2007, or 1 month before the effective date of the FY 2008 IPPS rule, we are addressing whether to propose to extend the special rule for multicampus hospitals beyond FY 2008 in this FY 2007 proposed rule. In the FY 2006 IPPS final rule, we indicated that we would continue to explore options that would allow individual campuses of multicampus hospitals to submit wage data necessary for geographic reclassification and also monitor the number of multicampus hospitals affected by this provision (70 FR 47445 and 47446).

After reviewing this situation further, we believe that if a campus of a multicampus hospital applies for reclassification, it should be required to support its application with campus specific data. Because a cost report is filed for an entire hospital, the campus would have to obtain a separate provider number and be treated for Medicare payment purposes as an independent entity in order to be able to provide wage data for the specific campus. If a hospital were to make a change in FY 2007 to its organizational structure to provide campus specific data to support a reclassification application, the earliest fiscal year that the campus would be eligible to reclassify would be FY 2012 because the cost report data that are used for geographic reclassification precede the payment year by 5 years (that is, FY 2003 cost report data will be used to determine the FY 2008 geographic reclassifications).

To our knowledge, only one hospital has used the special rule for multicampus hospitals. This hospital has since joined a successful FY 2007 urban county group reclassification application to the same area to which it was approved under the multicampus hospital rule. Thus, this hospital is no longer required to meet the multicampus hospital rule. Given that there is only one hospital that has used this rule and this hospital was able to reclassify under the normal reclassification rules, we believe the special reclassification rule that applies to multicampus hospitals is no longer needed. Therefore, we are proposing not to extend the special rule beyond FY 2008. For reclassification requests for FY 2009 and thereafter, a campus of a multicampus hospital would be required to obtain a separate provider number in order to provide the required wage data from the CMS hospital wage survey for the average hourly wage comparison in its MGCRB reclassification application. 4. Urban Group Hospital Reclassifications (Sec. 412.234(a)(3)(iii))

Section 412.234(a)(3)(iii) of the regulations sets forth criteria for urban hospitals to be reclassified as a group for FY 2007 and thereafter. Under these criteria, ``hospitals located in counties that are in the same Combined Statistical Area (CSA) (under the MSA definitions announced by the OMB on June 6, 2003) as the urban area to which they seek redesignation qualify as meeting the proximity requirement for reclassification to the urban area to which they seek redesignation.''

Last year, several commenters brought to our attention that, while the CSA standard allows for urban county group reclassifications in large urban areas throughout the United States (including 10 of the 11 CBSAs containing Metropolitan Divisions), the CSA standard precludes urban county group reclassifications between three Metropolitan Divisions within one CBSA in Florida. They urged us to modify our policy to also allow hospitals located in counties that are in the same CBSA (in the case of Metropolitan Divisions) as the area to which they seek redesignation to be considered to have met the proximity requirement. We agree with the commenter's proposed modification. The proximity standard for group reclassifications is intended to allow all

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of a county's hospitals to reclassify to an adjacent area where there is sufficient economic integration that there can be an expectation that both areas are competing in a similar labor market area. We believe there is sufficient economic integration between Metropolitan Divisions within a CBSA that urban county reclassifications within a CBSA or a CSA should be permitted. A CBSA, as defined by the OMB, is 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.''

Therefore, we are proposing to revise Sec. 412.234(a)(3) by adding a new paragraph (iv) to expand the proximity criteria to allow urban county groups to apply for reclassification to another area within the same CBSA. We are proposing to require that, beginning with FY 2008, hospitals must be located in counties that are in the same CSA or CBSA (under the MSA definitions announced by 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. 5. Effect of Change of Ownership on Urban County Group Reclassifications (Sec. Sec. 412.230, 412.234, and 489.18)

We have received questions asking for clarification of our policy regarding whether newly constructed hospitals and hospitals that do not accept assignment of the previous owner's provider agreement can join an urban county group reclassification.

The Medicare regulations at Sec. 412.230 require that, for individual hospital reclassifications, a hospital must provide a weighted 3-year average of its average hourly wages using data from the CMS hospital wage survey used to construct the wage index in effect for prospective payment purposes. Section 489.18(c) of the regulations provides that, when there is a change of ownership, the existing provider agreement will automatically be assigned to the new owner when there is a change of ownership as defined in the rules. Section 412.230(d)(2)(iv) of the regulations specifies that, in situations where a hospital becomes a new provider and the existing hospital's provider agreement is not assigned under Sec. 489.18, the wage data associated with the previous hospital's provider number will not be used in calculating the new hospital's 3-year average hourly wage. This policy is consistent with how we treat hospitals whose ownership has changed for other Medicare payment purposes. The regulations also state that once a new hospital has accumulated at least 1 year of wage data using survey data from the CMS hospital wage survey used to determine the wage index, it is eligible to apply for reclassification on the basis of those data.

While the regulations preclude a new provider from individually reclassifying until the hospital accumulates at least 1 year of wage data from the CMS hospital wage survey used to determine the wage index, a new provider may join a group reclassification under Sec. 412.234. Under Sec. 412.234, all hospitals in an urban county must apply for redesignation as a group. If we did not permit a new hospital to join group reclassifications, all hospitals in the county would not be part of the reclassification application and the urban county group would be precluded from reclassifying for 3 years until the new hospital accumulated at least 1 year of wage data. We believe it would be inequitable to preclude a group reclassification merely because there was one newly constructed hospital or one hospital in the county changed ownership and did not accept the prior owner's provider agreement. Alternatively, we believe that allowing group applications without a new hospital would be inconsistent with our regulations and unfair to new hospitals because it would put them at a competitive disadvantage with other hospitals in the county. Because such reclassifications are effective for 3 years, a new hospital that was not allowed to join a group reclassification would have to accept a lower wage index than all other hospitals in the county with which it competes for labor for up to 3 years. 6. Requested Reclassification for Hospitals Located in a Single Hospital MSA Surrounded by Rural Counties

In the FY 2006 IPPS final rule (70 FR 47448), we presented a commenter's concern about the special circumstances of a hospital located in a single hospital MSA surrounded by rural counties in relation to the wage index and the rules governing geographic reclassification. The commenter stated that an isolated hospital in a single hospital MSA is at a competitive disadvantage because the rural hospitals that surround the hospital have been reclassified to higher wage index areas or have been designated as rural referral centers, SCHs, MDHs, or CAHs. The urban hospital is ineligible for reclassification to a higher wage index area either as an individual hospital or as part of a group under the existing regulations. The commenter emphasized that this concern is especially significant given the fact that an isolated hospital in a single hospital MSA is the only hospital in its urban area, and, therefore, has an even greater obligation to the communities it serves.

The commenter advocated a change to the urban county group reclassification regulations whereby a hospital in a single hospital MSA surrounded by rural counties would be able to reclassify to the closest urban area that is part of a CSA located in the same State as the hospital. We did not adopt this suggested policy under the IPPS for FY 2006 because we did not believe it would be prudent to adopt the suggested policy in a final rule without first soliciting public comment.

The commenter's suggestion presents a number of issues on which we seek comment. First a single hospital in an urban area receives a wage index value that directly reflects the wages it pays, undiluted by those of any other hospital. Thus, it would appear that in such cases, the wage index is operating with substantial precision in adjusting the wage-related portion of the payment to accord with the actual wage experience of the hospital in question. We have sought comment on the circumstances facing single hospitals in urban areas in past rulemaking. The justification for reclassifying a hospital that is receiving a wage index reflecting its own wages in this way is not readily apparent. Second, it is open to question why this hospital's situation provides justification for special treatment under the wage index. We understand it is one of two 1886(d) hospitals located in an urban county entirely surrounded by rural counties and that it is within a modest distance of a number of hospitals that have received one form or another of special payment status relating to their rural locations. We are interested in receiving comment on whether these aspects indicate the need for a special wage index reclassification provision. Third, the commenter's suggested policy would allow a hospital to reclassify to a labor market area that is further away than other, closer urban labor market areas. We are concerned that such a reclassification would be inconsistent with the proximity standard we have generally used to reflect local labor markets. Each of these aspects of the suggested policy might affect a significant number of other hospitals and thus be viewed as having widespread precedent that we invite comment upon.

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H. Payment for Direct Graduate Medical Education

1. Background

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

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 methodology for the determination of a hospital-specific, base-period per resident amount (PRA) that is calculated by dividing a hospital's allowable costs of GME for a base period by its number of residents in the base period. The base period is, for most hospitals, the hospital's cost reporting period beginning in FY 1984 (that is, the period beginning between October 1, 1983, through September 30, 1984). Medicare direct GME payments are calculated by multiplying the PRA times the weighted number of full-time equivalent (FTE) residents working in all areas of the hospital (and nonhospital sites, when applicable), and the hospital's Medicare share of total inpatient days. The base year PRA is updated each year for inflation. However, 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, effective October 1, 2000, 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. Specifically, Pub. L. 106-113 established a ``floor'' for FY 2001 such that a hospital-specific PRA should not be less than 70 percent of the locality-adjusted national average PRA. In addition, it established a ``ceiling'' that froze or limited the annual inflation adjustment to a hospital-specific PRA if the PRA exceeded 140 percent of the locality-adjusted national average PRA. Section 511 of Pub. L. 106-554 increased the ``floor'' established by Pub. L. 106-113 to equal 85 percent of the locality-adjusted national average PRA for PRAs in existence in FY 2002. 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 (for FY 2001 and FY 2002) and the ceiling (for FY 2001 through 2013) to determine whether a hospital-specific PRA should be revised. We note that, under existing regulations at Sec. 413.77(c), if a hospital-specific PRA for FY 2001 or FY 2002 is revised due to application of the floor PRA, the revised PRA is the starting point for the PRA in future years, subject to the annual inflation adjustment and any other applicable adjustments.

Section 1886(h)(4)(F) of the Act established caps on the number of allopathic and osteopathic residents that hospitals may count for purposes of calculating direct GME payments. For most hospitals, the caps 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. Section 422 of Pub. L. 108-173 amended section 1886(h)(7) of the Act and provided for reductions to the resident caps of teaching hospitals that were training a number of FTE residents below their cap in a reference period, and authorized a ``redistribution'' of FTE resident slots to hospitals that could demonstrate a likelihood of using the additional resident slots within the first three cost reporting periods beginning on or after July 1, 2005. 2. Determination of Weighted Average Per Resident Amounts (PRAs) for Merged Teaching Hospitals (Sec. 413.77)

(If you choose to comment on issues in this section, please include the caption ``GME: PRA for Merged Hospitals'' at the beginning of your comment.)

As stated in the background section above, in accordance with section 1886(h) of the Act, Medicare pays teaching hospitals for the direct costs of GME based on the per resident direct GME costs in a base year. For most hospitals, the base year is FY 1984 (cost reporting periods beginning between October 1, 1983, and September 30, 1984). Although section 1886(h) of the Act provides for the establishment of a PRA for a hospital that trained residents in the 1984 base year, the statute does not address how to treat the PRA(s) of teaching hospitals that subsequently merge.

Our policy has always been that when two or more teaching hospitals merge, we determine a weighted PRA for the surviving merged hospital using direct GME costs and resident data from the base year cost report for each teaching hospital involved in the merger. This policy was detailed in Questions and Answers on Medicare GME Payments Issued on November 8, 1990: ``[When] two hospitals merge * * * the merged hospital's per resident amount * * * [is] based on the weighted average of the per resident amounts of both hospitals.'' We believe this is an equitable way to determine a PRA for the surviving merged hospital because it is based on the relative costs and sizes of the GME training programs in the respective facilities. Moreover, we believe this policy minimizes the role Medicare GME payments play in the choice of the surviving hospital entity. For example, there is no incentive to choose the surviving hospital based in part on the hospitals' relative PRAs.

To calculate the weighted average PRA for the merged entity, the fiscal intermediary begins by determining the base year PRAs and the base year FTE resident counts of the hospitals that merge. The weighted average PRA is calculated by adding the product of each hospital's base year PRA and its base year FTE resident count, and dividing that number by the total number of the base year FTE residents for those hospitals.

When our current methodology was first established for calculating the new PRA for a merged hospital, we adopted a policy to use base year PRAs and FTE resident counts. It was appropriate and workable to use data from the PRA base year because the base year data (usually for the 1984 fiscal year) associated with the hospital-specific PRAs were easily accessible. However, these data are now often over 20 years old and it has become administratively burdensome for both CMS and the fiscal intermediaries to access base year information in calculating the weighted average of the PRAs for merged hospitals.

In addition to it being administratively burdensome to use base year cost report data, where a hospital has two PRAs--one for primary care and obstetrics and gynecology residents and another for nonprimary care residents, these two PRAs are not being taken into account in developing the weighted average PRA for the merged hospital. As discussed earlier, hospitals that were training nonprimary care residents in FYs 1994 and 1995

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have a separate nonprimary care PRA because there was no update for inflation applied to the PRA for nonprimary care residents in those years (Sec. 413.77(c)(2)). Accordingly, many teaching hospitals currently have two PRAs: One for primary care and obstetrics and gynecology residents and one for all other residents. (Hospitals that first train residents after FY 1995 would only have a single PRA, even if they train both primary care residents and nonprimary care residents.) Because the current methodology for calculating the weighted average PRA for a merged teaching hospital is based solely on data from the PRA base year (which is usually prior to the years during which the PRAs were not adjusted for inflation to reflect nonprimary care residents), this methodology does not take into account that the merged hospitals may currently have more than one PRA.

Effective for cost reporting periods beginning on or after October 1, 2006, rather than use direct GME count of residents and PRA from hospitals' base year cost reports, we are proposing to simplify and revise the weighted average PRA methodology for determining a merged teaching hospital's PRA by using FTE resident data and PRA data from the most recently settled cost reports of the merging hospitals. It is less administratively burdensome to use these data, since these data are more recent and, therefore, more accessible. In addition, these data would reflect both a primary care and obstetrics and gynecology PRA and, if applicable, a nonprimary care resident PRA.

We note that prior to FY 2003, our policy for calculating the PRA for a new teaching hospital was to calculate the PRA based on the lower of the new teaching hospital's actual cost per resident in its base period or a weighted average of all the PRAs of existing teaching hospitals in the same geographic wage area, as that term is used under the prospective payment system (existing Sec. 413.77(e)(1)). (For ease of discussion, we refer to a hospital that did not participate in Medicare or that did not have any approved medical residency training programs during the period beginning between October 1, 1983, through September 30, 1984, and has since commenced participating in Medicare and begun training residents in an approved program, as a ``new teaching hospital.'') The weighted average PRA of teaching hospitals within a particular geographic wage area was determined using the base year PRA and the base year FTE resident count of each respective teaching hospital within the geographic wage area. However, as discussed in the August 1, 2002 IPPS final rule (67 FR 50067) effective October 1, 2002, we revised our policy to use PRAs and FTE resident data from the most recently settled cost reports of teaching hospitals in the same CBSA as the new teaching hospitals, rather than data from the 1984 base year (existing Sec. 413.77(e)(1)(ii)(B)). We revised this policy for establishing PRAs for new teaching hospitals because it is less administratively burdensome to use data from the hospitals' most recently settled cost reports and because the more recent data takes into account that hospitals have a primary care PRA and a nonprimary care PRA. In this proposed rule, we are proposing a similar policy revision for establishing a merged teaching hospital's PRA.

We are proposing that the fiscal intermediaries would use the following steps to calculate the weighted average PRA for the merged teaching hospital:

Step 1: Identify the primary care and obstetrics and gynecology FTE resident count, the nonprimary care FTE resident count for hospitals with two PRAs, or the single FTE resident count for hospitals with a single PRA, for each teaching hospital involved in the merger. (Use the sum of the FTE resident counts from line 3.07, line 3.08, and line 3.11 of the hospital's most recently settled Medicare cost report, CMS 2552- 96, Worksheet E-3, Part IV.)

Step 2: Identify the PRAs (either a hospital's primary care and obstetrics and gynecology PRA and nonprimary care PRA or, if applicable, a hospital's single PRA) from the most recently settled cost report for each hospital involved in the merger, and update the PRAs using the CPI-U inflation factor to coincide with the fiscal year end of the surviving teaching hospital. For example, if the surviving teaching hospital's fiscal year end is December 31, 2006, and the most recently settled cost report of the teaching hospital(s) involved in the merger is June 30, 2003, the PRAs from this cost report would be updated for inflation to December 31, 2006.

Step 3: Calculate the weighted average PRA for the single merged hospital using the PRAs and FTE resident counts from Step 1 and Step 2. For each teaching hospital in the merger:

(a) For hospitals with two PRAs, multiply the primary care PRA by the number of primary care and obstetrics and gynecology FTE residents.

(b) For hospitals with two PRAs, multiply the nonprimary care PRA by the number of nonprimary care FTE residents.

(c) For hospitals with a single PRA, multiple the single PRA by the hospital's total number of FTE residents.

(d) Add the products from applicable Steps 3(a), (b), and (c) for all teaching hospitals that merged.

(e) Add the number of FTE residents from Step 1 for all hospitals.

(f) Divide the sum from Step 3(d) by the sum from Step 3(e). The result is the weighted average PRA for the merged hospital.

As mentioned above, many hospitals currently have two PRAs, one for primary care residents and another for nonprimary care residents. An advantage to using data from the most recently settled cost reports of the hospitals involved in a merger is that the two PRAs are taken into account in determining the weighted average PRA for the merged hospital. Because two PRAs would be taken into account under this proposal, we considered whether a primary care PRA and a nonprimary care PRA should therefore be determined for the merged hospital. Although it would be possible to determine and retain two PRAs for a merged hospital when one or more hospitals involved in the merger had two PRAs, we are not proposing to do so. We are proposing that a single PRA also be determined for the merged hospital in this situation because it is more administratively straightforward for the fiscal intermediaries and the merged hospitals and since the merged hospital itself was not in existence in the years that the two PRAs were established (FY 1994 and FY 1995), we do not believe it is necessary to retain the two PRAs. Furthermore, because the two existing PRAs are taken into account when establishing the single PRA for the merged hospital, and the statutory provision that resulted in the creation of two PRAs has no continuing effect (because the updates were prohibited only for FY 1994 and FY 1995), we see no compelling reason to continue to carry two PRAs for a merged hospital.

The following is an example of how to calculate a weighted average PRA under this proposed revised methodology:

Example: Assume that Hospital A, Hospital B, and Hospital C merge and Hospital B with a fiscal year end of December 31, 2006, is the surviving hospital. In their respective most recently settled cost reports, Hospital A has 200 primary care and obstetrics and gynecology FTE residents and 150 nonprimary care FTE residents, and Hospital B has 50 primary care and obstetrics and gynecology FTE residents and 60 nonprimary care FTE residents.

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Hospital C became a teaching hospital in 2000 and has 25 FTE residents. After updating the primary care and nonprimary care PRAs for inflation by the CPI-U to December 31, 2006, Hospital A has a primary care PRA of $120,000 and a nonprimary care PRA of $115,000, Hospital B has a primary care PRA of $100,000 and a nonprimary care PRA of $97,000, and Hospital C has a single PRA of $90,000.

(a) Primary care:

Hospital A: $120,000 x 200 FTEs = $24,000,000

Hospital B: $100,000 x 50 FTEs = $5,000,000

(b) Nonprimary care:

Hospital A: $115,000 x 150 FTEs = $17,250,000

Hospital B: $97,000 x 60 FTEs = $5,820,000

(c) Single PRA: Hospital C: $90,000 x 25 FTEs = $2,250,000

(d) $24,000,000 + $5,000,000 + $17,250,000 + $5,820,000 + $2,250,000 = $54,320,000

(e) 200 + 50 + 150 + 60 + 25 = 485 total FTEs

(f) $54,320,000/485 FTEs = $112,000, the weighted average of the hospitals involved in the merger for fiscal year end December 31, 2006. 3. Determination of Per Resident Amounts (PRAs) for New Teaching Hospitals (Sec. 413.77(e))

(If you choose to comment on issues in this section, please include the caption GME: PRA for New Teaching Hospitals'' at the beginning of your comment.)

As we discussed earlier in the background portion of this section, the hospital-specific, base-period PRA used in the payment methodology for determining Medicare direct GME payments is calculated by dividing a hospital's allowable direct costs of GME in a base period by its number of residents in that base period. In the case of a hospital that did not train residents in its FY 1984 cost reporting period, a PRA is determined by comparing and taking the lower of a PRA based on direct GME costs and FTE residents in a base year or the updated weighted mean value of PRAs of all hospitals located in the same geographic wage area. For ease of discussion, we refer to a hospital that did not participate in Medicare or have any approved medical residency training programs during the base period beginning between October 1, 1983, through September 30, 1984, and has since commenced participating in Medicare and begun training residents in an approved program, as a ``new teaching hospital.'' A new teaching hospital's PRA is established by using the lower of its hospital-specific PRA based on the actual allowable direct GME costs and FTE residents during a base period as defined in Sec. 413.77(e) or the updated weighted mean value of PRAs of other teaching hospitals in the same geographic area.

Existing regulations at Sec. 413.77(e) specify that the base year for establishing a PRA for a new teaching hospital is the first cost reporting period in which the new teaching hospital participates in Medicare and the residents are on duty during the first month of that period. If the new teaching hospital begins training residents but does not have residents on duty during the first month of the first cost reporting period in which training occurs, the new teaching hospital is paid on a reasonable cost basis under Sec. 413.77(e) for any GME costs incurred by that hospital during that period. The intent of this policy for new teaching hospitals is to make a more accurate determination of a PRA based on the hospital's per resident direct GME costs in a cost reporting period in which GME costs have been incurred for that entire period. As we noted in a response to comments in a final rule published in the Federal Register on September 29, 1989 (54 FR 40310), we believe that where the new teaching hospital's cost reporting period begins on a date other than July 1 (the beginning of the academic year), for example, October 1 or January 1, the cost reporting period that includes costs and resident counts from the first year of the training program may not be reflective of the actual average costs per resident of the program because the full complement of residents might not be on duty, and those that are on duty might be receiving a salary for as few as 1 or 2 months of the cost reporting period. In the usual case, training in the program would continue into the following cost reporting period and residents would thus be on duty in the first month of this next cost reporting period. Consequently, our existing regulations at Sec. 413.77(e)(1) specify that the PRA is to be determined by using the cost and resident data from the first cost reporting period during which residents are training in the first month of the cost reporting period.

It has come to our attention that, in rare instances, it is possible for a new teaching hospital, either through happenstance or by purposeful gaming of the policy, to continue to be reimbursed for direct GME costs on a reasonable cost basis even beyond the first cost reporting period during which residents begin training at the hospital as long as no residents are on duty at the new teaching hospital in the first month of the subsequent cost reporting period(s). We believe this scenario is contrary to the statutory intent of section 1886(h) of the Act, which instructs that instead of payment on a reasonable cost basis, the Secretary is to determine and base direct GME payments on a PRA for each hospital with a residency program. For that reason, we are proposing to revise Sec. 413.77(e)(1) and (e)(1)(i) to provide that we will make a PRA determination even where residents are not on duty in the first month of a cost reporting period but where residents began training at the hospital in the prior cost reporting period. Effective for cost reporting periods beginning on or after October 1, 2006, if a new teaching hospital begins training residents in a cost reporting period beginning on or after October 1, 2006, and no residents are on duty during the first month of that period, the fiscal intermediary establishes a PRA for the hospital using: (1) The cost and resident data from the cost reporting period immediately following the one for which GME training at the hospital was first reported (that is, the base period); or (2) the updated weighted mean value of PRAs of all hospitals located in the same geographic wage area. We note that, as with existing policy, the proposed base year need not be a full cost reporting year. Even where that cost reporting period may be a short (less than 12 months) cost reporting period, we believe an appropriate PRA will be determined since the number of FTEs will be commensurate with the costs incurred in this short cost reporting period. 4. Requirements for Counting and Appropriate Documentation of FTE Residents: Clarification (Sec. Sec. 413.75(d), 413.78(b) and (e), 413.80, and 413.81)

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

Despite the fact that current policies concerning the counting of FTE residents for IME and direct GME payment purposes have been in effect since October 1985, we continue to receive questions on the proper counting and appropriate documentation for FTE residents for IME and direct GME payment purposes. As a result of these continuing questions, we are clarifying in this proposed rule the policies that apply in determining hospitals' FTE resident counts for Medicare GME payment purposes.

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In the existing regulations at Sec. 413.78(b) for direct GME payments, we specify that no individual may be counted as more than one FTE, and that a hospital cannot claim the time spent by residents training at another hospital. Therefore, if a resident spends time training in more than one hospital or except as provided at Sec. 413.78(e) in a nonprovider setting, the resident counts as a partial FTE based on the proportion of time the resident trains at the hospital or nonprovider setting to the resident's total time worked. (The same provisions apply to part-time residents as specified in Sec. 413.78(b).) A similar policy exists at Sec. 412.105(f)(1)(ii) and (iii) for purposes of counting FTE residents for IME payment purposes. As we have explained in previous Federal Register documents (55 FR 36064, September 4, 1990 and 67 FR 50077, August 1, 2002), these policies apply even when a hospital actually incurs the cost of training the resident(s) at another hospital(s). For example, during a cost reporting year, a full-time resident trains at Hospital A for 6 months and trains at Hospital B for 6 months. Hospital A is paying the salary and fringe benefits of the resident for the entire year. In this case, each hospital would only count 0.5 of an FTE for that resident. Hospital A would not be able to count the entire FTE for that resident, regardless of the fact that it incurred all of the training costs for the resident during that training year.

We also have become aware of issues that have arisen due to a hospital's failure to document the number of FTE residents claimed on its cost report. Proper documentation is required so that Medicare fiscal intermediaries can determine where and when a resident(s) is training and to allow the fiscal intermediary to make payment to the hospital based on the percentage of time the resident(s) spends at each training facility to the total time trained. A rotation schedule is the primary documentation that can support the direct GME and IME resident counts but other similar documentation may be acceptable. The following is a situation of which we learned that illustrates how inadequate documentation resulted in inappropriate counting of FTEs. Two hospitals, Hospital C and D, were ``associated'' with each other, with residents training at both hospitals. However, instead of differentiating between the number of FTEs and the actual amount of time spent at each hospital, Hospitals C and D totaled their respective FTEs and split them 50/50. Splitting the FTE count 50/50 resulted in inappropriate payment to both hospitals. Hospitals are not permitted to decide among themselves how their FTEs will be counted. A hospital may not count a greater number of FTE residents than is actually training at the hospital (or its nonhospital sites) during the year. Each hospital must maintain its own records which demonstrate, for the entire cost reporting period, the amount of time that the resident trained at the hospital and, if applicable, a nonhospital site. Furthermore, to the extent that residents train in nonhospital sites, the hospital claiming the FTEs in the nonhospital site must meet the requirements at Sec. 413.78(e).

Situations such as the one described above involving Hospital C and Hospital D are particularly harmful when one or more of the hospitals involved incorrectly report FTEs in the cost reporting period used to establish one or more of the hospitals' FTE resident caps, and as a result, the caps are incorrectly established. Unless the incorrect caps are revised pursuant to our regulations regarding review and revision of agency determinations, those caps will be applied to the hospital(s) in future years. For instance, we have learned of situations where a hospital's FTE resident caps were established incorrectly a number of years earlier and, due to administrative finality of settled cost reports, can no longer be adjusted. However, going forward, the hospital's count of FTEs must be based on where the residents are training and can only reflect the number of residents actually training in the hospital (or its nonhospital sites).

In order to ensure that FTEs are being properly counted, hospitals are required to furnish specific documentation to support the number of FTE residents included in the hospital's FTE count. Section 413.75(d) specifies the requirements concerning documentation of FTE residents. Proper documentation must include the following information: The name and social security number of the resident; the type of residency program in which the individual participates and the number of years the resident has completed in all types of residency programs; the dates the resident is assigned to the hospital and any hospital-based providers (similar to the rotation schedule); the dates the resident is assigned to other hospitals, or other freestanding providers, and any nonprovider setting during the cost reporting period, if any; and the name of the employer paying the resident's salary. In addition, the documentation should include the name of the medical, osteopathic, dental, or podiatric school from which the resident graduated and the date of graduation, and whether the resident is a foreign medical graduate, including documentation concerning whether the resident has satisfied the regulatory requirements for foreign medical graduates at Sec. 413.80. The information must be certified by an official of the hospital and, if different, an official responsible for administering the residency program. Again, proper documentation on where and when a FTE resident is training during a cost reporting period is essential in order for the hospital to receive direct GME and IME payments based on the proper number of FTE resident(s). Inaccurate, incomplete, or inappropriate documentation will lead to Medicare disallowing certain FTE residents from being counted for purposes of direct GME and IME payments. We note that we are not expanding or making any changes to current policy for proper documentation of FTEs. Rather, we are clarifying the existing regulations concerning proper counting and documentation of FTEs. 5. Resident Time Spent in Nonpatient Care Activities as Part of Approved Residency Programs (Sec. Sec. 413.9 and 413.78(a))

In section IV.H.4. of this preamble, we discussed the importance of properly documenting where and when residents are training in a particular hospital or nonhospital site, in order for that hospital to count those FTE residents for purposes of direct GME and IME payment. In addition, it is important for hospitals to be able to document the activities in which residents are engaged because there are certain activities that are not allowable for direct GME or IME payment purposes, even though those activities may be performed as part of an approved residency program. Specifically, it has come to our attention that there may be some confusion in the provider community as to whether the time that residents spend in nonpatient care activities that are part of the approved residency program may be counted for the purpose of direct GME and IME payments. We have most recently received questions as to whether the time residents spend in nonhospital sites in didactic activities such as journal clubs or classroom lectures may be included in determining the allowable FTE resident counts. To respond to these inquiries and to resolve any confusion, we are clarifying our policy concerning the counting of time spent in nonpatient care activities for the purpose of direct GME and IME payments in both hospital and nonhospital settings.

With respect to training in nonhospital settings, the time that

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residents spend in nonpatient care activities as part of an approved program, including didactic activities, cannot be included in a hospital's direct GME or IME FTE resident count. This longstanding policy is based on the statutory requirements for counting FTE residents training in nonhospital sites. For the purpose of direct GME payments, providers have been allowed since July 1, 1987, to count the time residents spend training in nonhospital sites under certain conditions. Section 1886(h)(4)(E) of the Act specifies that the implementing regulations concerning computation of direct GME for training in nonhospital sites ``shall provide that only time spent in activities relating to patient care shall be counted and that all the time so spent by a resident under an approved medical residency training program shall be counted towards the determination of full- time equivalency, without regard to the setting in which the activities are performed, if the hospital incurs all, or substantially all, of the costs for the training program in that setting'' (emphasis added).

For IME payment purposes, hospitals were first allowed to count the time residents spend training in nonhospital sites for discharges occurring on or after October 1, 1997. Section 1886(d)(5)(B)(iv) of the Act was amended by Pub. L. 105-33 in 1997 to provide that ``all the time spent by an intern or resident in patient care activities under an approved medical residency program at an entity in a nonhospital setting shall be counted towards the determination of full-time equivalency if the hospital incurs all, or substantially all, of the costs for the training program in that setting'' (emphasis added).

We understand that, as part of an approved medical residency program, residents are often required to participate in didactic and ``scholarly'' activities such as educational conferences, journal clubs, and seminars. Some of these activities may take place in nonhospital sites, such as freestanding clinics or physicians' offices, or in conference rooms at nonhospital settings. In implementing section 1886(h)(4)(E) of the Act for direct GME payment purposes, we specifically stated that ``only time spent in activities relating to patient care may be counted [in nonhospital sites]'' (54 FR 40292, September 29, 1989). In 1998, when we implemented the statute allowing FTE residents to be counted in nonhospital sites for IME, we reiterated that a hospital may only count resident training time ``in nonhospital sites for indirect and direct GME, respectively, if the resident is involved in patient care'' (63 FR 40986, July 31, 1998). While we have not explicitly defined in regulations ``patient care activities,'' we have applied the plain meaning of that term. In addition, we note that the scope of the term ``patient care'' had been well-established in the Medicare program even prior to issuance of the first rules on counting FTE residents for purposes of direct GME and IME payments. For example, prior to the IPPS, acute care hospitals were paid by Medicare for inpatient services based on their reasonable operating costs, or costs relating to the provision of reasonable and necessary ``patient care.'' The longstanding regulation at 42 CFR 413.9, entitled ``Costs related to patient care,'' states that ``all payments to providers of services must be based on the reasonable cost of services covered under Medicare and related to the care of beneficiaries.'' Thus, the scope of costs recognized as reasonable under Medicare had been limited to those relating to ``patient care,'' or to those relating to covered services for the care of beneficiaries. Although the agency appears to have made a conflicting statement in a letter directed to a particular individual implying that didactic time spent in nonhospital settings could be counted for direct GME and IME, that statement was inaccurate. We have applied and continue to apply the plain meaning of the statutory terms ``patient care activities'' and ``activities relating to patient care'' in the context of approved GME programs. That is, the plain meaning of patient care activities would certainly not encompass didactic activities. Rather, the plain meaning refers to the care and treatment of particular patients, or to services for which a physician or other practitioner may bill. Time spent by residents in such patient care activities may be counted for direct GME and IME payment purposes in the nonhospital site. Time spent by residents in other activities in the nonhospital site that do not involve the care and treatment of particular patients, such as didactic or ``scholarly'' activities, is not allowable for direct GME and IME payment purposes.

We note that there is a difference in the rules for counting FTE resident time for IME and direct GME payments when residents are training in a hospital. For direct GME payment purposes, under Sec. 413.78(a), ``residents in an approved program working in all areas of the hospital complex may be counted.'' As explained in the September 29, 1989 Federal Register document (54 FR 40286), the hospital complex consist of the hospital and the hospital-based providers and subproviders. Therefore, the distinction between patient care activities and nonpatient care activities is not relevant to direct GME FTE count determinations when the residents are training in the hospital complex. However, for IME payment purposes, consistent with the regulations at Sec. 413.9, only time spent in patient care activities in the hospital may be counted. It has been our longstanding policy that, regardless of the site of training, ``* * * we do not include residents in the IME count to the extent that the residents are not involved in furnishing patient care * * *'' (66 FR 39897, August 1, 2001). 6. Medicare GME Affiliated Groups: Technical Changes to Regulations

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

In the FY 2005 IPPS final rule (69 FR 49112 and 49254 through 49265), we redesignated the contents of Sec. 413.86 (which contained the regulations governing Medicare payment for direct GME) as Sec. Sec. 413.75 through 413.83 and made corresponding cross-reference changes in the text of these regulations. We have discovered that under the definition of ``Medicare GME affiliated group'' under Sec. 413.75(b), we incorrectly cited the cross-reference to the rotation requirements for GME affiliated groups in paragraphs (1), (2), and (3), as ``Sec. 413.79(g)(2)''. In this proposed rule, we are proposing to correct the cross-reference for the rotation requirements in paragraphs (2) and (3) of the definition to read ``Sec. 413.79(f)(2)''.

In the FY 2006 IPPS final rule (70 FR 47457 and 47489), we made additional changes in certain sections of the GME redesignated regulations to correct cross-references to other parts of 42 CFR Chapter IV relating to the definitions of the ``urban'' and ``rural'' location of a hospital. In one of the corrections, in paragraph (1) under the definition of ``Medicare GME affiliated group'' under Sec. 413.75(b), we inadvertently dropped the language in that paragraph relating to the rotational requirements for these groups, including the incorrect cross-reference to Sec. 413.79(g)(2). We are proposing to correct the language of paragraph (1) under the definition of ``Medicare GME affiliated group'' under Sec. 413.75(b) by adding the dropped language and correcting the cross-reference to read ``Sec. 413.79(f)(2).''

In the FY 2006 IPPS final rule (70 FR 47454 and 47489), we revised

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Sec. 413.79(e)(1)(iv) to provide that a new urban teaching hospital that qualifies for an adjustment to its FTE cap 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.'' We specified in the preamble of that final rule that this provision is effective for affiliation agreements entered into on or after October 1, 2005. However, we inadvertently did not include this effective date in the regulation text. We are proposing to revise Sec. 413.79(e)(1)(iv) to include the effective date as part of the text of that section.

In addition, we are proposing to correct a cross-reference in the introductory text of paragraph (f) of Sec. 413.79 relating to Medicare GME affiliated groups. The cross-reference to ``paragraph (e)(3)'' of Sec. 413.79 should read ``paragraph (d)'' of that section. This proposed change is necessary to accurately cite the reference to our rules regarding the 3-year rolling average.

I. Payment for the Costs of Nursing and Allied Health Education Activities: Clarification (Sec. 413.85)

(If you choose to comment on issues in this section, please include the caption ``Nursing and Allied Health Education Activities'' at the beginning of your comment.)

In addition to direct GME and IME payments to hospitals for the direct and indirect costs incurred for their graduate medical education programs in medicine, osteopathy, dentistry, and podiatry, Medicare makes payments to hospitals for two other categories of education- related costs for which different payment policies apply:

Approved nursing and allied health education programs operated by the hospital. The costs of these programs are excluded from the definition of inpatient hospital operating costs and are not included in the calculation of the per discharge payment rates for hospitals paid under the IPPS, or in the calculation of payments to hospitals and hospital units excluded from the IPPS that are subject to the rate-of-increase ceiling. These costs are separately identified and ``passed through'' (that is, paid separately on a reasonable cost basis).

All other costs that can be categorized as educational programs and activities (for example, continuing education, on the job training, or seminars). These costs are considered to be part of the hospitals' normal operating costs and payment for these costs is included in the per discharge payment amount for hospitals subject to the IPPS, the IRF PPS, or the LTCH PPS and the prospective per diem payment amount for facilities under the IPF PPS. Similarly, these costs are considered to be part of the hospitals' normal operating costs and are included as reasonable costs that are subject to the TEFRA rate-of- increase limits applicable to hospitals that continue to receive payments subject to those limits, including cancer and children's hospitals.

Regulations governing payment for the costs of approved and allied health education activities are located at 42 CFR 413.85.

In the FY 2004 IPPS final rule (68 FR 45429), we revised the regulations at Sec. 413.85(h)(3) to further clarify the difference between provider-operated and continuing education programs. We revised the regulations to state that, effective October 1, 2003, programs in which employees participate that do not lead to the ability to practice and begin employment in a nursing or allied health specialty are also treated as normal operating costs. We now realize that when we revised Sec. 413.85(h)(3) to include this clarification, we inadvertently did not specify that the provision was applicable to trainees as well as employees. In the preamble of the FY 2004 IPPS final rule, we stated that because Sec. 413.85(h)(3) refers to education that will not lead to the ability to practice and begin employment, we intended the provisions to apply not only to employees but to trainees as well. Therefore, in this proposed rule, we are proposing to make a technical change to Sec. 413.85(h)(3) to make it applicable to both employees and trainees. This proposed technical change would clarify that the educational activities in which employees or trainees participate, but that do not lead to the ability to practice and begin employment in a nursing or allied health specialty, are treated as normal operating costs. We note that we are not proposing to expand or make any changes to the current payment policy for nursing and allied health education activities; rather, we are merely proposing to clarify the language of the existing regulations.

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

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

Sections 1866(a)(1)(I), 1866(a)(1)(N), and 1867 of the Act impose specific obligations on certain Medicare-participating hospitals and CAHs. (Throughout this section of this proposed rule, when we reference the obligation of a ``hospital'' under these sections of the Act and in our regulations, we mean to include CAHs as well.) These obligations concern individuals who come to a hospital emergency department and request examination or treatment for medical conditions, and apply to all of these individuals, regardless of whether they are beneficiaries of any program under the Act.

The statutory provisions cited above are frequently referred to as the Emergency Medical Treatment and Labor Act (EMTALA), also known as the patient antidumping statute. EMTALA was passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), Pub. L. 99-272. Congress enacted these antidumping provisions in the Social Security Act to ensure that individuals with emergency medical conditions are not denied essential lifesaving services because of a perceived inability to pay.

Under section 1866(a)(1)(I)(i) of the Act, a hospital that fails to fulfill its EMTALA obligations under these provisions may be liable for termination of its Medicare provider agreement, which would result in loss of all Medicare and Medicaid payments.

In general, section 1867 of the Act sets forth requirements for medical screening examinations for individuals who come to the hospital and request examination or treatment for a medical condition. The section further provides that if a hospital finds that such an individual has an emergency condition, it is obligated to provide that individual with either necessary stabilizing treatment or an appropriate transfer to another medical facility where stabilization can occur.

The EMTALA statute also outlines the obligation of hospitals to receive appropriate transfers from other hospitals. Section 1867(g) of the Act states that a participating hospital that has specialized capabilities or facilities (such as burn units, shock-trauma units, neonatal intensive care units or (with respect to rural areas) regional referral centers as identified by the Secretary in regulation) shall not refuse to accept an appropriate transfer of an individual who requires these specialized capabilities or facilities if the hospital has the capacity to treat the individual.

The regulations implementing section 1867 of the Act are found at 42 CFR 489.24.

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2. Role of the EMTALA Technical Advisory Group (TAG)

Section 945 of Pub. L. 108-173 (MMA) required the Secretary to establish a Technical Advisory Group (TAG) to provide the Secretary with advice concerning issues related to EMTALA regulations and implementation. Section 945 of Pub. L. 108-173 further requires that the EMTALA TAG be composed of 19 members, including the Administrator of CMS, the Inspector General of HHS, hospital representatives and physicians representing various specialties, patient representatives, and representatives of organizations involved in EMTALA enforcement.

The EMTALA TAG was first established in 2005 and held three meetings during that year. At each of its meetings, the EMTALA TAG heard testimony from representatives of physician groups, hospital associations, and others regarding EMTALA issues and concerns. As explained more fully below in sections IV.K.3. and 4. of this preamble, we are proposing to revise the EMTALA regulations at Sec. 489.24 based on the recommendations adopted and forwarded to the Secretary by the EMTALA TAG. 3. Definition of ``Labor''

As noted in the background portion of this section, the EMTALA statute and regulations require that if an individual comes to a hospital emergency department and a request is made on the individual's behalf for examination or treatment for a medical condition, the hospital is obligated to provide that individual with an appropriate medical screening examination within the capability of the hospital. If the individual is found to have an emergency medical condition, the hospital is obligated by EMTALA to provide either necessary stabilizing treatment or an appropriate transfer to another medical facility where stabilization can occur.

Section 489.24(b) of the regulations defines the key terms used in the section. The term ``emergency medical condition'' is defined as--

``A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part; or with respect to a pregnant woman who is having contractions, that there is inadequate time to effect a safe transfer to another hospital before delivery; or that transfer may pose a threat to the health and safety of the woman or the unborn child.''

This definition is identical to the definition of ``emergency medical condition'' in section 1867(e)(1) of the Act. In recognition of the fact that this definition gives special consideration to women in labor, the term ``labor'' is itself defined, in paragraph (b) of Sec. 489.24, to mean ``the process of childbirth beginning with the latent or early phases of labor and continuing through the delivery of the placenta.'' The definition further states: ``A woman experiencing contractions is in true labor unless a physician certifies that, after a reasonable period of observation, the woman is in false labor.'' A woman found to be in false labor is considered not to have an emergency medical condition and that finding thus means that the hospital has no further EMTALA obligation to her.

The CMS interpretative guidelines used by State surveyors in EMTALA investigations provide that once an individual has presented to a hospital seeking emergency care, the determination as to whether an emergency medical condition exists is made by the examining physician(s) or other qualified medical person actually caring for the individual at the treating facility. The guidelines further provide that the medical screening examination must be conducted by one or more individuals who are determined to be qualified by the hospital bylaws or rules and regulations and who meet the hospital condition of participation in 42 CFR 482.55 regarding emergency services personnel and direction. (Of course, these individuals would not be expected or permitted to perform any screening functions other than those which they are allowed to perform under State scope of practice laws.) However, consistent with the definition of ``labor'' at Sec. 489.24(b), the guidelines also state that if a qualified medical person other than a physician determines that a woman is in false labor, a physician must certify the diagnosis. The guidelines permit this certification to be made based either on actual examination of the patient or on a telephone consultation with the qualified medical person who actually examined the patient. (Medicare State Operations Manual, Appendix V--Interpretive Guidelines--Responsibility of Participating Hospitals in Emergency Cases, TAG A-406.)

At its meeting held on June 15-17, 2005, the EMTALA TAG heard testimony from representatives of both physician and nonphysician professional societies regarding the competence of practitioners other than physicians to certify false labor. In particular, a representative of the American College of Nurse-Midwives stated that the current requirement that allows only a physician to certify false labor is overly restrictive and does not adequately recognize the training and competence of certified nurse-midwives. Testimony was also presented by the American College of Obstetricians and Gynecologists, which recommended amending the EMTALA regulations to allow certified nurse- midwives and other qualified medical persons to determine whether a woman is in false labor.

After extensive consideration of the issue, the members of the EMTALA TAG voted to recommend to the Secretary that the definition of ``labor'' at Sec. 489.24(b) be amended to permit certified nurse- midwives and other qualified medical personnel to certify false labor. The TAG recommended deleting the second sentence, which states that a woman experiencing contractions is in true labor unless a physician certifies that, after a reasonable time of observation, the woman is in false labor.

We agree with the TAG's recommendation that other health care practitioners besides physicians should be allowed to certify false labor, and believe that the recommendation is consistent with CMS' current policy regarding who may conduct medical screening examinations. However, we do not believe such a change can be best accomplished by simply deleting the second sentence of the current definition of ``labor'' in the existing regulations because doing so would also remove the explicit statement that a woman experiencing contractions is in labor unless she has been found to be in false labor. To achieve the principal objective of the EMTALA TAG recommendation without compromising the protections of EMTALA for women having contractions, we are proposing to modify the definition of ``labor'' in Sec. 489.24(b) by revising the second sentence of that definition to state that a woman experiencing contractions is in true labor unless a physician, certified nurse-midwife, or other qualified medical person acting within his or her scope of practice as defined in hospital medical staff bylaws and State law, certifies that, after a reasonable time of

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observation, the woman is in false labor. The effect of this change would be to have a single, uniform policy on the personnel who are authorized to make a determination as to whether an individual has an emergency medical condition. 4. Application of EMTALA Requirements to Hospitals Without Dedicated Emergency Departments

Section 489.24(b) of the regulations outlines when a hospital will be considered to be a hospital with a ``dedicated emergency department'' and makes it clear that only a hospital with a dedicated emergency department has an EMTALA responsibility with respect to an individual for whom no appropriate transfer is sought but who comes to the hospital seeking examination or treatment for a medical condition. However, it has come to CMS' attention that our policy regarding the application of EMTALA to hospitals that have specialized capabilities but are without dedicated emergency departments may be less well understood as it relates to individuals for whom an appropriate transfer is sought.

It has been CMS' longstanding policy that any Medicare- participating hospital with a specialized capability must, in accordance with section 1867(g) of the Act, accept, within the capacity of the hospital, an appropriate transfer from a requesting hospital. This policy has been applied to hospitals without regard to whether they have dedicated emergency departments. In fact, in the past, CMS has taken enforcement actions against hospitals with specialized capabilities that failed to accept appropriate transfers under EMTALA when the hospitals had the capacity to treat the transferred individuals.

At its meeting held on October 26-28, 2005, the EMTALA TAG heard testimony from representatives of physician groups, hospital associations, and others regarding EMTALA compliance by specialty hospitals that typically do not have dedicated emergency departments. After extensive consideration and discussion of the issues raised and views presented, the members of the EMTALA TAG voted to recommend to the Secretary that hospitals with specialized capabilities (as defined in Sec. 489.24(f) of the regulation) that do not have a dedicated emergency department be bound by the same responsibility to accept an appropriate transfer under EMTALA as hospitals with a dedicated emergency department.

We agree with the EMTALA TAG's assessment. We believe that the recommendation is consistent with CMS' current policy and highlights the need to clarify CMS' policy regarding hospitals with specialized capabilities. Therefore, in this proposed rule, we are proposing to modify the regulations at Sec. 489.24(f) to specifically indicate that any participating hospital with specialized capabilities or facilities, even if it does not have a dedicated emergency department, may not refuse to accept an appropriate transfer if the hospital has the capacity to treat the individual. We note that this proposed revision does not reflect any change in current CMS policy. We further note that the revision would not require hospitals without dedicated emergency departments to open dedicated emergency departments nor would it impose any EMTALA obligation on those hospitals with respect to individuals who come to the hospital as their initial point of entry into the medical system seeking a medical screening examination or treatment for a medical condition. Although this proposed revision seeks only to clarify, rather than change, current policy, we nevertheless, welcome comments on what effect, if any, commenters believe this proposed clarification may have on EMTALA compliance and patient health and safety. 5. Clarification of Reference to ``Referral Centers''

The language of the existing regulations at Sec. 489.24(f) duplicates the language of section 1867(g) of the Act in that it identifies, as an example of a hospital with specialized capabilities, ``(with respect to rural areas) regional referral centers identified by the Secretary in regulation)''. Because the term ``regional referral centers'' is not used elsewhere in the Medicare regulations, it is unclear whether the reference is to referral centers as defined in 42 CFR 412.96, which must be located in rural areas and meet other criteria spelled out in that section, or to any facilities that are located in rural areas and accept patients on referral. To maintain consistency in the Medicare regulations and avoid confusion as to which facilities are considered to have specialized capabilities for purposes of EMTALA, we are proposing to amend Sec. 489.24 by clarifying that ``regional referral centers'' are those centers meeting the requirements of Sec. 412.96.

K. Other Proposed Technical Changes

1. Proposed Cross-Reference Correction in Regulations on Limitations on Beneficiary Charges (Sec. 412.42)

(If you choose to comment on issues in this section, please include the caption ``Cross-Reference Sec. 412.42'' at the beginning of your comment.)

We are proposing to amend Sec. 412.42 to correct an obsolete cross-reference. Paragraph (d) of Sec. 412.42 contains a cross- reference to ``Sec. 405.310(k).'' This section was redesignated as Sec. 411.15(k) in 1989 (54 FR 41737, October 11, 1989). We are proposing to amend paragraph (d) of Sec. 412.42 to delete the obsolete cross-reference and insert the correct cross-reference. 2. Proposed Cross-Reference Corrections in Regulations on Payment Denials Based on Admissions and Quality Reviews (Sec. 412.48)

(If you choose to comment on issues in this section, please include the caption ``Cross-Reference Sec. 412.48'' at the beginning of your comment.)

We are proposing to amend Sec. 412.48 to correct an obsolete cross-reference. Paragraph (b) of Sec. 412.48 contains a cross- reference to ``Sec. Sec. 405.330 through 405.332''. Section 405.330 was redesignated as Sec. 411.400, and Sec. 405.332 was redesignated as Sec. 411.402 in 1989 (54 FR 41746, October 11, 1989). (There was no Sec. 405.331.) We are proposing to amend paragraph (b) of Sec. 412.48 to delete the obsolete cross-references and to insert the correct cross-references. 3. Proposed Cross-Reference Correction in Regulations on Outlier Payments (Sec. 412.84)

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

On June 9, 2003, we published a final rule in the Federal Register (68 FR 34494) that amended the portion of the hospital IPPS regulations that sets out the methodology for determining payments for extraordinarily high-cost cases (outliers). We changed the methodology because we concluded that, in certain cases, hospitals were dramatically and inappropriately increasing charges, thereby inflating CCRs, resulting in overestimation of these hospitals' costs per case, a critical factor in determining outlier payments.

As a part of these methodology changes, we required that outlier payments be reconciled using a hospital's settled cost report for the cost reporting year in which the outlier discharge occurred. This approach

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meant that there would be some delay in computing the final outlier payment. To address this issue, we added Sec. 412.84(m), which provided that reconciled outlier payments would be adjusted to account for the time value of any underpayments or overpayments.

We inadvertently included in paragraph (m) of Sec. 412.84 a cross- reference to paragraph (h)(3) of Sec. 412.84. The cross-reference should be to paragraph (i)(4), which sets out the requirement for reconciling outlier payments when the cost report for the year in which the discharge occurred is settled. We are proposing to amend paragraph (m) of Sec. 412.84 to correct the cross-reference to read ``paragraph (i)(4)'' of Sec. 412.84. 4. Removing References to Two Paper Claims Forms

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

Section 1862(a)(22) of the Act generally requires electronic submission of initial Medicare claims requesting payment for items and services. Section 1862(h) of the Act provides for limited exceptions when paper claims still may be used. Our existing regulations at 42 CFR 424.32 set out the requirements for submitting electronic and paper claims for payment, as well as when the exceptions apply and paper forms still may be used. Our existing regulations at paragraph (b) of Sec. 424.32 list six forms that are to be used for submitting paper claims.

We have evaluated the use of two of these forms, Form CMS-1490U (Request for Medicare Payment by Organization) and Form CMS-1491 (Request for Medicare Payment--Ambulance). We found that these forms have limited use, we would incur expensive costs in redesigning these forms to comply with other reporting requirements, and that an alternate form is available to claim payments. For these reasons, we intend to no longer use these forms. Therefore, we are proposing to remove the references to these forms from paragraph (b) of Sec. 424.32.

Form CMS-1490U is a paper claim form used by employers, unions, employer-employee organizations that pay physicians and suppliers for their services to employees, group practice prepayment plans, and health maintenance organizations. Form CMS-1490U is used to claim payment from carriers for bills already paid by these entities. We concluded that this form should no longer be used for several reasons. It is duplicative of Form CMS-1500 (Health Insurance Claim Form), which also may be used to claim payment for these services. We have encouraged suppliers to submit their paper claims using the Form CMS- 1500. Unlike Form CMS-1500, Form CMS-1490U cannot accommodate an additional reporting requirement, the National Provider Identifier (NPI), without an expensive redesign. Finally, according to our records, relatively few suppliers currently use the form. The CMS component that supplies blank copies of this form for users reported that, between 2002 and 2005, only 2,550 copies of Form CMS-1490U were ordered by carriers. A 2005 survey of Part B carriers indicated that requests for the form are very low and that receipts of the form vary from very few to none.

Form CMS-1491 is a paper claim form used by ambulance suppliers to apply for payment for ambulance services. We concluded that this form should no longer be used for several reasons. It also is duplicative of Form CMS-1500, which also may be used to claim payment for ambulance services. In addition, we have encouraged suppliers to submit their paper ambulance claims using the Form CMS-1500. Unlike Form CMS-1500, Form CMS-1491 cannot accommodate the NPI without an expensive redesign and usage of this form is low. A recent survey of carriers, initiated by Joint Signature Memorandum RO-2324, Request for Information Concerning the CMS-1491, issued October 30, 2003, from the Centers for Medicare Management, was conducted to ascertain the usage of Form CMS- 1491. The results of the survey showed that fewer than 2 percent (1.71 percent) of all suppliers of ambulance services currently use the Form CMS-1491. CMS received approximately 240,000 ambulance claims using Form CMS-1491 during the period from October 1, 2002, to September 30, 2003. These data were used for the most recent OMB renewal under the Paperwork Reduction Act. Since the last OMB renewal approval in 2001, CMS has printed a total of 1,620,000 forms at a cost of $42,890.

L. 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 comment.)

In accordance with the requirements of section 410A(a) of Pub. L. 108-173, the Secretary has established a 5-year demonstration program (beginning with selected hospitals' first cost reporting period beginning on or after October 1, 2004) to test the feasibility and advisability of establishing ``rural community hospitals'' for Medicare payment purposes for covered inpatient hospital services furnished to Medicare beneficiaries. A rural community hospital, as defined in section 410A(f)(1), is a hospital that:

Is located in a rural area (as defined in section 1886(d)(2)(D) of the Act) or is treated as being located in a rural area under section 1886(d)(8)(E) of the Act;

Has fewer than 51 beds (excluding beds in a distinct part psychiatric or rehabilitation unit) as reported in its most recent cost report;

Provides 24-hour emergency care services; and

Is not designated or eligible for designation as a CAH.

As we indicated in the FY 2005 IPPS final rule (69 FR 49078), in accordance with sections 410A(a)(2) and (a)(4) of Pub. L.108-173 and using 2002 data from the U.S. Census Bureau, we identified 10 States with the lowest population density from which to select hospitals: Alaska, Idaho, Montana, Nebraska, Nevada, New Mexico, North Dakota, South Dakota, Utah, and Wyoming (Source: U.S. Census Bureau Statistical Abstract of the United States: 2003). Nine rural community hospitals located within these States are currently participating in the demonstration program for FY 2007. (Of the 13 hospitals that participated in the first 2 years of the demonstration program, 4 hospitals located in Nebraska have withdrawn from the program; they have become CAHs.)

Under the demonstration program, participating hospitals are paid the reasonable costs of providing covered inpatient hospital services (other than services furnished by a psychiatric or rehabilitation unit of a hospital that is a distinct part), applicable for discharges occurring in the first cost reporting period beginning on or after the October 1, 2004, implementation date of the demonstration program. Payments to the participating hospitals will be the lesser amount of the reasonable cost or a target amount in subsequent cost reporting periods. The target amount in the second cost reporting period is defined as the reasonable costs of providing covered inpatient hospital services in the first cost reporting period, increased by the inpatient prospective payment update factor (as defined in section 1886(b)(3)(B) of the Act) for that particular cost reporting period. The target amount in subsequent cost reporting periods is defined as the preceding cost reporting period's target

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amount, increased by the inpatient prospective payment update factor (as defined in section 1886(b)(3)(B) of the Act) for that particular cost reporting period.

Covered inpatient hospital services are inpatient hospital services (defined in section 1861(b) of the Act), and include extended care services furnished under an agreement under section 1883 of the Act.

Section 410A of Pub. L. 108-173 requires that ``in conducting the demonstration program under this section, the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration program under this section was not implemented.'' Generally, when CMS implements a demonstration program on a budget neutral basis, the demonstration program is budget neutral in its own terms; in other words, the aggregate payments to the participating providers do not exceed the amount that would be paid to those same providers in the absence of the demonstration program. This form of budget neutrality is viable when, by changing payments or aligning incentives to improve overall efficiency, or both, a demonstration program may reduce the use of some services or eliminate the need for others, resulting in reduced expenditures for the demonstration program's participants. These reduced expenditures offset increased payments elsewhere under the demonstration program, thus ensuring that the demonstration program as a whole is budget neutral or yields savings. However, the small scale of this demonstration program, in conjunction with the payment methodology, makes it extremely unlikely that this demonstration program could be viable under the usual form of budget neutrality. Specifically, cost-based payments to the nine participating small rural hospitals are likely to increase Medicare outlays without producing any offsetting reduction in Medicare expenditures elsewhere. Therefore, a rural community hospital's participation in this demonstration program is unlikely to yield benefits to the participant if budget neutrality were to be implemented by reducing other payments for these providers.

In order to achieve budget neutrality for this demonstration program for FY 2007, we are proposing to adjust the national inpatient PPS rates by an amount sufficient to account for the added costs of this demonstration program. We are proposing to apply budget neutrality across the payment system as a whole rather than merely across the participants in this demonstration program. As we discussed in the FY 2005 and FY 2006 IPPS final rules (69 FR 49183 and 70 FR 47462), 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 2007, using the most recent cost report data (that is, data for FY 2004), adjusted to account for the increased estimated costs for the remaining nine participating hospitals, we estimate that the proposed adjusted amount would be $9,197,870. This proposed estimated adjusted amount reflects the estimated difference between the participating hospitals' costs and the IPPS payment based on data from the hospitals' cost reports. We discuss the proposed payment rate adjustment that would be required to ensure the budget neutrality of the demonstration program for FY 2007 in section II.A.4. of the Addendum to this proposed rule.

M. Health Care Information Transparency Initiative

(If you choose to comment of issues in this section, please include the caption ``Transparency of Health Care Information'' at the beginning of your comment.)

The United States faces a dilemma in health care. Although the rate of increase in health care spending slowed last year, costs are still growing at an unsustainable rate. The United States spends $1.9 trillion on health care, or 16 percent of the gross domestic product (GDP). By 2015, projections are that health care will consume 20 percent of GDP. The Medicare program alone consumes 3.4 percent of the GDP; by 2040, it will consume 8.1 percent of the GDP and by 2070, 14 percent of the GDP.

Part of the reason health care costs are rising so quickly is that most consumers of health care--the patients--are frequently not aware of the actual cost of their care. Health insurance shields them from the full cost of services, and they do have only limited information about the quality and costs of their care. Consequently, consumers do not have the incentive or means to carefully shop for providers offering the best value. Thus, providers of care are not subject to the competitive pressures that exist in other markets for offering quality services at the best possible price. Reducing the rate of increase in health care prices and avoiding health services of little value could help to stem the growth in health care spending, and potentially translate into fewer individuals who are unable to afford health insurance. Part of the President's health care agenda is to expand Health Savings Accounts (HSAs), which would provide consumers with greater financial incentives to compare providers in terms of price and quality, and choose those that offer the best value.

In order to exercise such choices, consumers must have accessible and useful information on price and quality of health care items and services. Typically, health care providers do not publicly quote or publish their prices. Moreover, list prices, or charges, generally differ from the actual prices negotiated and paid by different health plans. Thus, even if consumers were financially motivated to shop for the best price, it would be very difficult at the current time for them to access usable information.

Similarly, individuals have very little information available to them about the quality of care that they receive. Although there are preliminary steps underway to rectify that fact, including the hospital quality reporting initiative in which a significant number of acute care hospitals are participating (see sections IV.A and IV.B of this preamble), those data are nascent and consumers lack sufficient information on which to base a judgment about where to receive care based on quality of care.

For these reasons, the Department intends to launch a major health care information transparency initiative in 2006. This effort will build on steps already taken by CMS to make quality and price information available. For example, we currently collect quality information and publish it through the CMS Hospital Compare Web site, which we reference in other parts of this proposed rule. We also make available unprecedented information on the prices of drugs to beneficiaries in the Medicare prescription drug plan for each pharmacy in the United States.

We intend to take further steps to collect and publish useful information on quality and cost. The Department intends to identify several regions in the United States where health care costs are high, and where there is significant interest in reducing health care costs and improving health care quality. The Department will use its leadership role in health care policy to help lead change in those areas.

The Secretary also has significant regulatory authority as well. In this proposed rule, we are soliciting comments on several proposals that the Secretary might adopt to increase the transparency of quality and pricing

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information, and how this can be used to attenuate the growth in health care costs. In addition, we are soliciting comments from the public on additional ways that we could use our regulatory authority to enhance transparency of quality and pricing information.

Several possibilities exist. First, we could publish a list of hospital charges either for every region of the country or for selected regions of the country. In addition, we could publish the rates that Medicare actually pays to a particular hospital for every DRG or for selected DRGs that could be adjusted to take into account the hospital's labor market area, teaching hospital status, and DSH status. Some might argue that publishing these payment rates does not provide meaningful information to consumers because Medicare payment rates are not set by the market, but rather by a statutory payment formula. In addition, providing information on hospital payments only does not disclose the true cost of an episode of care because it would not take into account the cost of physician services, laboratory tests, and other procedures that go along with hospital charges. On the other hand, Medicare payment rates may provide a helpful benchmark, especially for uninsured individuals, to determine whether the charges they see on a hospital bill bear any relationship to what third-party fee-for-service payors pay to the hospital.

A second option would be for the Secretary to use his authority to establish conditions of participation for hospitals to propose a rule that relates to charges for uninsured patients. For example, the conditions of participation could include a requirement that hospitals post their prices and/or post their policies regarding discounts or other assistance for uninsured patients.

Yet another alternative to posting Medicare DRG payment rates would be to make publicly available the total Medicare payments for an episode of care. For example, one of the most common inpatient hospital procedures under the Medicare program (based on total dollars spent) is hip replacement surgery. Under this proposal, we could make publicly available the expected total payment for an episode of care for hip replacement surgery, including the inpatient hospital stay, physician payments (including the surgeon and the anesthesiologist), and payments for post-acute care services such as services provided in an IRF, SNF, or LTCH. We are currently assessing methods for making such information available and are seeking comments on how to do so as quickly and effectively as possible.

We are seeking comment on any ways in which the Department can encourage transparency in health care quality and pricing whether through its leadership on voluntary initiative or through regulatory requirements. We also are seeking comment on the Department's statutory authority to impose such requirements. Discussion of particular options in this proposed rule should not be taken as an indication that the Department will adopt any of these proposals. Rather, the proposals are included here to foster comment on possible options to promote the aims of transparency of quality and pricing information and the Department's authority and ability potentially to implement these options. The Department is anxious to receive comments on any of these proposals, or on other options that may be available that the Department could adopt either through voluntary initiatives or through its regulatory authority.

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

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

A. Background

Section 1886(g) of the Act requires the Secretary to pay for the capital-related costs of inpatient acute hospital services ``in accordance with a 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 (FFY) 2001 was the last year of the 10-year transition period established to phase in the PPS for hospital inpatient capital-related costs. For cost reporting periods beginning in FY 2002, capital PPS payments are based solely on the Federal rate for most acute care hospitals (other than certain new hospitals and hospitals receiving certain exception payments). The basic methodology for determining capital prospective payments using the Federal rate is set forth in Sec. 412.312. For the purpose of calculating payments for each discharge, the standard Federal rate is adjusted as follows:

(Standard Federal Rate) x (DRG Weight) x (Geographic Adjustment Factor (GAF)) x (Large Urban Add-on, if applicable) x (COLA for hospitals located in Alaska and Hawaii) x (1 + Capital DSH Adjustment Factor + Capital IME Adjustment Factor, if applicable).

Hospitals also may receive outlier payments for those cases that qualify under the threshold established for each fiscal year as specified in Sec. 412.312(c) of the regulations.

The regulations at Sec. 412.348(f) provide that a hospital may request an additional payment if the hospital incurs unanticipated capital expenditures in excess of $5 million due to extraordinary circumstances beyond the hospital's control. This policy was originally established for hospitals during the 10-year transition period, but as we discussed in the August 1, 2002 IPPS final rule (67 FR 50102), we revised the regulations at Sec. 412.312 to specify that payments for extraordinary circumstances are also made for cost reporting periods after the transition period (that is, cost reporting periods beginning on or after October 1, 2001). Additional information on the exception payment for extraordinary circumstances in Sec. 412.348(f) can be found in the FY 2005 IPPS final rule (69 FR 49185 and 49186).

During the transition period, under Sec. Sec. 412.348(b) through (e), eligible hospitals could receive regular exception payments. These exception payments guaranteed a hospital a minimum payment percentage of its Medicare allowable capital-related costs depending on the class of hospital (Sec. 412.348(c)), but were available only during the 10- year transition period. After the end of the transition period, eligible hospitals can no longer receive this exception payment. However, even after the transition period, eligible hospitals receive additional payments under the special exceptions provisions at Sec. 412.348(g), which guarantees all eligible hospitals a minimum payment of 70 percent of its Medicare allowable capital-related costs provided that special exceptions payments do not exceed 10 percent of total capital IPPS payments. Special exceptions payments may be made only for the 10 years from the cost reporting year in which the hospital completes its qualifying project, and the hospital must have completed the project no later than the hospital's cost reporting period beginning before October 1, 2001. Thus, an eligible hospital may receive special exceptions payments for up to 10 years beyond the end of the capital PPS transition period. Hospitals eligible for

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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 Medicare allowable capital-related costs through its first 2 years of operation, unless the new hospital elects to receive fully prospective payment based on 100 percent of the Federal rate. (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 capital PPS Puerto Rico specific rate and 25 percent of the capital PPS Federal rate. However, effective October 1, 1997 (FY 1998), in conjunction with the change to the operating PPS blend percentage for Puerto Rico hospitals required by section 4406 of Pub. L. 105-33, we revised the methodology for computing capital PPS payments to hospitals in Puerto Rico to be based on a blend of 50 percent of the capital PPS Puerto Rico rate and 50 percent of the capital PPS Federal rate. Similarly, in conjunction with the change in operating PPS payments to hospitals in Puerto Rico for FY 2005 required by section 504 of Pub. L. 108-173, we again revised the methodology for computing capital PPS payments to hospitals in Puerto Rico to be based on a blend of 25 percent of the capital PPS Puerto Rico rate and 75 percent of the capital PPS Federal rate effective for discharges occurring on or after October 1, 2004.

B. Treatment of Certain Urban Hospitals Reclassified as Rural Hospitals Under Sec. 412.103

We are proposing technical changes to Sec. Sec. 412.316(b) and 412.320(a)(1) to clarify that hospitals reclassified as rural under Sec. 412.103 are not eligible for the large urban add-on payment or for the capital DSH adjustment. These proposed changes would reflect our historic policy that hospitals reclassified as rural under Sec. 412.103 also will be considered rural under the capital PPS. Since the genesis of the capital PPS in FY 1992, the same geographic classifications used under the operating PPS also have been used under the capital PPS.

These proposed changes and clarifications are necessary because we inadvertently made an error when we updated our capital PPS regulations to incorporate OMB's new CBSA definitions for IPPS hospital labor market areas beginning in FY 2005. In the FY 2005 IPPS final rule (69 FR 49187 through 49188), in order to incorporate the new CBSA designations and the provisions of the newly established Sec. 412.64, which incorporated the CBSA-based geographic classifications, we revised Sec. 412.316(b) and Sec. 412.320 to specify that, effective for discharges occurring on or after October 1, 2004, the capital PPS payment adjustments are based on the geographic classifications under Sec. 412.64. However, Sec. 412.64 does not reference the provisions of Sec. 412.103 regarding the urban-to-rural reclassifications, as was previously found in Sec. 412.63(b)(1).

We believe that this error must be corrected in order to maintain our historic policy for treating urban-to-rural hospital reclassifications under the operating PPS the same for purposes of the capital PPS. Therefore, we are proposing to specify under Sec. Sec. 412.316(b)(2) and (b)(3) and 412.320(a)(1)(ii) and (a)(1)(iii) that, for discharges on or after October 1, 2006, hospitals that are reclassified from urban to rural under Sec. 412.103 would be considered rural.

C. Other Technical Corrections Relating to the Capital PPS Geographic Adjustment Factors

We are proposing to make technical corrections to the regulations under paragraphs (a) and (c) of Sec. 412.316. Specifically, we are proposing to make a technical change under Sec. 412.316(a) to correct the cross-reference to ``Sec. 412.63(k)'' to clarify that the same wage index that applies to hospitals under the operating PPS is used to determine the geographic adjustment factor (GAF) under the capital PPS. We would cross-refer instead to subpart D of Part 412 to capture the applicable requirements in their entirety. This technical correction does not change any current payment policies because the regulation, as written, makes clear that the GAF adjustment for local cost variation under the capital PPS is based on a hospital's operating PPS wage index value. Thus, the same payment policies that are in effect prior to FY 2007 (that is, the GAF is based on a hospital's operating PPS wage index value) would continue in effect for FY 2007 and beyond; the only change in the regulation would be a correction of the erroneous cross- reference.

In addition, we are proposing to make a technical correction under Sec. 412.316(c) to correct the cross-reference to ``Sec. 412.115'' to clarify that, for hospitals located in Alaska and Hawaii, the same COLA factor that applies to these hospitals under the operating PPS is used to determine the COLA factor under the capital PPS. The existing regulation erroneously references the COLA factor used to determine payment under Sec. 412.115, which is not related to the operating PPS COLA factor or any other payment factors. Again, we would cross-refer instead to subpart D of Part 412 to capture the applicable requirements in their entirety. This proposed technical correction would not change any current payment policy; rather it would make clear that the capital PPS COLA factor is based on the hospital's COLA factor under the operating PPS. This proposed technical correction reflects our historic policy that the COLA factor under the capital PPS is based on the hospital's operating PPS COLA factor, which is how the capital PPS COLA

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factor has been determined since the implementation of the capital PPS in FY 1992. Thus, the same payment policy that has been in effect prior to FY 2007 (that is, the use of the operating PPS COLA factor as shown in the table in section II.B.2 of the Addendum of this proposed rule in determining a hospital's capital PPS COLA factor) would continue to be in effect for FY 2007 and beyond; the only change in the regulation would be a correction of the erroneous cross-reference.

VI. 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 Excluded Hospitals and Hospital Units (Sec. 413.40)

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

Historically, hospitals and hospital units excluded from the prospective payment system received payment for inpatient hospital services they furnished on the basis of reasonable costs, subject to a rate-of-increase ceiling. An annual per discharge limit (the target amount as defined in Sec. 413.40(a)) was set for each hospital or hospital unit based on the hospital's own cost experience in its base year. The target amount was multiplied by the Medicare discharges and applied as an aggregate upper limit (the ceiling as defined in Sec. 413.40(a)) on total inpatient operating costs for a hospital's cost reporting period. Prior to October 1, 1997, these payment provisions applied consistently to all categories of excluded providers (rehabilitation hospitals and units (now referred to as IRFs), psychiatric hospitals and units (now referred to as IPFs), LTCHs, children's hospitals, and cancer hospitals).

Payment for children's hospitals and cancer hospitals that are excluded from the IPPS continues to be subject to the rate-of-increase ceiling based on the hospital's own historical cost experience. (We note that, in accordance with Sec. 403.752(a) of the regulations, RNHCIs are also subject to the rate-of-increase limits established under Sec. 413.40 of the regulations.) For IPFs, IRFs, and LTCHs, reasonable cost payment provisions changed significantly for cost reporting periods beginning on or after October 1, 1997.

Section 1886(b)(3)(H) of the Act 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 ``existing'' IPFs, IRFs, or LTCHs for the applicable 5-year period, the target amount is the lower of: the hospital-specific target amount (Sec. 413.40(c)(4)(iii)(A)) or the 75th percentile cap (Sec. 413.40(c)(4)(iii)(B)).

For cost reporting periods beginning on or after October 1, 2002, all IRFs are paid 100 percent of the adjusted Federal rate under the IRF PPS. Therefore, an IRF, considered existing under section 1886(b)(3)(H) of the Act would have no portion of its payment subject to Sec. 413.40(c)(4)(ii) of the regulations for cost reporting periods beginning on or after October 1, 2002.

For cost reporting periods beginning on or after October 1, 2002, to the extent an IPF or LTCH 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, because 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 by the applicable update factor. For example, if a provider was paid the cap amount in FY 2002, the target amount for FY 2003 would be the amount paid in FY 2002, updated to FY 2003 (that is, the target amount from the previous year increased by the applicable update factor). As discussed below, IPFs, IRFs, and LTCHs are now paid under separate PPSs, although some are subject to transition payment provisions.

In addition, a new method of determining the payment amount for ``new'' excluded providers was established under section 1886(b)(7) of the Act. The law was applicable for three classes of excluded providers--IRFs, IPFs, and LTCHs--with a first cost reporting period beginning on or after October 1, 1997. For the first two cost reporting periods, these ``new'' excluded providers would be paid the lesser of their net inpatient operating costs or 110 percent of the national median of target amounts for its class of hospitals for cost reporting periods ending during FY 1996. This amount was updated to the first cost reporting period the hospital received payment, and adjusted for differences in area wage levels, as implemented in the regulations at Sec. 413.40(f)(2)(ii). For the third and subsequent cost reporting periods, Sec. 413.40(c)(4)(v) applies.

The 110 percent of the national median payment limits for new providers under TEFRA (Sec. 413.40(f)(2)(ii)) do not apply to those LTCHs or IPFs whose first cost reporting period begins on or after the date the particular class of hospitals implemented their respective PPS because they are paid 100 percent of their Federal PPS rate. IRFs are paid 100 percent of the Federal rate under the IRF PPS for cost reporting periods beginning on or after October 1, 2002. Therefore, the 110 percent of the median payment limitations are not applicable to IRFs for cost reporting periods beginning on or after that date. 2. Separate 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 IRFs for cost reporting periods beginning on or after October 1, 2000, and before October 1, 2002, with payments based entirely on the adjusted Federal prospective payment for cost reporting periods beginning on or after October 1, 2002. Section 1886(j) of the Act was amended by section 125 of Pub. L. 106-113 to require the Secretary to use a discharge as the payment unit under the PPS for inpatient hospital services furnished by IRFs and to establish classes of patient discharges by functional-related groups. Section 305 of Pub. L. 106-554 further amended section 1886(j) of the Act to allow IRFs, subject to the blend methodology, to elect to be paid the full Federal prospective payment rather than the transitional period payments specified in the Act.

On August 7, 2001, we issued a final rule in the Federal Register (66 FR 41316) establishing the PPS for IRFs, effective for cost reporting periods beginning on or after January 1, 2002.

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There was a transition period for cost reporting periods beginning on or after January 1, 2002, and ending before October 1, 2002. For cost reporting periods beginning on or after October 1, 2002, payments are based entirely on the adjusted Federal prospective payment rate determined under the IRF PPS. 3. Separate 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.

On May 7, 2004, we issued in the Federal Register a final rule (69 FR 25673) that updated the payment rates for the LTCH PPS and made policy changes effective for a new LTCH PPS rate year of July 1, 2004 through June 30, 2005. For the LTCH PPS rate year of July 1, 2005 through June 30, 2006, we issued in the Federal Register a final rule (70 FR 24168) that further updated the payment rates and made policy changes. The 5-year period for LTCHs to transition from reasonable cost-based reimbursement to the fully Federal prospective rate will end with cost reporting periods beginning on or after October 1, 2005, and before October 1, 2006. 4. Separate 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 IPFs (that is, psychiatric hospitals and psychiatric units of acute care hospitals). On November 15, 2004, we issued in the Federal Register a final rule (69 FR 66922) that established the IPF PPS, effective for IPF cost reporting periods beginning on or after January 1, 2005. Under the final rule, we compute a Federal per diem base rate to be paid to all IPFs for inpatient psychiatric services based on the sum of the average routine operating, ancillary, and capital costs for each patient day of psychiatric care in an IPF, adjusted for budget neutrality. The Federal per diem base rate is adjusted to reflect certain patient characteristics, including age, specified DRGs, selected high-cost comorbidities, days of the stay, and certain facility characteristics, including a wage index adjustment, rural location, indirect teaching costs, the presence of a full-service emergency department, and COLAs for IPFs located in Alaska and Hawaii. We have established a 3-year transition period during which IPFs whose first cost reporting periods began before January 1, 2005, will be paid based on a blend of reasonable cost-based payment and IPF PPS payments. For cost reporting periods beginning on or after January 1, 2008, all IPFs will be paid 100 percent of the Federal per diem payment amount. 5. Grandfathering of Hospitals-Within-Hospitals (HwHs) and Satellite Facilities

(If you choose to comment on this section, please include the caption ``Hospitals-Within-Hospitals'' at the beginning of your comment.)

Existing regulations at 42 CFR 412.22(e) define a hospital-within- a-hospital (HwH) as a hospital that occupies space in a building also used by another hospital, or in one or more separate buildings located on the same campus as buildings used by another hospital. In order to be paid outside of the IPPS as an excluded hospital, a HwH is required to demonstrate compliance with requirements at Sec. 412.22(e)(1) through (e)(3), as applicable, which were established to create operational and organizational separateness between the HwH and the host hospital with which it is co-located.

The existing regulations at Sec. 412.22(h), relating to satellite facilities of hospitals excluded from the IPPS, define a satellite facility as a part of a hospital that provides inpatient services in a building also used by another hospital, or in one or more entire buildings located on the same campus as buildings used by another hospital. Section 412.25(e), relating to satellite facilities of excluded hospital units, defines a satellite facility as a part of a hospital unit that provides inpatient services in a building also used by another hospital, or in one or more entire buildings located on the same campus as buildings used by another hospital.

There are significant similarities between the definition of a satellite facility and the definition of a HwH as it relates to their co-location with other Medicare hospital-level providers (hosts). There are also similarities in our policy concerns about the potential for patient-shifting (and its consequences for the Medicare program) between the co-located entities and their hosts. Regarding HwHs and satellite facilities, particularly LTCH HwHs and satellite facilities of LTCHs, which were the original entities that we regulated beginning with FY 1995, we have repeatedly expressed our concerns (for example, in the FY 2005 IPPS final rule (69 FR 49191)) that a HwH's or a satellite facility's ``configuration could result in patient admission, treatment, and discharge patterns that are guided more by attempts to maximize Medicare payments than by patient welfare.'' (69 FR 48916 and 49191). We further believe that ``the unregulated linking of an IPPS hospital and a hospital excluded from the IPPS could lead to two Medicare payments for what was essentially one episode of patient care.'' (69 FR 48916 and 49191). Therefore, we established ``separateness and control'' criteria to govern these relationships with host hospitals, at Sec. 412.22(e) for HwHs, and at Sec. Sec. 412.22(h) and 412.25(e) for satellite facilities of excluded hospitals and satellite facilities of hospital units, respectively. Moreover, for each type of entity, we provided for the ``grandfathering'' of existing facilities, thereby exempting those that were in existence prior to the establishment of the ``separateness and control'' requirements from compliance with the criteria. At Sec. 412.22(f), we provided for the grandfathering of HwHs that were in existence on or before September 30, 1995 or for HwHs that changed the terms and conditions under which they operated between September 30, 1995 and before October 1, 2003, and continued to operate under the terms and conditions in effect on September 30, 2003. At Sec. 412.22(h)(3) and (h)(4) we grandfathered of satellite facilities that were part of a hospital, that were in existence on September 30, 1999, and that met certain other conditions. Further, at Sec. 412.25(e)(3) and (e)(4), we grandfathered satellite facilities that were part of a hospital unit, were in existence on September 30, 1999, and that met certain other conditions.

The regulations addressing ``separateness and control'' policies for each of the above types of entities are presently not entirely uniform. This situation has arisen, in part, because the policies were implemented at different times and also because there are differences among the types of entities. (For example, in the FY 2003 IPPS final rule (67 FR 49982 and 50105), we included a detailed discussion of the ``performance of basic functions'' test utilized for HwHs and how this test was not applicable to satellite facilities.) There are also differences between

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specific features of the grandfathering provisions for HwHs and satellite facilities, despite the fact that, as noted above, the intent of each of the grandfathering provisions was the same (for HwHs at Sec. 412.22(f), for satellite facilities of hospitals at Sec. 412.22(h)(3)(i) and (h)(4), and for satellite facilities of hospital units at Sec. 412.25(e)(3) and (e)(4)). The regulations exempt certain of these entities from compliance with the ``separateness and control'' criteria governing the relationships with their host hospitals as long as they continue to operate under the same ``terms and conditions,'' including the number of beds and square footage considered to be part of the hospital or satellite facility, for purposes of Medicare participation and payment in effect as of the date that they were grandfathered.

This particular policy was adopted because we believed that those entities that were designated as grandfathered, versus those that were required to meet the ``separateness and control'' requirements, should not be permitted to alter their operations from the ``snapshot in time'' taken when they were grandfathered and thus benefit even more from this status. (LTCH HwHs and satellite facilities of LTCHs that are not grandfathered are also subject to a payment adjustment at Sec. 412.534 related to Medicare discharges of patients who were admitted from their host hospitals.) In other words, we believed that grandfathered facilities received a benefit not enjoyed by nongrandfathered facilities--namely, they were free from compliance with the ``separateness and control'' regulations and we did not want to allow these entities to realize additional economic advantages by expansion that would increase their Medicare payments by virtue of their grandfathered status. Furthermore, it has been our policy that if a grandfathered HwH or satellite facility of the HwH chooses not to operate under the same terms and conditions in effect as of its grandfathering, it could still be paid under the applicable excluded hospital payment system if it changed its relationship with its host to the extent that it has come into compliance with the applicable ``separateness and control'' requirements.

Because the underlying rationale for the grandfathering policies for both HwHs and satellite facilities of HwHs is the same, upon review of these various provisions, we believe that, where appropriate, the grandfathering provisions should be consistent. Under the authority of section 1871(a)(1) of the Act, which authorizes the Secretary to prescribe such regulations as may be necessary to carry out the administration of the Medicare program, we are proposing the following revisions to make the policies consistent. As set forth below, we are proposing to revise the HwH provision at Sec. 412.22(f) to include an exception to the requirement that a grandfathered HwH be operated under the terms and conditions in effect on October 1, 2003, that corresponds to the existing exceptions for HwH satellite facilities and for satellite facilities of hospital units at Sec. 412.22(h)(4) and 412.25(e)(4), respectively. (As provided in Sec. 412.22(f), the original September 1, 1995, ``snapshot in time'' date for grandfathered HwHs was extended to hospitals that changed the terms and conditions under which they operated between September 1, 1995, and before October 1, 2003, in the FY 2004 IPPS final rule (68 FR 45462).) Specifically, we are proposing a corresponding change to the HwH grandfathering provision at Sec. 412.22(f)(3) that would allow for increases or decreases in square footage, or decreases in the number of beds of the HwH that are needed for specific circumstances beyond the control of the facility. We are specifying that increases or decreases in square footage or decreases in the number of beds that are required because of the relocation of a facility to permit construction or renovation necessary for compliance with Federal, State, or local law affecting the physical facility or because of catastrophic events such as fires, floods, earthquakes, or tornadoes. (64 FR 14535) We are proposing to add some phraseology to the existing provision in Sec. 412.22(h)(4) for consistency with the regulations for grandfathered satellite facilities cited above.

As noted above, our existing grandfathering regulations at Sec. Sec. 412.22(f), 412.22(h)(3) and (h)(4), and 412.25(e)(3) and (e)(4) require that the grandfathered entity make no change in either its square footage or number of beds in order to retain its grandfathered status. In establishing grandfathering provisions, generally, we intended to protect certain existing hospitals and satellite facilities from ``the potentially adverse impact of recent, more specific regulations that we now believe to be essential to the goals of the Medicare program'' (68 FR 45463). Moreover, it was our intention that our ``snapshot in time'' policy prevented grandfathered entities that were advantaged more than their nongrandfathered peer facilities as a result of their protected status from realizing additional benefits by changing their ``terms and conditions'' that could increase their Medicare reimbursement. However, as noted above, we did provide that a grandfathered HwH or satellite facility would have the option of changing square footage or number of beds if it decided to forego its grandfathered status and comply with the applicable ``separateness and control'' regulations.

Recently, several grandfathered LTCH HwHs and satellite facilities questioned whether a decrease in their square footage or their number of beds would result in negating their grandfathered status, because compliance with the each of the above cited grandfathering provisions require that they continue to operate under the same terms and conditions, including the number of beds and square footage considered to be part of the hospital, the satellite facility, or the hospital unit in effect on the day that the grandfathering policy was implemented. We also have been urged to modify our policies to allow these grandfathered entities to increase in square footage and number of beds without requiring compliance with the ``separateness and control'' policies discussed above. Clearly, under existing regulations, a decrease or an increase in square footage or number of beds would result in a loss of status as a grandfathered HwH or hospital satellite facility (unless Sec. 412.22(h)(4) or Sec. 412.25(b)(3) applies) because the existing regulations prohibit any change in the terms and conditions of operation, as described above.

We had two objectives in establishing our grandfathering policy. The first was to allow existing HwHs and satellite facilities to continue to be paid outside of the IPPS, despite the fact that, among other factors, no demonstration of operational or organizational separateness between these grandfathered entities and their host hospitals were required, as they were for HwHs established after September 30, 1995, and for satellite facilities established after September 30, 1999. However, the second objective was to ensure that these entities would not make changes that would lead to increased costs to the Medicare program. The nexus of these two objectives has been the basis of our ``snapshot in time'' policy discussed above. (For HwHs, as noted above, the ``snapshot in time'' date for changes in ``terms and conditions'' was extended to before October 1, 2003, if the HwH changed its terms and conditions under which it operated after September 30, 1995, but before October 1, 2003, in the FY 2004 IPPS final rule (68 FR 45462).)

As a result of the requests that we reconsider our policy for an HwH or

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satellite facility that decreases or increases square footage or number of beds, we revisited the requirement for grandfathered entities to continue to operate under the ``same terms and conditions'' in effect when they were grandfathered. We have determined that, although increases in square footage or number of beds would confer additional benefits on grandfathered entities, as compared with those HwHs and satellite facilities that were required to comply with ``separateness and control'' policies at Sec. Sec. 412.22(e), 412.22(h), and 412.25(e) by allowing expansion and result in additional costs to the Medicare program, this would not be the case regarding a decrease in either the square footage or the numbers of beds because a decrease in the number of beds or square footage would not result in additional costs to the Medicare program. Therefore, we are proposing revisions to the regulations at Sec. 412.22(f) for grandfathered HwHs and at Sec. Sec. 412.22(h) and 412.25(e)(5) for grandfathered satellites of hospitals and satellites of hospital units, respectively, to allow these entities to decrease their square footage or number of beds, or both, without jeopardizing their grandfathered status. Specifically, we are proposing to add a new paragraph (f)(3) to Sec. 412.22; a new paragraph (h)(5) to Sec. 412.22(h) (existing paragraphs (h)(5) through (h)(7) would be redesignated as paragraphs (h)(6) through (h)(8), respectively); and a new paragraph (e)(5) to Sec. 412.25 (existing paragraph (e)(5) would be redesignated as paragraph (e)(6)). We are also proposing to revise the introductory text to paragraph (f) of Sec. 412.22; paragraphs (h)(1), (h)(3), and (h)(4) of Sec. 412.22; and paragraph (e)(3) of Sec. 412.25.

Because grandfathered HwHs or grandfathered satellite facilities may be co-located with an acute care hospital or may be co-located with another excluded hospital (69 FR 49198), we want to emphasize that under our proposed policy revisions described above, where the HwH or satellite facility decreases its number of beds or square footage, there could be an impact on the host hospital if it is also grandfathered from compliance with the ``separateness and control'' requirements. (Because excluded hospitals are prohibited from having excluded hospital units under Sec. 412.25(a)(1)(ii), this discussion is limited to HwHs and satellite facilities of hospitals.) For example, if grandfathered HwH ``A'' is co-located with another hospital excluded from the IPPS, hospital ``B'' (which is a rehabilitation hospital), a decrease in the number of beds in hospital ``A'' could impact the grandfathered status of hospital ``B'' if hospital ``B'' absorbed the extra beds. In such a case, if the determination were made that hospital ``B'' would expand, in order to maintain status as an excluded hospital, hospital ``B'' would then have to meet the applicable ``separateness and control'' requirements at Sec. 412.22(e). 6. Proposed Changes to the Methodology for Determining LTCH Cost-to- Charge Ratios (CCRs) and the Reconciliation of High-Cost and Short-Stay Outlier Payments Under the LTCH PPS a. Background

In the June 9, 2003 high-cost outlier final rule (68 FR 34498), we made revisions to our policies concerning the determination of LTCHs' CCRs and the reconciliation of high-cost and short-stay outlier payments under the LTCH PPS. As we stated in that final rule, (68 FR 34507), because the LTCH PPS high-cost outlier and short-stay outlier policies are modeled after the IPPS outlier policy, we believe they are susceptible to the same payment vulnerabilities and, therefore, merited revision. Specifically, because we believe that a hospital has the ability to inappropriately increase its outlier payments during the time lag between the current charges and the CCR from the settled cost report, through dramatic charge increases, we established new regulations under the LTCH PPS that would allow fiscal intermediaries to use more up-to-date data when determining the CCRs for each LTCH. We revised our regulations to specify that fiscal intermediaries will use either the most recent settled cost report or the most recent tentative settled cost report, whichever is from the later cost reporting period, because, in many cases, using CCRs from tentative settled cost report reduces the time lag for updating CCRs by a year or more.

However, even the later CCRs calculated from the tentative settled cost reports would overestimate costs for hospitals that have continued to increase charges much faster than costs during the time between the tentative settled cost report and the time when the claim is processed. Therefore, we also revised the regulations to specify that, in the event more recent charge data indicate that an alternative CCR would be more appropriate, CMS has the authority to direct the fiscal intermediary to change the LTCH's CCR to reflect the change evidenced by the more recent data. In addition, we further revised the regulations to allow a hospital to contact its fiscal intermediary to request that its CCR, otherwise applicable, be changed if the LTCH presents substantial evidence that its CCR is inaccurate. (68 FR 34497 and 34506 through 34508)

Also in the June 9, 2003 final rule, we noted that as hospitals raise their charges faster than their costs increase, over time their CCRs will decline. If hospitals continue to increase charges at a faster rate than their costs increase over a long period of time, or if they increase charges at extreme rates, their CCRs may fall below the range considered reasonable and fiscal intermediaries may assign a statewide average CCR. These statewide averages are generally considerably higher than the threshold. Therefore, prior to the change in the regulations, these hospitals benefited from an artificially high ratio being applied to their already high charges. Furthermore, hospitals could continue to increase charges faster than costs, without any further downward adjustment to their CCR. Consequently, in that same final rule, we revised the regulations to specify that a fiscal intermediary may use a statewide average CCR if it is unable to determine an accurate CCR in one of three circumstances (discussed in greater detail below). (68 FR 34499 through 34500 and 34506 through 34507)

In addition, in the June 9, 2003 final rule (68 FR 34500 through 34501 and 34506 through 34508), we noted that we had become increasingly aware that some hospitals had taken advantage of the former outlier policy by increasing their charges at extremely high rates, knowing that there would be a time lag before their CCRs would be adjusted to reflect the higher charges. We believed that even the revisions to the regulations described above would not completely eliminate all such opportunity. We explained that we believed that a hospital would still be able to dramatically increase its charges by far above the rate-of-increase in costs during any given year. Because this possibility was of great concern, we added a provision to our regulations to provide that outlier payments would become subject to reconciliation when hospitals' cost reports are settled.

Because we continue to have these same concerns, in the RY 2007 LTCH PPS proposed rule (71 FR 4648, 4674 through 4676, and 4690 through 4692), we discussed our current methodology for determining hospitals' CCRs under the LTCH PPS high-cost and short-stay outlier policies, and we presented proposals to refine our methodology for determining the annual CCR ceiling and

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statewide average CCRs. In that same proposed rule, we also discussed our existing policy for the reconciliation of LTCH PPS high-cost and short-stay outlier payments, along with our proposal to codify in Subpart O of 42 CFR Part 412 those policies, including proposed modifications and editorial clarifications to those existing policies.

Historically, annual updates to LTCH CCR ceiling and statewide average CCRs have been effective on October 1. In that RY 2007 LTCH PPS proposed rule, we proposed that the proposed revisions to the policies governing the determination of LTCHs' CCRs and the reconciliation of high-cost and short-stay outlier payments would be effective October 1, 2006. In addition, our proposal stated that the LTCH CCR ceiling and statewide average CCRs that would be effective October 1, 2006, would be presented in the annual IPPS proposed and final rules.

We received a few specific comments concerning the proposed changes to the policies governing the determination of LTCHs' CCRs. Several other commenters referenced one of the specific comments on the proposed changes to the methodology for determining LTCH CCRs in their own comments on the RY 2007 LTCH PPS proposed rule. Based on one commenter's synopsis of our proposed changes concerning the determination of LTCH's CCRs, we believe that the commenters clearly understood the nature and purpose of the proposed changes. However, the commenter pointed out that, in the RY 2007 LTCH PPS proposed rule, we did not provide an analysis of the effect of this proposed change, nor did we provide an example of the new CCR values under this proposed methodology. Another commenter did not ``object in concept to the proposed combination of [IPPS] operating and capital cost-to-charge ratios'' (to compute a ``total'' CCR for each IPPS hospital by adding together each hospital's operating CCR and its capital CCR) from which to compute the LTCH CCR ceiling and applicable statewide average CCRs. However, the commenter also pointed out that we did not provide any impact data and requested that we defer adoption of that proposed change until such data are provided for comment.

Therefore, we are proposing in this IPPS proposed rule the same changes to the policies governing the determination of LTCHs' CCRs and the reconciliation of high-cost and short-stay outlier payments that we proposed in the RY 2007 LTCH PPS proposed rule. We are including in this proposed rule the values of the proposed LTCH CCR ceiling (discussed below in this section) and the proposed statewide average LTCH CCRs (as shown in Table 8C of the Addendum to this IPPS proposed rule) that would be effective October 1, 2006, based on our proposed policy changes (along with the values of the proposed LTCH CCRs that would be determined under our current methodology). b. High-Cost Outliers

Under the broad authority conferred upon the Secretary by section 123 of the BBRA as amended by section 307(b) of BIPA, when we implemented the LTCH PPS, we established an adjustment for additional payments for outlier cases that have extraordinarily high-costs relative to the costs of most discharges at Sec. 412.525(a). Providing additional payments for outliers strongly improves the accuracy of the LTCH PPS in determining resource costs at the patient level and hospital level. Specifically, under Sec. 412.525(a), we make outlier payments for any discharge if the estimated cost of the case exceeds the adjusted LTCH PPS payment for the LTC-DRG plus a fixed-loss amount. Under the LTCH PPS high-cost outlier policy, the LTCH's loss is limited to the fixed-loss amount and a fixed percentage of costs above the marginal cost factor. We calculate the estimated cost of a case by multiplying the overall hospital CCR by the Medicare allowable covered charge. In accordance with Sec. 412.525(a)(3), we pay outlier cases 80 percent of the difference between the estimated cost of the patient case and the outlier threshold (the sum of the adjusted Federal prospective payment for the LTC-DRG and the fixed-loss amount). (1) CCR Ceiling

As noted above, we determine the estimated cost of the case by multiplying the LTCH's overall CCR by the Medicare allowable charges for the case. As we discussed in greater detail in the June 9, 2003 IPPS high-cost outlier final rule (68 FR 34506 through 34516), because the LTCH PPS high-cost outlier policy (Sec. 412.525) is modeled after the IPPS outlier policy, we believed that it and the short-stay outlier policy (Sec. 412.529) are susceptible to the same payment vulnerabilities that became evident under the IPPS and, therefore, merited revision. Thus, we revised the high-cost outlier policy at Sec. 412.525(a) and the short-stay policy at Sec. 412.529 in that same final rule for the determination of LTCHs' CCRs and the reconciliation of outlier payments.

Under the LTCH PPS, a single prospective payment per discharge is made for both inpatient operating and capital-related costs. Therefore, we compute a single ``overall'' or ``total'' CCR for LTCHs based on the sum of their operating and capital-related costs (as described in Chapter 3, section 150.24, of the Medicare Claims Processing Manual (CMS Pub. 100-4) as compared to total charges. Specifically, a LTCH's CCR is calculated by dividing an LTCH's total Medicare costs (that is, the sum of its operating and capital inpatient routine and ancillary costs) divided by its total Medicare charges (that is, the sum of its operating and capital inpatient routine and ancillary charges). (Instructions regarding the changes established in the June 9, 2003 IPPS high-cost outlier final rule for both LTCHs and IPPS hospitals can be found in Program Transmittal A-03-058 (Change Request 2785; July 3, 2003)).

As a result of the changes established in the June 9, 2003 IPPS high-cost outlier final rule, as we discussed in previous LTCH PPS final rules (RY 2004, 68 FR 34144 through 34146; RY 2005, 69 FR 25687 through 25690; and RY 2006, 70 FR 24192 through 24194), under our current policy, an LTCH is assigned the applicable statewide average CCR if, among other things, an LTCH's CCR is found to be in excess of the applicable maximum CCR threshold (that is, the combined IPPS operating and capital CCR ceiling). As we explained in that same final rule (68 FR 34507), CCRs above this threshold are most likely due to faulty data reporting or entry, and, therefore, these CCRs should not be used to identify and make payments for outlier cases. Such data are clearly errors and should not be relied upon. Thus, under our established policy, if an LTCH's CCR is above the applicable ceiling, the applicable combined IPPS statewide average CCR is assigned to the LTCH instead of the CCR computed from data in its most recent (settled or tentatively settled) cost report.

As we explained in the RY 2006 LTCH PPS final rule (70 FR 24192), we believe it is appropriate to use the combined IPPS operating and capital CCR ceiling and the applicable combined IPPS statewide average CCRs in determining LTCHs' CCRs because LTCHs' cost and charge structures are similar to that of IPPS acute care hospitals. For instance, LTCHs are certified as acute care hospitals, as set forth in section 1861(e) of the Act, to participate as a hospital in the Medicare program, and these hospitals, in general, are paid as LTCHs only because their Medicare average length of stay is greater than 25 days (Sec. 412.23(e)). Furthermore, as also explained in that

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same final rule, prior to qualifying as a LTCH under Sec. 412.23(e)(2)(i), a hospital generally is paid as an acute care hospital under the IPPS during the period in which it demonstrates that it has an average length of stay of greater than 25 days. In addition, because there are less than 400 LTCHs, and they are unevenly geographically distributed throughout the United States, there may not be sufficient LTCH CCR data to determine an appropriate LTCH PPS CCR ceiling using LTCH data.

As noted above, under the LTCH PPS, there is a single prospective payment per discharge for both inpatient operating and capital-related costs, and therefore, we compute a single ``overall'' or ``total'' CCR for LTCHs based on the sum of their Medicare operating and capital- related costs and charges. However, under the IPPS, Medicare per discharge payments to acute care hospitals for the costs of inpatient operating services are made under the ``operating IPPS'' and per discharge payments to acute care hospitals for inpatient capital- related costs are made under the ``capital IPPS.'' Because separate payments are made to acute care hospitals under the IPPS for operating and capital-related costs, separate operating and capital CCRs are calculated and used in determining IPPS high-cost outlier payments. Accordingly, under the IPPS, a separate ``operating'' CCR ceiling and a ``capital'' CCR ceiling are determined annually. As we explained above and as stated in annual instructions (Program Transmittal A-02-093 (Change Request 2288, September 27, 2002); Program Transmittal A-03-073 (Change Request 2891, August 22, 2003); Program Transmittal 309 (Change Request 3459, October 1, 2004); and Program Transmittal 692 (Change Request 4046, September 30, 2005)), under our current policy, if a LTCH's CCR is above the applicable ``combined'' IPPS operating and capital CCR ceiling (that is, adding the separate IPPS operating ceiling and the capital CCR ceiling together), the applicable statewide average CCR is assigned to the LTCH. For instance, for FY 2006, the IPPS operating CCR ceiling is 1.254 and the IPPS capital CCR ceiling is 0.169 (70 FR 47496). Therefore, under our current policy, the ``combined'' operating and capital CCR ceiling is 1.423 (1.254 + 0.169 = 1.423) as specified in Program Transmittal 692 (Change Request 4046, September 30, 2005).

Because LTCHs have a single ``total'' CCR (rather than separate operating and capital CCRs), under the broad authority of section 123 of the BBRA and section 307(b)(1) of BIPA, we are proposing to revise Sec. 412.525(a)(4) to specify that, for discharges occurring on or after October 1, 2006, if, among other things, a LTCH's CCR is in excess of the LTCH CCR ceiling (which would be calculated as 3 standard deviations above the corresponding national geometric mean total CCR (established and published annually by CMS)), the fiscal intermediary may use a statewide average CCR (also established annually by CMS and discussed in more detail below). (We note, as discussed in greater detail below in this section, in conjunction with this proposed change in the calculation of the LTCH CCR ceiling, we are also proposing a change in our methodology for calculating the applicable statewide average CCRs under the LTCH PPS to be based on hospital-specific ``total'' CCRs.)

Specifically, under proposed revised Sec. 412.525(a)(4)(iv)(C)(2), for discharges occurring on or after October 1, 2006, we are proposing that we would determine the single ``total'' CCR ceiling, based on IPPS CCR data, by first calculating the total (that is, operating and capital) CCR for each hospital and then determining the average total CCR for all hospitals. For example, if a hospital's operating CCR is 0.432 and its capital CCR is 0.027, its total CCR would be 0.459 (0.432 + 0.027 = 0.459). This calculation would be repeated for all hospitals in order to determine total CCRs for all hospitals. Next, those total CCRs would be used to determine the average total CCR and standard deviation across all hospitals. The LTCH CCR ceiling would then be established at 3 standard deviations from the mean total CCR, rather than determining the LTCH total CCR ceiling by adding the separate IPPS operating CCR and capital CCR ceilings, which are each separately determined at 3 standard deviations from the average operating CCR and average capital CCR, respectively, as we do under our current policy (as demonstrated above).

Under this proposed policy, we would use the same IPPS CCR data that we currently use to annually determine the separate IPPS operating CCR and capital CCR ceilings (that we add together under our current policy to determine the annual CCR ceiling for LTCHs) to compute IPPS hospital-specific total CCRs that would be used to determine the single LTCH total CCR ceiling. We believe that determining a LTCH CCR ceiling based on IPPS total (operating and capital-related) Medicare costs and charges rather than adding the separate IPPS CCR ceilings determined from operating CCRs and capital CCRs, respectively, would be more consistent with the LTCH PPS single payment, which does not differentiate payments between operating and capital-related costs. Our rationale for proposing to continue to use IPPS data to determine the LTCH CCR ceiling annually continues to be the same as the one stated above.

To summarize, our current methodology (that is, using the ``combined'' IPPS CCR ceiling) calculates two separate IPPS CCRs (an operating CCR and a capital CCR) by taking 3 standard deviations from the average of all IPPS operating CCRs and 3 standard deviations from the average of all IPPS capital CCRs separately to determine the IPPS operating CCR ceiling and IPPS capital CCR ceiling, respectively. Then we added the IPPS operating CCR ceiling and the IPPS capital CCR ceiling together to get a combined'' LTCH CCR ceiling. The proposed methodology would add each IPPS hospital's operating CCR and its capital CCR together first to get a ``total'' CCR for each IPPS hospital, and then determine the average (that is, national geometric mean) of all of those total CCRs across all IPPS hospitals. Next we would take 3 standard deviations above the corresponding national geometric mean total CCR to calculate the LTCH CCR ceiling. The underlying data upon which this calculation is based, that is, the IPPS CCRs, would remain the same.

Based on the most recent complete IPPS total CCR data from the December 2005 update to the Provider-Specific File, we are proposing a total CCR ceiling of 1.313 under the LTCH PPS that would be effective October 1, 2006. We note that this proposed ceiling was determined based on the same data used to determine the separate proposed IPPS operating CCR ceiling (1.25) and the proposed IPPS capital CCR ceiling (0.158) discussed in section II.A.4.c. of the Addendum to this proposed rule. Furthermore, we are proposing that, if more recent data are available (that is, data from the March 2006 update to the Provider- Specific File, for example), we would use those data to determine the final total CCR ceiling under the LTCH PPS for FY 2007 using the proposed methodology described above.

The LTCH CCR ceiling determined under our current ``combined'' methodology would result in a slightly higher LTCH CCR ceiling (that is, 1.25 + 0.158 = 1.408) for FY 2007 compared to the proposed ``total'' CCR ceiling of 1.313 for FY 2007. However, we note that, based on CCRs from the December 2005 update of the Provider-Specific File, there were no LTCHs that have a CCR that is greater than the proposed ceiling of 1.313 (the highest LTCH CCR in the database of 363 LTCHs is 1.132).

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As we explained in the RY 2007 LTCH PPS proposed rule (71 FR 4675), we are proposing to amend Sec. 412.525 by adding a new paragraph (a)(4)(iv)(C)(2) to reflect the refined methodology for determining the annual CCR ceiling under the LTCH PPS. We are proposing that the revision would be effective for discharges occurring on or after October 1, 2006, rather than July 1, 2006, because we are proposing to continue to use the same IPPS data used to determine the individual IPPS operating and capital CCR ceilings established and published annually in the IPPS proposed and final rules. Because both the separate IPPS operating and capital CCRs ceilings and the LTCH ``total'' CCR ceiling would be determined using the same data, we believe it would be administratively expedient to continue to establish the LTCH CCR ceiling to be effective for discharges occurring on or after October 1 of each year. (As stated previously, this is consistent with our current policy, where the LTCH CCR ceiling is updated annually on October 1.) Therefore, under this proposal, the public would continue to consult the annual IPPS proposed and final rules for changes to the LTCH CCR ceiling that would be effective for discharges occurring on or after October 1. Under this proposal, the current LTCH CCR ceiling established for discharges occurring on or after October 1, 2005, in the FY 2006 IPPS final rule would remain in effect for discharges occurring on or before September 30, 2006. (2) Statewide Average CCRs

In the June 9, 2003 IPPS high-cost outlier final rule, we also established our existing policy for discharges occurring on or after August 8, 2003, that, in addition to assigning the applicable statewide average CCR to a LTCH whose CCR is above the ceiling, the fiscal intermediary may use the applicable statewide average CCR for LTCHs for whom data with which to calculate a CCR are not available (for example, missing or faulty data) or for new LTCHs that have not yet submitted their first Medicare cost report. (For this purpose, a ``new'' LTCH is defined as an entity that has not accepted assignment of an existing hospital's provider agreement in accordance with Sec. 489.18.) We note that, consistent with our current policy, either CMS or the hospital may request the use of a different (higher or lower) CCR based on substantial evidence that such a CCR more accurately reflects the hospital's actual costs and charges. This applies to new LTCHs (as defined above) as well. For instance, CMS may determine that the applicable statewide average CCR should not be applied to hospitals that convert from acute care IPPS hospitals to LTCHs (and receive a new LTCH provider number). Rather, the cost and charge data from the IPPS hospital's cost report (even if they are for more or less than a 12- month cost reporting period) would be used to determine the LTCH's CCR.

Thus, in addition to proposing to revise our methodology for determining the annual CCR ceiling under the LTCH PPS for discharges occurring on or after October 1, 2006, under the broad authority of section 123 of the BBRA and section 307(b)(1) of BIPA, we are proposing to revise Sec. 412.525(a)(4), for discharges occurring on or after October 1, 2006, to codify in Subpart O of 42 CFR Part 412 the remaining LTCH PPS high-cost policy changes that were established in the June 9, 2003 IPPS high-cost outlier final rule (68 FR 34506 through 34513), including proposed modifications and editorial clarifications to those existing policies established in that final rule, which are discussed in greater detail below in this section. We are proposing these additional revisions to Sec. 412.525(a)(4) because we believe that making these revisions would more precisely describe the application of those policies as they relate to the determination of LTCH CCRs and because these proposed changes would be consistent with the proposed changes to the calculation of the LTCH CCR ceiling discussed above in this section.

Specifically, we are proposing to specify in new Sec. 412.525(a)(4)(iv)(C) that the fiscal intermediary may use a statewide average CCR, which would be established annually by CMS, if it is unable to determine an accurate CCR for a LTCH in one of the following three circumstances: (1) New LTCHs that have not yet submitted their first Medicare cost report (for this purpose, consistent with current policy, a new LTCH would be defined as an entity that has not accepted assignment of an existing hospital's provider agreement in accordance with Sec. 489.18); (2) LTCHs whose CCR is in excess of the LTCH CCR ceiling (that is, 3 standard deviations above the corresponding national geometric mean total CCR, as discussed in greater detail previously in this proposed rule); and (3) other LTCHs for whom data with which to calculate a CCR are not available (for example, missing or faulty data). (Other sources of data that the fiscal intermediary may consider in determining an LTCH's CCR included data from a different cost reporting period for the LTCH, data from the cost reporting period preceding the period in which the hospital began to be paid as an LTCH (that is, the period of at least 6 months that it was paid as a short-term acute care hospital), or data from other comparable LTCHs, such as LTCHs in the same chain or in the same region.)

In addition, under proposed Sec. 412.525(a)(4)(iv)(C), for discharges occurring on or after October 1, 2006, we are proposing that we would annually establish statewide average ``total'' CCRs (as explained below in this section) for use under the LTCH PPS based on IPPS data rather than assigning the combined (operating and capital- related) statewide average CCRs (Transmittal 692 (Change Request 4046, September 30, 2005)). Specifically, under this proposed policy, we would use the same IPPS CCR data that we currently use to annually establish the separate IPPS operating and capital statewide CCRs (that we add together under our current policy to determine the applicable ``combined'' statewide average CCR for LTCHs) to compute statewide average total CCRs by first calculating the total (that is, operating and capital) CCR for each hospital and then determining the weighted average total CCR for all hospitals in each State rather than adding together the separate applicable IPPS operating and capital statewide weighted average CCRs as we do under our current policy.

We also are proposing that these statewide average ``total'' (operating and capital) CCRs that would be used under the LTCH PPS would continue to be published annually in the IPPS proposed and final rules, and, therefore, the public would continue to consult the annual IPPS proposed and final rules for changes to the applicable statewide average total CCRs that would be effective for discharges occurring on or after October 1. Under this proposal, the current applicable statewide average operating and capital CCRs, established for discharges occurring on or after October 1, 2005, would remain in effect for discharges occurring on or before September 30, 2006. Our rationale for proposing to establish statewide average ``total'' CCRs (as described above in this section) based on IPPS data under proposed Sec. 412.525(a)(4)(iv)(C) is the same as the one stated above for proposing to use IPPS data to determine a ``total'' LTCH CCR ceiling.

Under the current methodology, we determine a ``combined'' statewide average CCRs for LTCHs located in rural areas of a State that accounts for operating and capital costs and charges and a ``combined'' statewide average CCRs for LTCHs located in urban areas of a State that accounts for operating and capital-related costs and charges. In

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order to calculate a combined statewide average CCR under our current methodology, we must first calculate separate statewide average operating CCRs and capital CCRs. Under the IPPS, two statewide average operating CCRs are computed for each State: a statewide average CCR for rural areas and a statewide average CCR for urban areas. One statewide average capital CCR is computed for each State (applicable to both urban and rural areas). We use the same capital CCR for urban and rural areas because capital costs are the same regardless of geographic location. Below, we outline our existing methodology for calculating the combined statewide average CCR for a rural LTCH:

Step 1: Calculate the weighted average operating CCR for all IPPS hospitals located in rural areas of the State (as shown in the third column of Table 8A of the Addendum to this proposed rule).

Step 2: Calculate the weighted average capital CCR for all IPPS hospitals located in the State (both rural and urban areas) (as shown in Table 8B of the Addendum to this proposed rule).

Step 3: Add the weighted average rural operating CCR (Step 1) together with the weighted average capital CCR (Step 2) in order to arrive at a ``combined'' statewide average CCR for LTCHs in rural areas of the State.

For example, for a rural LTCH located in Alabama, under our current methodology, the ``combined'' statewide average CCR for FY 2007 would be 0.360, computed as the operating statewide rural average CCR of 0.334 (Table 8A of the Addendum to this proposed rule) plus the capital statewide average CCR 0.026 (Table 8B of the Addendum to this proposed rule). This same methodology is applied when determining the ``combined'' statewide average CCR for LTCHs located in urban areas under our current methodology, except that in Step 1 we substitute the average operating CCR for all rural IPPS hospitals with the weighted average operating CCR for all urban IPPS hospitals for the State (as shown in the second column of Table 8A of the Addendum to this proposed rule) and in Step 3, we add the weighted average urban operating CCR in Step 1 to the weighted average capital CCR in Step 2 in order to arrive at a ``combined'' statewide average CCR for LTCHs in urban areas of the State.

Under our proposed methodology for calculating a statewide average ``total'' CCR under the LTCH PPS that accounts for operating and capital-related costs and charges, first, for each IPPS hospital, we would add its operating CCR and its capital CCR together to determine its ``total'' CCR. Then we would use the ``total'' CCRs for all urban IPPS hospitals in the State to compute a statewide average total CCR for the urban areas of a State, and we would use the ``total'' CCR for all rural IPPS hospitals in the State to compute a statewide average CCR for the rural areas of a State. Below, we outline our proposed methodology for calculating the total statewide average CCR for a rural LTCH:

Step 1: Calculate the total CCR for each rural IPPS hospital by adding together its operating CCR and its capital CCR.

Step 2: Calculate the weighted average total CCR for all rural IPPS hospitals in the State (as shown in the third column of Table 8C of the Addendum to this proposed rule). For example, for a rural LTCH located in Alabama, under our proposed methodology, the proposed ``total'' statewide average CCR for FY 2007 would be 0.365 (Table 8C of the Addendum to this proposed rule). This same proposed methodology would be applied when determining the ``total'' statewide average CCR for LTCHs located in urban areas, except that we would replace ``rural IPPS hospitals'' with ``urban IPPS hospitals'' in Steps 1 and 2. (The total statewide average CCRs for urban LTCHs is shown in the second column of Table 8A of the Addendum to this proposed rule.) Under this proposal, the underlying data, that is, the IPPS CCRs, would remain the same.

Based on the most recent complete IPPS total CCR data from the December 2005 update of the Provider-Specific File, the proposed LTCH PPS statewide average CCRs that would be effective October 1, 2006, are presented in Table 8C of the Addendum to this proposed rule. (We note that, as is the case under the IPPS, all areas in the District of Columbia, New Jersey, Puerto Rico, and Rhode Island are classified as urban, and therefore, there are no proposed rural statewide average total CCRs listed for those jurisdictions in Table 8C of the Addendum to this proposed rule. We also note that, as is the case under the IPPS, although Massachusetts has areas that are designated as rural, there are no short-term acute care IPPS hospitals or LTCHs located in those areas as of March 2006, and therefore, there is no proposed rural statewide average total CCR listed for rural Massachusetts in Table 8C of the Addendum of this proposed rule.) Furthermore, we are proposing that, if more recent data are available (that is, data from the March 2006 update of the Provider-Specific File, for example), we would use those data to determine the final LTCH PPS statewide average CCRs for FY 2007 using the proposed methodology describe above.

Comparing the proposed statewide average ``total'' CCRs in Table 8C of the Addendum to this proposed rule to the ``combined'' statewide average CCRs that would be calculated using our existing methodology from the proposed operating PPS statewide average CCRs in Table 8A of the Addendum to this proposed rule and the proposed capital PPS statewide average CCRs in Table 8B of the Addendum to this proposed rule shows that the proposed changes to our methodology for determining LTCH statewide average CCRs would result in only minor changes in the average CCR for each State. In particular, the largest decrease in a statewide average CCR (with the exception of Maryland, as discussed below) would be in urban Indiana (-1.9 percent). However, there are currently no LTCHs located in Indiana. The largest increase in a statewide average CCR would be in urban District of Columbia (2.8 percent), and there are currently only 2 LTCHs located in the District of Columbia.

We are proposing to determine the urban and rural statewide average total CCRs for Maryland LTCHs paid under the LTCH PPS using, as a proxy, the national average total CCR for urban IPPS hospitals and the national average total CCR for rural IPPS hospitals, respectively. We are proposing this proxy because we believe that the CCR data on the Provider-Specific File for Maryland hospitals may not be accurate. We believe that the CCR data based on Maryland hospitals' cost report and charge data may not be accurate because acute care hospitals in Maryland are operating under a waiver of the Medicare's ratesetting methodologies for inpatient and outpatient services under the authorities of sections 1814(b)(3) and 1833(a)(2) of the Act. The State's Health Services Cost Review Commission (HSCRC) is the regulatory body that establishes hospital-specific rates for all hospital services in Maryland.

Because all Maryland short-term acute care hospitals are paid based on the hospital-specific rates set by the HSCRC rather than under the IPPS, CCRs are not required to determine their Medicare payments (as they are for other acute care hospitals that are not governed under the waiver at sections 1814(b)(3) and 1833(a)(2) of the Act, and who are reimbursed for their treatment of Medicare patients under the IPPS). Therefore, CCRs in the Provider-Specific File for Maryland acute care hospitals, for the most part, are missing (because they are not used for payment). Those CCRs that are input into the Provider-

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Specific File for Maryland acute care hospitals by the fiscal intermediary are most likely unaudited because they are not used for making payments. For all these reasons, we are concerned that CCRs for Medicare acute care hospitals located in Maryland that are in the Provider-Specific File may not be reliable. Therefore, we believe that they should not be used as proxies for setting the statewide average total CCRs for Maryland LTCHs.

We believe it would be more appropriate to establish statewide average total CCRs for Maryland LTCHs based on national average total CCRs of IPPS hospitals that were audited by fiscal intermediaries. We are proposing to establish statewide average total CCRs for Maryland LTCHs based on the national average total CCRs of all IPPS hospitals because we believe that the average of the CCRs of all the IPPS hospitals across the country that were audited by fiscal intermediaries would be based on sufficient rigorous complete data that would be a representative proxy for the ratio of costs-to-charges of LTCHs in Maryland that are subject to LTCH PPS. (We note that, under our proposal, the fiscal intermediary may assign the statewide average CCR in one of three circumstances (that is, ``new'' LTCHs, as defined above; LTCHs with a CCR that is in excess of the LTCH ceiling; and LTCHs with unavailable data, as discussed above)).

However, we are soliciting comments or suggestions for an alternative proxy statewide average CCR to use for LTCHs that are located in Maryland and are paid under the LTCH PPS. (3) Data Used to Determine a CCR

Similar to our current policy, we are also proposing to specify under proposed new Sec. 412.525(a)(4)(iv)(B) that, for discharges occurring on or after October 1, 2006, the CCR applied at the time a claim is processed would be based on either the most recent settled cost report or the most recent tentatively settled cost report, whichever is from the latest cost reporting period. Furthermore, we are proposing under proposed new Sec. 412.525(a)(4)(iv)(A) to state that CMS may specify an alternative to the CCR computed under proposed new Sec. 412.525(a)(4)(iv)(B); that is, the CCR computed from the most recent settled cost report or the most recent tentatively settled cost report, whichever is later, or a hospital may also request that the fiscal intermediary use a different (higher or lower) CCR based on substantial evidence presented by the hospital. These proposed revisions to our policy for determining a LTCH's CCR for discharges occurring on or after October 1, 2006, under proposed revised new Sec. 412.525(a)(4)(iv)(A) and (B) are similar to our existing policy established in the June 9, 2003 IPPS high-cost outlier final rule (68 FR 34506 through 34513). In addition, we are proposing a technical correction to existing Sec. 412.525(a)(3) to change the plural reference from cost-to-charge ``ratios'' to the singular reference to a cost-to-charge ``ratio'' because, under the LTCH PPS, a single (total) CCR is computed for LTCHs. (4) Reconciliation of High-Cost Outlier Payments Upon Cost Report Settlement

In the June 9, 2003 high-cost outlier final rule (68 FR 34508 through 34512), we established a policy for LTCHs that provided that, effective for LTCH PPS discharges occurring on or after August 8, 2003, any reconciliation of outlier payments will be based upon the actual CCR computed from the costs and charges incurred in the period during which the discharge occurs. In that same final rule, we also established that, for discharges occurring on or after August 8, 2003, at the time of any reconciliation, outlier payments may be adjusted to account for the time value of any underpayments or overpayments based upon a widely available index to be established in advance by the Secretary and will be applied from the midpoint of the cost reporting period to the date of reconciliation. These changes regarding the reconciliation of outlier payments under the LTCH PPS were made in conjunction with the changes regarding the determination of LTCHs' CCRs that we established under Sec. 412.525(a)(4) in the June 9, 2003 IPPS high-cost outlier final rule, as discussed in greater detail in section IV.D.3.b. of this preamble. (We note that the instructions for implementing these regulations under both the IPPS and the LTCH PPS are discussed in further detail in Program Transmittal A-03-058. Additional information on the administration of the reconciliation process under the IPPS is provided in Program Transmittal 707 (Change Request 3966, October 12, 2005). We note that, in addition to the proposed changes to the high-cost outlier and short-stay outlier policies presented in this proposed rule, we are currently developing additional instructions on the administration of the existing reconciliation process under the LTCH PPS that would be similar to the IPPS reconciliation process.)

As discussed above, we are proposing, for discharges occurring on or after October 1, 2006, to codify into the LTCH PPS section of the regulations (Subpart O of 42 CFR Part 412) the provisions governing the determination of LTCHs' CCRs, including proposed modifications and editorial clarifications to our existing methodology for determining the annual LTCH CCR ceiling and applicable statewide average CCRs under the LTCH PPS.

In this proposed rule, under the broad authority of section 123 of the BBRA and section 307(b)(1) of BIPA, we are also proposing to revise Sec. 412.525(a)(4), for discharges occurring on or after October 1, 2006, to codify in Subpart O of 42 CFR Part 412 the provisions discussed above concerning the reconciliation of LTCH PPS outlier payments, including proposed editorial clarifications discussed in greater detail below in this section, that would more precisely describe the application of those policies. We are proposing the additional revisions to Sec. 412.525(a)(4) concerning the reconciliation of outlier payments, which are discussed in greater detail below in this section, because these proposed changes would be consistent with the proposed changes to the calculation of the LTCH CCR ceiling discussed above.

Specifically, at proposed new Sec. 412.525(a)(4)(iv)(D), similar to our current policy, we are proposing to specify that, for discharges occurring on or after October 1, 2006, any reconciliation of outlier payments would be based on the CCR calculated based on a ratio of costs to charges computed from the relevant cost report and charge data determined at the time the cost report coinciding with the discharge is settled. In addition, at proposed new Sec. 412.525(a)(4)(iv)(E), similar to our current policy, we are proposing to specify that, for discharges occurring on or after October 1, 2006, at the time of any reconciliation, outlier payments may be adjusted to account for the time value of any underpayments or overpayments. Consistent with our current policy, we also are proposing that such an adjustment would be based upon a widely available index to be established in advance by the Secretary and would be applied from the midpoint of the cost reporting period to the date of reconciliation.

We are proposing to make these additions to Sec. 412.525(a)(4) because we believe that such proposed changes reinforce the concept that the LTCH PPS has a single payment rate for inpatient operating and capital-related costs (as discussed in greater detail previously), and because we believe it would be more appropriate and administratively simpler to include all of the regulatory provisions concerning the determination of LTCH PPS outlier payments applicable under the LTCH

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PPS regulations in Subpart O of 42 CFR Part 412. c. Short-Stay Outliers (1) Background

When we implemented the LTCH PPS, under Sec. 412.529, we established a special payment policy for short-stay outlier cases, that is, LTCH PPS cases with a length of stay that is less than or equal to five-sixths of the geometric average length of stay for each LTC-DRG. As noted previously, generally LTCHs are defined by statute as having an average length of stay of greater than 25 days. We believe that a short-stay outlier payment adjustment results in more appropriate payments, because these cases most likely would not receive a full course of a LTCH-level of treatment in such a short period of time and a full LTC-DRG payment may not always be appropriate. Under the existing short-stay outlier policy at Sec. 412.529, for LTCH PPS discharges with a length of stay of up to and including five-sixths the geometric average length of stay for the LTC-DRG, in general, we adjust the per discharge payment under the LTCH PPS by the least of 120 percent of the estimated cost of the case, 120 percent of the LTC-DRG specific per diem amount multiplied by the length of stay of that discharge, or the full LTC-DRG payment. (We note we have proposed changes to this general payment formula in the RY 2007 LTCH PPS proposed rule (71 FR 4679).) Consistent with the LTCH PPS high-cost outlier policy, we calculate the estimated cost of a case by multiplying the overall hospital CCR by the Medicare allowable covered charge. (2) Determination of LTCH CCRs and Reconciliation

In the June 9, 2003 IPPS outlier final rule (68 FR 34507), we revised the short-stay policy at Sec. 412.529 (and the high-cost outlier policy at Sec. 412.525(a)) because, as we discussed above in this section, we believed that the short-stay outlier (and high-cost outlier) policy are susceptible to the same payment vulnerabilities that became evident under the IPPS and, therefore, merited revision. Therefore, in the regulations under existing Sec. 412.529(c)(5)(ii) and (iii), we established a policy for the determination of LTCH CCRs and the reconciliation of short-stay outlier payments, for discharges occurring on or after August 8, 2003 (Sec. 412.529(c)(5)(ii)) and October 1, 2003 (Sec. 412.529(c)(5)(iii)), respectively. (As noted above in this section, in that same final rule, we established the same changes to the high-cost outlier policy at existing Sec. 412.525(a)(4)(ii) and (iii).)

As we discuss above in this section, we are proposing to revise the existing regulations at Sec. 412.525(a)(4) to codify in Subpart O of 42 CFR Part 412 the provisions governing the determination of LTCHs' CCRs, including proposed modifications and editorial clarifications to our existing methodology for determining the annual LTCH CCR ceiling and applicable statewide average CCRs under the LTCH PPS, and the provisions governing the reconciliation of high-cost outlier payments.

We are proposing these changes, as we discuss in greater detail below in this section, because we believe that such proposed changes would be more consistent with the LTCH PPS single payment rate, and because we believe it would be more appropriate and administratively simpler to include the regulatory provisions that pertain only to LTCHs for the determination of LTCH PPS outlier payments applicable under the LTCH PPS regulations in Subpart O of 42 CFR Part 412 (as opposed to Subpart A). Because CCRs are also used in determining short-stay outlier payments under Sec. 412.529, we are proposing, under the broad authority of section 123 of the BBRA as amended by section 307(b)(1) of BIPA, to revise Sec. 412.529(c) consistent with the proposed changes to Sec. 412.525(a)(4) discussed above in this section.

Specifically, we are proposing in new Sec. 412.529(c)(5)(iv)(C)(2) to specify that, for discharges occurring on or after October 1, 2006, if, among other things, a LTCH's CCR is in excess of the LTCH CCR ceiling (which would be calculated as 3 standard deviations above the corresponding national geometric mean CCR (established and published annually by CMS)), the fiscal intermediary may use a statewide average CCR (also established annually by CMS). (We note that, similar to our current policy, we are also proposing under proposed Sec. Sec. 412.529(c)(5)(iv)(C)(1) and (3) that the fiscal intermediary may use a statewide average CCR in two other circumstances, which are discussed in greater detail below in this section.)

Under our current methodology for determining the LTCH CCR ceiling, we add together the separate IPPS operating CCR ceiling and IPPS capital CCR ceiling, which are determined at 3 standard deviations from the average operating CCR and average capital CCR, respectively. Under proposed Sec. 412.529(c)(5)(iv)(C)(2), for discharges occurring on or after October 1, 2006, we are proposing that we would determine the single ``total'' CCR ceiling (as we proposed under the high-cost outlier policy at proposed Sec. 412.525(a)(4)(iv)(C)(2), as explained previously in this section) by first calculating the total (that is, operating and capital) CCR for each IPPS hospital and then determining the average total CCR for all IPPS hospitals. For example, if an IPPS hospital's operating CCR is 0.432 and its capital CCR is 0.027, its total CCR would be 0.459 (0.432 + 0.027 = 0.459). This calculation would be repeated for all IPPS hospitals in order to determine a total CCR for each IPPS hospital. Next, those total CCRs would be used to determine the average total CCR. Once the average total CCR across all IPPS hospitals is determined, we would take 3 standard deviations above the corresponding national geometric mean total CCR (in the previous step) to determine the LTCH CCR ceiling. This proposed change is similar to the proposed change to the LTCH PPS high-cost outlier policy discussed previously in this section. (We note, as discussed in greater detail below in this section, in conjunction with this proposed change in the calculation of the LTCH CCR ceiling, we are also proposing a change in our methodology for calculating the applicable statewide average CCRs under the LTCH PPS to be based on ``total'' hospital- specific CCRs.)

Specifically, we are proposing under the short-stay outlier policy at proposed new Sec. 412.529(c)(5)(iv)(C) to use the same IPPS CCR data that we currently use to annually determine the separate IPPS operating CCR and capital CCR ceilings (that we add together under our current policy to determine the annual CCR ceiling for LTCHs) to compute the single LTCH ``total'' CCR ceiling based on IPPS hospital- specific total (operating and capital-related) Medicare costs and charges, as explained above in this section.

In other words, our current methodology (that is, using the ``combined'' IPPS CCR ceiling) calculates two separate IPPS CCRs (an operating CCR and a capital-related CCR) by taking 3 standard deviations from the average of all IPPS operating CCRs and 3 standard deviations from the average of all IPPS capital CCRs separately to determine the IPPS operating CCR ceiling and the IPPS capital CCR ceiling, respectively. Then we added the IPPS operating CCR ceiling and the IPPS capital CCR ceiling together to get a ``combined'' LTCH PPS ceiling. The proposed methodology would add each IPPS hospital's operating CCR and its capital CCR together first, to get a ``total'' CCR and then take the average of all of those total

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CCRs across all IPPS hospitals to calculate a ceiling (that is, 3 standard deviations above the corresponding national geometric mean total CCR). The underlying data, upon which this calculation is based, that is, the IPPS CCRs, would remain the same.

As we explained in the RY 2007 LTCH PPS proposed rule (71 FR 4691), under this proposal, the total CCR ceiling would continue to be published annually in the IPPS proposed and final rules and, therefore, the public should continue to consult the annual IPPS proposed and final rules for changes to the applicable LTCH PPS statewide average total CCRs that would be effective for discharges occurring on or after October 1, 2006 (because, under this proposal the current applicable combined statewide average CCRs, established for discharges occurring on or after October 1, 2005 in the FY 2006 IPPS final rule, would remain in effect for discharges occurring on or before September 30, 2006.) The rationale for this proposed change to the short-stay outlier policy at proposed Sec. 412.529(c)(5)(iv)(C) mirrors the rationale provided for the proposed changes to the high-cost outlier policy at proposed Sec. 412.525(a)(4)(iv)(C) discussed above in this section.

Therefore, in this proposed rule, based on the most recent complete IPPS total CCR data from the December 2005 update of the Provider- Specific File, we are proposing a total CCR ceiling of 1.313 under the LTCH PPS that would be effective October 1, 2006. We note that this proposed ceiling was determined based on the same data used to determine to the separate proposed IPPS operating CCR ceiling (1.25) and the proposed IPPS capital CCR ceiling (0.158) discussed in section II.A.4.c. of the Addendum to this proposed rule. Furthermore, we are proposing that, if more recent data are available (that is, data from the March 2006 update of the Provider-Specific File, for example), we would use that data to determine the final total CCR ceiling under the LTCH PPS for FY 2007 using the proposed methodology described above. As noted previously in this section, the LTCH CCR ceiling determined under our current ``combined'' methodology would result in a slightly higher LTCH CCR ceiling (that is. 1.25 + 0.158 = 1.408) for FY 2007 compared to the proposed ``total'' CCR ceiling of 1.313 for FY 2007. However, we note that, based on CCRs from the December 2005 update of the Provider- Specific File, there were no LTCHs that have a CCR that is greater than the proposed ceiling of 1.313 (the highest LTCH CCR in the database of 363 LTCHs is 1.132).

Consistent with the proposed changes to Sec. Sec. 412.525(a)(4)(iv)(A) through (C), under the broad authority of section 123 of the BBRA and section 307(b)(1) of BIPA, we are also proposing at new Sec. Sec. 412.529(c)(5)(iv)(A) through (C), for discharges occurring on or after October 1, 2006, to codify in Subpart O of 42 CFR Part 412 the remaining LTCH PPS short-stay outlier policy changes concerning the determination of LTCHs' CCRs that were established in the June 9, 2003 IPPS high-cost outlier final rule (68 FR 34506 through 34513), including proposed modifications and editorial clarifications to those existing policies established in that final rule in order to more precisely describe the application of those policies as they relate to LTCHs.

Specifically, similar to our current policy and consistent with the proposed changes to the high-cost outlier policy at Sec. 412.525(a)(4) discussed previously in this section, we are proposing in Sec. 412.529(c)(5)(iv)(C) to specify that the fiscal intermediary may use a statewide average CCR, which would be established annually by CMS, if it is unable to determine an accurate CCR for a LTCH in one of the following three circumstances: (1) New LTCHs that have not yet submitted their first Medicare cost report (for this purpose, consistent with current policy, a new LTCH would be defined as an entity that has not accepted assignment of an existing hospital's provider agreement in accordance with Sec. 489.18); (2) LTCHs whose CCRs are in excess of the LTCH CCR ceiling (that is, 3 standard deviations above the corresponding national geometric mean total CCR); and (3) other LTCHs for whom data with which to calculate a CCR are not available (for example, missing or faulty data). (As noted above, other sources of data that the fiscal intermediary may consider in determining a LTCH's CCR include data from a different cost reporting period for the LTCH, data from the cost reporting period preceding the period in which the hospital began to be paid as a LTCH (that is, the period of at least 6 months that it was paid as a short-term acute care hospital), or data from other comparable LTCHs, such as other LTCHs in the same chain or in the same region. As also noted above and consistent with our current regulations, either CMS or the hospital may request the use of a different (higher or lower) CCR based on substantial evidence that such a CCR more accurately reflects the hospital's actual costs and charges. This applies to new LTCHs (as defined above) as well. For instance, CMS may determine that the applicable statewide average CCR should not be applied to hospitals that convert from acute care IPPS hospitals to LTCHs (and receive a new LTCH provider number). Rather, the cost and charge data from the IPPS hospital's cost report (even if it is for more or less than a 12-month cost reporting period) would be used to determine the LTCH's CCR.)

In addition, similar to our current practice and consistent with the proposed change to the high-cost outlier policy discussed previously in this proposed rule under Sec. 412.525(a)(4)(iv)(C), we are proposing that, under Sec. 412.529(c)(5)(iv)(C), for discharges occurring on or after October 1, 2006, we would annually establish statewide average ``total'' CCRs for use under the LTCH PPS based on IPPS data by first calculating the total (that is, operating and capital) CCR for each hospital and then determining the weighted average total CCR for all hospitals in each State rather than assigning the combined (operating and capital) statewide weighted average CCRs, as we do under our current policy. Specifically, in proposing to compute statewide average total CCRs, we would use the same IPPS CCR data that we currently use to annually establish the separate IPPS operating statewide average CCRs and capital statewide CCRs (that we add together under our current policy to determine the applicable ``combined'' statewide average CCR for LTCHs) to compute statewide average total CCRs as explained above in this section.

To summarize, our current methodology (that is, using the ``combined'' IPPS operating and capital statewide average CCRs) calculates two separate IPPS average CCRs for each State (an operating statewide average CCR (one average CCR for urban areas and another average CCR for rural areas) and a capital statewide average (for all areas within each State)) by taking the weighted average of all IPPS operating CCRs in each State (for urban areas and for rural areas separately) and the weighted average of all IPPS capital CCRs in each State (for all areas), and then adding the two averages together for the particular State to get a ``combined'' statewide average CCR (one for urban areas and one for rural areas). The proposed methodology would add each IPPS hospital's operating CCR and its capital CCR together first, and then takes the weighted average of all of those total CCRs for all urban IPPS hospitals in the State to get the urban statewide average CCR and for all rural IPPS hospitals in the State to get the rural statewide average CCR. This process is repeated for each State

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(except Maryland, as discussed below). The underlying data, that is, the IPPS CCRs, would remain the same. In this proposed rule, based on the most recent complete IPPS total CCR data from the December 2005 update of the Provider-Specific File, the proposed LTCH PPS statewide average CCRs that would be effective October 1, 2006 are presented in Table 8C of the Addendum to this proposed rule. (We note that, as is the case under the IPPS, all areas in the District of Columbia, New Jersey, Puerto Rico, and Rhode Island are classified as urban, and therefore, there are no proposed rural statewide average total CCRs listed for those jurisdictions in Table 8C of the Addendum to this proposed rule. We also note that, as is the case under the IPPS, although Massachusetts has areas that are designated as rural, there are no short-term acute care IPPS hospitals or LTCHs located in those areas as of March 2006, and therefore, there is no proposed rural statewide average total CCR listed for rural Massachusetts in Table 8C of the Addendum of this proposed rule.)

Furthermore, as stated above, we are proposing that, if more recent data are available (that is, data from the March 2006 update of the Provider-Specific File, for example), we would use those data to determine the final LTCH PPS statewide average CCRs for FY 2007 using the proposed methodology described above.

As we also noted above, we are proposing to determine the urban and rural statewide average total CCRs for Maryland LTCHs paid under the LTCH PPS using, as a proxy, the national average total CCR for urban IPPS hospitals and the national average total CCR for rural IPPS hospitals, respectively. We are proposing this proxy because we believe that the CCR data on the Provider-Specific File for Maryland hospitals may not be accurate. As discussed in greater detail above, we believe that the CCR data in the Provider-Specific File based on Maryland short-term acute care hospitals' cost report and charge data may not be reliable because acute care hospitals in Maryland are waived from Medicare's ratesetting methodologies for inpatient and outpatient services under the authorities of sections 1814(b)(3) and 1833(a)(2) of the Act. The State's HSCRC is the regulatory body that establishes hospital-specific rates for all hospital services in Maryland. Because Maryland hospitals are paid based on the hospitals-specific rates set by HSCRC rather than under the IPPS, CCRs are not required to determine their Medicare payments (as they are for other acute care hospitals that are not governed under the waiver in sections 1814(b)(3) and 1833(a)(2) of the Act, and who are reimbursed for their treatment of Medicare patients under the IPPS). Therefore, as discussed above, CCRs in the Provider-Specific File for Maryland acute care hospitals, for the most part, are missing or unaudited (because they are not used for making payments).

Thus, we believe it would be more appropriate to establish statewide average total CCRs for Maryland LTCHs based on a national average total CCRs of IPPS hospitals that were audited by fiscal intermediaries. We are proposing to establish statewide average total CCRs for Maryland based on the national average total CCRs of all IPPS hospitals because we believe that the average of the CCRs of all of the IPPS hospitals across the country that were audited by fiscal intermediaries would be based on sufficient rigorous complete data that would be a representative proxy for the ratio of costs to charges of LTCHs located in Maryland that are subject to the LTCH PPS. (We note, that under our proposal, the fiscal intermediary may assign the statewide average CCR in one of three circumstances (that is, ``new'' LTCHs, as defined above; LTCHs with a CCR that is in excess of the LTCH CCR ceiling; and LTCHs with unavailable data, as discussed above).) However, we are soliciting comments on suggestions for an alternative proxy statewide average CCR to use for LTCHs that are located in Maryland that are paid under the LTCH PPS.

In addition, under this proposal, the statewide average total CCRs would continue to be published annually in the IPPS proposed and final rules and, therefore, the public would continue to consult the annual IPPS proposed and final rules for changes to the applicable LTCH PPS statewide average total CCRs that would be effective for discharges occurring on or after October 1, 2006 (because, under this proposal, the current applicable combined statewide average CCRs, established for discharges occurring on or after October 1, 2005, in the FY 2006 IPPS final rule, would remain in effect for discharges occurring on or before September 30, 2006). Our rationale for this proposed change to the short-stay outlier policy at proposed Sec. 412.529(c)(5)(iv)(C) mirrors the rationale provided for the proposed changes to the high- cost outlier policy at proposed Sec. 412.525(a)(4)(iv)(C) discussed in greater detail above in this section.

We also are proposing under Sec. 412.529(c)(5)(iv)(B), similar to our current policy and consistent with the proposed change to the high- cost outlier policy discussed above, for discharges occurring on or after October 1, 2006, that the CCR applied at the time a claim is processed would be based on either the most recent settled cost report or the most recent tentative settled cost report, whichever is from the latest cost reporting period. We are proposing under Sec. 412.529(c)(5)(iv)(A) that CMS may specify an alternative to the CCR computed from the most recent settled cost report or the most recent tentative settled cost report, whichever is later, or a hospital may also request that its fiscal intermediary use a different (higher or lower) CCR based on substantial evidence presented by the hospital. As noted previously in this proposed rule, these proposed revisions to our policy for determining a LTCH's CCR for discharges occurring on or after October 1, 2006, under proposed revised Sec. 412.529(c)(5)(iv)(A) and (B) are similar to our existing policy established in the June 9, 2003 IPPS high-cost outlier final rule (68 FR 34506 through 34513) and consistent with the proposed changes to the high-cost outlier policy previously discussed in this proposed rule.

Furthermore, similar to our current policy and consistent with the proposed change to the high-cost outlier policy discussed previously in this section, under the broad authority under section 123 of the BBRA as amended by section 307(b) of BIPA, we are also proposing under Sec. 412.529(c)(5)(iv), for discharges occurring on or after October 1, 2006, to codify in the LTCH PPS regulations (Subpart O of 42 CFR Part 412) the outlier reconciliation provisions that were established in the June 9, 2003 IPPS high-cost outlier final rule (68 FR 34506 through 34513), including proposed editorial clarifications to those provisions (which are the same as the proposed changes to the high-cost outlier policy discussed above in this section).

Specifically, under proposed Sec. 412.529(c)(5)(iv)(D), similar to our current policy and consistent with the proposed change to the high- cost outlier policy, we are proposing to specify that, for discharges occurring on or after October 1, 2006, any reconciliation of outlier payments would be based on the CCR calculated based on a ratio of costs to charges computed from the relevant cost report and charge data determined at the time the cost report coinciding with the discharge is settled. In addition, at proposed Sec. 412.529(c)(5)(iv)(E), similar to our current policy and consistent with the proposed change to the high-cost outlier policy, we are proposing to specify that, for discharges occurring on or after October 1, 2006, at the time of any reconciliation, outlier payments may be

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adjusted to account for the time value of any underpayments or overpayments. This adjustment would be based upon a widely available index that would be established in advance by the Secretary and would be applied from the midpoint of the cost reporting period to the date of reconciliation. Our rationale for these proposed changes to the short-stay outlier policy at proposed Sec. 412.529(c)(5)(iv)(D) and (E) mirrors the rationale provided for the proposed changes to the high-cost outlier policy at proposed Sec. 412.525(a)(4)(iv)(D) and (E), discussed in greater detail above in this section. 7. Technical Corrections Relating to LTCHs

We are proposing to make the following technical changes to various sections of the regulations relating to LTCHs to update or correct cross-references or to include inadvertently omitted provisions:

a. In the following sections, we are proposing to correct several incorrect cross-references in the existing regulations:

In Sec. 412.505(b)(1), changing the cross-reference ``Sec. 412.22(e) and (h)(5)'' to the phrase ``Sec. 412.22(e)(3) and (h)(6), if applicable''.

In Sec. 412.508(c)(3), changing the cross-reference ``Sec. 1001.301'' to ``Sec. 1001.201.''

In Sec. 412.541(b)(2)(i), changing the cross-reference ``Sec. 412.533(b)'' to ``Sec. 412.533(a)(5) and Sec. 412.533(c)'' to correctly refer to the provisions on the determination of the LTCH PPS rates.

b. We are proposing to revise Sec. 412.511 to change the cross- reference ``Sec. 412.22(e) and (h)(5)'' to the phrase ``Sec. 412.22(e)(3) and (h)(6)'' and to clarify the requirement that LTCHs must meet under Sec. Sec. 412.22(e)(3) and (h)(6) to report co- location status as part of its overall reporting requirements.

c. We are proposing to revise Sec. 412.525(d) by adding new paragraphs (d)(3) and (d)(4) to specify two additional payment adjustments to the per discharge payments under the LTCH PPS that were inadvertently omitted; that is, the special payment under the onsite transfer and readmission policy at Sec. 412.532 and the special payment provisions for LTCH HwHs and satellites of LTCHs at Sec. 412.534.

d. We are proposing to revise Sec. 412.532(a)(2) to correct the cross-reference to the definition of a satellite facility by changing ``Sec. 412.22(f)'' to ``Sec. 412.22(h)''. In addition, we are proposing to revise paragraph (b) of Sec. 412.532 to include satellite facilities and SNFs as part of the definition of entities that may be ``co-located'' or ``onsite'' with a hospital. In existing Sec. 412.532, (a)(2) and (a)(3), we include satellite facilities and SNFs, respectively, within the onsite provider payment policy as entities that may be co-located with a LTCH, but omitted to mention them in Sec. 412.533(b) as being included when we defined ``co-located or onsite'' facilities. We are proposing to conform Sec. 412.532(b) to include their mention. 8. Proposed Cross-Reference Correction in Authority Citations for 42 CFR Parts 412 and 413

As stated earlier, on November 15, 2004, we published in the Federal Register the final rule establishing a PPS for IPFs (69 FR 66922). As a part of that rule, we amended the authority citations for 42 CFR parts 412 and 413 to include references to section 124 of Public Law 106-113. Section 124 directed us to take various actions regarding a per diem PPS for IPFs. We included incorrect cross-references to the United States Statutes at Large citation for this provision. We are proposing to amend the authority citations for parts 412 and 413 by removing the incorrect cross-reference to ``113 Stat. 1515'' and inserting the correct cross-reference ``113 Stat. 1501A-332''.

B. Critical Access Hospitals (CAHs)

(If you choose to comment on this section, please include the caption ``CAHs'' 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 under 42 CFR part 485, Subpart F, will be certified as CAHs by CMS. Regulations governing payments to CAHs for services to Medicare beneficiaries are located in 42 CFR part 413. 2. Sunset of Designation of CAHs as Necessary Providers: Technical Correction

Under section 1820(c)(2)(B)(i) of the Act, a CAH is required to be located more than a 35-mile drive (or in the case of mountainous terrain or only 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. Section 405(h) of Public Law 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. As a result of this amendment, as of January 1, 2006, States are no longer able to designate CAH status based upon a determination that an entity is a necessary provider of health care. However, section 405(h) of Public Law 108-173 also included a grandfathering provision for CAHs that are certified as necessary providers prior to January 1, 2006. Under this provision, a CAH that is designated as a necessary provider in its State's rural health plan prior to January 1, 2006, is permitted to maintain its necessary provider designation.

The regulations that specify the location requirements for CAHs described above are set forth at 42 CFR 485.610(c). To implement the amendment made by section 405(h) of Public Law 108-173, we published a final rule in the Federal Register on August 11, 2004 (69 FR 49271) to revise the regulations under paragraph (c) of Sec. 485.610. In that revision, we inadvertently included an erroneous date: In the second sentence of paragraph (c), we stated that a CAH that is designated as a necessary provider as of October 1, 2006, will maintain its necessary provider designation after October 1, 2006. Although a correction notice was published in the Federal Register on October 7, 2004 (69 FR 60252), the notice corrected only the second citation of the date in that paragraph. As a result, the second sentence of Sec. 485.610(c) continues to state, incorrectly, that a CAH that is designated as a necessary provider as of October 1, 2006, will maintain its necessary provider designation as of January 1, 2006.

To avoid further confusion, and to ensure that the regulations implementing the CAH location requirement under section 1820(c)(2)(B)(i)(II) of the Act specify that requirement accurately, we are proposing to revise the second sentence of Sec. 485.610(c) to state that a CAH that was designated as a necessary provider on or before December 31, 2005, will maintain its necessary provider designation as of January 1, 2006. We note that this change would merely correct the previous error and does not reflect any change in our policy as to how the statutory provision is implemented.

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VII. Payment for Services Furnished Outside the United States

(If you choose to comment on this section, please include the caption ``Services Outside the United States'' at the beginning of your comment.)

A. Background

Section 1862(a)(4) of the Act generally prohibits payment under Medicare for items and services furnished outside the United States. Under sections 1861(x) and 210(i) of the Act, ``United States'' is defined to include the 50 States, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, and America Samoa. Furthermore, under Public Law 94-241, ``those laws which provide Federal services and financial assistance programs'' apply to the Northern Mariana Islands to the same extent as they do to Guam. In addition, we have interpreted the term ``United States'' as including U.S. territorial waters. We consider shipboard services furnished in a port of the United States or within 6 hours before arrival at, or departure from, a port of the United States to be furnished in the United States territorial waters. (54 FR 41723) Therefore, in our regulations at Sec. 411.9(a), we define the United States to include the 50 States, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, the Northern Mariana Islands, and for purposes of services furnished on board ship, the territorial waters adjoining the land areas of the United States. This general prohibition has exceptions, under which payment may be made for inpatient hospital services, emergency inpatient hospital services, and for physician and ambulance services associated with these hospital services that are furnished outside the United States.

Payment may be made for inpatient hospital services if a Medicare beneficiary who is a United States resident received these services at a hospital located outside of the United States that either was closer to, or was substantially more accessible from, the beneficiary's residence than the nearest United States hospital that was adequately equipped and available to treat the beneficiary. Payment may be made for emergency inpatient hospital services if a beneficiary was in the United States (or in Canada while traveling between Alaska and another State without unreasonable delay and by the most direct route) when the emergency arose, and the hospital located outside the United States was closer to, or substantially more accessible from, the place where the emergency arose than the nearest available adequately equipped hospital within the United States. Payment may be made for physician and ambulance services furnished in connection with these inpatient and emergency inpatient hospital services. Our existing regulations that implement these statutory provisions are located at 42 CFR 409.3, 409.5, 410.14, 410.66, 411.9, 413.74 and Subparts G and H of Part 424.

B. Proposed Clarification of Regulations

Services that fall under these exceptions typically are furnished in Canada or Mexico. However, in accordance with section 1814(f) of the Act and the definition of the term ``United States'' (42 CFR 411.9(a)), it is permissible for Medicare to pay for services furnished in foreign countries other than Canada and Mexico. For example, if a Medicare beneficiary who is in Guam needed emergency inpatient hospital services and the nearest available hospital adequately equipped to treat that beneficiary was located in the Philippines, Medicare payment would be permitted for the services.

Several of our existing regulations (Sec. Sec. 409.3, 409.5, 410.66, and 413.74) specifically refer to services furnished in Canada and Mexico and do not indicate that it is permissible for Medicare payment to be made for services furnished in other foreign countries. The references in these sections also are more limited than the provisions of 42 CFR part 424, subpart H, the portion of our regulations that addresses treatment furnished in a foreign country. Therefore, we are proposing to amend those regulations that refer to Canada and Mexico in order to conform them to the Act and to our other regulations addressing these situations.

We also are proposing to make some related technical changes. In Sec. Sec. 409.3(e) and 424.123(c)(2), we are proposing to change the references from the Joint Commission on Accreditation of Hospitals (JCAH) to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the current name of that organization. In Sec. 424.121(c), we are proposing to change the obsolete cross-reference from Sec. 405.313 to the correct cross-reference, Sec. 411.9.

VIII. Payment for Blood Clotting Factor Administered to Inpatients With Hemophilia

(If you choose to comment on the issues in this section, please add 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 inpatients with hemophilia from the definition of ``operating costs of inpatient hospital services.'' Section 6011(b) of Pub. L. 101-239 states that the Secretary of Health and Human Services shall determine the payment amount made to hospitals under Medicare Part A 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 factors furnished to hospital inpatients and for payment for the furnishing fee are located in Sec. Sec. 412.2(f)(8) and 412.115(b).

In FY 2005, we made payments for blood clotting factors furnished to inpatients at 95 percent of average wholesale price (AWP), consistent with the rates then paid under section 1842(o) of the Act for Medicare Part B drugs (including blood clotting factor furnished to beneficiaries who are not inpatients).

Section 303 of Pub. L. 108-173 added section 1847A to the Act. Effective January 1, 2005, this section 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), while section 1842(o)(5) of the Act provides for a Medicare Part B payment of a furnishing fee for blood clotting factor. On November 15, 2004, we published regulations in the Federal Register (69 FR 66310 through 66319) that implemented the provisions of section 1847A of the Act. These regulations are codified at Subpart K of Part 414 and Sec. 410.63, respectively.

The furnishing fee is updated each calendar year as specified by section 1842(o)(5) of the Act. The furnishing fee for clotting factor for years after CY 2005 is equal to the fee for the previous year increased by the percentage increase in the consumer price index (CPI) for medical care for the 12-month period ending with June of the previous year. This requirement is set forth in our regulations at Sec. 410.63.

In the FY 2006 IPPS final rule (70 FR 47473), we amended our regulations at Sec. Sec. 412.2(f)(8) and 412.115(b) to state that, for discharges occurring on or after October 1, 2005, we make payment for blood clotting factor administered to hospital inpatients using the Medicare Part B payment amounts for blood clotting factor as determined under subpart K of 42 CFR part 414 and for the furnishing fee as determined under Sec. 410.63.

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On November 21, 2005, we issued regulations in the Federal Register (70 FR 70225) updating the furnishing fee payment amount for CY 2006. We announced that the increase in the CPI for medical care for the 12 months ending June 30, 2005 was 4.2 percent. Consequently, the furnishing fee for CY 2006, initially established effective January 1, 2005, at $0.14 per unit of clotting factor, for CY 2006 was set at $0.146 per individual unit (I.U.) for blood clotting factor. We indicated in the preamble to that rule that while ``the furnishing fee payment rate is calculated at 3 digits, the actual amount paid to providers and suppliers is rounded to 2 digits.''

The fiscal intermediaries continue to use the Medicare Part B Drug Pricing File to make payments for blood clotting factor. The furnishing fee is included in the ASP price per unit sent with the Medicare Part B Drug Pricing File that is updated annually. By using the Medicare Part B Drug Pricing File, Medicare will be making consistent payments for blood clotting factor provided to inpatients and outpatients. For further updates on pricing, we refer readers to the Medicare Part B drug pricing regulations.

IX. Limitation on Payments to Skilled Nursing Facilities for Bad Debt

A. Background

Under section 1861(v)(1) of the Act and Sec. 413.89 of our existing regulations, Medicare may pay for uncollectible deductible and coinsurance amounts to those entities eligible to receive payment for bad debt. Under our existing regulations, Medicare generally pays 100 percent of allowable bad debt amounts to SNFs, CAHs, rural health clinics, federally qualified health clinics, community mental health clinics, health maintenance organizations reimbursed on a cost basis, competitive medical plans, and health care prepayment plans. To determine if bad debt amounts are allowable, the requirements at Sec. 413.89 and the Provider Reimbursement Manual (PRM) (CMS Pub.15 Part 1, Chapter 3) must be met.

However, under our existing regulations, Medicare payments for allowable bad debt amounts for hospitals are reduced by 30 percent. Moreover, Medicare does not pay for bad debt amounts arising from anesthetists' services paid under a fee schedule. In addition, although Medicare pays end-stage renal disease (ESRD) facilities 100 percent of allowable bad debt claims, these payments are capped at facilities' unrecovered cost (Sec. 413.178 of the regulations).

B. Changes Made by Section 5004 of Pub. L. 109-171

Section 5004 of Pub. L. 109-171 (DRA of 2005) amended section 1861(v)(1) of the Act to mandate that, for cost reporting periods beginning on or after October 1, 2005, Medicare payments to SNFs for certain allowable bad debt amounts be reduced. Specifically, for patients that are not full-benefit dual eligible individuals (as defined in section 1935(c)(6)(A)(ii) of the Act), allowable bad debt amounts attributable to the coinsurance amounts under the Medicare program are reduced by 30 percent (deductibles are not applicable to patients in SNFs). Allowable bad debt amounts for patients that are full-benefit dual eligible individuals (as defined in section 1935(c)(6)(A)(ii) of the Act) will continue to be paid at 100 percent.

C. Proposed Regulation Changes

We are proposing to conform the Medicare regulations under Sec. 413.89 to the provisions of section 5004 of Pub. L. 109-171. Specifically, we are proposing to revise paragraph (h) by redesignating the existing contents as paragraph (h)(1) and add a new paragraph (h)(2) to reflect this payment limitation. We are proposing to include in proposed paragraph (h)(2) a cross-reference to the definition of ``full-benefit dual eligible individual'' found at Sec. 423.772 of our regulations. In addition, we are proposing to revise Sec. 413.89(a) to add a cross-reference to the existing limitations on payments to hospitals and the new limitations on payments to SNFs found in paragraph (h), and to correct the cross-reference to the exception for payments for bad debts arising from anesthetists' services paid under a fee schedule from ``paragraph (h)'' to ``paragraph (i).''

X. MedPAC Recommendations

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

We are required by section 1886(e)(4)(B) of the Act to respond to MedPAC's IPPS recommendations in our annual proposed IPPS rule. We have reviewed MedPAC's March 2006 ``Report to the Congress: Medicare Payment Policy'' and have given it careful consideration in conjunction with the proposed policies set forth in this document. MedPAC's Recommendation 2A states that ``The Congress should increase payment rates for the acute inpatient and outpatient prospective payment systems in 2007 by the projected increase in the hospital market basket index less half of the Commission's expectation for productivity growth.'' This recommendation is discussed in Appendix B to this proposed rule.

In section II.C. of the preamble of this proposed rule, we further address MedPac's 2005 recommendations included in Recommendation 1 in the March 2005 Report to Congress on Physician-Owned Specialty Hospitals as well as Recommendation 3, which recommended that the Secretary implement MedPAC's recommended policies over a transition period. The recommendations in Recommendation 1 relate to refining the DRGs used under the IPPS to more fully capture differences in severity of illness among patients; basing the DRG relative weights on the estimated cost of providing care rather than on charges; and basing the weights on the national average of hospitals' relative values in each DRG. In section II.E. of the preamble to this proposed rule, we also further address Recommendation 2 of the March 2005 Report on Physician- Owned Specialty Hospitals, which recommended adjusting the DRG relative weights to account for differences in the prevalence of high-cost outlier cases.

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.

XI. 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.

[[Page 24138]]

1. CMS Wage Data

This file contains the hospital hours and salaries for FY 2003 used to create the proposed FY 2007 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.

Processing year

Wage data year

PPS fiscal year

2006

2003

2007 2005

2002

2006 2004

2001

2005 2003

2000

2004 2002

1999

2003 2001

1998

2002 2000

1997

2001 1999

1996

2000 1998

1995

1999 1997

1994

1998 1996

1993

1997 1995

1992

1996 1994

1991

1995 1993

1990

1994 1992

1989

1993 1991

1988

1992

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 2007 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 2007 PPS Update 3. FY 2007 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 2007 PPS Update 4. FY 2007 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 2007 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 2007 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 2007 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 2007 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

Periods beginning and before on or after

PPS-IV........................................ 10/01/86 10/01/87 PPS-V......................................... 10/01/87 10/01/88 PPS-VI........................................ 10/01/88 10/01/89 PPS-VII....................................... 10/01/89 10/01/90 PPS-VIII...................................... 10/01/90 10/01/91 PPS-IX........................................ 10/01/91 10/01/92 PPS-X......................................... 10/01/92 10/01/93 PPS-XI........................................ 10/01/93 10/01/94 PPS-XII....................................... 10/01/94 10/01/95

(Note: The PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS- XVIII, PPS-XIX PPS-XX, and PPS-XXI Minimum Data Sets are part of the PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS-XVIII, PPS-XIX, PPS-XX, and PPS-XXI Hospital Data Set Files (refer to item 10 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 a 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

File Cost: $770.00 per year

Periods beginning and before on or after

PPS-IX........................................ 10/01/91 10/01/92 PPS-X......................................... 10/01/92 10/01/93 PPS-XI........................................ 10/01/93 10/01/94 PPS-XII....................................... 10/01/94 10/01/95

(Note: The PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS- XVIII, PPS-XIX PPS-XX, and PPS-XXI Capital Data Sets are part of the PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS-XVIII, PPS-XIX, PPS XX, and PPS-XXI Hospital Data Set Files (refer to item 10 below).)

10. PPS-XIII to PPS-XXI Hospital Data Set

The file contains cost, statistical, financial, and other data from the Medicare Hospital Cost Report. The data set includes only the most current cost report (as submitted, final settled, or reopened) submitted for a Medicare-certified hospital by the Medicare fiscal intermediary to CMS. The data set is updated at the end of each calendar quarter and is available on the last day of the following month.

Media: Diskette/Internet

File Cost: $2,500.00

Periods beginning and before on or after

PPS-XIII...................................... 10/01/95 10/01/96 PPS-XIV....................................... 10/01/96 10/01/97 PPS-XV........................................ 10/01/97 10/01/98 PPS-XVI....................................... 10/01/98 10/01/99 PPS-XVII...................................... 10/01/99 10/01/00 PPS-XVIII..................................... 10/01/00 10/01/01 PPS-XIX....................................... 10/01/01 10/01/02 PPS-XX........................................ 10/01/02 10/01/03 PPS-XXI....................................... 10/01/03 10/01/04

[[Page 24139]]

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 2007 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 2007 13. DRG Relative Weights (Formerly Table 5 DRG)

This file contains a listing of DRGs, DRG narrative descriptions, relative weights, and geometric and arithmetic mean lengths of stay as published in the Federal Register. 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 2007 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 2007 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 refer to statistical outliers, not payment outliers.)

Two versions of this file are created each year. They support the following:

NPRM published in the Federal Register.

Final rule published in the Federal Register.

Media: Diskette/Internet

File Cost: $165.00

Periods Available: FY 2007 PPS Update 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 2007 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 fairly evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) of the PRA requires that we solicit comment on the following issues:

The need for the information collection and its usefulness in carrying out the proper functions of our agency.

The accuracy of our estimate of the information collection burden.

The quality, utility, and clarity of the information to be collected.

Recommendations to minimize the information collection burden on the affected public, including automated collection techniques.

The following information collection requirements included in this proposed rule and their associated burdens are subject to the PRA.

We are soliciting public comment on each of the issues for the following sections of this document that contain information collection requirements.

Section 412.64--Reporting of Hospital Quality Data for Annual Hospital Payment Update

Section 412.64(d)(2) requires hospitals, in order to qualify for the full annual market basket update, to submit quality data on a quarterly basis to CMS, as specified by CMS. In this proposed rule, we are setting out the specific requirements related to the data that must be submitted for the update for FY 2007.

The burden associated with this section is the time and effort associated with collecting, copying and submitting the 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

[[Page 24140]]

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 respondents will vary according to the level of voluntary participation. One hundred percent of the data may be collected electronically.

Our validation process requires participating hospitals to submit 5 charts per quarter. The burden associated with this requirement is the time and effort associated with collecting, copying, and submitting these charts. It will take approximately 2 hours per hospital to submit the 5 charts per quarter. There will be a total of approximately 19,000 charts (3,800 hospitals x 5 charts per hospital) submitted by the hospitals to CMS per quarter for a total burden of 7,600 hours per quarter and a total annual burden of 30,400 hours.

The burden associated with the requirements under Sec. 412.64 are currently approved under OMB Number 0938-0918. OMB approval will expire on December 31, 2008.

Proposed Revised Sec. 412.92(b)(3) Special Treatment: Sole Community Hospitals

Proposed revised Sec. 412.92(b)(3) would require an approved SCH to notify the appropriate CMS Regional Office of any change which would affect its classification as an SCH.

The burden associated with this requirement is the time and effort it would take for the SCH to provide such notification to the CMS Regional Office. We estimate that on an annual basis it would take an SCH 1 hour to provide notification. While this requirement is subject to the PRA, we believe the requirement is exempt because it impacts less than 10 SCHs.

Proposed Revised Sec. 412.108(b)(4) Special Treatment: Medicare- Dependent, Small Rural Hospitals

Proposed revised Sec. 412.108(b)(4) would require an approved MDH to notify the appropriate CMS Regional Office of any change which would affect its status as an MDH.

The burden associated with this requirement is the time and effort it would take for the MDH to provide such notification to the CMS Regional Office. We estimate that on an annual basis it would take an MDH 1 hour to provide notification. While this requirement is subject to the PRA, we believe the requirement is exempt because it impacts less than 10 MDHs.

If you comment on these 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, Regulations Development Group, Attn.: Melissa Musutto, CMS-1488-P. Room C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850; and Office of Information and Regulatory Affairs, Office of Management and Budget Room 10235, New Executive Office Building, Washington, DC 20503, Attn.: Carolyn Lovett, CMS Desk Officer, CMS-1488-P, carolyn_lovett@omb.eop.gov. Fax (202) 395-5167.

C. Public Comments

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

XII. Regulation Text

List of Subjects

42 CFR Part 409

Health Facilities, Medicare.

42 CFR Part 410

Health facilities, Health professions, Kidney diseases, Laboratories, Medicare, Rural areas, 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 424

Emergency medical services, Health facilities, Health professions, Medicare.

42 CFR Part 485

Grant programs-health, Health facilities, Medicaid, Medicare, Reporting and recordkeeping requirements.

42 CFR Part 489

Health facilities, Medicare, Reporting and recordkeeping requirements.

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

PART 409--HOSPITAL INSURANCE BENEFITS

1. The authority citation for part 409 continues to read as follows:

Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).

2. Section 409.3 is amended by revising paragraph (e) under the definition of ``Qualified hospital'' to read as follows:

Sec. 409.3 Definitions.

* * * * *

Qualified hospital means a facility that--* * *

(e) If it is a foreign hospital, is licensed, or approved as meeting the standard for licensing, by the appropriate foreign licensing agency, and for purposes of furnishing nonemergency services to U.S. residents, is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), or by a foreign program under standards that CMS finds to be equivalent to those of JCAHO.

3. Section 409.5 is revised to read as follows:

Sec. 409.5 General description of benefits.

Hospital insurance (Part A of Medicare) helps pay for inpatient hospital or inpatient CAH services and posthospital SNF care. It also pays for home health services and hospice care. There are limitations on the number of days of care that Medicare can pay for and there are deductible and coinsurance amounts for which the beneficiary is responsible. For each type of service, certain conditions must be met as specified in the pertinent sections of this subpart and in part 418 of this chapter regarding hospice care. Conditions for payment of emergency inpatient services furnished by a nonparticipating U.S. hospital and for services furnished in a foreign country are set forth in subparts G and H of part 424 of this chapter.

PART 410--SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS

4. The authority citation for part 410 continues to read as follows:

Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).

[[Page 24141]]

5. Section 410.66 is revised to read as follows:

Sec. 410.66 Emergency outpatient services furnished by a nonparticipating hospital and services furnished in a foreign country.

Conditions for payment of emergency inpatient services furnished by a nonparticipating U.S. hospital and for services furnished in a foreign country are set forth in subparts G and H of part 424 of this chapter.

PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES

6. The authority citation for part 412 is revised to read as follows:

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

7. Section 412.22 is amended by--

a. Revising the introductory text of paragraph (f).

b. Adding a new paragraph (f)(3).

c. Revising paragraph (h)(1).

d. In paragraph (h)(2), removing the phrase ``(h)(3), (h)(6), and (h)(7) of this section'' and adding the phrase ``(h)(3), (h)(7), and (h)(8) of this section'' in its place.

e. Revising the introductory text of paragraph (h)(3).

f. Revising paragraph (h)(4).

g. Redesignating paragraphs (h)(5), (h)(6), and (h)(7) as paragraphs (h)(6), (h)(7), and (h)(8), respectively.

h. Adding a new paragraph (h)(5).

The revisions and addition read as follows:

Sec. 412.22 Excluded hospitals and hospital units: General rules.

* * * * *

(f) Application for certain hospitals. Except as provided in paragraph (f)(3) of this section, if a hospital was excluded from the prospective payment systems under the provisions of this section on or before September 30, 1995, and at that time occupied space in a building also used by another hospital, or in one or more buildings located on the same campus as buildings used by another hospital, the criteria in paragraph (e) of this section do not apply to the hospital as long as the hospital-- * * * * *

(3) For cost reporting periods beginning on or after October 1, 2006, in applying the provisions of paragraph (f)(1) or (f)(2) of this section, any hospital that was excluded from the prospective payment systems under the provisions of this section on or before September 30, 1995, and at that time occupied space in a building also used by another hospital, or in one or more buildings located on the same campus as buildings used by another hospital--

(i) May decrease its square footage or number of beds, or both, without affecting the provisions of paragraph (f)(1) or (f)(2) of this section;

(ii) May increase or decrease the square footage or decrease the number of beds considered to be part of the hospital at any time, if these changes are made necessary by relocation of the hospital--

(A) To permit construction or renovation necessary for compliance with changes in Federal, State, or local law affecting the physical facility; or

(B) Because of catastrophic events such as fires, floods, earthquakes, or tornadoes. * * * * *

(h) Satellite facilities. (1) For purposes of paragraphs (h)(2) through (h)(5) of this section, a satellite facility is a part of a hospital that provides inpatient services in a building also used by another hospital, or in one or more entire buildings located on the same campus as buildings used by another hospital. * * * * *

(3) Except as provided in paragraphs (h)(4) and (h)(5) of this section, the provisions of paragraph (h)(2) of this section do not apply to-- * * * * *

(4) In applying the provisions of paragraph (h)(3) of this section, any hospital structured as a satellite facility on September 30, 1999, may increase or decrease the square footage of the satellite facility or may decrease the number of beds in the satellite facility considered to be part of the satellite facility at any time, if these changes are made necessary by relocation of a facility --

(i) To permit construction or renovation necessary for compliance with changes in Federal, State, or local law affecting the physical facility; or

(ii) Because of catastrophic events such as fires, floods, earthquakes, or tornadoes.

(5) For cost reporting periods beginning on or after October 1, 2006, in applying the provisions of paragraph (h)(3) of this section, a satellite facility may decrease its number of beds or square footage, or both, without affecting the provisions of paragraph (h)(3) of this section. * * * * *

8. Section 412.25 is amended by--

a. In paragraph (e)(2), removing the cross-reference ``(e)(5)'' and adding the cross-reference ``(e)(6)'' in its place.

b. Revising paragraph (e)(3).

c. Redesignating paragraph (e)(5) as paragraph (e)(6).

d. Adding a new paragraph (e)(5).

The revision and addition read as follows:

Sec. 412.25 Excluded hospital units: Common requirements.

* * * * *

(e) * * *

(3) Except as specified in paragraphs (e)(4) and (e)(5) of this section, the provisions of paragraph (e)(2) of this section do not apply to any unit structured as a satellite facility on September 30, 1999, and excluded from the prospective payment systems on that date, to the extent the unit continues operating under the same terms and conditions, including the number of beds and square footage considered to be part of the unit, in effect on September 30, 1999. * * * * *

(5) For cost reporting periods beginning on or after October 1, 2006, in applying the provisions of paragraph (e)(3) of this section, a satellite facility may decrease its number of beds or square footage, or both, without affecting the provision of paragraph (e)(3) of this section. * * * * *

Sec. 412.42 [Amended]

9. In paragraph (d) of Sec. 412.42, the cross-reference ``Sec. 405.310(k)'' is removed, and the cross-reference ``Sec. 411.15(k)'' is added in its place.

Sec. 412.48 [Amended]

10. In paragraph (b) of Sec. 412.48, the cross-reference ``Sec. Sec. 405.330 through 405.332'' is removed and the cross- reference ``Sec. 411.400 and Sec. 411.402'' is added in its place.

11. Section 412.64 is amended by--

a. Revising paragraph (d)(2).

b. Adding a new paragraph (h)(6).

The revision and addition read as follows:

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

* * * * *

(d) * * *

(2)(i) In the case of a ``subsection (d) hospital,'' as defined under section 1886(d)(1)(B) of the Act, that does not submit quality data on a quarterly basis to CMS, in the form and manner specified by CMS, the applicable percentage change specified in paragraph (d)(1) of this section is reduced:

(A) For fiscal years 2005 and 2006, by 0.4 percentage points; and

[[Page 24142]]

(B) For fiscal year 2007 and subsequent fiscal years, by 2.0 percentage points.

(ii) Any reduction of the percentage change will apply only to the fiscal year involved and will not be taken into account in computing the applicable percentage change for a subsequent fiscal year. * * * * *

(h) * * *

(6) If a new rural hospital that is subject to the hospital inpatient prospective payment system opens in a State that has an imputed rural floor and has rural areas, CMS uses the imputed floor as the hospital's wage index until the hospital's first cost report as an inpatient prospective payment system provider is contemporaneous with the cost reporting period being used to develop a given fiscal year's wage index. * * * * *

12. A new Sec. 412.79 is added to Subpart E to read as follows:

Sec. 412.79 Determination of the hospital-specific rate for inpatient operating costs for Medicare-dependent, small rural hospitals based on a Federal fiscal year 2002 base period.

(a) Base-period costs--(1) General rule. Except as provided in paragraph (a)(2) of this section, for each MDH, the intermediary determines the MDH's Medicare Part A allowable inpatient operating costs, as described in Sec. 412.2(c), for the 12-month or longer cost reporting period ending on or after October 1, 2001, and before October 1, 2002.

(2) Exceptions. (i) If the MDH's last cost reporting period ending before October 1, 2002, is for less than 12 months, the base period is the MDH's most recent 12-month or longer cost reporting period ending before that short cost reporting period.

(ii) If the MDH does not have a cost reporting period ending on or after October 1, 2001, and before October 1, 2002, and does have a cost reporting period beginning on or after October 1, 2000, and before October 1, 2001, that cost reporting period is the base period unless the cost reporting is for less than 12 months. In that case, the base period is the MDH's most recent 12-month or longer cost reporting period ending before that short cost reporting period.

(b) Costs on a per discharge basis. The intermediary determines the MDH's average base-period operating cost per discharge by dividing the total operating costs by the number of discharges in the base period. For purposes of this section, a transfer as described in Sec. 412.4(b) is considered to be a discharge.

(c) Case-mix adjustment. The intermediary divides the average base- period cost per discharge by the MDH's case-mix index for the base period.

(d) Updating base period costs. For purposes of determining the updated base-period costs for cost reporting periods beginning in Federal fiscal year 2002, the update factor is determined using the methodology set forth in Sec. 412.73(c)(14) and (c)(15).

(e) DRG adjustment. The applicable hospital-specific cost per discharge is multiplied by the appropriate DRG weighting factor to determine the hospital-specific base payment amount (target amount) for a particular covered discharge.

(f) Notice of hospital-specific rate. The intermediary furnishes the MDH a notice of its hospital-specific rate which contains a statement of the hospital's Medicare Part A allowable inpatient operating costs, number of Medicare discharges, and case-mix index adjustment factor used to determine the hospital's cost per discharge for the Federal fiscal year 2002 base period.

(g) Right to administrative and judicial review. An intermediary's determination of the hospital-specific rate for a hospital is subject to administrative and judicial review. Review is available to an MDH upon receipt of the notice of the hospital-specific rate. The notice is treated as a final intermediary determination of the amount of program reimbursement for purposes of subpart R of Part 405 of this chapter, governing provider reimbursement determinations and appeals.

(h) Modification of hospital-specific rate. (1) The intermediary recalculates the hospital-specific rate to reflect the following:

(i) Any modifications that are determined as a result of administrative or judicial review of the hospital-specific rate determinations; or

(ii) Any additional costs that are recognized as allowable costs for the MDH's base period as a result of administrative or judicial review of the base-period notice of amount of program reimbursement.

(2) With respect to either the hospital-specific rate determination or the amount of program reimbursement determination, the actions taken on administrative or judicial review that provide a basis for recalculations of the hospital-specific rate include the following:

(i) A reopening and revision of the MDH's base-period notice of amount of program reimbursement under Sec. Sec. 405.1885 through 405.1889 of this chapter.

(ii) A prehearing order or finding issued during the provider payment appeals process by the appropriate reviewing authority under Sec. 405.1821 or Sec. 405.1853 of this chapter that resolved a matter at issue in the MDH's base-period notice of amount of program reimbursement.

(iii) An affirmation, modification, or reversal of a Provider Reimbursement Review Board decision by the Administrator of CMS under Sec. 405.1875 of this chapter that resolved a matter at issue in the hospital's base-period notice of amount of program reimbursement.

(iv) An administrative or judicial review decision under Sec. Sec. 405.1831, 405.1871, or 405.1877 of this chapter that is final and no longer subject to review under applicable law or regulations by a higher reviewing authority, and that resolved a matter at issue in the hospital's base-period notice of amount of program reimbursement.

(v) A final, nonappealable court judgment relating to the base- period costs.

(3) The adjustments to the hospital-specific rate made under paragraphs (h)(1) and (2) of this section are effective retroactively to the time of the intermediary's initial determination of the rate.

(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.

Sec. 412.84 [Amended]

13. In paragraph (m) of Sec. 412.84, the cross-reference ``paragraph (h)(3)'' is removed and the cross-reference ``paragraph (i)(4)'' is added in its place.

14. Section 412.90 is amended by revising paragraph (j) to read as follows:

Sec. 412.90 General rules.

* * * * *

(j) Medicare-dependent, small rural hospitals. For cost reporting periods beginning on or after April 1, 1990, and before October 1, 1994, and for discharges occurring on or after October 1, 1997, and before October 1, 2011, CMS adjusts the prospective payment rates for inpatient operating costs determined under subparts D and E of this part if a hospital is classified as a Medicare-dependent, small rural hospital. * * * * *

15. Section 412.92 is amended by--

[[Page 24143]]

a. In paragraph (b)(2)(iv) of Sec. 412.92, the word ``djustment'' is removed and the word ``adjustment'' is added in its place.

b. Revising paragraph (b)(3) to read as follows:

Sec. 412.92 Special treatment: Sole community hospitals.

* * * * *

(b) * * *

(3) Duration of classification. An approved classification as a sole community hospital remains in effect without need for reapproval unless there is a change in the circumstances under which the classification was approved. An approved sole community hospital must notify the appropriate CMS regional office of any change that would affect its classification as a sole community hospital. If CMS determines that a sole community hospital failed to comply with this requirement, CMS will cancel the hospital's classification as a sole community hospital effective on the earliest discernable date that the fiscal intermediary can determine that the hospital no longer met the criteria for such classification. * * * * *

Sec. 412.105 [Amended]

16. In paragraph (f)(1)(ii)(C) of Sec. 412.105, the cross- reference ``Sec. 413.78(c) or Sec. 413.78(d)'' is removed and the cross-reference ``Sec. 413.78(c), Sec. 413.78(d), or Sec. 413.78(e)'' is added in its place.

17. Section 412.106 is amended by--

a. Revising paragraph (a)(1)(iii).

b. Republishing the introductory text of paragraph (d)(2)(iv).

c. Revising paragraph (d)(2)(iv)(C)(3).

d. Adding a new paragraph (d)(2)(iv)(D).

e. Adding a new paragraph (d)(2)(v).

The revision and additions read as follows:

Sec. 412.106 Special treatment: Hospitals that serve a disproportionate share of low-income patients.

(a) * * *

(1) * * *

(iii) The hospital's location, in an urban or rural area, is determined in accordance with the definitions in Sec. 412.64, except that a reclassification that results from an urban hospital reclassified as rural as set forth in Sec. 412.103 is classified as rural. * * * * *

(d) * * *

(2) * * *

(iv) If the hospital meets the criteria of paragraph (c)(1)(iv) of this section-- * * * * *

(C) * * *

(3) Except as provided in paragraph (d)(2)(iv)(D) of this section, the maximum payment adjustment factor is 12 percent.

(D) Effective for discharges occurring on or after October 1, 2006, for a hospital that is classified as a Medicare-dependent, small rural hospital under Sec. 412.108, the payment adjustment factor limitation specified in paragraph (d)(2)(iv)(C)(3) does not apply.

(v) If the hospital meets the criteria of paragraph (c)(2) of this section, the payment adjustment factor is as follows:

(A) 30 percent for discharges occurring on or after April 1, 1990, and before October 1, 1991.

(B) 35 percent for discharges occurring on or after October 1, 1991. * * * * *

18. Section 412.108 is amended by--

a. Revising paragraph (a)(1) introductory text.

b. Revising paragraph (b)(4).

c. Adding a new paragraph (c)(2)(iii).

The revisions and addition read as follows:

Sec. 412.108 Special Treatment: Medicare-dependent, small rural hospitals.

(a) Criteria for classification as a Medicare-dependent, small rural hospital.--(1) General considerations. For cost reporting periods beginning on or after April 1, 1990, and ending before October 1, 1994, or for discharges occurring on or after October 1, 1997, and before October 1, 2011, a hospital is classified as a Medicare-dependent, small rural hospital if it is located in a rural area (as defined in subpart D of this part) and meets all of the following conditions: * * * * *

(b) * * *

(4) A determination of MDH status made by the fiscal intermediary is effective 30 days after the date the fiscal intermediary provides written notification to the hospital. An approved MDH status determination remains in effect unless there is a change in the circumstances under which the status was approved. An approved MDH must notify the appropriate CMS regional office of any change that would affect its status as an MDH. If CMS determines that an MDH failed to comply with this requirement, CMS will cancel the hospital's MDH status effective on the earliest discernable date that the fiscal intermediary can determine that the hospital no longer met the criteria for such status. * * * * *

(c) * * *

(2) * * *

(iii) For discharges occurring during cost reporting periods (or portions thereof) beginning on or after October 1, 2006, and before October 1, 2011, 75 percent of the amount that the Federal rate determined under paragraph (c)(1) of this section is exceeded by the highest of the following:

(A) The hospital-specific rate as determined under Sec. 412.73.

(B) The hospital-specific rate as determined under Sec. 412.75.

(C) The hospital-specific rate as determined under Sec. 412.79. * * * * *

19. Section 412.234 is amended by--

a. In paragraph (a)(3)(ii), removing the term ``fiscal year'' and adding the term ``Federal fiscal year'' in its place.

b. Revising paragraph (a)(3)(iii).

c. Adding a new paragraph (a)(3)(iv).

The revisions and addition read 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, hospitals located in counties that are in the same Combined Statistical Area (CSA) (under the MSA definitions announced by the OMB on June 6, 2003) as the urban area to which they seek redesignation qualify as meeting the proximity requirement for reclassification to the urban area to which they seek redesignation.

(iv) For Federal fiscal year 2008 and thereafter, hospitals located in counties that are in the same Combined Statistical Area (CSA) or Core-Based Statistical Area (CBSA) (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 requirements for reclassification to the urban area to which they seek redesignation. * * * * *

20. Section 412.316 is amended by--

a. Revising paragraph (a).

b. Revising paragraph (b)(2).

c. Adding a new paragraph (b)(3).

d. Revising paragraph (c).

The revisions and addition read as follows:

Sec. 412.316 Geographic adjustment factors.

(a) Local cost variation. CMS adjusts for local cost variation based on the hospital wage index value that is applicable to the hospital under subpart D of this part. The adjustment factor equals the hospital wage index value applicable to the hospital raised to the .6848 power and is applied to 100 percent of the Federal rate.

[[Page 24144]]

(b) * * *

(2) For discharges occurring on or after October 1, 2004, the definition of large urban area under Sec. 412.63(c)(6) continues to be in effect for purposes of the payment adjustment under this section, based on the geographic classification under Sec. 412.64, except as provided for in paragraph (b)(3) of this section.

(3) For purposes of this section, the geographic classifications specified under Sec. 412.64 apply, except that, effective for discharges occurring on or after October 1, 2006, for an urban hospital that is reclassified as rural as set forth in Sec. 412.103, the geographic classification is rural.

(c) Cost-of-living adjustment. CMS provides an additional payment to a hospital located in Alaska and Hawaii equal to [0.3152 x (the cost-of-living adjustment factor used to determine payments under subpart D of this part-1)] percent.

21. Section 412.320 is amended by--

a. Revising paragraph (a)(1)(ii).

b. Adding a new paragraph (a)(1)(iii).

The revision and addition read as follows:

Sec. 412.320 Disproportionate share adjustment factor.

(a) * * *

(1) * * *

(ii) For discharges occurring on or after October 1, 2004, the payment adjustment under this section is based on the geographic classifications specified under Sec. 412.64, except as provided for in paragraph (a)(1)(iii) of this section.

(iii) For purposes of this section, the geographic classifications specified under Sec. 412.64 apply, except that, effective for discharges occurring on or after October 1, 2006, for an urban hospital that is reclassified as rural as set forth in Sec. 412.103, the geographic classification is rural. * * * * *

22. Section 412.505 is amended by revising paragraph (b)(1) to read as follows:

Sec. 412.505 Conditions for payment under the prospective payment system for long-term care hospitals.

* * * * *

(b) General requirements. (1) Effective for cost reporting periods beginning on or after October 1, 2002, a long-term care hospital must meet the conditions for payment of this section, Sec. 412.22(e)(3) and (h)(6), if applicable, and Sec. 412.507 through Sec. 412.511 to receive payment under the prospective payment system described in this subpart for inpatient hospital services furnished to Medicare beneficiaries. * * * * *

Sec. 412.508 [Amended]

23. In paragraph (c)(3) of Sec. 412.508, the cross-reference ``Sec. 1001.301'' is removed and the cross-reference ``1001.201'' is added in its place.

24. Section 412.511 is revised to read as follows:

Sec. 412.511 Reporting and recordkeeping requirements.

A long-term care hospital participating in the prospective payment system under this subpart must meet the requirement of Sec. Sec. 412.22(e)(3) and 412.22(h)(6) to report co-located status, if applicable, and the recordkeeping and cost reporting requirements of Sec. Sec. 413.20 and 413.24 of this subchapter.

25. Section 412.525 is amended by--

a. Revising paragraph (a)(3).

b. Revising paragraph (a)(4)(ii).

c. Revising paragraph (a)(4)(iii).

d. Adding a new paragraph (a)(4)(iv).

e. Adding a new paragraph (d)(3).

f. Adding a new paragraph (d)(4).

The revisions and additions read as follows:

Sec. 412.525 Adjustments to the Federal prospective payment.

(a) * * *

(3) The additional payment equals 80 percent of the difference between the estimated cost of the patient's care (determined by multiplying the hospital-specific cost-to-charge ratio by the Medicare allowable covered charge) and the sum of the adjusted LTCH PPS Federal prospective payment and the fixed-loss amount.

(4) * * *

(ii) For discharges occurring on or after August 8, 2003, and before October 1, 2006, high-cost outlier payments are subject to the provisions of Sec. 412.84(i)(1), (i)(3), and (i)(4) and (m) for adjustments of cost-to-charge ratios.

(iii) For discharges occurring on or after October 1, 2003, and before October 1, 2006, high-cost outlier payments are subject to the provisions of Sec. 412.84(i)(2) for adjustments to cost-to-charge ratios.

(iv) For discharges occurring on or after October 1, 2006, high- cost outlier payments are subject to the following provisions:

(A) CMS may specify an alternative to the cost-to-charge ratio otherwise applicable under paragraph (a)(4)(iv)(B) of this section. A hospital may also request that its fiscal intermediary use a different (higher or lower) cost-to-charge ratio based on substantial evidence presented by the hospital. A request must be approved by the CMS Regional Office.

(B) The cost-to-charge ratio applied at the time a claim is processed is based on either the most recent settled cost report or the most recent tentatively settled cost report, whichever is from the latest cost reporting period.

(C) The fiscal intermediary may use a statewide average cost-to- charge ratio, which CMS establishes annually, if it is unable to determine an accurate cost-to-charge ratio for a hospital in one of the following circumstances:

(1) A new hospital that has not yet submitted its first Medicare cost report. (For this purpose, a new hospital is defined as an entity that has not accepted assignment of an existing hospital's provider agreement in accordance with Sec. 489.18 of this chapter.)

(2) A hospital whose cost-to-charge ratio is in excess of 3 standard deviations above the corresponding national geometric mean cost to charge ratio. CMS establishes and publishes this mean annually.

(3) Any other hospital for which data to calculate a cost-to-charge ratio are not available.

(D) Any reconciliation of outlier payments is based on the cost-to- charge ratio calculated based on a ratio of costs to charges computed from the relevant cost report and charge data determined at the time the cost report coinciding with the discharge is settled.

(E) At the time of any reconciliation under paragraph (a)(4)(iv)(D) of this section, outlier payments may be adjusted to account for the time value of any underpayments or overpayments. Any adjustment is based upon a widely available index to be established in advance by the Secretary, and is applied from the midpoint of the cost reporting period to the date of reconciliation. * * * * *

(d) * * *

(3) Patients who are transferred to onsite providers and readmitted to a long-term care hospital, as provided for in Sec. 412.532.

(4) Long-term care hospitals-within-hospitals and satellites of long-term care hospitals as provided in Sec. 412.534.

26. Section 412.529 is amended by revising paragraph (c)(5) to read as follows:

Sec. 412.529 Special payment provision for short-stay outliers.

* * * * *

(c) * * *

(5)(i) For discharges occurring on or after October 1, 2002, and before August 8, 2003, no reconciliations are made to

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

[[pp. 24145-24194]] Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2007 Rates

[[Continued from page 24144]]

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short-stay outlier payments upon cost report settlement to account for differences between cost-to-charge ratio and the actual cost-to-charge ratio of the case.

(ii) For discharges occurring on or after August 8, 2003, and before October 1, 2006, short-stay outlier payments are subject to the provisions of Sec. 412.84(i)(1), (i)(3), and (i)(4) and (m) for adjustments of cost-to-charge ratios.

(iii) For discharges occurring on or after October 1, 2003, and before October 1, 2006, short-stay outlier payments are subject to the provisions of Sec. 412.84(i)(2) for adjustments to cost-to-charge ratios.

(iv) For discharges occurring on or after October 1, 2006, short- stay outlier payments are subject to the following provisions:

(A) CMS may specify an alternative to the cost-to-charge ratio otherwise applicable under paragraph (c)(5)(iv)(B) of this section. A hospital may also request that its fiscal intermediary use a different (higher or lower) cost-to-charge ratio based on substantial evidence presented by the hospital. This request must be approved by the CMS Regional Office.

(B) The cost-to-charge ratio applied at the time a claim is processed is based on either the most recent settled cost report or the most recent tentatively settled cost report, whichever is from the latest cost reporting period.

(C) The fiscal intermediary may use a statewide average cost-to- charge ratio, which CMS establishes annually, if it is unable to determine an accurate cost-to-charge ratio for a hospital in one of the following circumstances:

(1) A new hospital that has not yet submitted its first Medicare cost report. (For this purpose, a new hospital is defined as an entity that has not accepted assignment of an existing hospital's provider agreement in accordance with Sec. 489.18 of this chapter.)

(2) A hospital whose cost-to-charge ratio is in excess of 3 standard deviations above the corresponding national geometric mean. CMS establishes and publishes this mean annually.

(3) Any other hospital for which data to calculate a cost-to-charge ratio are not available.

(D) Any reconciliation of outlier payments is based on the cost-to- charge ratio calculated based on a ratio of costs to charges computed from the relevant cost report and charge data determined at the time the cost report coinciding with the discharge is settled.

(E) At the time of any reconciliation under paragraph (c)(5)(iv)(D) of this section, outlier payments may be adjusted to account for the time value of any underpayments or overpayments. Any adjustment is based upon a widely available index to be established in advance by the Secretary, and is applied from the midpoint of the cost reporting period to the date of reconciliation.

27. Section 412.532 is amended by--

a. Revising paragraph (a)(2).

b. Revising paragraph (b).

The revisions read as follows:

Sec. 412.532 Special payment provisions for patients who are transferred to onsite providers and readmitted to a long-term care hospital.

(a) * * *

(2) A satellite facility, as defined in Sec. 412.22(h), that is co-located with the long-term care hospital. * * * * *

(b) As used in this section, ``co-located'' or ``onsite'' facility means a hospital, satellite facility, unit, or SNF that occupies space in a building also used by another hospital or unit or in one or more buildings on the same campus, as defined in Sec. 413.65(a)(2) of this subchapter, as buildings used by another hospital or unit. * * * * *

Sec. 412.541 [Amended]

28. In Sec. 412.541, paragraph (b)(2)(i), remove the cross- reference ``Sec. 412.533(b)'' and add in its place ``Sec. 412.533(a)(5) and Sec. 412.533(c)''.

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

29. The authority citation for part 413 is revised to read as follows:

Authority: Secs. 1102, 1812(d), 1814(b), 1815, 1833(a), (i), and (n), 1861(v), 1871, 1881, 1883, and 1886 of the Social Security Act (42 U.S.C. 1302, 1395d(d), 1395f(b), 1395g, 1395l(a), (i), and (n), 1395x(v), 1395hh, 1395rr, 1395tt, and 1395ww); and sec. 124 of Pub. L. 106-133 (113 Stat. 1501A-332).

30. Section 413.74 is amended by revising paragraph (a) to read as follows:

Sec. 413.74 Payment to a foreign hospital.

(a) Principle. Section 1814(f) of the Act provides for the payment of emergency and nonemergency inpatient hospitals services furnished by foreign hospitals to Medicare beneficiaries. Subpart H of part 424 of this chapter, together with this section, specifies the conditions for payment. * * * * *

31. Section 413.75 is amended by--

a. In paragraph (b), revising paragraph (1) under the definition of ``Medicare GME affiliated group''. b. In paragraph (b), removing the cross-reference ``Sec. 413.79(g)(2)'' under paragraph (2) of the definition of ``Medicare GME affiliated group'' and adding the cross-reference ``Sec. 413.79(f)(2)'' in its place.

c. In paragraph (b), removing the cross-reference ``Sec. 413.79(g)(2)'' under paragraph (3) of the definition of ``Medicare GME affiliated group'' and adding the cross-reference ``Sec. 413.79(f)(2)'' in its place.

The revision reads 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) or in a contiguous area and meet the rotation requirements in Sec. 413.79(f)(2). * * * * *

32. Section 413.77 is amended by revising paragraphs (e)(1) introductory text and (e)(1)(i) to read as follows:

Sec. 413.77 Direct GME payments: Determination of per resident amounts.

* * * * *

(e) Exceptions--(1) Base period for certain hospitals. If a hospital did not have any approved medical residency training programs or did not participate in Medicare during the base period, but either condition changes in a cost reporting period beginning on or after July 1, 1985, the fiscal intermediary establishes a per resident amount for the hospital using the information from the first cost reporting period during which the hospital participates in Medicare and the residents are on duty during the first month of that period. Effective for cost reporting periods beginning on or after October 1, 2006, if a hospital did not have any approved medical residency training programs or did not participate in Medicare during the base period, but either condition changes in a cost reporting period beginning on or after October 1, 2006, and the residents are not on duty during the first month of that period, the fiscal intermediary establishes a per resident amount for the hospital using the information from the first cost reporting period immediately following the cost reporting period during which the hospital participates in Medicare and residents began training at the hospital. The per resident

[[Page 24146]]

amount is based on the lower of the amount specified in paragraph (e)(1)(i) or paragraph (e)(1)(ii) of this section, subject to the provisions of paragraph (e)(1)(iii) of this section. Any GME costs incurred by the hospital during the cost reporting period prior to the base period used for calculating the PRA are reimbursed on a reasonable cost basis.

(i) The hospital's actual cost per resident incurred in connection with the GME program(s) based on the cost and resident data from the hospital's base year cost reporting period as established in paragraph (e)(1) of this section. * * * * *

33. Section 413.79 is amended by--

a. Revising paragraph (e)(1)(iv).

b. In the introductory text of paragraph (f), removing the cross- reference ``paragraph (e)(3) of this section'' and adding the cross- reference ``paragraph (d) of this section'' in its place.

The revision reads as follows:

Sec. 413.79 Direct GME payments: Determination of the weighted number of FTE residents.

* * * * *

(e) * * *

(1) * * *

(iv) Effective for affiliation agreements entered into on or after October 1, 2005, 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. * * * * *

34. Section 413.85 is amended by revising paragraph (h)(3) to read as follows:

Sec. 413.85 Costs of approved nursing and allied health education activities.

* * * * *

(h) * * *

(3) Educational seminars, workshops, and continuing education programs in which the employees or trainees participate that enhance the quality of medical care or operating efficiency of the provider and, effective October 1, 2003, do not lead to the ability to practice and begin employment in a nursing or allied health specialty. * * * * *

35. Section 413.89 is amended by--

a. Revising paragraph (a).

b. Revising paragraph (h).

The revisions read as follows:

Sec. 413.89 Bad debts, charity, and courtesy allowances.

(a) Principle. Bad debts, charity, and courtesy allowances are deductions from revenue and are not to be included in allowable cost. However, subject to the limitations described under paragraph (h) of this section and the exception for anesthetists' services described under paragraph (i) of this section, bad debts attributable to the deductibles and coinsurance amounts are reimbursable under the program. * * * * *

(h) Limitations on bad debts. (1) Hospitals. In determining reasonable costs for hospitals, the amount of bad debt otherwise treated as allowable costs (as defined in paragraph (e) of this section) is reduced by--

(i) For cost reporting periods beginning during fiscal year 1998, by 25 percent;

(ii) For cost reporting periods beginning during fiscal year 1999, by 40 percent;

(iii) For cost reporting periods beginning during fiscal year 2000, by 45 percent; and

(iv) For cost reporting periods beginning during a subsequent fiscal year, by 30 percent.

(2) Skilled nursing facilities. For cost reporting periods beginning during fiscal year 2006 or during a subsequent fiscal year, the amount of skilled nursing facility bad debts for coinsurance otherwise treated as allowable costs (as defined in paragraph (e) of this section) for services furnished to a patient who is not a full- benefit dual eligible individual (as defined in Sec. 423.772) is reduced by 30 percent. * * * * *

PART 424--CONDITIONS FOR MEDICARE PAYMENT

36. The authority citation for part 424 continues to read as follows:

Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).

Sec. 424.32 [Amended]

37. In Sec. 424.32, in paragraph (b), the phrase ``CMS-1490U- Request for Medicare Payment by Organization. (For use by an organization requesting payment for medical services.)'' is removed and the phrase ``CMS-1491-Request for Medicare Payment-Ambulance. (For use by an organization requesting payment for ambulance services.)'' is removed.

Sec. 424.121 [Amended]

38. In Sec. 424.121, paragraph (c) is amended by removing the cross-reference ``Sec. 405.313'' and adding the cross-reference ``Sec. 411.9'' in its place.

39. Section 424.123 is amended by revising paragraph (c)(2) to read as follows:

Sec. 424.123 Conditions for payment for nonemergency inpatient hospital services furnished by a hospital closer to the individual's residence.

* * * * *

(c) * * *

(2) Accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or accredited or approved by a program of the country where it is located under standards the CMS finds to be essentially equivalent to those of the JCAHO. * * * * *

PART 485--CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS

40. The authority citation for part 485 continues to read as follows:

Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).

Sec. 485.610 [Amended]

41. In paragraph (c) of Sec. 485.610, the phrase ``as of October 1, 2006'' is removed and the phrase ``on or before December 31, 2005'' is added in its place.

PART 489--PROVIDER AGREEMENTS AND SUPPLIER APPROVAL

42. The authority citation for part 489 continues to read as follows:

Authority: Secs. 1102, 1819, 1861, 1864(m), 1866, 1869, and 187l of the Social Security Act (42 U.S.C. 1302, 1395i-3, 1395x, 1395aa(m), 1395cc, 1395ff, and 1395hh).

43. Section 489.24 is amended by--

a. Revising the definition of ``Labor'' under paragraph (b).

b. Revising paragraph (f).

The revisions read as follows:

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

* * * * *

(b) * * *

Labor means the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is in true labor unless a physician, certified nurse-midwife, or other qualified medical person acting within his or her scope of practice as defined in hospital medical staff bylaws and State law, certifies that, after a reasonable time of observation, the woman is in false labor. * * * * *

[[Page 24147]]

(f) Recipient hospital responsibilities. A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at Sec. 412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. * * * * *

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

Dated: March 30, 2006. Mark B. McClellan, Administrator, Centers for Medicare & Medicaid Services.

Dated: April 10, 2006. Michael O. Leavitt, Secretary.

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

Addendum--Proposed Schedule of Standardized Amounts Effective With Discharges Occurring On or After October 1, 2006 and Update Factors and Rate-of-Increase Percentages Effective With Cost Reporting Periods Beginning On or After October 1, 2006

(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, 2006, except for SCHs, MDHs, and hospitals located in Puerto Rico, each hospital's payment per discharge under the IPPS has been based on 100 percent of the Federal national rate, which has been based on the national adjusted standardized amount. This amount reflects the national average hospital cost per case from a base year, updated for inflation.

SCHs are paid based on whichever of the following rates yields the greatest aggregate payment: the Federal national rate; the updated hospital-specific rate based on FY 1982 costs per discharge; the updated hospital-specific rate based on FY 1987 costs per discharge; or the updated hospital-specific rate based on FY 1996 costs per discharge.

Under section 1886(d)(5)(G) of the Act, MDHs were paid for FY 2006 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.) Section 5003(a)(1) of Pub. L. 109-171 extended and modified the MDH special payment provision which was previously set to expire on October 1, 2006, to discharges occurring on or after October 1, 2006, but before October 1, 2011. Under section 5003(b) of Pub. L. 109-171, if the change results in an increase to its target amount, MDHs must rebase their hospital-specific rates to their FY 2002 cost reports. In addition, under section 5003(c) of Pub. L. 109-171, MDHs will now be paid based on the Federal national rate or, if higher, the Federal national rate plus 75 percent of the difference between the Federal national rate and the updated hospital-specific rate. Further, based upon section 5003(d) of Pub. L. 109-171, MDHs will no longer be subject to the 12-percent cap on their DSH payment adjustment factor.

For hospitals in Puerto Rico, the payment per discharge is based on the sum of 25 percent of a Puerto Rico rate that reflects base year average costs per case of Puerto Rico hospitals and 75 percent of the Federal national rate. (See section II.D.3. of this Addendum for a complete description.)

As discussed below in section II. of this Addendum, we are proposing to make changes in the determination of the prospective payment rates for Medicare inpatient operating costs for FY 2007. The proposed changes, to be applied effective with discharges occurring on or after October 1, 2006, 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 2007. 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 2007. Section V. of this Addendum sets forth proposed policies on payment for blood clotting factors administered to hemophilia inpatients. 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 2007

The basic methodology for determining prospective payment rates for hospital inpatient operating costs for FY 2005 and subsequent fiscal years is set forth at Sec. 412.64. The basic methodology for determining the prospective payment rates for hospital inpatient operating costs for hospitals located in Puerto Rico for FY 2005 and subsequent fiscal years is set forth at Sec. Sec. 412.211 and 412.212. Below we discuss the factors used for determining the prospective payment rates.

In summary, the proposed standardized amounts set forth in Tables 1A, 1B, 1C, and 1D of section VI. of this Addendum reflect--

Equalization of the standardized amounts for urban and other areas at the level computed for large urban hospitals during FY 2004 and onward, as provided for under section 1886(d)(3)(A)(iv) of the Act, updated by the applicable percentage increase required under sections 1886(b)(3)(B)(i)(XX) and 1886(b)(3)(B)(viii) of the Act.

The two labor-related shares that are applicable to the standardized amounts and Puerto Rico-specific standardized amounts, depending on whether the hospital's payments would be higher with a lower (in the case of a wage index less than or equal to 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.

Proposed updates of 3.4 percent for all areas (that is, the full market basket percentage increase of 3.4 percent), as required by section 1886(b)(3)(B)(i)(XX) of the Act, as amended by section 5001 of Pub. L. 109-171, and reflecting the requirements of section 1886(b)(3)(B)(viii) of the Act, as added by section 5001(a)(3) of Pub. L. 109-171, to reduce the applicable percentage increase by 2.0 percentage points for a hospital that fails to submit data, in a form and manner specified by the Secretary, relating to the quality of inpatient care furnished by the hospital;

An adjustment to 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 2006 budget neutrality factor and applying a revised factor;

An adjustment to apply the new outlier offset by removing the FY 2006 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

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hospital costs from a base period (section 1886(d)(2)(A) of the Act) or, for Puerto Rico, adjusted target amounts from a base period (section 1886(d)(9)(B)(i) of the Act), updated and otherwise adjusted in accordance with the provisions of section 1886(d) of the Act. The September 1, 1983 interim final rule (48 FR 39763) contained a detailed explanation of how base-year cost data (from cost reporting periods ending during FY 1981) were established in the initial development of standardized amounts for the IPPS. The September 1, 1987 final rule (52 FR 33043 and 33066) contains a detailed explanation of how the target amounts were determined, and how they are used in computing the Puerto Rico rates.

Sections 1886(d)(2)(B) and (d)(2)(C) of the Act require us to update base-year per discharge costs for FY 1984 and then standardize the cost data in order to remove the effects of certain sources of cost variations among hospitals. These effects include case-mix, differences in area wage levels, cost-of-living adjustments for Alaska and Hawaii, indirect medical education costs, and costs to hospitals serving a disproportionate share of low- income patients.

In accordance with section 1886(d)(3)(E) of the Act, the Secretary estimates, from time-to-time, the proportion of hospitals' costs that are attributable to wages and wage-related costs. The standardized amount is divided into labor-related and nonlabor- related amounts; only the proportion considered the labor-related amount is adjusted by the wage index. Section 1886(d)(3)(E) of the Act requires that 62 percent of the standardized amount be adjusted by the wage index, unless doing so would result in lower payments to a hospital than would otherwise be made. (Section 1886(d)(9)(C)(iv)(II) of the Act extends this provision to the labor-related share for hospitals located in Puerto Rico.)

For FY 2007, we are proposing not to adjust the national and Puerto Rico-specific labor-related and nonlabor-related share from the percentages established in FY 2006. Accordingly, we are proposing to adjust 62 percent of the national standardized amount for all hospitals whose wage indexes are less than or equal to 1.0000. For all hospitals whose wage values are greater than 1.0000, we are proposing to adjust 69.7 percent of the national standardized amount by the hospitals' wage indexes. For hospitals in Puerto Rico, we are proposing to adjust 58.7 percent of the Puerto Rico-specific standardized amount for all hospitals whose Puerto Rico-specific wage indexes are less than or equal to 1.0000. For Puerto Rico hospitals whose Puerto Rico-specific wage index values are greater than 1.0000, we are proposing to adjust 62 percent of the Puerto Rico-specific standardized amount.

The proposed standardized amounts appear in Table 1A, 1B, and 1C of the Addendum to this proposed rule.

2. Computing the Average Standardized Amount

Section 1886(d)(3)(A)(iv) of the Act requires that, beginning with FY 2004 and thereafter, an equal standardized amount is to be computed for all hospitals at the level computed for large urban hospitals during FY 2003, updated by the applicable percentage update. Section 1886(d)(9)(A) of the Act equalizes the Puerto Rico- specific urban and rural area rates. Accordingly, we are using this proposed rule to provide for a single national standardized amount and a single Puerto Rico standardized amount for FY 2007.

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 2007 by the full estimated market basket percentage increase for hospitals in all areas, as specified in section 1886(b)(3)(B)(i)(XX) of the Act, as amended by section 5001(a)(1) of Pub. L. 109-171. The percentage change in the market basket reflects the average change in the price of goods and services purchased by hospitals to furnish inpatient care. The most recent forecast of the hospital market basket increase for FY 2007 is 3.4 percent. Thus, for FY 2007, the proposed update to the average standardized amount is 3.4 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)(viii) of the Act, as added by section 5001(a)(3) of Pub. L. 109-171, provides for a reduction of 2.0 percentage points to the update percentage increase (also known as the market basket update) for FY 2007 and each subsequent fiscal year for any ``subsection (d) hospital'' that does not submit quality data as discussed in section IV.A. of the preamble of this proposed rule. The proposed standardized amounts in Tables 1A through 1C of section VI. of this Addendum reflect these differential amounts.

Although the update factors for FY 2007 are set by law, we are required by section 1886(e)(4) of the Act to recommend, taking into account MedPAC's recommendations, appropriate update factors for FY 2007 for both IPPS hospitals and hospitals and hospital units excluded from the IPPS. Our recommendation on the update factors (which is required by sections 1886(e)(4)(A) and (e)(5)(A) of the Act) is set forth in Appendix B of this proposed rule.

4. Other Adjustments to the Average Standardized Amount

As in the past, we are proposing to adjust the FY 2007 standardized amount to remove the effects of the FY 2006 geographic reclassifications and outlier payments before applying the proposed FY 2007 updates. We then apply the new offsets for outliers and geographic reclassifications to the proposed standardized amount for FY 2007.

We do not remove the prior year's budget neutrality adjustments for reclassification and recalibration of the DRG weights and for updated wage data because, in accordance with sections 1886(d)(4)(C)(iii) and 1886(d)(3)(E) of the Act, estimated aggregate payments after the changes in the DRG relative weights and wage index should equal estimated aggregate payments prior to the changes. If we removed the prior year adjustment, we would not satisfy these conditions.

Budget neutrality is determined by comparing aggregate IPPS payments before and after making the changes that are required to be budget neutral (for example, 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 2007, 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 third year of this 3-year transition, we are proposing to adjust the standardized amounts for FY 2007 to ensure budget neutrality for this policy. We discuss this proposed

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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 proposed wage update budget neutrality factor. As discussed in the FY 2006 IPPS final rule (70 FR 47493), FY 2007 is the third and final 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 proposing to adjust 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 2005 discharge data to simulate payments and compared aggregate payments using the FY 2006 relative weights and wage indexes to aggregate payments using the proposed FY 2007 relative weights and wage indexes. The same methodology was used for the FY 2006 budget neutrality adjustment.

Based on this comparison, we computed a proposed budget neutrality adjustment factor equal to 0.998363. 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 0.998963. These proposed budget neutrality adjustment factors are applied to the standardized amounts without removing the effects of the FY 2006 budget neutrality adjustments. In addition, as discussed in section IV.E. of the preamble to this proposed rule, we are applying the same proposed DRG reclassification and recalibration budget neutrality factor of 0.998963 to the hospital-specific rates that are to be effective for cost reporting periods beginning on or after October 1, 2006.

Using the same data, we calculated a proposed transition budget neutrality adjustment to account for the ``hold harmless'' policy under which urban hospitals that became rural under the new labor market area definitions were assigned the wage index of the urban area in which they were located under the previous labor market area definitions for a 3-year period of FY 2005, FY 2006, and FY 2007 (see Table 2 in section VI. of this Addendum). Using the pre- reclassified wage index, we simulated payments under the new labor market area definitions and compared them to simulated payments under the ``hold harmless'' policy. Based on this comparison, we computed a proposed transition budget neutrality adjustment of 0.999591.

b. Reclassified Hospitals--Budget Neutrality Adjustment

Section 1886(d)(8)(B) of the Act provides that, effective with discharges occurring on or after October 1, 1988, certain rural hospitals are deemed urban. In addition, section 1886(d)(10) of the Act provides for the reclassification of hospitals based on determinations by the MGCRB. Under section 1886(d)(10) of the Act, a hospital may be reclassified for purposes of the wage index.

Under section 1886(d)(8)(D) of the Act, the Secretary is required to adjust the standardized amount to ensure that aggregate payments under the IPPS after implementation of the provisions of sections 1886(d)(8)(B) and (C) and 1886(d)(10) of the Act are equal to the aggregate prospective payments that would have been made absent these provisions. We note that neither the wage index reclassifications provided under section 508 of Pub. L. 108-173 nor the wage index adjustments provided under section 1886(d)(13) of the Act 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 1886(d)(13)(H) of the Act similarly provides that any increase in a wage index under section 1886(d)(13) shall not be taken into account ``in applying any budget neutrality adjustment with respect to such index'' under section 1886(d)(8)(D) of the Act. To calculate this proposed budget neutrality factor, we used FY 2005 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 0.991727 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 2006 budget neutrality adjustment factor. We note that the proposed FY 2007 adjustment reflects FY 2007 wage index reclassifications approved by the MGCRB or the Administrator, and the effects of MGCRB reclassifications approved in FY 2005 and FY 2006 (section 1886(d)(10)(D)(v) of the Act makes wage index reclassifications effective for 3 years).

c. Outliers

Section 1886(d)(5)(A) of the Act provides for payments in addition to the basic prospective payments for ``outlier'' cases involving extraordinarily high costs. To qualify for outlier payments, a case must have costs greater than the sum of the prospective payment rate for the DRG, any IME and DSH payments, any new technology add-on payments, and the ``outlier threshold'' or ``fixed loss'' amount (a dollar amount by which the costs of a case must exceed payments in order to qualify for an outlier payment). We refer to the sum of the prospective payment rate for the DRG, any IME and DSH payments, any new technology add-on payments, and the outlier threshold as the outlier ``fixed-loss cost threshold.'' To determine whether the costs of a case exceed the fixed-loss cost threshold, a hospital's cost-to-charge ratio is applied to the total covered charges for the case to convert the charges to costs. Payments for eligible cases are then made based on a marginal cost factor, which is a percentage of the costs above the fixed-loss cost threshold. The marginal cost factor for FY 2007 is 80 percent--the same marginal cost factor we have used since FY 1995 (59 FR 45367).

In accordance with section 1886(d)(5)(A)(iv) of the Act, outlier payments for any year are projected to be not less than 5 percent nor more than 6 percent of total operating DRG payments plus outlier payments. Section 1886(d)(3)(B) of the Act requires the Secretary to reduce the average standardized amount by a factor to account for the estimated proportion of total DRG payments made to outlier cases. Similarly, section 1886(d)(9)(B)(iv) of the Act requires the Secretary to reduce the average standardized amount applicable to hospitals in Puerto Rico to account for the estimated proportion of total DRG payments made to outlier cases. More information on outlier payments may be found on the CMS Web site at http://www.

cms.hhs.gov/ AcuteInpatientPPS/ 04--outlier. asp# TopOfPage.

i. Proposed FY 2007 Outlier Fixed-Loss Cost Threshold

For FY 2007, we are proposing to use the same methodology used for FY 2006 (70 FR 47493) to calculate the outlier threshold. As we have done in the past, to calculate the proposed FY 2007 outlier threshold, we simulated payments by applying proposed FY 2007 rates and policies using cases from the FY 2005 MedPAR files. Therefore, in order to determine the proposed FY 2007 outlier threshold, we are proposing to inflate the charges on the MedPAR claims by 2 years, from FY 2005 to FY 2007.

In certain years in the past, we have inflated MedPAR claims by calculating a 2-year average annual rate-of-change in charges-per- case using the charge data for the two most recent years for which we had relatively complete MedPAR data. As discussed in the FY 2006 IPPS final rule (70 FR 47494), however, we believe that charge data from FY 2003 may be distorted due to the atypically high rate of hospital charge inflation during FY 2003. Therefore, we are not proposing to inflate charges using a 2-year average annual rate-of- change from FY 2003 to FY 2004 and FY 2004 to FY 2005.

Instead, we are proposing to continue to use a refined methodology that takes into account the lower inflation in hospital charges that is occurring as a result of the outlier final rule (68 FR 34494), which changed our methodology for determining outlier payments by implementing the use of more current and accurate CCRs. Our refined methodology uses more recent data that reflects the rate-of-change in hospital charges under the new outlier policy. Specifically, we are proposing to establish the proposed FY 2007 outlier threshold as follows: Using the latest data available, we propose to calculate the 1-year average annualized rate-of-change in charges-per-case from the last quarter of FY 2004 in combination with the

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first quarter of FY 2005 (July 1, 2004 through December 31, 2004) to the last quarter of FY 2005 in combination with the first quarter of FY 2006 (July 1, 2005 through December 31, 2005). This rate of change was 7.57 percent (1.0757) or 15.15 percent (1.1515) over 2 years.

As we have done in the past, we are proposing to establish the proposed FY 2007 outlier threshold using hospital cost-to-charge ratios from the December 2005 update to the Provider-Specific File-- the most recent available at the time of this proposed rule. 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 an outlier fixed-loss cost threshold for FY 2007 equal to the prospective payment rate for the DRG, plus any IME and DSH payments, and any add-on payments for new technology, plus $25,530.

We note that the case-weighted national average cost-to-charge ratio declined by approximately 1 percent from the March 2005 to the December 2005 update of the Provider-Specific File. Hospital charges continue to increase at a steady rate of growth between 7 and 8 percent over each of the last 2 years, resulting in a decline to the cost-to-charge ratios that are used to compute the outlier threshold. Using lower cost-to-charge ratios from the December 2005 Provider-Specific File, in combination with the FY 2005 MedPAR claims and inflated charges, contributes to a higher proposed outlier threshold for FY 2007 compared to FY 2006.

As we did in establishing the FY 2006 outlier threshold (70 FR 47494), in our projection of FY 2007 outlier payments, we are not making an adjustment for the possibility that hospitals' cost-to- charge ratios and outlier payments may be reconciled upon cost report settlement. We continue to 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 will actually have these ratios reconciled upon cost report settlement. In addition, it is difficult to predict which specific hospitals will have cost-to-charge ratios and outlier payments reconciled in their cost reports in any given year. We also note that reconciliation occurs because hospitals' actual cost-to- charge ratios for the cost reporting period are different than the interim cost-to-charge ratios used to calculate outlier payments when a bill is processed. Our simulations assume that cost-to-charge ratios accurately measure hospital costs and, therefore, are more indicative of post-reconciliation than pre-reconciliation outlier payments. As a result, we are proposing to continue to omit any assumptions about the effects of reconciliation from the outlier threshold calculation.

ii. Other Changes Concerning Outliers

As stated in the FY 1994 IPPS final rule (58 FR 46348, September 1, 1993), we establish outlier thresholds that are applicable to both hospital inpatient operating costs and hospital inpatient capital-related costs. When we modeled the combined operating and capital outlier payments, we found that using a common set of thresholds resulted in a lower percentage of outlier payments for capital-related costs than for operating costs. We project that the thresholds for FY 2007 will result in outlier payments equal to 5.1 percent of operating DRG payments and 4.87 percent of capital payments based on the Federal rate.

In accordance with section 1886(d)(3)(B) of the Act, we are proposing to reduce the proposed FY 2007 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 2007 are as follows:

Operating standardized Capital Federal amounts

rate

National..........................

0.948984

0.951305 Puerto Rico.......................

0.970984

0.968473

We are proposing to apply the outlier adjustment factors to the FY 2007 rates after removing the effects of the FY 2006 outlier adjustment factors on the standardized amount.

To determine whether a case qualifies for outlier payments, we apply hospital-specific cost-to-charge ratios to the total covered charges for the case. Operating and capital costs for the case are calculated separately by applying separate operating and capital cost-to-charge ratios. These costs are then combined and compared with the outlier fixed-loss cost threshold.

The outlier final rule (68 FR 34494) eliminated the application of the statewide average cost-to-charge ratios for hospitals whose cost-to-charge ratios fall below 3 standard deviations from the national mean cost-to-charge ratio. However, for those hospitals for which the fiscal intermediary computes operating cost-to-charge ratios greater than 1.25 or capital cost-to-charge ratios greater than 0.158, 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 cost-to-charge ratios to determine whether a hospital qualifies for outlier payments.\22\ 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, 2006, these proposed statewide average ratios would replace the ratios published in the IPPS final rule for FY 2006 (70 FR 47672). 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 2007 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. For an explanation of Table 8C, please see section VI. of this Addendum.

\22\ These figures represent 3.0 standard deviations from the mean of the log distribution of cost-to-charge ratios for all hospitals.

We finally note that we published a manual update (Change Request 3966) to outliers on October 12, 2005. The manual update covered an array of topics, including cost-to-charge ratios, reconciliation, and the time value of money. To download and view the manual update, please visit http://www. cms.hhs.gov/

transmittals/downloads/R707CP.pdf.

iii. FY 2005 and FY 2006 Outlier Payments

In the FY 2006 IPPS final rule (70 FR 47496), we stated that, based on available data, we estimated that actual FY 2005 outlier payments would be approximately 4.1 percent of actual total DRG payments. This estimate was computed based on simulations using the FY 2004 MedPAR file (discharge data for FY 2004 bills). That is, the estimate of actual outlier payments did not reflect actual FY 2005 bills, but instead reflected the application of FY 2005 rates and policies to available FY 2004 bills.

Our current estimate, using available FY 2005 bills, is that actual outlier payments for FY 2005 were approximately 4.10 percent of actual total DRG payments. Thus, the data indicate that, for FY 2005, the percentage of actual outlier payments relative to actual total payments is lower than we projected before FY 2005 (and, thus, is less than the percentage by which we reduced the standardized amounts for FY 2005). We note that, for FY 2006, the outlier threshold was lowered to $23,600 compared to $25,800 for FY 2005. The outlier threshold was lower in FY 2006 than FY 2005 as a result of slower growth in hospital charge inflation following implementation of the outlier final rule that went into effect on August 9, 2003. Nevertheless, consistent with the policy and statutory interpretation we have maintained since the inception of the IPPS, we do not plan to make retroactive adjustments to outlier payments to ensure that total outlier payments for FY 2005 are equal to 5.1 percent of total DRG payments.

We currently estimate that actual outlier payments for FY 2006 will be approximately 4.71 percent of actual total DRG payments, 0.39 percentage point lower than the 5.1 percent we projected in setting the outlier

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policies for FY 2006. This estimate is based on simulations using the FY 2005 MedPAR file (discharge data for FY 2005 bills). We used these data to calculate an estimate of the actual outlier percentage for FY 2006 by applying FY 2006 rates and policies, including an outlier threshold of $23,600 to available FY 2005 bills. Even though we are estimating payments below the 5.1 percent threshold for FY 2006, our simulations using FY 2005 Medicare data show consistent levels of charge inflation and a need to increase the threshold for FY 2007 to ensure that 5.1 percent of total IPPS payments are paid as outliers. However, our current estimate of the outlier threshold for FY 2007 may change in the final rule based on updated data.

iv. Technical Changes

Subpart F of Part 412 of the existing regulations discusses payment for outlier cases and special payment for new technology. We have become aware of an inadvertent mistake in Sec. 412.84(m). Currently, Sec. 412.84(m) discusses the application of the time value of money when a hospital's outlier payments are reconciled. When referencing reconciliation, the section by mistake references paragraph (h)(3) instead of paragraph (i)(4). We are proposing to revise Sec. 412.84(m) to reference the current policy under paragraph (i)(4).

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 IV.M. 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 $1,021,985. We based this estimate on the recent historical experience of the difference between inpatient cost and payment for hospitals that are participating in the demonstration. For 9 participating hospitals, the total annual impact of the demonstration program is estimated to be $9,197,870. The required adjustment to the Federal rate used in calculating Medicare inpatient prospective payments as a result of the demonstration is 0.999905.

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 2007 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 Puerto Rico-specific amounts are shown in Table 1C. The amounts shown in Tables 1A and 1B differ only in that the labor- related share applied to the standardized amounts in Table 1A is 69.7 percent, and the labor-related share applied to the standardized amounts in Table 1B is 62 percent. In accordance with sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act, we are applying the labor-related share of 62 percent, unless the application of that percentage would result in lower payments to a hospital than would otherwise be made. The effect of this application is that the labor-related share of the standardized amount is 62 percent for all hospitals (other than those in Puerto Rico) whose wage indexes are less than or equal to 1.0000.

In addition, Tables 1A and 1B include proposed standardized amounts reflecting the full 3.4 percent proposed update for FY 2007, and proposed standardized amounts reflecting the 2.0 percentage point reduction to the proposed update (a 1.4 percent update) applicable for hospitals that fail to submit quality data consistent with section 1886(b)(3)(B)(viii) of the Act.

The following table illustrates the proposed changes from the FY 2006 national average standardized amount. The first column shows the proposed changes from the FY 2006 standardized amounts for hospitals that satisfy the quality data submission requirement for receiving the full update (3.4 percent). The second column shows the proposed changes for hospitals receiving the reduced update (1.4 percent). The first row of the table shows the proposed updated (through FY 2006) average standardized amount after restoring the FY 2006 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, we did not remove the FY 2006 budget neutrality factors for DRG reclassification and recalibration from the amounts in the table. We have added separate rows to this table to reflect the different labor-related shares that apply to hospitals.

Comparison of FY 2006 Standardized Amounts to Proposed FY 2007 Single Standardized Amount With Full Update and Reduced Update

Full update (3.4 Reduced update percent)

(1.4 percent)

FY 2006 Base Rate, after

Labor: $3,505.76.. Labor: $3,505.76. removing reclassification

Nonlabor:

Nonlabor: budget neutrality,

$1,524.03.

$1,524.03. demonstration budget neutrality, wage index transition budget neutrality factors and outlier offset (based on the proposed labor and nonlabor market share percentage for FY 2007). Proposed FY 2007 Update Factor.. 1.034............. 1.014. Proposed FY 2007 DRG

0.998363.......... 0.998363. Recalibrations and Wage Index Budget Neutrality Factor. Proposed FY 2007

0.991727.......... 0.991727. Reclassification Budget Neutrality Factor. Adjusted for Blend of FY 2006 Labor: $3,589.08.. Labor: $3,519.67. DRG Recalibration and Wage Nonlabor:

Nonlabor: Index Budget Neutrality Factors. $1,560.25.

$1,530.07. Proposed FY 2007 Outlier Factor. 0.948984.......... 0.948984. Proposed FY 2007 Labor Market 0.999591.......... 0.999591. Wage Index Transition Budget Neutrality Factor. Proposed Rural Demonstration 0.999905.......... 0.999905. Budget Neutrality Factor. Proposed Rate for FY 2007 (after Labor: $3,028.19.. Labor: $2,969.62. multiplying FY 2006 base rate Nonlabor:

Nonlabor: by above factors) where the $1,855.98.

$1,820.08. wage index is less than or equal to 1.0000. Proposed Rate for FY 2007 (after Labor: $3,404.27.. Labor: $3,338.42. multiplying FY 2006 base rate Nonlabor:

Nonlabor: by above factors) where the $1,479.90.

$1,451.28. wage index is greater than 1.0000.

Under section 1886(d)(9)(A)(ii) of the Act, the Federal portion of the Puerto Rico payment rate is based on the discharge-weighted average of the national large urban standardized amount (as set forth in Table 1A). The proposed labor-related and

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nonlabor-related portions of the national average standardized amounts for Puerto Rico hospitals for FY 2007 are set forth in Table 1C of section VI. of this Addendum. This table also includes the Puerto Rico standardized amounts. The labor-related share applied to the Puerto Rico specific standardized amount is 58.7 percent, or 62 percent, depending on which is more advantageous to the hospital. (Section 1886(d)(9)(C)(iv) of the Act, as amended by section 403(b) of Pub. L. 108-173, provides that the labor-related share for hospitals in Puerto Rico will be 62 percent, unless the application of that percentage would result in lower payments to the hospital.)

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

Tables 1A through 1C, as set forth in section VI. of this Addendum, contain the labor-related and nonlabor-related shares that we are proposing to use to calculate the prospective payment rates for hospitals located in the 50 States, the District of Columbia, and Puerto Rico for FY 2007. 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 2007 wage index. The proposed FY 2007 wage indexes are set forth in Tables 4A-1, 4A-2, 4B, 4C-1, 4C-2, 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 2007, 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, 2006, we will publish them in the final rule and use them in determining FY 2007 payments.

Table of Cost-of-Living Adjustment Factors: Alaska and Hawaii Hospitals

Cost of living Area

adjustment factor

Alaska-All areas..........................................

1.25 Hawaii: County of Honolulu......................................

1.25 Hawaii..................................................

1.165 County of Kauai.........................................

1.2325 County of Maui..........................................

1.2375 County of Kalawao.......................................

1.2375

(The above factors are based on data obtained from the U.S. Office of Personnel Management.)

C. DRG Relative Weights

As discussed in section II. of the preamble of this proposed rule, we have developed a classification system for all hospital discharges, assigning them into DRGs, and have developed relative weights for each DRG that reflect the resource utilization of cases in each DRG relative to Medicare cases in other DRGs. Table 5 of section VI. of this Addendum contains the relative weights that we are proposing to use for discharges occurring in FY 2007. These factors have been recalibrated as explained in section II. of the preamble of this proposed rule.

D. Calculation of the Proposed Prospective Payment Rates for FY 2007

General Formula for Calculation of Prospective Payment Rates for FY 2007

The proposed operating prospective payment rate for all hospitals paid under the IPPS located outside of Puerto Rico, except SCHs and MDHs, for FY 2007 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 for FY 2007 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 for FY 2007 equals the higher of the Federal rate, or the Federal rate plus 75 percent of the difference between the Federal rate and the hospital-specific rate as described below. The proposed prospective payment rate for Puerto Rico for FY 2007 equals 25 percent of the Puerto Rico rate from Table 1C in section VI. of this Addendum plus 75 percent of the applicable national rate from Table 1A or Table 1B in section VI. of this Addendum.

1. Federal Rate

For discharges occurring on or after October 1, 2006 and before October 1, 2007, 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 2.0 percentage points for nonqualifying hospitals).

Step 2--Multiply the labor-related portion of the standardized amount by the applicable wage index for the geographic area in which the hospital is located or the area to which the hospital is reclassified (see Tables 4A-1, 4A-2, 4B, 4C-1, and 4C-2 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. In addition, for hospitals that qualify for a low-volume payment adjustment under section 1886(d)(12) of the Act, the payment in Step 5 would be increased by 25 percent.

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

a. Calculation of Hospital-Specific Rate

Section 1886(b)(3)(C) of the Act provides that SCHs are paid based on whichever of the following rates yields the greatest aggregate payment: the Federal rate; the updated hospital-specific rate based on FY 1982 costs per discharge; the updated hospital- specific rate based on FY 1987 costs per discharge; or the updated hospital-specific rate based on FY 1996 costs per discharge.

As discussed above, MDHs must rebase their hospital-specific rates to their FY 2002 cost reports if doing so results in higher payments. In addition, effective for discharges occurring on or after October 1, 2006, MDHs are paid based on the Federal national rate or, if higher, the Federal national rate plus 75 percent of the difference between the Federal national rate and the greater of the updated hospital-specific rates based on either FY 1982, FY 1987 or FY 2002 costs per discharge. Further, MDHs will no longer be subject to the 12-percent cap on their DSH payment adjustment factor.

Hospital-specific rates have been determined for each of these hospitals based on the FY 1982 costs per discharge, the FY 1987 costs per discharge, or, for SCHs, the FY 1996 costs per discharge or for MDHs the FY 2002 cost per discharge. For a more detailed discussion of the calculation of the hospital-specific rates, we refer the reader to the FY 1984 IPPS interim final rule (September 1, 1983, 48 FR 39772); the April 20, 1990 final rule with comment (55 FR 15150); the FY 1991 IPPS final rule (September 4, 1990, 55 FR 35994); and the FY 2001 IPPS final rule (August 1, 2000, 65 FR 47082). In addition, for both SCHs and MDHs, the hospital-specific rate is adjusted by the budget neutrality adjustment factor (that is, by the proposed recalibration budget neutrality

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factor of 0.998963) as discussed in section IV.C. 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, 2006.

b. Updating the FY 1982, FY 1987, FY 1996, and FY 2002 Hospital- Specific Rates for FY 2007

We are proposing to increase the hospital-specific rates by 3.4 percent (the hospital market basket percentage increase) for SCHs and MDHs for FY 2007. Section 1886(b)(3)(C)(iv) of the Act provides that the update factor applicable to the hospital-specific rates for SCHs is equal to the update factor provided under section 1886(b)(3)(B)(iv) of the Act, which, for SCHs in FY 2007, is the market basket rate-of-increase. Section 1886(b)(3)(D) of the Act provides that the update factor applicable to the hospital-specific rates for MDHs also equals the update factor provided under section 1886(b)(3)(B)(iv) of the Act, which, for FY 2007, is the market basket rate-of-increase.

3. General Formula for Calculation of Proposed Prospective Payment Rates for Hospitals Located in Puerto Rico Beginning On or After October 1, 2006 and Before October 1, 2007

Section 1886(d)(9)(E)(iv) of the Act provides that, effective for discharges occurring on or after October 1, 2004, hospitals located in Puerto Rico are paid based on a blend of 75 percent of the national prospective payment rate and 25 percent of the Puerto Rico-specific rate.

a. Puerto Rico Rate

The Puerto Rico prospective payment rate is determined as follows:

Step 1--Select the 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. (see Table 5 of section IV. of the Addendum).

Step 5--Multiply the result in Step 4 by 25 percent.

b. National Rate

The national prospective payment rate is determined as follows:

Step 1--Select the 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 applicable wage index for the geographic area in which the hospital is located or the area to which the hospital is reclassified (see Table 4F of section VI. of this Addendum).

Step 3--Add the amount from Step 2 and the nonlabor-related portion of the national average standardized amount.

Step 4--Multiply the amount from Step 3 by the appropriate DRG relative weight (see Table 5 of section VI. of the Addendum).

Step 5--Multiply the result in Step 4 by 75 percent.

The sum of the Puerto Rico rate and the national rate computed above equals the prospective payment for a given discharge for a hospital located in Puerto Rico. This rate may then be further adjusted if the hospital qualifies for either the IME or DSH adjustment.

III. Proposed Changes to Payment Rates for Acute Care Hospital Inpatient Capital-Related Costs for FY 2007

(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 2007, which would be effective for discharges occurring on or after October 1, 2006. 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 payments are no longer being made under the regular exception policy effective with cost reporting periods beginning in FY 2002, we no longer use the capital cost model. The capital cost model and its application during the transition period are described in Appendix B of the FY 2002 IPPS final rule (66 FR 40099).

Section 412.374 provides for the use of a blended payment system for payments to Puerto Rico hospitals under the PPS for acute care hospital inpatient capital-related costs. Accordingly, under the capital PPS, we compute a separate payment rate specific to Puerto Rico hospitals using the same methodology used to compute the national Federal rate for capital-related costs. In accordance with section 1886(d)(9)(A) of the Act, under the PPS 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

[[Page 24154]]

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 2006 IPPS final rule (70 FR 47503), we established a capital Federal rate of $420.65 for FY 2006. In the discussion that follows, we explain the factors that we are proposing to use to determine the FY 2007 capital Federal rate. In particular, we explain why the proposed FY 2007 capital Federal rate would increase approximately 0.9 percent compared to the FY 2006 capital Federal rate. However, we estimate aggregate capital payments would decrease by 0.4 percent during this same period. This decrease is due to a decrease in the estimated total number of Medicare fee-for-service discharges for FY 2007 as compared to the estimated total number of Medicare fee-for-service discharges in FY 2006. We are estimating a decrease in Medicare fee-for-service discharges in FY 2007 as compared to FY 2006, in part because we are projecting an increase in beneficiary Medicare managed care enrollment as a result of the implementation of several provisions of Pub. L. 108-173. Therefore, although we are projecting that capital PPS payments per discharge would increase slightly from FY 2006 to FY 2007, we project that aggregate capital PPS payments would decrease for the same period.

Total payments to hospitals under the IPPS are relatively unaffected by changes in the capital prospective payments. Since capital payments constitute about 10 percent of hospital payments, a 1-percent change in the capital Federal rate yields only about 0.1 percent change in actual payments to hospitals. As noted above, aggregate payments under the capital IPPS are estimated to decrease slightly in FY 2007 compared to FY 2006.

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 2007 under that framework is 0.8 percent based on the best data available at this time. The proposed update factor is based on a projected 0.8 percent increase in the CIPI, a 0.0 percent adjustment for intensity, a 0.0 percent adjustment for case-mix, a 0.0 percent adjustment for the FY 2005 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 2007 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 II, of Appendix B in the FY 2006 IPPS final rule (70 FR 47707).)

For FY 2007, 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 2007. The net adjustment for change in case-mix is the difference between the projected increase in case-mix and the projected total increase in case-mix. Therefore, the proposed net adjustment for case-mix change in FY 2007 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 2005 DRG reclassification and recalibration as part of our proposed update for FY 2007. We estimate that FY 2005 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 2007 to maintain budget neutrality.

The capital update framework also contains an adjustment for forecast error. The input price index forecast is based on historical trends and relationships ascertainable at the time the update factor is established for the upcoming year. In any given year, there may be unanticipated price fluctuations that may result in differences between the actual increase in prices and the forecast used in calculating the update factors. In setting a prospective payment rate under the framework, we make an adjustment for forecast error only if our estimate of the change in the capital input price index for any year is off by 0.25 percentage points or more. There is a 2-year lag between the forecast and the measurement of the forecast error. A forecast error of -0.1 percentage point was calculated for the FY 2005 update. That is, current historical data indicate that the forecasted FY 2005 CIPI used in calculating the FY 2005 update factor (0.7 percent) slightly overstated the actual realized price increases (0.6 percent) by 0.1 percentage point. This slight overprediction was mostly due to an underestimation in the deceleration of the average yield of the long-term municipal bonds. The forecast correctly anticipated the deceleration of the municipal bond rates; however, it underestimated the magnitude of the deceleration resulting from the relatively looser Federal monetary policy (that is, delaying interest rate hikes). However, because this estimation of the change in the CIPI is less than 0.25 percentage points, it is not reflected in the update recommended under this framework. Therefore, we are proposing to make a 0.0 percent adjustment for forecast error in the update for FY 2007.

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Under the capital IPPS update framework, we also make an adjustment for changes in intensity. We calculate this adjustment using the same methodology and data that were used in the framework used in the past under the operating IPPS. The intensity factor for the operating update framework reflects how hospital services are utilized to produce the final product, that is, the discharge. This component accounts for changes in the use of quality-enhancing services, for changes in within-DRG severity, and for expected modification of practice patterns to remove noncost-effective services.

We calculate case-mix constant intensity as the change in total charges per admission, adjusted for price level changes (the CPI for hospital and related services) and changes in real case-mix. The use of total charges in the calculation of the intensity factor makes it a total intensity factor; that is, charges for capital services are already built into the calculation of the factor. Therefore, we have incorporated the intensity adjustment from the operating update framework into the capital update framework. Without reliable estimates of the proportions of the overall annual intensity increases that are due, respectively, to ineffective practice patterns and to the combination of quality-enhancing new technologies and within-DRG complexity, we assume, as in the operating update framework, that one-half of the annual increase is due to each of these factors. The capital update framework thus provides an add-on to the input price index rate of increase of one- half of the estimated annual increase in intensity, to allow for within-DRG severity increases and the adoption of quality-enhancing technology.

We have developed a Medicare-specific intensity measure based on a 5-year average. Past studies of case-mix change by the RAND Corporation (``Has DRG Creep Crept Up? Decomposing the Case Mix Index Change Between 1987 and 1988'' by G. M. Carter, J. P. Newhouse, and D. A. Relles, R-4098-HCFA/ProPAC (1991)) suggest that real case-mix change was not dependent on total change, but was usually a fairly steady 1.0 to 1.4 percent per year. We use 1.4 percent as the upper bound because the RAND study did not take into account that hospitals may have induced doctors to document medical records more completely in order to improve payment.

We calculate case-mix constant intensity as the change in total charges per admission, adjusted for price level changes (the CPI for hospital and related services), and changes in real case-mix. As we noted above, in accordance with Sec. 412.308(c)(1)(ii), we began updating the capital standard Federal rate in FY 1996 using an update framework that takes into account, among other things, allowable changes in the intensity of hospital services. For FYs 1996 through 2001, we found that case-mix constant intensity was declining and we established a 0.0 percent adjustment for intensity in each of those years. For FYs 2002 and 2003, we found that case- mix constant intensity was increasing and we established a 0.3 percent adjustment and 1.0 percent adjustment for intensity, respectively. For FYs 2004 and 2005, we found that the charge data appeared to be skewed (as discussed in greater detail below) and we established a 0.0 percent adjustment in each of those years. Furthermore, we stated that we would continue to apply a 0.0 percent adjustment for intensity until any increase in charges can be tied to intensity rather than attempts to maximize outlier payments.

As noted above, our intensity measure is based on a 5-year average, and therefore, the proposed intensity adjustment for FY 2007 is based on data from the 5-year period FY 2001 through FY 2005. We found a dramatic increase in hospital charges for each of those 5 years without a corresponding increase in the hospital case- mix index. These findings are similar to the considerable increase in hospitals' charges, which we found when we were determining the intensity factor in the FY 2004, FY 2005 and FY 2006 update recommendations as discussed in the FY 2004 IPPS final rule (68 FR 45482), the FY 2005 IPPS final rule (69 FR 49285) and the FY 2006 IPPS final rule (70 FR 47500), respectively. If hospitals were treating new or different types of cases, which would result in an appropriate increase in charges per discharge, then we would expect hospitals' case-mix to increase proportionally.

As we discussed in the FY 2006 IPPS final rule (70 FR 47500), because our intensity calculation relies heavily upon charge data and we believe that these charge data may be inappropriately skewed, we established a 0.0 percent adjustment for intensity for FY 2006.

On June 9, 2003, we published revisions to our outlier policy for determining the additional payment for extraordinarily high-cost cases (68 FR 34494 through 34515). These revised policies were effective on August 8, 2003, and October 1, 2003. While it does appear that a response to these policy changes is beginning to occur, that is, the change in charges for FYs 2004 and 2005 are somewhat less than the previous 4 years, they still show a significant annual increase in charges without a corresponding increase in hospital case-mix. The increase in charges in FY 2004, for example, is approximately 12 percent, which, while less than the increase in the previous 3 years, is still much higher than increases in years prior to FY 2001. In addition, this approximate 12-percent increase in charges for FY 2004 significantly exceeds the case-mix increase for the same period. Based on the approximate 12- percent increase in charges for FY 2004, we believe residual effects of hospitals' charge practices prior to the implementation of the outlier policy revisions established in the June 9, 2003 final rule continue to appear in the data because hospitals may not have had enough time to adopt changes in their behavior in response to the new outlier policy. Thus, we believe that the FY 2004 and FY 2005 charge data may still be skewed. Because the intensity adjustment is based on a 5-year average, and although the new outlier policy was generally effective in FY 2004, we believe it still will be several years before all the effects of hospitals attempting to maximize outlier payments are removed from the intensity calculation. Therefore, we are proposing a 0.0 percent adjustment for intensity for FY 2007. In the past (FYs 1996 through 2001) when we found intensity to be declining, we believed a zero (rather than negative) intensity adjustment was appropriate. Similarly, we believe that it is appropriate to apply a zero intensity adjustment for FY 2007 until any increase in charges can be tied to intensity rather than to attempts to maximize outlier payments.

Above, we described the basis of the components used to develop the proposed 0.8 percent capital update factor for FY 2007 as shown in the table below.

CMS Proposed FY 2007 Update Factor to the Capital Federal Rate

Capital Input Price Index....................................

0.8 Intensity....................................................

0.0 Case-Mix Adjustment Factors: Real Across DRG Change.....................................

1.0 Projected Case-Mix Change.................................. -1.0

Subtotal.................................................

0.0 Effect of FY 2005 Reclassification and Recalibration.........

0.0 Forecast Error Correction....................................

0.0

Total Proposed Update....................................

0.8

b. Comparison of CMS and MedPAC Update Recommendation

In the past, MedPAC has included update recommendations for capital PPS in a Report to Congress. In its March 2006 Report to Congress, MedPAC did not make an update recommendation for capital PPS payments for FY 2007. However, in that same report, MedPAC made an update recommendation for hospital inpatient and outpatient services (page 46). MedPAC reviews inpatient and outpatient services together because they are so closely interrelated. For FY 2007, MedPAC recommended an increase in the payment rate for the operating IPPS by the projected increase in the hospital market basket index, less half of MedPAC's expectation for productivity growth (or 0.45 percent, based on its assessment of beneficiaries' access to care and changes in hospital capacity, volume of services, access to capital, quality of care, and the relationship of Medicare payments and hospitals' costs. In addition, MedPAC recommended combining the annual rate update with an incentive payment policy for quality. (MedPAC's Report to the Congress: Medicare Payment Policy, March 2006, Section 2A.)

2. Proposed Outlier Payment Adjustment Factor

Section 412.312(c) establishes a unified outlier methodology for inpatient operating and inpatient capital-related costs. A single set of thresholds is used to identify outlier cases for both inpatient operating and inpatient capital-related payments. Section 412.308(c)(2) provides that the standard Federal rate for inpatient capital-related costs be reduced by an adjustment factor equal to the estimated proportion of capital-related outlier payments to total inpatient capital-related PPS payments. The outlier thresholds are set so that operating outlier payments are projected to be 5.1 percent of total operating DRG payments.

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In the FY 2006 IPPS final rule (70 FR 47501), we estimated that outlier payments for capital would equal 4.85 percent of inpatient capital-related payments based on the capital Federal rate in FY 2006. Based on the thresholds as set forth in section II.A.4.c. of this Addendum, we estimate that outlier payments for capital-related costs would equal 4.87 percent for inpatient capital-related payments based on the Federal rate in FY 2007. Therefore, we are proposing to apply an outlier adjustment factor of 0.9513 to the capital Federal rate. Thus, the percentage of capital outlier payments to total capital standard payments for FY 2007 would be slightly higher than the percentages for FY 2006.

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 2007 outlier adjustment of 0.9513 is a -0.02 percent change from the FY 2006 outlier adjustment of 0.9515. Therefore, the net change in the outlier adjustment to the proposed capital Federal rate for FY 2007 is 0.9998 (0.9513/0.9915). Thus, the proposed outlier adjustment decreases the proposed FY 2007 capital Federal rate by 0.02 percent compared with the FY 2006 outlier adjustment.

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

Section 412.308(c)(4)(ii) requires that the capital Federal rate be adjusted so that aggregate payments for the fiscal year based on the capital Federal rate after any changes resulting from the annual DRG reclassification and recalibration and changes in the GAF are projected to equal aggregate payments that would have been made on the basis of the capital Federal rate without such changes. Because we implemented a separate GAF for Puerto Rico, we apply separate budget neutrality adjustments for the national GAF and the Puerto Rico GAF. We apply the same budget neutrality factor for DRG reclassifications and recalibration nationally and for Puerto Rico. Separate adjustments were unnecessary for FY 1998 and earlier because the GAF for Puerto Rico was implemented in FY 1998.

In the past, we used the actuarial capital cost model (described in Appendix B of the FY 2002 IPPS final rule (66 FR 40099)) to estimate the aggregate payments that would have been made on the basis of the capital Federal rate with and without changes in the DRG classifications and weights and in the GAF to compute the adjustment required to maintain budget neutrality for changes in DRG weights and in the GAF. During the transition period, the capital cost model was also used to estimate the regular exception payment adjustment factor. As we explain in section III.A.4. of this Addendum, beginning in FY 2002, an adjustment for regular exception payments is no longer necessary. Therefore, we are no longer using the capital cost model. Instead, we are using historical data based on hospitals' actual cost experiences to determine the exceptions payment adjustment factor for special exceptions payments.

To determine the proposed factors for FY 2007, we compared (separately for the national capital rate and the Puerto Rico capital rate) estimated aggregate capital Federal rate payments based on the FY 2006 DRG relative weights and the FY 2006 GAF to estimated aggregate capital Federal rate payments based on the proposed FY 2007 relative weights and the proposed FY 2007 GAF. As we established in the FY 2006 IPPS final rule (70 FR 47503), the budget neutrality factors were 0.9920 for the national capital rate and 0.9959 for the Puerto Rico capital rate. In making the comparison, we set the exceptions reduction factor to 1.00. To achieve budget neutrality for the changes in the national GAF, based on calculations using updated data, we are proposing to apply an incremental budget neutrality adjustment of 1.0003 for FY 2007 to the previous cumulative FY 2006 adjustments of 0.9920, yielding an adjustment of 0.9922, through FY 2007 (calculations done on unrounded numbers). For the Puerto Rico GAF, we are proposing to apply an incremental budget neutrality adjustment of 1.0017 for FY 2007 to the previous cumulative FY 2006 adjustment of 0.9959, yielding a cumulative adjustment of 0.9986 through FY 2007.

We then compared estimated aggregate capital Federal rate payments based on the FY 2006 DRG relative weights and the FY 2006 GAF to estimated aggregate capital Federal rate payments based on the proposed FY 2007 DRG relative weights and the proposed FY 2007 GAF. The proposed incremental adjustment for DRG classifications and changes in relative weights is 1.0009 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 2007 are 0.9932 nationally and 0.9986 for Puerto Rico. The following table summarizes the adjustment factors for each fiscal year: BILLING CODE 4120-01-P

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[GRAPHIC] [TIFF OMITTED] TP25AP06.021

BILLING CODE 4120-01-C

The methodology used to determine the proposed recalibration and geographic (DRG/GAF) budget neutrality adjustment factor for FY 2007 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 2006 IPPS final rule (70 FR 47503), we calculated a GAF/DRG budget neutrality factor of 1.0008 for FY 2006. For FY 2007, we are proposing to establish a GAF/DRG budget neutrality factor of 1.0012. The GAF/DRG budget neutrality factors are built permanently into the capital rates; that is, they are applied cumulatively in determining the capital Federal rate. This follows from the requirement that estimated

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aggregate payments each year be no more or less than they would have been in the absence of the annual DRG reclassification and recalibration and changes in the GAF. The incremental change in the proposed adjustment from FY 2006 to FY 2007 is 1.0012. The cumulative change in the proposed capital Federal rate due to this proposed adjustment is 0.9932 (the product of the incremental factors for FYs 1993 though 2006 and the proposed incremental factor of 1.0012 for FY 2007). (We note that averages of the incremental factors that were in effect during FYs 2005 and 2006, respectively, were used in the calculation of the proposed cumulative adjustment of 1.0012 for FY 2007.)

This proposed factor accounts for DRG reclassifications and recalibration and for changes in the GAF. It also incorporates the effects on the proposed GAF of FY 2007 geographic reclassification decisions made by the MGCRB compared to FY 2006 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 2007 capital Federal rate because, in accordance with Sec. 412.348(b), regular exception payments were only made for cost reporting periods beginning on or after October 1, 1991 and before October 1, 2001. Accordingly, as we explained in the FY 2002 IPPS final rule (66 FR 39949), in FY 2002 and subsequent fiscal years, no payments will be made under the regular exceptions provision. However, in accordance with Sec. 412.308(c), we still need to compute a budget neutrality adjustment for special exception payments under Sec. 412.348(g). We describe our methodology for determining the exceptions adjustment used in calculating the proposed FY 2007 capital Federal rate below.

Under the special exceptions provision specified at Sec. 412.348(g)(1), eligible hospitals include SCHs, urban hospitals with at least 100 beds that have a disproportionate share percentage of at least 20.2 percent or qualify for DSH payments under Sec. 412.106(c)(2), and hospitals with a combined Medicare and Medicaid inpatient utilization of at least 70 percent. An eligible hospital may receive special exceptions payments if it meets: (1) A project need requirement as described at Sec. 412.348(g)(2), which, in the case of certain urban hospitals, includes an excess capacity test as described at Sec. 412.348(g)(4); (2) an age of assets test as described at Sec. 412.348(g)(3); and (3) a project size requirement as described at Sec. 412.348(g)(5).

Based on information compiled from our fiscal intermediaries, six hospitals have qualified for special exceptions payments under Sec. 412.348(g). Since we have cost reports ending in FY 2005 for all of these hospitals, we calculated the adjustment based on actual cost experience. Using data from cost reports ending in FY 2005 from the December 2005 update of the HCRIS data, we divided the capital special exceptions payment amounts for the six hospitals that qualified for special exceptions by the total capital PPS payment amounts (including special exception payments) for all hospitals. Based on the data from cost reports ending in FY 2005, this ratio is rounded to 0.0003. Because we have not received all cost reports ending in FY 2005, we also divided the FY 2005 special exceptions payments by the total capital PPS payment amounts for all hospitals with cost reports ending in FY 2004. 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 2007. Therefore, the proposed exceptions adjustment factor is equal to 0.9997 (1--0.0003) to account for special exceptions payments in FY 2007.

In the FY 2006 IPPS final rule (70 FR 47503), we estimated that total (special) exceptions payments for FY 2006 would equal 0.03 percent of aggregate payments based on the capital Federal rate. Therefore, we applied an exceptions adjustment factor of 0.9997 (1-- 0.0003) in determining the FY 2006 capital Federal rate. As we stated above, we estimate that exceptions payments in FY 2007 will equal 0.03 percent of aggregate payments based on the proposed FY 2007 capital Federal rate. Therefore, we are proposing to apply an exceptions payment adjustment factor of 0.9997 to the capital Federal rate for FY 2007. The proposed exceptions adjustment factor for FY 2007 is the same as the factor used in determining the FY 2006 capital Federal rate in the FY 2006 IPPS final rule (70 FR 47503). The exceptions reduction factors are not built permanently into the capital rates; that is, the factors are not applied cumulatively in determining the capital Federal rate. Therefore, the net change in the exceptions adjustment factor used in determining the proposed FY 2007 capital Federal rate is 1.0000 (0.9997/0.9997).

5. Proposed Capital Standard Federal Rate for FY 2007

In the FY 2006 IPPS final rule (70 FR 47503), we established a capital Federal rate of $420.65 for FY 2006. In this proposed rule, we are proposing to establish a capital Federal rate of $424.42 for FY 2007. The proposed capital Federal rate for FY 2007 was calculated as follows:

The proposed FY 2007 update factor is 1.0080; that is, the proposed update is 0.8 percent.

The proposed FY 2007 budget neutrality adjustment factor that is applied to the capital standard Federal payment rate for proposed changes in the DRG relative weights and in the GAF is 1.0012.

The proposed FY 2007 outlier adjustment factor is 0.9513.

The proposed FY 2007 (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 not proposing to make 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 2007 affected the computation of the proposed FY 2007 capital Federal rate in comparison to the average FY 2006 capital Federal rate. The proposed FY 2007 update factor has the effect of increasing the proposed capital Federal rate by 0.80 percent compared to the average FY 2006 Federal rate. The proposed GAF/DRG budget neutrality factor has the effect of increasing the proposed capital Federal rate by 0.12 percent. The proposed FY 2007 outlier adjustment factor has the effect of decreasing the proposed capital Federal rate by 0.02 percent compared to the average FY 2006 capital Federal rate. The proposed FY 2007 exceptions payment adjustment factor remains unchanged from the FY 2006 exceptions payment adjustment factor, and therefore, has a 0.0 percent net effect on the proposed FY 2007 capital Federal rate. The combined effect of all the proposed changes is to increase the proposed capital Federal rate by 0.90 percent compared to the average FY 2006 capital Federal rate.

Comparison of Factors and Adjustments [FY 2006 Capital Federal Rate and Proposed FY 2007 Capital Federal Rate]

Proposed FY

Percent FY 2006

2007

Change change

Update Factor \1\........................................... 1.0080 1.0080 1.0080

0.80 GAF/DRG Adjustment Factor \1\............................... 1.0008 1.0012 1.0012

0.12

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Outlier Adjustment Factor \2\............................... 0.9515 0.9513 0.9998

-0.02 Exceptions Adjustment Factor \2\............................ 0.9997 0.9997 0.0000

0.00 Capital Federal Rate........................................ $420.65 $424.42 1.0090

0.90 Outlier Adjustment Factor \2\............................... 0.9515 0.9513 0.9998

-0.02

\1\ The proposed update factor and the GAF/DRG budget neutrality factors are built permanently into the capital rates. Thus, for example, the incremental change from FY 2006 to FY 2007 resulting from the application of the proposed 1.0012 GAF/DRG budget neutrality factor for FY 2007 is 1.0012. \2\ The proposed outlier reduction factor and the proposed exceptions adjustment factor are not built permanently into the capital rates; that is, these factors are not applied cumulatively in determining the capital rates. Thus, for example, the net change resulting from the application of the proposed FY 2007 outlier adjustment factor would be 0.9513/0.9515, or 0.9998.

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 1.0017, while the proposed DRG adjustment is 1.0009, for a combined proposed cumulative adjustment of 0.9986.

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 2006, before application of the GAF, the special capital rate for Puerto Rico hospitals was $201.93 for discharges occurring on or after October 1, 2005 through September 30, 2006. With the changes we are proposing to make to the factors used to determine the capital rate, the proposed FY 2007 special capital rate for Puerto Rico is $202.98.

B. Calculation of the Proposed Inpatient Capital-Related Prospective Payments for FY 2007

Because the 10-year capital PPS transition period ended in FY 2001, all hospitals (except ``new'' hospitals under Sec. 412.324(b) and under Sec. 412.304(c)(2)) are paid based on 100 percent of the capital Federal rate in FY 2006. The applicable capital Federal rate was determined by making adjustments as follows:

For outliers, by dividing the capital standard Federal rate by the outlier reduction factor for that fiscal year; and

For the payment adjustments applicable to the hospital, by multiplying the hospital's GAF, disproportionate share adjustment factor, and IME adjustment factor, when appropriate.

For purposes of calculating payments for each discharge during FY 2007, 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 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 2007 are in section II.A.4.c. of this Addendum. For FY 2007, 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 $25,530.

An eligible hospital may also qualify for a special exceptions payment under Sec. 412.348(g) for up through the 10th year beyond the end of the capital transition period if it meets: (1) A project need requirement described at Sec. 412.348(g)(2), which in the case of certain urban hospitals includes an excess capacity test as described at Sec. 412.348(g)(4); and (2) a project size requirement as described at Sec. 412.348(g)(5). Eligible hospitals include SCHs, urban hospitals with at least 100 beds that have a DSH patient percentage of at least 20.2 percent or qualify for DSH payments under Sec. 412.106(c)(2), and hospitals that have a combined Medicare and Medicaid inpatient utilization of at least 70 percent. Under Sec. 412.348(g)(8), the amount of a special exceptions payment is determined by comparing the cumulative payments made to the hospital under the capital PPS to the cumulative minimum payment level. This amount is offset by: (1) Any amount by which a hospital's cumulative capital payments exceed its cumulative minimum payment levels applicable under the regular exceptions process for cost reporting periods beginning during which the hospital has been subject to the capital PPS; and (2) any amount by which a hospital's current year operating and capital payments (excluding 75 percent of operating DSH payments) exceed its operating and capital costs. Under Sec. 412.348(g)(6), the minimum payment level is 70 percent for all eligible hospitals.

During the transition period, new hospitals (as defined under Sec. 412.300) were exempt from the capital 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

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operation, we pay the hospital based on 100 percent of the capital Federal rate (that is, the same methodology used to pay all other hospitals subject to the capital PPS).

C. Capital Input Price Index

1. Background

Like the operating input price index, the capital input price index (CIPI) is a fixed-weight price index that measures the price changes associated with capital costs during a given year. The CIPI differs from the operating input price index in one important aspect--the CIPI reflects the vintage nature of capital, which is the acquisition and use of capital over time. Capital expenses in any given year are determined by the stock of capital in that year (that is, capital that remains on hand from all current and prior capital acquisitions). An index measuring capital price changes needs to reflect this vintage nature of capital. Therefore, the CIPI was developed to capture the vintage nature of capital by using a weighted-average of past capital purchase prices up to and including the current year.

We periodically update the base year for the operating and capital input prices to reflect the changing composition of inputs for operating and capital expenses. The CIPI was last rebased to FY 2002 in the FY 2006 IPPS final rule (70 FR 47387).

2. Forecast of the CIPI for FY 2007

Based on the latest forecast by Global Insight, Inc. (first quarter of 2006), we are forecasting the CIPI to increase 0.8 percent in FY 2007. This reflects a projected 1.4 percent increase in vintage-weighted depreciation prices (building and fixed equipment, and movable equipment) and a 3.0 percent increase in other capital expense prices in FY 2007, partially offset by a 2.3 percent decline in vintage-weighted interest expenses in FY 2007. The weighted average of these three factors produces the 0.8 percent increase for the CIPI as a whole in FY 2007.

IV. Payment Rates for Excluded Hospitals and Hospital Units: Proposed 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 VI. of the preamble of this proposed rule, the inpatient operating costs of children's hospitals and cancer hospitals that are excluded from the IPPS are paid on the basis of reasonable cost subject to the rate-of-increase ceiling established under the authority of sections 1886(b)(3)(A)(i) and (ii) of the Act and Sec. 413.40 of the regulations. The ceiling is based on a target amount per discharge under TEFRA. In addition, in accordance with Sec. 403.752(a) of the regulations, RNHCIs also are paid under Sec. 413.40 which uses section 1886(b)(3)(B)(ii) of the Act to update the percentage increase in the rate of increase limits. The most recent proposed projected forecast of the market basket percentage increase for FY 2007 for children's hospitals, cancer hospitals, and RNHCIs using the IPPS market basket (70 FR 47396 through 47405) is 3.4 percent.

LTCHs, rehabilitation hospitals and units, and psychiatric hospitals and units, historically, were excluded from the IPPS and subject to the rate-of-increase limits under Sec. 413.40, as well. However, prospective payment systems have been developed for each of the three types of hospitals, and each kind of hospital is currently paid under its own PPS, either at 100 percent of the Federal rate or according to a transition period methodology, if applicable. (For more detailed discussion of these payment methodologies, see 69 FR 49190; 69 FR 66922; 68 FR 45674; and 67 FR 55954.)

For cost reporting periods beginning on or after October 1, 2002, to the extent a LTCH or a psychiatric hospital or unit has all or a portion of its payment determined under reasonable cost principles, the target amounts for the reasonable cost-based portion of the blended payment are determined in accordance with sections 1886(b)(3)(A)(i) and 1886(b)(3)(B)(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, because 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 by the applicable update factor. For example, if a provider was paid the cap amount for FY 2002 (Sec. 413.40(c)(4)(iii)), the target amount for FY 2003 would be the amount paid in FY 2002, updated to FY 2003 (that is, the target amount from the previous year increased by the applicable update factor).

Effective for cost reporting periods beginning on or after October 1, 2002, IRFs 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, an existing LTCH (that is, not defined as new under Sec. 412.23(e)(4)) could have elected to be paid based on 100 percent of the standard Federal prospective payment rate during the transition period. However, we also established a 5-year transition period from reasonable cost-based payments (subject to the TEFRA limit) to fully Federal prospective payment amounts during which an existing LTCH could receive a PPS-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.

Effective for cost reporting periods that will begin on or after October 1, 2006, the LTCHs that receive payment based on a blended payment amount will no longer receive a portion of their payment that is based, in part, on reasonable cost subject to the rate-of- ceiling under Sec. 413.40. This is because, in accordance with Sec. 412.533, LTCHs are paid 100 percent of the adjusted Federal prospective payment amount and zero percent of the amount calculated under reasonable cost principles for cost reporting periods beginning on or after October 1, 2006.

As part of the PPS for existing IPFs, we have established a 3- year transition period during which existing IPFs will be paid based on a blend of reasonable cost-based payment (subject to the TEFRA limit) and the prospective per diem payment rate. IPFs that are paid under a blended methodology will have the reasonable cost-based portion of their payment subject to a hospital target amount. The most recent proposed projected forecast of the market basket percentage increase for FY 2007 for the reasonable cost-based portion of an IPF's payment using the excluded hospital market basket (70 FR 47396 through 47405) is 3.6 percent. For cost reporting periods beginning on or after January 1, 2008, IPFs will be paid 100 percent of the Federal prospective per diem amount.

The proposed market basket percentage increases for FY 2007 are made by CMS' Office of the Actuary and reflect the average change in the price of goods and services purchased by hospitals to furnish inpatient hospital care. As discussed in section IV. of the preamble in the FY 2006 IPPS final rule, we use the IPPS market basket for children's hospitals, cancer hospitals, and RNHCIs, and the excluded hospital market basket for LTCHs, and IPFs for the reasonable cost portion of its payment to the extent a portion of its PPS payment is based on reasonable costs. We are not proposing any changes to our method of calculating the hospital market basket for IPPS or for excluded hospitals. As we indicated above, the proposed IPPS market basket is 3.4 percent and the proposed excluded hospital market basket is 3.6 percent.

B. New Excluded Hospitals and Units

Section 1886(b)(7) of the Act established a payment methodology for new (cost reporting periods beginning on or after October 1, 1997) rehabilitation hospitals and units, psychiatric hospitals and units, and LTCHs. For the first two 12-month cost reporting periods, payment was based on the lower of the hospital's net inpatient operating costs or 110 percent of the national median of target amounts for the particular class of hospital for FY 1996, updated to the applicable cost reporting period, and adjusted for differences in area wage levels. Consequently, beginning with the FY 1998 IPPS final rule, we published annually in the Federal Register, the updated 110 percent median of the wage-neutral national target amounts, divided into the labor and nonlabor-related share, for each of the three classes of providers affected by the payment limitation. As explained in the FY 2006 IPPS final rule (70 FR 47466 through 47467), the charts containing the updated 110 percent median payment amount

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information are no longer needed and are discontinued.

V. Proposed Payment for Blood Clotting Factor Administered to Inpatient With Hemophilia

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

As discussed in section VIII. of the preamble to this proposed rule, in the FY 2006 IPPS final rule (70 FR 47473), we amended our regulations at Sec. Sec. 412.2(f)(8) and 412.115(b) to state that, for discharges occurring on or after October 1, 2005, we make payment for blood clotting factor administered to hospital inpatients using the Medicare Part B payment amounts for blood clotting factor as determined under Subpart K of 48 CFR Part 414 and for the furnished fee as determined under Sec. 410.63.

In accordance with Sec. 410.63(c)(2) and our November 21, 2005 regulations (70 FR 70225), the furnishing fee for blood clotting factor for CY 2006 was determined to be $0.146 per individual unit (I.U.). Although the furnishing fee payment rate is calculated at 3 digits, the actual amount paid to providers and suppliers is rounded to 2 digits. In section VIII of the preamble to this proposed rule, we are proposing that the fiscal intermediaries continue to make payment amounts for blood clotting factor administered to hemophilia inpatients using the Medicare Part B payment amounts determined under Subpart K of 42 CFR Part 414 and that payment amounts for the furnishing fee for the blood clotting factor be calculated at 3 digits, currently at $0.146 per I.U. of blood clotting factor.

The fiscal intermediaries continue to use the Medicare Part B Drug Pricing File to make payments for blood clotting factors. The furnishing fee is included in the ASP price per unit sent with the Medicare Part B Drug Pricing File that is updated quarterly. By using the Medicare Part B Drug Pricing File, Medicare will be making consistent payments for blood clotting factor provided to inpatients and outpatients. For further updates on pricing, we refer reader to the Medicare Part B drug pricing regulations.

[[Page 24162]]

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-1, 4A-2, 4B, 4C-1, 4C-2, 4F, 4J, 5, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H, 7A, 7B, 8A, 8B, 8C, 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 2005; Hospital Wage Indexes for Federal Fiscal Year 2007; Hospital Average Hourly Wage for Federal Fiscal Years 2005 (2001 Wage Data), 2006 (2002 Wage Data), and 2007 (2003 Wage Data); Wage Indexes and 3-Year Average of Hospital Average Hourly Wages Table 3A--FY 2007 and 3-Year Average Hourly Wage for Urban Areas by CBSA Table 3B--FY 2007 and 3-Year Average Hourly Wage for Rural Areas by CBSA Table 4A-1--Wage Index and Capital Geographic Adjustment Factor (GAF) for Urban Areas by CBSA--FY 2007 Table 4A-2--Wage Index and Capital Geographic Adjustment Factor (GAF) for Certain Urban Areas by CBSA for the Period April 1 through September 30, 2007 Table 4B--Wage Index and Capital Geographic Adjustment Factor (GAF) for Rural Areas by CBSA--FY 2007 Table 4C-1--Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That Are Reclassified by CBSA--FY 2007 Table 4C-2--Wage Index and Capital Geographic Adjustment Factor (GAF) for Certain Hospitals That Are Reclassified by CBSA for the Period April 1 through September 30, 2007 Table 4F--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF) by CBSA--FY 2007 Table 4J--Out-Migration Adjustment--FY 2007 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 2005 MedPAR Update December 2005 GROUPER V23.0 Table 7B--Medicare Prospective Payment System Selected Percentile Lengths of Stay: FY 2005 MedPAR Update December 2005 GROUPER V24.0 Table 8A--Statewide Average Operating Cost-to-Charge Ratios--March 2006 Table 8B--Statewide Average Capital Cost-to-Charge Ratios--March 2006 Table 8C--Statewide Average Total Cost-to-Charge Ratios for LTCHs-- March 2006 Table 9A--Hospital Reclassifications and Redesignations by Individual Hospital and CBSA--FY 2007 Table 9B--Hospital Reclassifications and Redesignations by Individual Hospital Under Section 508 of Pub. L. 108-173--FY 2007 Table 9C--Hospitals Redesignated as Rural under Section 1886(d)(8)(E) of the Act--FY 2007 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 2006 Table 11--Proposed FY 2007 LTC-DRGs, Relative Weights, Geometric Average Length of Stay, and 5/6ths of the Geometric Average Length of Stay

Table 1A.--National Adjusted Operating Standardized Amounts, Labor/Nonlabor [69.7 Percent Labor Share/30.3 Percent Nonlabor Share If Wage Index Greater Than 1]

Full update (3.4 percent)

Reduced update (1.4 percent)

Labor-related

Nonlabor-related

Labor-related

Nonlabor-related

$3,404.27

$1,479.90

$3,338.42

$1,451.28

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 (3.4 percent)

Reduced update (1.4 percent)

Labor-related

Nonlabor-related

Labor-related

Nonlabor-related

$3,028.19

$1,855.98

$2,969.62

$1,820.08

Table 1C.--Adjusted Operating Standardized Amounts For Puerto Rico, Labor/Nonlabor

Rates if wage index Rates if wage index less greater than 1

than or equal to 1

Labor Nonlabor Labor Nonlabor

National.................................................... $3,404.27 $1,479.90 $3,028.19 $1,855.98 Puerto Rico................................................. 1,442.78 884.28 1,365.99 961.07

[[Page 24163]]

Table 1D.--Capital Standard Federal Payment Rate

Rate

National................................................... $424.42 Puerto Rico................................................ 202.98

Table 2.--Hospital Case-Mix Indexes for Discharges Occurring in Federal Fiscal Year 2005; Hospital Wage Indexes for Federal Fiscal Year 2007; Hospital Average Hourly Wages for Federal Fiscal Years 2005 (2001 Wage Data), 2006 (2002 Wage Data), and 2007 (2003 Wage Data); Wage Indexes and 3-Year Average of Hospital Average Hourly Wages

FY 2007 wage index FY 2007 Average Average Average Average Provider No.

Case-mix (10/1/2006- wage index hourly wage hourly wage hourly wage hourly index \3\ 3/31/2007) (4/1/2007- FY 2005 \1\ FY 2006 \1\ FY 2007 \1\ wage** (3 9/30/2007)

years)

010001....................................................... 1.4947 0.7670 0.7670 20.6563 21.6546 22.0902 21.4932 010004.......................................................

***

*

* 22.7585

*

* 22.7585 010005 h..................................................... 1.1314 0.8919 0.8919 20.4937 22.4906 23.8467 22.3126 010006....................................................... 1.4662 0.8008 0.8008 21.0241 23.4823 23.8950 22.7642 010007....................................................... 1.0715 0.7670 0.7670 16.8811 18.2430 19.0895 18.0746 010008....................................................... 0.9849 0.8035 0.8035 23.8333 20.4591 17.3246 20.3331 010009....................................................... 0.9669 0.8829 0.8829 21.6422 23.2229 23.6476 22.8732 010010 h..................................................... 1.0466 0.9286 0.9286 22.3021 21.4974 26.9296 23.3707 010011....................................................... 1.6004 0.8919 0.8919 24.8166 27.4850 28.1598 26.8482 010012....................................................... 1.2403 0.8841 0.8841 21.7622 22.7020 24.7514 23.0667 010015....................................................... 1.0209 0.7670 0.7670 20.4732 21.5111 22.2383 21.4475 010016....................................................... 1.5262 0.8919 0.8919 23.0414 25.1502 25.3918 24.5277 010018....................................................... 1.4713 0.8919 0.8919 20.5888 22.2990 23.4042 22.0807 010019....................................................... 1.2326 0.8008 0.8008 20.1336 22.0906 22.7718 21.6962 010021 h..................................................... 1.2234 0.7670 0.7670 20.7108 18.6785 19.2877 19.5086 010022....................................................... 0.9812 0.9307 0.9307 25.8797 24.5670 26.0470 25.5065 010023....................................................... 1.9126 0.8035 0.8035 23.7791 27.6174 25.9797 25.7195 010024....................................................... 1.6759 0.8035 0.8035 20.0067 20.7265 21.9289 20.8398 010025....................................................... 1.2800 0.8256 0.8256 19.8561 21.2674 22.9338 21.3262 010027....................................................... 0.7764 0.7670 0.7670 14.9585 15.3704 16.1874 15.4627 010029....................................................... 1.5817 0.8256 0.8256 21.6724 22.6976 24.0249 22.8346 010031.......................................................

***

*

* 20.9463

*

* 20.9463 010032....................................................... 0.8957 0.7670 0.7670 18.5073 19.1555 17.6770 18.4274 010033....................................................... 2.0838 0.8919 0.8919 25.5165 26.3784 27.2283 26.3825 010034....................................................... 0.9964 0.8035 0.8035 17.1625 16.9686 16.8532 16.9851 010035....................................................... 1.2688 0.8919 0.8919 23.1319 22.2870 24.4137 23.2651 010036....................................................... 1.1331 0.7670 0.7670 20.5125 22.9747 21.3352 21.6253 010038....................................................... 1.3544 0.8040 0.8040 20.3935 21.4509 23.8325 21.9490 010039....................................................... 1.6215 0.9027 0.9027 23.4151 25.8820 26.9189 25.4404 010040....................................................... 1.6072 0.8107 0.8107 21.6708 22.8851 25.2353 23.2539 010043....................................................... 1.0549 0.8919 0.8919 19.5422 22.5945 22.3782 21.5638 010044....................................................... 1.0631 0.8919 0.8919 23.0220 21.4036 23.4140 22.5922 010045....................................................... 1.1631 0.8919 0.8919 20.5658 19.8803 21.3661 20.5979 010046....................................................... 1.5002 0.8107 0.8107 20.8935 21.6965 22.5938 21.7035 010047....................................................... 0.8900 0.7825 0.7825 19.5937 21.0604 24.7497 21.7929 010049....................................................... 1.1465 0.7670 0.7670 17.7801 20.2413 21.7057 19.9626 010050....................................................... 1.0283 0.8919 0.8919 21.5625 22.1584 23.7598 22.4501 010051....................................................... 0.8413 0.8644 0.8644 14.7053 15.2208 16.2672 15.4065 010052....................................................... 0.8875 0.7791 0.7791 21.3673 16.4959 35.3506 23.1645 010053....................................................... 1.0530

*

* 17.4160 19.0108

* 18.2193 010054....................................................... 1.0888 0.8829 0.8829 23.1894 22.5554 23.2781 23.0051 010055....................................................... 1.5338 0.7670 0.7670 19.1847 22.3800 22.4711 21.3064 010056....................................................... 1.5870 0.8919 0.8919 22.7183 23.7144 23.9525 23.4706 010058....................................................... 0.9554 0.8919 0.8919 20.3182 18.5537 18.7069 19.3775 010059....................................................... 1.0321 0.8829 0.8829 23.6963 21.3237 22.9583 22.7109 010061....................................................... 1.0134 0.8176 0.8176 20.5683 21.9370 26.4117 23.1046 010062....................................................... 1.0729 0.7670 0.7670 18.1323 18.3435 20.1842 18.8535 010064....................................................... 1.7037 0.8919 0.8919 25.4345 26.1110 25.8259 25.7663 010065....................................................... 1.4924 0.8035 0.8035 20.0108 21.3785 23.3126 21.5967 010066....................................................... 0.8390 0.7670 0.7670 17.0935 17.6152 19.9192 18.2254 010068.......................................................

***

*

* 17.5690 19.0789 22.7410 19.7954 010069....................................................... 1.0208 0.7670 0.7670 19.6317 21.3608 22.9841 21.2452 010072.......................................................

***

*

* 21.5419 21.8169 24.5806 22.6157 010073....................................................... 0.9714 0.7670 0.7670 16.4043 16.4168 17.2624 16.6999 010078....................................................... 1.5197 0.8040 0.8040 21.0633 21.6857 23.2584 22.0108 010079....................................................... 1.1653 0.9027 0.9027 20.4254 21.8199 22.9204 21.7330 010083 h..................................................... 1.1662 0.7999 0.7999 20.2166 22.3041 22.2041 21.5896 010084....................................................... 1.4968 0.8919 0.8919 22.5219 24.7127 26.7869 24.6686

[[Page 24164]]

010085....................................................... 1.3213 0.8829 0.8829 23.7007 24.4710 24.9367 24.3634 010086....................................................... 1.0963 0.7670 0.7670 19.4332 18.6081 22.6793 20.2158 010087....................................................... 1.9768 0.7955 0.7955 21.6226 22.5225 23.2584 22.4539 010089....................................................... 1.2732 0.8919 0.8919 22.2508 22.8448 25.7005 23.6155 010090....................................................... 1.7279 0.7955 0.7955 21.4322 23.6948 26.3719 23.7551 010091....................................................... 0.9676 0.7670 0.7670 19.4222 18.6912 21.7995 19.8855 010092....................................................... 1.6101 0.8644 0.8644 22.0709 24.4592 26.0211 24.1412 010095....................................................... 0.8483 0.8644 0.8644 13.4426 13.9326 14.2458 13.8767 010097....................................................... 0.7214 0.8035 0.8035 17.1735 16.7548 19.7546 17.8691 010098....................................................... 1.0614 0.7670 0.7670 19.6717 14.3076 19.7314 17.4056 010099....................................................... 1.0007 0.7670 0.7670 18.1849 18.7909 20.5469 19.1587 010100 h..................................................... 1.6896 0.7999 0.7999 20.0027 21.2915 23.6080 21.6931 010101....................................................... 1.1300 0.7978 0.7978 21.0085 21.6593 24.1741 22.2531 010102....................................................... 0.9498 0.7670 0.7670 19.9196 21.0903 24.0016 21.7005 010103....................................................... 1.9055 0.8919 0.8919 24.2201 26.1163 27.4955 25.9641 010104....................................................... 1.8131 0.8919 0.8919 24.1929 24.7394 27.7171 25.5564 010108....................................................... 1.1587 0.8035 0.8035 23.7803 28.4624 25.2790 25.7731 010109....................................................... 0.9898 0.8121 0.8121 21.7128 21.6194 17.8168 20.3493 010110....................................................... 0.7972 0.7670 0.7670 19.2706 17.5957 22.8948 19.6997 010112....................................................... 1.0411 0.7670 0.7670 17.2963 16.8902 16.6350 16.9597 010113....................................................... 1.6585 0.7955 0.7955 20.4181 21.4121 22.5051 21.4462 010114....................................................... 1.3874 0.8919 0.8919 21.5319 22.3752 24.9211 22.9538 010115....................................................... 0.8657

*

* 17.5985 21.7478

* 19.2200 010118....................................................... 1.2164 0.7785 0.7785 18.8560 19.7673 21.4598 20.1886 010119.......................................................

***

*

* 21.8215

*

* 21.8215 010120....................................................... 0.9951 0.7670 0.7670 20.5855 20.9450 21.0977 20.8812 010121.......................................................

***

*

* 17.0329 24.0867

* 19.3686 010125....................................................... 1.0529 0.7670 0.7670 16.8419 18.4114 21.5078 18.8306 010126....................................................... 1.1487 0.8035 0.8035 23.1856 23.1381 23.4829 23.2663 010128....................................................... 0.8668 0.7670 0.7670 17.9354 21.4201 22.0056 20.5563 010129 h..................................................... 1.0141 0.8076 0.8076 18.7821 21.3555 22.7075 21.0365 010130....................................................... 0.9442 0.8919 0.8919 18.4944 23.2488 24.8205 21.9717 010131....................................................... 1.3884 0.9027 0.9027 24.2197 25.7837 27.7993 26.0170 010137....................................................... 1.2455 0.8919 0.8919 29.7665 24.7366 26.6554 26.9261 010138....................................................... 0.6116 0.7670 0.7670 13.5082 13.8475 14.4665 13.9564 010139....................................................... 1.5878 0.8919 0.8919 24.9410 25.3014 26.7377 25.6921 010143....................................................... 1.1706 0.8919 0.8919 22.1312 22.0215 26.1276 23.4216 010144....................................................... 1.5785 0.7955 0.7955 20.6425 20.8209 22.3801 21.3097 010145....................................................... 1.3931 0.8644 0.8644 23.1976 24.9531 25.7002 24.6568 010146....................................................... 1.1068 0.8040 0.8040 19.9944 20.8917 22.8918 21.2823 010148....................................................... 0.8957 0.7670 0.7670 18.5309 20.5589 23.1208 20.7425 010149....................................................... 1.2762 0.8035 0.8035 23.1593 26.5854 25.2688 24.9404 010150....................................................... 1.0607 0.8035 0.8035 20.6738 21.6377 23.5727 21.9452 010152....................................................... 1.1816 0.7955 0.7955 22.1626 22.6202 23.0833 22.6354 010157....................................................... 1.1543 0.8008 0.8008 21.3574 24.3560 24.4951 23.3774 010158....................................................... 1.1432 0.8220 0.8220 22.4440 24.3531 24.3408 23.6867 010161.......................................................

***

*

* 27.5119

*

* 27.5119 010162.......................................................

***

*

*

*

* 30.6197 30.6197 010164....................................................... 1.1708 0.7978 0.7978

*

*

*

* 010165....................................................... 1.5089 0.9027 0.9027

*

*

*

* 010166....................................................... 1.7090

*

*

*

*

*

* 020001....................................................... 1.6912 1.2062 1.2062 31.6091 32.8120 35.3482 33.3208 020004....................................................... 1.1433 1.0669 1.0669 29.9926 32.0966 31.4487 31.1921 020006....................................................... 1.2733 1.2062 1.2062 33.4210 36.0540 35.6547 35.1161 020008....................................................... 1.2806 1.2062 1.2062 34.5856 35.9236 36.2733 35.6184 020012....................................................... 1.3394 1.1063 1.1063 29.3419 31.8995 32.7496 31.3425 020014....................................................... 1.1853 1.0669 1.0669 32.1233 32.0893 30.0133 31.3617 020017....................................................... 1.9918 1.2062 1.2062 32.9281 33.5852 36.7983 34.4089 020018....................................................... 0.9347 1.9343 1.9343

*

*

*

* 020019....................................................... 0.9039 1.9343 1.9343

*

*

*

* 020020....................................................... 0.8722

*

*

*

*

*

* 020024....................................................... 1.1284 1.0669 1.0669 27.9799 33.0644 29.0436 30.0116 020026....................................................... 1.6273 1.9343 1.9343

*

*

*

* 020027....................................................... 0.8979 1.9343 1.9343

*

*

*

* 030001....................................................... 1.4328 1.0307 1.0307 27.7572 29.9840 33.2450 30.4046 030002....................................................... 2.0991 1.0307 1.0307 27.9628 29.0519 30.2114 29.0057

[[Page 24165]]

030006....................................................... 1.6331 0.9239 0.9239 24.0169 25.8872 26.2503 25.4671 030007....................................................... 1.4120 1.1121 1.1121 26.9442 29.6174 31.2754 29.3738 030009.......................................................

***

*

* 21.4065 22.3992 26.0201 22.5654 030010....................................................... 1.3771 0.9239 0.9239 22.8647 24.8275 28.0899 25.2470 030011....................................................... 1.4547 0.9239 0.9239 22.8422 25.1361 27.5948 25.3205 030012....................................................... 1.3826 0.9858 0.9858 25.5205 26.3859 27.7968 26.6212 030013....................................................... 1.4350 0.9179 0.9179 23.5229 25.7050 27.1721 25.5234 030014....................................................... 1.4890 1.0307 1.0307 25.1189 25.6259 28.4109 26.3536 030016....................................................... 1.2235 1.0307 1.0307 27.1583 26.7003 28.5953 27.4983 030017....................................................... 2.0967 1.0307 1.0307 24.4055 26.2452 31.2902 27.3461 030018....................................................... 1.2445 1.0307 1.0307 24.4308 28.9476 30.0034 27.5160 030019....................................................... 1.3225 1.0307 1.0307 28.4917 27.3156 30.4092 28.8240 030022....................................................... 1.5620 1.0307 1.0307 25.1461 26.4404 30.9356 27.5456 030023....................................................... 1.6994 1.1611 1.1611 28.4112 33.8333 34.3731 32.2119 030024....................................................... 2.0605 1.0307 1.0307 28.3470 31.6658 33.8834 31.3965 030027....................................................... 0.9510

*

* 21.0527 20.4031

* 20.7264 030030....................................................... 1.5508 1.0307 1.0307 24.6005 30.2712 32.7083 29.0268 030033....................................................... 1.2744 1.1121 1.1121 26.6009 26.6531 28.3920 27.2450 030036....................................................... 1.4226 1.0307 1.0307 26.5708 30.3521 31.8947 29.8589 030037....................................................... 2.2721 1.0307 1.0307 30.3907 28.6453 32.1766 30.5501 030038....................................................... 1.6855 1.0307 1.0307 26.5178 29.5509 30.7744 29.0959 030040....................................................... 0.9044 0.9158 0.9158 22.5130 24.8145 27.0303 24.8110 030043....................................................... 1.2719 0.9158 0.9158 26.0825 24.7932 24.7174 25.1254 030044....................................................... 0.8466

*

* 19.5714

*

* 19.5714 030055 h..................................................... 1.4275 1.1417 1.1417 23.1837 24.5202 27.1476 25.0481 030059.......................................................

***

*

* 24.7676

*

* 24.7676 030060....................................................... 1.1831 0.9158 0.9158 22.3551 24.3523 25.0412 23.8848 030061....................................................... 1.6392 1.0307 1.0307 23.4722 25.5529 28.9415 26.0923 030062....................................................... 1.2655 0.9158 0.9158 21.9849 23.8068 26.5482 24.1628 030064....................................................... 1.9610 0.9239 0.9239 24.6732 25.4922 28.3696 26.2797 030065....................................................... 1.6072 1.0307 1.0307 25.6738 27.1646 29.2736 27.4560 030067....................................................... 1.0836 0.9158 0.9158 19.1332 20.4376 20.6472 20.0627 030068....................................................... 1.1530 0.9158 0.9158 19.7030 20.8846 22.1437 20.9244 030069 h..................................................... 1.3792 1.1417 1.1417 25.6243 26.3518 30.5875 27.3999 030071....................................................... 0.9063 1.4448 1.4448

*

*

*

* 030073....................................................... 0.8491 1.4448 1.4448

*

*

*

* 030074....................................................... 0.9153 1.4448 1.4448

*

*

*

* 030077....................................................... 0.8067 1.4448 1.4448

*

*

*

* 030078....................................................... 0.9638 1.4448 1.4448

*

*

*

* 030080....................................................... 1.4675 0.9239 0.9239 24.3573 25.2077 26.8022 25.4224 030083....................................................... 1.3724 1.0307 1.0307 24.9269 27.5353 28.0562 26.8708 030084....................................................... 0.8694 1.4448 1.4448

*

*

*

* 030085....................................................... 1.5851 0.9239 0.9239 23.2070 24.5792 26.3130 24.7847 030087....................................................... 1.6022 1.0307 1.0307 26.3878 26.6594 30.1137 27.8776 030088....................................................... 1.3772 1.0307 1.0307 23.2478 26.6796 28.0619 26.0537 030089....................................................... 1.5203 1.0307 1.0307 26.2166 27.1835 28.3816 27.3548 030092....................................................... 1.4300 1.0307 1.0307 25.4127 27.3203 30.6136 27.9388 030093....................................................... 1.2279 1.0307 1.0307 23.5623 25.8955 27.5072 25.9035 030094....................................................... 1.3717 1.0307 1.0307 26.9985 29.5948 32.6317 29.7783 030099....................................................... 0.8328 0.9158 0.9158 26.7996 26.3236 25.9313 26.3941 030100....................................................... 2.0714 0.9239 0.9239

* 29.0691 29.5931 29.3347 030101 h..................................................... 1.4542 1.1417 1.1417 25.0077 26.1927 27.6535 26.3284 030102....................................................... 2.6166 1.0307 1.0307

* 29.0942 29.6919 29.4041 030103....................................................... 1.6786 1.0307 1.0307 28.2832 30.1994 32.9960 30.4822 030105....................................................... 2.3179 1.0307 1.0307 27.6900 31.3094 31.9342 30.6375 030106....................................................... 1.6852 1.0307 1.0307 30.4791 34.7222 34.0269 32.6905 030107....................................................... 1.9370 1.0307 1.0307

*

* 34.7976 34.7976 030108....................................................... 2.1298 1.0307 1.0307

*

*

*

* 030109....................................................... 2.6413 1.0307 1.0307

*

* 16.7958 16.7958 030110....................................................... 1.4204 1.0307 1.0307

*

* 33.6019 33.6019 030111....................................................... 1.0628 0.9239 0.9239

*

*

*

* 030112....................................................... 1.9419 1.0307 1.0307

*

*

*

* 030113....................................................... 0.9339

*

*

*

*

*

* 030114....................................................... 1.3901

*

*

*

*

*

* 030115....................................................... 1.3316

*

*

*

*

*

* 040001....................................................... 1.0958 0.8779 0.8779 23.1475 23.7718 21.8122 22.8805

[[Page 24166]]

040002....................................................... 1.2276 0.7366 0.7366 19.3429 20.1384 20.4562 20.0058 040003....................................................... 1.2375

*

* 18.5000

*

* 18.5000 040004....................................................... 1.6200 0.8779 0.8779 23.3504 25.0286 26.2802 24.9024 040007....................................................... 1.7125 0.8918 0.8918 23.4565 25.7142 27.2033 25.4311 040010....................................................... 1.3944 0.8779 0.8779 22.0984 23.0274 24.1107 23.1027 040011....................................................... 1.0404 0.7366 0.7366 19.0319 20.3970 20.3176 19.9412 040014....................................................... 1.4709 0.8667 0.8667 24.0846 25.3451 26.0281 25.1431 040015....................................................... 1.0464 0.7366 0.7366 18.0793 19.2831 20.1555 19.1800 040016....................................................... 1.6831 0.8918 0.8918 22.7219 22.1228 25.7321 23.5240 040017....................................................... 1.1298 0.8599 0.8599 19.4365 21.9875 21.3748 20.9608 040018....................................................... 1.0715 0.7761 0.7761 23.8515 23.6044 24.3463 23.9210 040019....................................................... 1.1033 0.9032 0.9032 21.5316 23.7328 24.6250 23.3182 040020....................................................... 1.5722 0.9032 0.9032 20.9136 21.6603 21.9802 21.5335 040021....................................................... 1.2758 0.8918 0.8918 24.7771 25.6917 25.3027 25.2694 040022....................................................... 1.5344 0.8779 0.8779 23.7462 25.4052 27.5251 25.5185 040024....................................................... 0.6960

*

* 20.1101

*

* 20.1101 040026....................................................... 1.5365 0.8812 0.8812 24.3053 25.4072 27.5446 25.8166 040027....................................................... 1.4625 0.8345 0.8345 19.9348 21.1412 21.3991 20.8293 040029....................................................... 1.5492 0.8918 0.8918 22.8770 24.0704 24.4352 23.8327 040032.......................................................

***

*

* 18.5171

*

* 18.5171 040035.......................................................

***

*

* 13.4265

*

* 13.4265 040036....................................................... 1.6193 0.8918 0.8918 24.2851 26.3226 26.7026 25.8362 040039....................................................... 1.2931 0.8206 0.8206 17.7976 19.5998 20.6232 19.3622 040041....................................................... 1.1459 0.8667 0.8667 22.0188 22.1531 22.7230 22.3095 040042....................................................... 1.3639 0.9367 0.9367 18.9550 19.9627 20.6357 19.8706 040045....................................................... 0.9944

*

* 18.7952 17.2280

* 17.9500 040047....................................................... 1.1045 0.8206 0.8206 21.5334 21.9163 22.7571 22.0400 040050....................................................... 1.1711 0.7366 0.7366 15.4782 16.3930 17.6674 16.5402 040051....................................................... 0.9556 0.7366 0.7366 18.8943 19.1401

* 19.0196 040053....................................................... 1.0141

*

* 20.8153 20.7824

* 20.7984 040054....................................................... 1.1450 0.7366 0.7366 16.7370 18.2684 17.8810 17.6265 040055....................................................... 1.6026 0.7761 0.7761 22.2237 23.3156 22.5541 22.7083 040062....................................................... 1.7081 0.7761 0.7761 21.6403 23.3083 23.6394 22.8746 040066.......................................................

***

*

* 23.4616

*

* 23.4616 040067....................................................... 1.0279 0.7366 0.7366 15.1441 16.8799 18.6028 16.7821 040069....................................................... 1.0422 0.9032 0.9032 21.7607 24.4662 24.3733 23.5051 040071....................................................... 1.4755 0.8667 0.8667 22.9350 24.3824 24.5703 23.9588 040072....................................................... 1.0619 0.7366 0.7366 20.8269 19.9009 21.6484 20.7448 040074....................................................... 1.1734 0.8918 0.8918 22.6147 25.2423 24.6178 24.0892 040075....................................................... 0.9567

*

* 16.2583 18.3254

* 17.2857 040076....................................................... 1.0182 0.8667 0.8667 21.0442 20.6272 23.0707 21.5644 040077....................................................... 0.9726

*

* 18.3261 18.2082

* 18.2646 040078....................................................... 1.6359 0.8812 0.8812 24.4589 24.5378 23.6641 24.2102 040080....................................................... 1.0378 0.7952 0.7952 21.3483 22.3392 23.4566 22.4402 040081....................................................... 0.8376 0.7366 0.7366 13.7148 15.1081 15.4211 14.7485 040084....................................................... 1.1802 0.8918 0.8918 22.6441 24.7225 27.5794 25.0806 040085....................................................... 1.0444 0.7366 0.7366 18.0756 29.8444 22.6181 22.5790 040088....................................................... 1.3259 0.8715 0.8715 21.2974 22.6183 23.0136 22.3299 040091....................................................... 1.2045 0.8133 0.8133 23.0252 23.1320 24.5553 23.5683 040100....................................................... 1.3571 0.8667 0.8667 19.3560 20.0460 20.9265 20.1488 040105....................................................... 1.0217

*

* 15.8171 18.2182

* 16.9121 040109....................................................... 1.1287

*

* 18.8624 22.8801

* 20.7540 040114....................................................... 1.7651 0.8918 0.8918 23.5628 24.8992 26.3883 24.9878 040118....................................................... 1.4456 0.7952 0.7952 24.2547 24.7363 25.7793 24.8977 040119....................................................... 1.4191 0.8667 0.8667 20.1631 21.0103 23.4451 21.5482 040126....................................................... 0.8957

*

* 12.5944 14.0701 15.4020 13.9828 040132.......................................................

***

*

* 36.5525 28.1390

* 32.3748 040134....................................................... 2.4406 0.8918 0.8918

* 27.3412 30.4316 28.9159 040137....................................................... 1.3274 0.8918 0.8918 23.4672 25.2907 26.4443 25.0310 040138....................................................... 1.3548 0.8779 0.8779 23.3615 25.7513 28.5258 26.2151 040140.......................................................

***

*

* 25.1224

*

* 25.1224 040141....................................................... 0.8243 0.8779 0.8779

* 24.0901 26.4956 25.3872 040142....................................................... 1.4333 0.8812 0.8812

* 27.9695 22.2893 24.7923 040143.......................................................

***

*

*

*

* 35.7717 35.7717 040144.......................................................

***

*

*

*

* 21.0608 21.0608 040145....................................................... 1.7845 0.7952 0.7952

*

*

*

*

[[Page 24167]]

040147....................................................... 1.6530

*

*

*

*

*

* 040302....................................................... 0.7642

*

*

*

*

*

* 040323....................................................... 0.6969

*

*

*

*

*

* 040324....................................................... 0.8299

*

*

*

*

*

* 050002....................................................... 1.3835 1.5669 1.5669 31.9709 34.1948 36.4919 34.3441 050006....................................................... 1.6033 1.2884 1.2884 27.6176 30.5373 34.9121 30.7219 050007....................................................... 1.4652 1.5049 1.5049 37.5804 38.7033 43.7992 40.0756 050008....................................................... 1.3291 1.5075 1.5075 36.9371 39.1539 44.3345 40.2397 050009....................................................... 1.7796 1.4527 1.4527 35.5384 39.6393 44.6602 40.0554 050013....................................................... 1.9303 1.4527 1.4527 31.7637 31.9837 36.6624 33.4866 050014....................................................... 1.1619 1.3350 1.3350 29.5726 33.0373 34.2931 32.4016 050015....................................................... 1.2530 1.1291 1.1291 30.1398 30.7940 32.9364 31.3257 050016....................................................... 1.3081 1.1719 1.1719 25.5735 26.2162 25.0655 25.5928 050017....................................................... 2.0744 1.3350 1.3350 30.5863 36.6593 41.3084 36.1871 050018....................................................... 1.1775 1.1762 1.1762 20.3179 22.3472 23.5749 22.0407 050022....................................................... 1.5578 1.1291 1.1291 28.2773 29.8632 32.3919 30.2730 050024....................................................... 1.1455 1.1371 1.1371 26.9378 27.5587 29.6260 28.0641 050025....................................................... 1.9363 1.1371 1.1371 31.7242 36.1622 34.1382 34.0294 050026....................................................... 1.5437 1.1371 1.1371 26.6406 28.3027 32.1634 29.1587 050028....................................................... 1.2579 1.1291 1.1291 21.5448 26.6160 27.9303 24.9072 050029.......................................................

***

*

* 34.3934

*

* 34.3934 050030....................................................... 1.2571 1.1291 1.1291 22.9148 24.9707 27.3246 25.0300 050036....................................................... 1.6518 1.1291 1.1291 27.4915 32.7929 33.9665 31.5046 050038....................................................... 1.5557 1.5281 1.5281 35.0441 38.7527 42.3234 38.7342 050039....................................................... 1.6694 1.1291 1.1291 29.8179 31.6734 35.2640 32.1617 050040....................................................... 1.3231 1.1762 1.1762 31.8983 34.3279 35.1377 33.7788 050042....................................................... 1.4842 1.2884 1.2884 29.8062 33.9415 39.2888 34.3247 050043....................................................... 1.6420 1.5669 1.5669 39.6054 43.1589 46.8909 43.1599 050045....................................................... 1.2924 1.1291 1.1291 22.7051 23.8408 25.5028 24.0609 050046....................................................... 1.1753 1.1739 1.1603 25.2786 25.6875 27.3051 26.1065 050047....................................................... 1.7513 1.5075 1.5075 39.3993 40.9874 45.6968 42.1673 050054....................................................... 1.2085 1.1291 1.1291 27.1437 24.1262 21.5112 24.0692 050055....................................................... 1.2513 1.5075 1.5075 36.9386 37.5879 44.0022 39.3279 050056....................................................... 1.3372 1.1762 1.1762 29.4829 27.9330 30.8781 29.4498 050057....................................................... 1.6796 1.1291 1.1291 26.2099 29.4351 29.9720 28.5742 050058....................................................... 1.5522 1.1762 1.1762 27.3584 33.8215 34.2823 31.7862 050060....................................................... 1.5248 1.1291 1.1291 26.5515 27.3282 29.5772 27.8373 050061.......................................................

***

*

*

* 32.2172

* 32.2172 050063....................................................... 1.3301 1.1762 1.1762 32.0515 33.3039 35.3038 33.4928 050065....................................................... 1.8339 1.1600 1.1603 33.8223 34.0280 35.1370 34.3436 050067....................................................... 1.1518 1.1731 1.1731 29.6982 31.9597 34.7752 32.3897 050069....................................................... 1.6789 1.1600 1.1603 28.6752 31.2172 34.9317 31.6324 050070....................................................... 1.3261 1.5049 1.5049 40.5645 45.3382 49.7618 45.6981 050071....................................................... 1.2702 1.5669 1.5669 41.1036 44.9464 51.5757 46.4017 050072....................................................... 1.2617 1.5669 1.5669 40.8108 44.2651 50.8845 45.8517 050073....................................................... 1.2713 1.5669 1.5669 41.3430 45.9765 51.3203 46.7321 050075....................................................... 1.1620 1.5669 1.5669 43.7101 47.2356 55.9906 49.6104 050076....................................................... 1.6785 1.5669 1.5669 43.0845 46.4990 53.7174 48.3873 050077....................................................... 1.5579 1.1371 1.1371 29.6264 32.0245 34.5870 32.2078 050078....................................................... 1.2213 1.1762 1.1762 25.6814 31.1425 32.6611 29.5911 050079....................................................... 1.5002 1.5669 1.5669 42.7385 47.8597 49.6550 46.8148 050082....................................................... 1.6455 1.1739 1.1603 28.9139 37.7783 40.5118 36.0157 050084....................................................... 1.5694 1.2038 1.2038 28.2664 33.0179 35.8900 32.2531 050088.......................................................

***

*

* 26.4093 25.7385

* 26.0862 050089....................................................... 1.3345 1.1600 1.1603 29.4884 33.5323 35.0765 32.7927 050090....................................................... 1.2940 1.5049 1.5049 31.1774 32.9584 34.1010 32.7532 050091....................................................... 1.1259 1.1762 1.1762 30.1534 30.8560 32.2866 31.1304 050093....................................................... 1.5086 1.1291 1.1291 31.1083 33.4119 36.3766 33.6827 050096....................................................... 1.2678 1.1762 1.1762 24.2277 24.6680 29.0265 26.0314 050097.......................................................

***

*

* 26.6788

*

* 26.6788 050099....................................................... 1.5000 1.1600 1.1603 28.7711 31.0437 34.0709 31.4119 050100....................................................... 1.8497 1.1371 1.1371 28.0303 29.6949 32.1909 30.0363 050101....................................................... 1.3351 1.5669 1.5669 35.4655 40.3195 42.6624 39.6163 050102....................................................... 1.3060 1.1291 1.1291 24.9381 29.1364 32.5557 28.7040 050103....................................................... 1.5640 1.1762 1.1762 28.7375 34.2529 34.1636 32.4158 050104....................................................... 1.3813 1.1762 1.1762 29.1240 29.7326 33.2730 30.7456

[[Page 24168]]

050107....................................................... 1.4706 1.1291 1.1291 27.6002 33.1358 32.9560 31.1819 050108....................................................... 1.9403 1.3350 1.3350 31.4271 35.5711 40.0597 35.9841 050110....................................................... 1.2736 1.1291 1.1291 20.0769 26.1453 27.0752 24.1400 050111....................................................... 1.3212 1.1762 1.1762 26.6345 28.1588 27.7673 27.5460 050112....................................................... 1.5308 1.1762 1.1762 34.0258 36.8026 37.1212 36.0398 050113....................................................... 1.3140 1.5049 1.5049 34.2851 33.8064 38.7793 35.6638 050114....................................................... 1.4334 1.1762 1.1762 29.2858 31.1294 33.7817 31.4992 050115....................................................... 1.4811 1.1371 1.1371 27.5207 30.9288 29.7825 29.4457 050116....................................................... 1.6951 1.1762 1.1762 28.8193 34.5110 37.0771 33.5192 050117....................................................... 2.3561 1.1884 1.1884 28.2227 32.4414 34.3628 31.0394 050118....................................................... 1.1866 1.1731 1.1731 33.0650 35.4044 40.0173 36.1567 050121....................................................... 1.2724 1.1291 1.1291 25.5962 27.9537 30.3495 28.0779 050122....................................................... 1.5554 1.2038 1.2038 29.7629 34.2416 33.7869 32.6896 050124....................................................... 1.3010 1.1762 1.1762 26.7065 28.0288 29.6897 28.1843 050125....................................................... 1.3922 1.5281 1.5281 40.9218 41.7020 40.7957 41.1327 050126....................................................... 1.4204 1.1762 1.1762 29.6203 29.3360 32.5210 30.5081 050127....................................................... 1.3341 1.3350 1.3350 23.6208 26.1222 33.3619 26.9264 050128....................................................... 1.5385 1.1371 1.1371 28.3278 31.0662 32.3557 30.6445 050129....................................................... 1.7922 1.1600 1.1603 27.8488 32.2680 36.3489 32.4090 050131....................................................... 1.3140 1.5082 1.5082 38.6834 40.5321 46.3164 41.7664 050132....................................................... 1.3868 1.1762 1.1762 29.4317 35.1544 37.0147 33.9609 050133....................................................... 1.4974 1.1461 1.1461 27.6030 31.3530 32.6669 30.5790 050135....................................................... 1.0165 1.1762 1.1762 24.9415 24.3927 22.8053 23.8553 050136....................................................... 1.2848 1.5049 1.5049 35.2834 37.4560 43.2698 38.6465 050137....................................................... 1.2925 1.1762 1.1762 36.5409 38.4827 40.4779 38.6009 050138....................................................... 2.1552 1.1762 1.1762 43.8671 46.9557 47.6585 46.1884 050139....................................................... 1.3295 1.1762 1.1762 35.1013 37.6217 39.0103 37.2783 050140....................................................... 1.4309 1.1600 1.1603 37.5473 39.6269 42.1233 39.8915 050144....................................................... 1.3888 1.1762 1.1762 32.4042 33.5109 34.0982 33.3800 050145....................................................... 1.3655 1.4457 1.4457 39.5676 42.3134 48.1345 43.3982 050148....................................................... 1.0959 1.1291 1.1291 24.7063 27.3005 28.8900 27.0245 050149....................................................... 1.4738 1.1762 1.1762 30.1596 33.2270 37.1830 33.9364 050150....................................................... 1.2309 1.3350 1.3350 31.5333 31.7560 33.9978 32.4639 050152....................................................... 1.4829 1.5075 1.5075 40.3464 43.6487 46.4718 43.5222 050153....................................................... 1.5515 1.5281 1.5281 40.4446 43.3190 43.6382 42.5499 050155.......................................................

***

*

* 21.8829 21.8550 16.9856 19.9780 050158....................................................... 1.3045 1.1762 1.1762 33.6400 35.1326 35.7746 34.9077 050159....................................................... 1.2085 1.1739 1.1603 30.8069 31.3199 32.3724 31.5413 050167....................................................... 1.2968 1.2038 1.2038 25.9850 28.5179 30.6646 28.3647 050168....................................................... 1.6582 1.1600 1.1603 30.8036 33.2506 36.3166 33.5327 050169....................................................... 1.4331 1.1762 1.1762 26.2864 27.4644 30.0990 28.0689 050172....................................................... 1.2604 1.1291 1.1291 27.1497 28.5604 25.7654 27.0886 050173....................................................... 1.2462 1.1600 1.1603 27.6097 30.3582 29.5083 29.1194 050174....................................................... 1.6356 1.5049 1.5049 36.3117 40.1747 43.9133 40.1381 050175....................................................... 1.2512 1.1762 1.1762 31.5615 30.5733 33.4885 31.8687 050177.......................................................

***

*

* 24.7531 25.1442 24.8662 24.9253 050179....................................................... 1.2173 1.1731 1.1731 25.8072 27.1155 30.1673 27.9651 050180....................................................... 1.5914 1.5669 1.5669 40.8101 40.2504 38.1691 39.6057 050188....................................................... 1.4277 1.5281 1.5281 39.3507 39.5110 41.5956 40.1682 050189....................................................... 1.0446 1.4457 1.4457 20.0709 29.1280 29.5245 26.1888 050191....................................................... 1.5168 1.1762 1.1762

* 34.2091 38.9681 36.4880 050192....................................................... 1.0079 1.1291 1.1291 21.2448 27.0424 27.1667 25.1695 050193....................................................... 1.2523 1.1600 1.1603 30.7341 29.6421 34.2248 31.5406 050194....................................................... 1.3621 1.5509 1.5509 38.6750 40.9096 45.2123 41.6588 050195....................................................... 1.5019 1.5669 1.5669 43.9696 48.4358 50.0403 47.5753 050196....................................................... 1.0951 1.1291 1.1291 25.2168 32.1933 33.9150 30.7046 050197....................................................... 2.0347 1.5669 1.5669 40.8832 48.9052 51.0016 46.9043 050204....................................................... 1.4560 1.1762 1.1762 25.2512 28.6423 32.1731 28.6226 050205....................................................... 1.4361 1.1762 1.1762 28.0504 27.8611 29.2978 28.4343 050207....................................................... 1.2589 1.1291 1.1291 27.0216 29.5215 30.5777 28.9980 050211....................................................... 1.2871 1.5669 1.5669 38.3319 41.2166 37.1447 38.8162 050214.......................................................

***

*

* 24.4785 23.9972 25.6142 24.6874 050215....................................................... 1.8301 1.5281 1.5281 41.6886 43.7985 43.1523 42.9010 050217....................................................... 1.2241

*

* 23.6286

*

* 23.6286 050219....................................................... 1.1942 1.1762 1.1762 22.9226 22.4065 26.6745 24.0446 050222....................................................... 1.6433 1.1371 1.1371 26.3882 29.1094 32.9502 29.6111

[[Page 24169]]

050224....................................................... 1.6708 1.1600 1.1603 26.7916 29.3143 28.8640 28.3306 050225....................................................... 1.4668 1.1291 1.1291 29.5184 29.9656 34.0444 31.2944 050226....................................................... 1.5929 1.1600 1.1603 29.2259 30.5867 33.2724 31.0874 050228....................................................... 1.3599 1.5669 1.5669 40.1362 42.4226 42.9194 41.8170 050230....................................................... 1.4695 1.1600 1.1603 34.1417 32.9555 35.0745 34.0630 050231....................................................... 1.6381 1.1762 1.1762 30.1298 30.9607 32.4202 31.1914 050232....................................................... 1.6137 1.1719 1.1719 24.4383 27.4099 27.6649 26.4468 050234....................................................... 1.2181 1.1371 1.1371 29.2421 29.6560 32.7366 30.5308 050235....................................................... 1.5375 1.1762 1.1762 27.8965 29.2979 32.4385 29.8741 050236....................................................... 1.3795 1.1739 1.1603 28.1969 32.1647 34.3346 31.5469 050238....................................................... 1.4857 1.1762 1.1762 29.1481 31.1764 32.8459 31.1416 050239....................................................... 1.5990 1.1762 1.1762 28.2327 31.0963 34.5993 31.3400 050240....................................................... 1.6409 1.1762 1.1762 35.2284 35.5735 36.3640 35.7323 050242....................................................... 1.3786 1.5509 1.5509 39.7629 44.3130 47.8288 44.0747 050243....................................................... 1.5396 1.1291 1.1291 31.8153 31.4883 33.3571 32.2620 050245....................................................... 1.3396 1.1600 1.1603 27.0949 28.6527 26.3353 27.3622 050248....................................................... 1.0135 1.4457 1.4457 31.6240 35.3864 32.9444 33.3125 050251....................................................... 1.0330 1.1524 1.1524 26.5021 27.2675 28.5383 27.5142 050253.......................................................

***

*

* 22.2450 24.0044 23.7595 23.2530 050254....................................................... 1.2518 1.3350 1.3350 24.1512 27.0041 30.9210 27.4105 050256....................................................... 1.6462 1.1762 1.1762 28.4728 29.8194 30.3954 29.5443 050257....................................................... 0.9608 1.1291 1.1291 20.8367 21.3216 18.4749 20.0450 050261....................................................... 1.3115 1.1291 1.1291 25.3005 27.3234 28.7777 27.2755 050262....................................................... 2.0841 1.1762 1.1762 36.1162 44.0256 39.3464 39.8642 050264....................................................... 1.3655 1.5669 1.5669 41.3478 41.1211 46.2652 42.9907 050267.......................................................

***

*

* 26.7060

*

* 26.7060 050270....................................................... 0.8638 1.1371 1.1371 30.0540 32.4812 34.4844 32.3873 050272....................................................... 1.3545 1.1600 1.1603 25.9103 27.1989 29.5863 27.5860 050276....................................................... 1.2458 1.5669 1.5669 41.2251 39.3778 41.0210 40.5582 050277....................................................... 1.0130 1.1762 1.1762 35.8246 32.5213 35.8637 34.5741 050278....................................................... 1.5373 1.1762 1.1762 28.0351 29.9244 32.1019 30.1313 050279....................................................... 1.1861 1.1600 1.1603 25.5299 27.6573 29.7339 27.6818 050280....................................................... 1.6912 1.3205 1.3205 30.6723 35.2030 40.9920 35.5779 050281....................................................... 1.4270 1.1762 1.1762 26.2623 27.3824 28.5186 27.3907 050283....................................................... 1.4222 1.5669 1.5669 38.5600 43.0638 44.5318 42.1410 050286.......................................................

***

*

* 19.4973

*

* 19.4973 050289....................................................... 1.6421 1.5049 1.5049 38.6875 41.1774 42.7353 40.9116 050290....................................................... 1.5832 1.1762 1.1762 32.6388 34.5482 38.0526 35.1131 050291....................................................... 1.8467 1.5049 1.5049 29.6162 35.3653 39.7762 34.7389 050292....................................................... 1.0868 1.1291 1.1291 27.0775 26.8879 25.7186 26.5226 050295....................................................... 1.4657 1.1291 1.1291 31.5960 36.1950 35.7270 34.7452 050296....................................................... 1.1664 1.5281 1.5281 34.9952 39.0061 42.1606 38.8925 050298....................................................... 1.1617 1.1600 1.1603 25.8232 27.7416 29.5427 27.7148 050299....................................................... 1.3599 1.1762 1.1762 27.7535 31.5435 35.3234 31.7208 050300....................................................... 1.4966 1.1600 1.1603 28.3862 30.7148 30.9822 30.1038 050301....................................................... 1.3290 1.1291 1.1291 28.5769 31.9995 33.4929 31.4366 050305....................................................... 1.4188 1.5669 1.5669 40.9978 44.8630 47.4120 44.4443 050308....................................................... 1.4727 1.5281 1.5281 38.0564 43.0691 45.3244 42.1179 050309....................................................... 1.4190 1.3350 1.3350 28.9181 34.4145 39.0822 34.4798 050312.......................................................

***

*

* 32.6846 33.9022 39.2083 34.8872 050313....................................................... 1.2280 1.2038 1.2038 27.5321 31.8003 36.4300 32.2898 050315....................................................... 1.3061 1.1291 1.1291 26.1224 28.5933 32.5499 29.2160 050320....................................................... 1.2485 1.5669 1.5669 36.3252 40.2352 44.1674 40.1172 050324....................................................... 1.8751 1.1371 1.1371 30.9958 32.9792 35.1320 33.2026 050325....................................................... 1.1433 1.1467 1.1467 30.2280 30.6117 30.2526 30.3712 050327....................................................... 1.7507 1.1600 1.1603 29.8327 33.0087 35.2380 32.7821 050329....................................................... 1.2606 1.1291 1.1291 26.8021 26.2120 23.5644 25.4937 050331....................................................... 1.2324

*

* 20.9847 20.2692 0.0000 20.6171 050333....................................................... 1.1135 1.1291 1.1291 15.3119 23.4009 19.6469 18.9090 050334....................................................... 1.6725 1.4457 1.4457 38.7635 40.7467 44.4184 41.3547 050335....................................................... 1.4631 1.1467 1.1467 27.4046 28.9403 33.3349 29.9569 050336....................................................... 1.2386 1.2038 1.2038 25.3062 28.5659 30.4356 28.1945 050342....................................................... 1.2404 1.1291 1.1291 24.7654 26.8507 29.5020 27.1298 050348....................................................... 1.7064 1.1600 1.1603 33.2676 37.7898 31.6594 34.1821 050349....................................................... 0.9631 1.1291 1.1291 16.9251 17.4791 17.5811 17.3402 050350....................................................... 1.3701 1.1762 1.1762 29.4262 31.1833 31.8456 30.8831

[[Page 24170]]

050351....................................................... 1.5271 1.1762 1.1762 29.3082 30.8661 30.9044 30.3838 050352....................................................... 1.3579 1.3350 1.3350 24.2931 33.9362 36.5470 31.4422 050353....................................................... 1.5360 1.1762 1.1762 26.6332 31.8291 29.8341 29.3493 050355.......................................................

***

*

* 11.2498

*

* 11.2498 050357....................................................... 1.4425 1.1291 1.1291 26.7265 32.3095 33.8000 30.4700 050359....................................................... 1.2211 1.1291 1.1291 23.6030 25.7739 28.7656 26.1226 050360....................................................... 1.5358 1.5082 1.5082 38.8658 37.0769 48.6833 41.5316 050366....................................................... 1.2149 1.1291 1.1291 25.7692 31.1854 34.7036 30.3816 050367....................................................... 1.4299 1.5669 1.5669 34.4959 38.7727 39.7345 38.0017 050369....................................................... 1.4248 1.1762 1.1762 27.1327 29.5697 31.1003 29.2945 050373....................................................... 1.3683 1.1762 1.1762 32.2315 31.9271 33.6616 32.6188 050376....................................................... 1.5389 1.1762 1.1762 30.7562 32.9393 33.4664 32.3997 050377.......................................................

***

*

* 20.2484

*

* 20.2484 050378....................................................... 0.9845 1.1762 1.1762 33.9087 34.2417 34.9267 34.3818 050379.......................................................

***

*

* 31.7645 32.9575

* 32.3515 050380....................................................... 1.6161 1.5281 1.5281 39.1098 42.0782 47.6500 42.7763 050382....................................................... 1.3883 1.1762 1.1762 26.0927 29.4323 30.3595 28.6792 050385....................................................... 1.3188 1.5049 1.5049 25.5735 34.5184 37.1708 32.3860 050390....................................................... 1.1686 1.1291 1.1291 28.7761 26.0066 28.4859 27.6662 050391.......................................................

***

*

* 21.3012 18.1004 17.3151 18.6962 050392....................................................... 1.2184

*

* 22.7209

*

* 22.7209 050393....................................................... 1.4363 1.1762 1.1762 28.2369 30.0661 33.7433 30.5690 050394....................................................... 1.5925 1.1739 1.1603 26.0074 27.5061 28.6006 27.4286 050396....................................................... 1.5970 1.1291 1.1291 30.5470 33.5699 33.2548 32.4895 050397....................................................... 0.8840 1.1291 1.1291 27.4716 28.1640 26.3981 27.3054 050407....................................................... 1.1776 1.5075 1.5075 35.6035 37.9066 41.8534 38.5688 050410.......................................................

***

*

* 19.4995 21.3814

* 20.4290 050411....................................................... 1.4503 1.1762 1.1762 37.3817 37.8064 39.9558 38.4595 050414....................................................... 1.2989 1.3350 1.3350 28.8561 34.6672 40.1702 34.4823 050417....................................................... 1.2539 1.1291 1.1291 25.2930 29.5031 35.5015 30.1379 050419....................................................... 1.3384

*

* 28.4471 33.3125

* 30.8677 050420....................................................... 1.1790 1.1762 1.1762 26.1838 24.9401 35.6349 28.5400 050423....................................................... 0.9624 1.1291 1.1291 28.5944 30.6416 27.2663 28.9029 050424....................................................... 2.0096 1.1371 1.1371 29.9133 31.0730 34.8883 32.0453 050425....................................................... 1.3417 1.3350 1.3350 38.5317 42.4177 49.8051 44.1546 050426....................................................... 1.3805 1.1600 1.1603 30.0077 30.6899 33.7075 31.4665 050430....................................................... 0.9578 1.1524 1.1524 24.6684 25.0607 24.1967 24.5819 050432....................................................... 1.6517 1.1762 1.1762 30.3547 30.8030 33.3848 31.5269 050433....................................................... 0.9334 1.1291 1.1291 20.7565 23.0806 21.8447 21.8898 050434....................................................... 1.1118 1.1291 1.1291 25.9506 26.1621 31.5749 28.1756 050435....................................................... 1.1492 1.1371 1.1371 32.2183 28.0306 30.8458 30.2661 050438....................................................... 1.5756 1.1762 1.1762 26.4668 27.2662 35.3830 29.8308 050441....................................................... 1.9802 1.5281 1.5281 38.2823 42.9765 45.2125 42.1714 050444....................................................... 1.3356 1.1884 1.1884 27.6971 30.5504 34.8554 31.2912 050447....................................................... 0.9565 1.1371 1.1371 21.8552 25.2573 27.5371 24.9581 050448....................................................... 1.2766 1.1291 1.1291 25.0983 27.9759 29.4935 27.5949 050454....................................................... 1.8575 1.5075 1.5075 36.8383 43.5311 39.2067 39.9010 050455....................................................... 1.5997 1.1291 1.1291 24.5314 22.7235 27.9979 25.1532 050456....................................................... 1.1131 1.1762 1.1762 22.1675 22.5630 21.7036 22.0233 050457....................................................... 1.6072 1.5075 1.5075 40.2725 45.5829 47.8507 44.5817 050464....................................................... 1.6871 1.1731 1.1731 37.1342 37.3692 39.4867 37.9820 050468....................................................... 1.4951 1.1762 1.1762 29.4280 29.5448 28.0800 28.9842 050469....................................................... 1.1606 1.1291 1.1291 27.3281 28.9079 30.0283 28.7511 050470....................................................... 1.0676 1.1291 1.1291 18.4689 24.6755 27.9194 24.0596 050471....................................................... 1.7588 1.1762 1.1762 34.5484 34.5211 36.7915 35.2853 050476....................................................... 1.4381 1.1548 1.1548 30.9974 34.6585 36.3598 33.8764 050477....................................................... 1.3548 1.1762 1.1762 34.6400 34.6995 38.0704 35.8949 050478....................................................... 1.0037 1.1291 1.1291 30.9865 33.3998 35.2408 33.2560 050481....................................................... 1.4293 1.1762 1.1762 31.9177 33.7446 37.8839 34.5090 050485....................................................... 1.6324 1.1762 1.1762 28.8459 31.4233 36.5912 32.2964 050488....................................................... 1.3306 1.5669 1.5669 40.5313 42.9904 44.2163 42.6485 050491.......................................................

***

*

* 30.6461 32.1379 34.6829 32.1991 050492....................................................... 1.5281 1.1291 1.1291 27.4933 27.1540 28.5116 27.7452 050494....................................................... 1.4219 1.4294 1.1607 35.1457 35.9909 39.9419 37.0297 050496....................................................... 1.7826 1.5669 1.5669 38.2871 42.2672 43.6264 41.5275 050497.......................................................

***

*

* 15.9501

*

* 15.9501

[[Page 24171]]

050498....................................................... 1.3331 1.3350 1.3350 28.2667 33.0298 38.4968 33.2353 050502....................................................... 1.7102 1.1762 1.1762 28.7200 29.5615 29.5347 29.2993 050503....................................................... 1.4527 1.1371 1.1371 29.2001 31.6418 34.6646 31.9860 050506....................................................... 1.6799 1.1719 1.1719 32.4509 36.0164 39.2455 36.0522 050510....................................................... 1.1963 1.5669 1.5669 44.3883 47.5510 53.3925 48.9441 050512....................................................... 1.2973 1.5669 1.5669 41.8921 46.9233 52.5188 47.8701 050515....................................................... 1.3889 1.1371 1.1371 37.4251 38.9978 40.9092 39.1963 050516....................................................... 1.4805 1.3350 1.3350 29.4936 36.2772 41.3786 35.5878 050517....................................................... 1.2150 1.1600 1.1603 23.6034 23.9007 20.4043 22.4083 050523....................................................... 1.3334 1.5669 1.5669 34.7491 35.5452 33.8904 34.6993 050526....................................................... 1.2525 1.1600 1.1603 29.9495 31.3744 28.6212 29.8713 050528....................................................... 1.1675 1.1291 1.1291 28.6273 29.6838 30.6464 29.7397 050531....................................................... 1.0277 1.1762 1.1762 25.0157 26.9420 27.4627 26.4967 050534....................................................... 1.4487 1.1291 1.1291 29.7546 29.8603 33.2952 30.9702 050535....................................................... 1.4985 1.1600 1.1603 32.3646 32.3723 34.8889 33.3056 050537....................................................... 1.4722 1.3350 1.3350 27.4196 31.3844 36.4258 31.8666 050539....................................................... 1.2551

*

* 28.0586 29.8242

* 29.0033 050541....................................................... 1.3930 1.5669 1.5669 43.7765 46.1121 53.9701 48.2244 050543....................................................... 0.7326 1.1600 1.1603 25.7161 26.1103 26.9874 26.2597 050545....................................................... 0.7166 1.1762 1.1762 42.9451 30.5554 31.4513 35.1847 050546....................................................... 0.7168 1.1291 1.1291 52.7180 30.2329 33.9577 38.6191 050547....................................................... 0.9861 1.5049 1.5049 45.1842 33.2205 34.4268 37.9709 050548....................................................... 0.7147 1.1600 1.1603 37.1314 30.3775 33.5332 34.1652 050549....................................................... 1.5821 1.4294 1.1603 33.8288 34.9818 36.8840 35.2563 050550....................................................... 1.3092 1.1600 1.1603 31.1918 30.2302 31.3077 30.9052 050551....................................................... 1.3263 1.1600 1.1603 31.6782 31.6165 34.6310 32.6691 050552....................................................... 1.0959 1.1762 1.1762 26.8274 27.1744 31.8084 28.6605 050557....................................................... 1.5467 1.1731 1.1731 28.3111 31.8048 31.8447 30.7712 050559.......................................................

***

*

* 26.9662

*

* 26.9662 050561....................................................... 1.2629 1.1762 1.1762 37.5863 38.8651 39.1626 38.5888 050567....................................................... 1.5546 1.1600 1.1603 30.1167 32.9829 36.4373 33.2519 050568....................................................... 1.1828 1.1353 1.1353 22.5008 24.4061 24.1895 23.7155 050569....................................................... 1.2260 1.4294 1.4294 30.4874 33.0259 34.1734 32.6118 050570....................................................... 1.5499 1.1600 1.1603 32.6896 34.0171 35.5233 34.1290 050571....................................................... 1.2097 1.1762 1.1762 32.1656 33.6156 34.9236 33.5914 050573....................................................... 1.6925 1.1291 1.1291 30.5249 34.1991 35.5274 33.4579 050575....................................................... 1.1724 1.1762 1.1762 23.2447 25.2513 25.2933 24.6933 050577.......................................................

***

*

* 28.7060 30.8841 32.5645 30.7682 050578....................................................... 1.4960 1.1762 1.1762 31.5953 33.8825 37.2259 34.1510 050579.......................................................

***

*

* 40.2740 39.4976 42.9387 40.7876 050580....................................................... 1.2568 1.1600 1.1603 29.4337 31.6256 33.1490 31.4028 050581....................................................... 1.4088 1.1762 1.1762 32.0823 32.1801 35.0108 33.1503 050583....................................................... 1.6923 1.1371 1.1371 33.5209 33.3697 35.7392 34.1719 050584....................................................... 1.4362 1.1600 1.1603 24.5757 24.8180 28.8553 26.1102 050585....................................................... 1.2218 1.1600 1.1603 27.2982 22.7121 22.4887 23.8337 050586....................................................... 1.2754 1.1600 1.1603 25.3551 27.4173 26.3755 26.3132 050588....................................................... 1.2773 1.1762 1.1762 32.3603 32.8212 33.0991 32.7769 050589....................................................... 1.2077 1.1600 1.1603 30.6273 30.9547 35.0014 32.2283 050590....................................................... 1.3770 1.3350 1.3350 31.5987 32.2142 39.4654 34.5389 050591....................................................... 1.1729 1.1762 1.1762 28.5915 28.8549 30.9334 29.4952 050592....................................................... 1.1345 1.1600 1.1603 32.5000 24.4542 27.7236 27.9860 050594....................................................... 1.9344 1.1600 1.1603 34.6747 34.7946 36.8272 35.4259 050597....................................................... 1.2248 1.1762 1.1762 25.4868 27.5691 29.5797 27.5512 050599....................................................... 1.9037 1.3350 1.3350 30.8420 38.1975 33.8834 34.3184 050601....................................................... 1.5196 1.1762 1.1762 35.0325 34.7409 36.6564 35.4896 050603....................................................... 1.3875 1.1600 1.1603 28.6982 30.2464 34.1227 31.1484 050604....................................................... 1.2051 1.5281 1.5281 45.4433 49.9429 56.4414 51.0552 050608....................................................... 1.3413 1.1291 1.1291 22.1999 23.3630 25.9073 23.7863 050609....................................................... 1.3376 1.1600 1.1603 38.4561 41.1797 43.2731 41.0915 050613....................................................... 1.0079 1.5049 1.5049

*

* 45.7255 45.7255 050615....................................................... 1.1030 1.1762 1.1762 32.8786 33.2909 36.1435 34.1052 050616....................................................... 1.3862 1.1739 1.1603 28.5636 36.9017 39.1701 35.1520 050618....................................................... 0.9803 1.1291 1.1291 25.4500 27.4539 30.9826 28.0403 050623.......................................................

***

*

* 29.6550 32.0627

* 30.7447 050624....................................................... 1.2767 1.1762 1.1762 28.1941 32.2907 34.8735 31.8503 050625....................................................... 1.7608 1.1762 1.1762 33.5137 36.3631 38.7997 36.2505

[[Page 24172]]

050630.......................................................

***

*

* 28.0726 30.9410

* 29.5481 050633....................................................... 1.2327 1.1719 1.1719 33.4771 35.3734 38.2742 35.7436 050636....................................................... 1.3124 1.1371 1.1371 27.2360 30.5156 33.1069 30.3577 050641....................................................... 1.1728 1.1762 1.1762 20.4720 21.4612 20.4706 20.7862 050644....................................................... 0.8979 1.1762 1.1762 25.6614 27.6547 29.0068 27.4716 050662....................................................... 0.8775 1.5281 1.5281 47.5065 32.6362 33.6809 38.4416 050663....................................................... 1.1419 1.1762 1.1762 25.1493 25.7747 26.8993 25.9210 050667....................................................... 0.9036 1.4527 1.4527 25.9250 26.3937 27.2269 26.5042 050668....................................................... 1.1034 1.5075 1.5075

* 31.8065 40.9413 35.0252 050674....................................................... 1.3084 1.3350 1.3350 38.4454 42.6866 48.7644 43.7800 050677....................................................... 1.4769 1.1762 1.1762 37.3389 38.7984 39.9638 38.8140 050678....................................................... 1.3278 1.1600 1.1603 29.1159 30.7220 32.1066 30.7504 050680....................................................... 1.2190 1.5669 1.5669 35.6614 38.3946 38.9269 37.8867 050681....................................................... 1.7997 1.1762 1.1762

*

*

*

* 050682....................................................... 0.9911 1.1291 1.1291 21.7264 21.7791 17.7264 20.0252 050684....................................................... 1.1508 1.1291 1.1291 25.2575 26.4234 28.9330 26.8758 050686....................................................... 1.2563 1.1291 1.1291 38.5595 40.9486 42.8975 40.9700 050688....................................................... 1.2419 1.5281 1.5281 41.3305 41.9325 44.3596 42.6254 050689....................................................... 1.5018 1.5669 1.5669 40.3815 42.2018 46.1901 42.9969 050690....................................................... 1.2765 1.5049 1.5049 43.9228 47.2769 52.2448 48.3299 050693....................................................... 1.3208 1.1600 1.1603 34.8040 35.0621 35.5736 35.1560 050694....................................................... 1.0803 1.1291 1.1291 26.7041 28.9544 32.3426 29.3794 050695....................................................... 1.0920 1.2038 1.2038 30.1226 35.6549 39.4080 35.4440 050696....................................................... 2.1492 1.1762 1.1762 36.9314 35.9220 38.1340 36.9904 050697....................................................... 1.1158 1.3205 1.3205 19.2603 25.1984 16.9270 19.9625 050698....................................................... 1.0543

*

*

*

*

*

* 050699.......................................................

***

*

* 25.6818 26.8210 31.2540 27.9556 050701....................................................... 1.3443 1.1291 1.1291 29.6896 29.6253 33.5009 31.4867 050704....................................................... 1.0465 1.1762 1.1762 24.6609 25.3488 28.9925 26.5384 050707....................................................... 1.1989 1.5049 1.5049 32.4877 34.0550 35.8114 34.0977 050708....................................................... 1.7111 1.1291 1.1291 21.2163 22.5034 32.9787 25.2406 050709....................................................... 1.4082 1.1600 1.1603 21.9079 25.6119 26.9167 24.7734 050710....................................................... 1.3359 1.1291 1.1291 34.8311 39.9858 47.0098 41.2427 050713.......................................................

***

*

* 20.7448 20.2803 21.3180 20.6998 050714....................................................... 1.4106 1.5509 1.5509 32.4491 33.6676 32.9341 33.0470 050717....................................................... 1.6850 1.1762 1.1762 34.5519 38.0796 38.9983 37.0998 050718....................................................... 1.1405 1.1291 1.1291 15.4037 21.4996 25.9059 20.4331 050720....................................................... 0.9455 1.1600 1.1603 24.8117 30.0812 29.7498 28.4890 050722....................................................... 0.9800 1.1371 1.1371

*

* 33.9652 33.9652 050723....................................................... 1.3104 1.1762 1.1762 34.9814 35.0119 39.8595 36.7280 050724....................................................... 1.9939 1.1291 1.1291

* 34.4267 29.4969 31.8092 050725....................................................... 0.9799 1.1762 1.1762 22.0946 21.7816 24.4527 22.7171 050726....................................................... 1.5792 1.1731 1.1731 27.0928 27.8433 32.0629 29.3587 050727....................................................... 1.3104 1.1762 1.1762 23.7179 24.3026 30.9146 26.5349 050728....................................................... 1.3772 1.5049 1.5049 31.4768 36.0820 39.6245 35.3141 050729....................................................... 1.4087 1.1762 1.1762

* 34.2580 36.8283 35.5529 050730....................................................... 1.1560 1.1762 1.1762

* 51.5425 37.2860 43.9757 050732....................................................... 2.4527 1.1291 1.1291

*

*

*

* 050733....................................................... 1.5564 1.3205 1.3205

*

*

*

* 050735....................................................... 1.4593

*

*

*

*

*

* 050736....................................................... 1.2171

*

*

*

*

*

* 050737....................................................... 1.4960

*

*

*

*

*

* 050738....................................................... 1.3749

*

*

*

*

*

* 050739....................................................... 1.6624

*

*

*

*

*

* 050740....................................................... 1.2695

*

*

*

*

*

* 050741....................................................... 1.4605

*

*

*

*

*

* 050742....................................................... 1.4578

*

*

*

*

*

* 050743....................................................... 1.1704

*

*

*

*

*

* 050744....................................................... 2.0392

*

*

*

*

*

* 050745....................................................... 1.2940

*

*

*

*

*

* 050746....................................................... 1.7795

*

*

*

*

*

* 050747....................................................... 1.3787

*

*

*

*

*

* 050749....................................................... 1.2647

*

*

*

*

*

* 050750....................................................... 2.2585

*

*

*

*

*

* 050751....................................................... 2.1455

*

*

*

*

*

* 050752....................................................... 1.3908

*

*

*

*

*

*

[[Page 24173]]

060001....................................................... 1.5478 0.9930 0.9930 24.9410 26.8470 28.5246 26.7856 060003....................................................... 1.4520 1.0805 1.0805 24.7856 24.2224 30.1449 26.4193 060004....................................................... 1.3094 1.0924 1.0924 28.0656 29.9649 32.9128 30.3597 060006....................................................... 1.4136 0.9331 0.9331 22.7493 24.5704 25.5300 24.3032 060007.......................................................

***

*

* 21.4792

*

* 21.4792 060008....................................................... 1.2525 0.9331 0.9331 21.8037 23.3859 23.0325 22.7676 060009....................................................... 1.4588 1.0924 1.0924 27.0511 28.7645 31.2466 29.0996 060010....................................................... 1.7178 0.9689 0.9689 27.2290 28.9850 28.4315 28.2640 060011....................................................... 1.5317 1.0924 1.0924 26.1958 27.2833 34.2985 29.1788 060012....................................................... 1.4984 0.9331 0.9331 24.1557 26.2469 27.9068 26.0885 060013....................................................... 1.4281 0.9331 0.9331 24.9708 24.5994 27.6808 25.7684 060014....................................................... 1.8075 1.0924 1.0924 29.6744 31.2588 32.4518 31.1092 060015....................................................... 1.6923 1.0924 1.0924 30.1158 30.4533 33.5968 31.2391 060016....................................................... 1.2587 0.9331 0.9331 23.9655 25.6527 26.9441 25.5481 060018....................................................... 1.3005 0.9331 0.9331 23.6620 25.7628 25.3149 24.9213 060020....................................................... 1.5999 0.9331 0.9331 22.2052 22.6748 23.5825 22.8530 060022....................................................... 1.6231 0.9697 0.9697 25.7832 26.5238 28.8935 27.0838 060023....................................................... 1.7032 1.0805 1.0805 26.7285 27.7644 29.7290 28.0786 060024....................................................... 1.8041 1.0924 1.0924 28.7231 29.0130 30.3956 29.4074 060027....................................................... 1.5798 1.0805 1.0805 26.6348 28.0909 30.2413 28.4406 060028....................................................... 1.4361 1.0924 1.0924 27.9686 30.0448 32.0442 30.0599 060030....................................................... 1.3963 0.9689 0.9689 26.0011 26.6251 27.6439 26.7912 060031....................................................... 1.5545 0.9697 0.9697 25.6207 26.3650 28.4559 26.8116 060032....................................................... 1.5252 1.0924 1.0924 28.2234 30.4247 31.9803 30.1845 060034....................................................... 1.6754 1.0924 1.0924 28.4604 29.8445 31.4601 29.9383 060036....................................................... 1.1583 0.9331 0.9331 20.4635 20.7131 20.8128 20.6604 060041....................................................... 0.9165 0.9331 0.9331 22.7123 23.4978 23.9297 23.4036 060043....................................................... 1.0621 0.9331 0.9331 20.0939 18.7896 17.2960 18.6864 060044....................................................... 1.1635 1.0805 1.0805 25.2471 25.0360 26.8821 25.7042 060049....................................................... 1.3952 0.9594 0.9594 26.8089 29.0598 30.6057 28.8870 060050.......................................................

***

*

* 21.9108

*

* 21.9108 060054....................................................... 1.4677 1.0037 1.0037 23.5803 22.3490 24.3711 23.4286 060057.......................................................

***

*

* 26.9891

*

* 26.9891 060064....................................................... 1.6788 1.0924 1.0924 30.0963 31.3105 33.4859 31.6328 060065....................................................... 1.3952 1.0924 1.0924 28.5282 31.1987 33.7362 31.1126 060071....................................................... 1.1650 0.9331 0.9331 20.2706 25.7248 27.5209 24.6844 060075....................................................... 1.2838 1.0037 1.0037 30.7835 32.7563 33.9644 32.5290 060076....................................................... 1.2449 0.9331 0.9331 25.5406 26.8236 26.4669 26.2923 060096....................................................... 1.5490 1.0805 1.0805 27.4085 30.0602 33.4708 30.3136 060100....................................................... 1.7275 1.0924 1.0924 29.7690 32.1537 33.3856 31.7750 060103....................................................... 1.3008 1.0805 1.0805 28.8063 30.3002 33.2964 30.8687 060104....................................................... 1.3986 1.0924 1.0924 30.8625 32.0889 33.4664 32.1175 060107....................................................... 1.4001 1.0924 1.0924 26.8267 26.1883 27.1594 26.7219 060111.......................................................

***

*

* 31.2571

*

* 31.2571 060112....................................................... 1.7095 1.0924 1.0924

*

* 36.1471 36.1471 060113....................................................... 1.2832 1.0924 1.0924

*

*

*

* 060114....................................................... 1.2889 1.0924 1.0924

*

*

*

* 060115....................................................... 0.8453

*

*

*

*

*

* 060116....................................................... 1.2462

*

*

*

*

*

* 060117....................................................... 1.2872

*

*

*

*

*

* 070001....................................................... 1.6340 1.2701 1.2511 32.2718 34.0302 35.1488 33.8080 070002....................................................... 1.8265 1.1750 1.1750 29.0663 31.1530 32.9351 31.0526 070003....................................................... 1.0862 1.1750 1.1750 31.3716 32.4197 33.5145 32.4479 070004....................................................... 1.1975 1.1750 1.1750 27.3004 29.2544 30.2004 28.9166 070005....................................................... 1.3661 1.2701 1.2511 29.3265 32.1668 33.4862 31.7706 070006 \2\................................................... 1.3682 1.3038 1.3008 33.9310 36.8469 38.1568 36.3107 070007....................................................... 1.3065 1.2020 1.2020 30.3648 31.7125 35.6535 32.6301 070008....................................................... 1.2465 1.1750 1.1750 24.9176 26.4806 27.6747 26.3851 070009....................................................... 1.2280 1.1750 1.1750 28.8649 30.2706 32.5288 30.5697 070010....................................................... 1.7865 1.3038 1.3008 33.1535 32.5798 34.7931 33.5340 070011....................................................... 1.4018 1.1750 1.1750 27.5391 29.9105 31.1602 29.5355 070012....................................................... 1.1831 1.1750 1.1750 40.3337 44.1424 30.3498 37.0108 070015....................................................... 1.3748 1.1750 1.1750 30.9728 33.4595 35.2743 33.2900 070016....................................................... 1.3865 1.2701 1.2511 29.6662 31.0903 31.3403 30.7038 070017....................................................... 1.3862 1.2701 1.2511 30.3951 31.7223 33.4075 31.8732 070018 \2\................................................... 1.3414 1.3038 1.3008 35.7189 37.6081 39.4816 37.7074

[[Page 24174]]

070019....................................................... 1.3161 1.2701 1.2511 29.6290 31.8148 34.6720 32.0589 070020....................................................... 1.3759 1.1823 1.1823 29.9507 31.0935 33.3626 31.4683 070021....................................................... 1.2443 1.1750 1.1750 31.4397 33.2357 36.0196 33.5900 070022....................................................... 1.7575 1.2701 1.2511 32.3625 35.4120 38.9946 35.6213 070024....................................................... 1.3670 1.2020 1.2020 31.0243 32.0430 35.2369 32.7950 070025....................................................... 1.8013 1.1750 1.1750 29.2540 30.9938 31.9792 30.7563 070027....................................................... 1.3452 1.1750 1.1750 27.3487 31.8018 30.8014 30.0429 070028....................................................... 1.6360 1.3038 1.3008 29.5653 31.5036 35.1796 32.0982 070029....................................................... 1.3189 1.1750 1.1750 26.3871 27.7213 30.7435 28.2936 070031....................................................... 1.3075 1.2701 1.2511 27.2359 28.9190 30.4813 28.9306 070033....................................................... 1.3631 1.3038 1.3008 35.5355 37.1929 39.7676 37.5730 070034 \2\................................................... 1.4079 1.3038 1.3008 35.6831 36.3899 38.1857 36.7733 070035....................................................... 1.2940 1.1750 1.1750 27.1816 27.5585 30.3920 28.3695 070036....................................................... 1.6631 1.2093 1.2093 34.0555 36.1610 38.8442 36.4123 070038....................................................... 1.1294 1.2093 1.2511 31.1133 25.7516 25.5738 26.3181 070039....................................................... 0.9397 1.2701 1.2511 35.0164 31.2269 32.8867 33.0224 080001....................................................... 1.6313 1.0941 1.0941 30.2463 30.0242 32.7311 31.0532 080002.......................................................

***

*

* 26.4192 27.7932 29.1393 27.8103 080003....................................................... 1.5848 1.0941 1.0941 27.1131 29.2266 31.1057 29.2127 080004....................................................... 1.4833 1.0878 1.0878 26.0092 27.4921 29.3258 27.6577 080006....................................................... 1.2902 0.9843 0.9843 24.4204 25.6160 27.0472 25.7475 080007....................................................... 1.4550 1.0254 1.0254 24.6485 27.0074 29.7437 27.1759 090001....................................................... 1.7661 1.1028 1.1028 31.3552 35.0413 37.9529 34.8066 090002.......................................................

***

*

* 29.6780

*

* 29.6780 090003....................................................... 1.2598 1.1076 1.1076 27.0514 29.2660 31.2552 29.2762 090004....................................................... 1.9157 1.1076 1.1076 29.9785 32.2021 35.6103 32.6016 090005....................................................... 1.3435 1.1076 1.1076 30.2504 30.7728 32.4581 31.1497 090006....................................................... 1.4536 1.1076 1.1076 25.9086 29.5590 29.1423 28.1875 090007.......................................................

***

*

* 30.1419

*

* 30.1419 090008....................................................... 1.3953 1.1076 1.1076 29.6744 29.1059 32.8342 30.3957 090011....................................................... 2.0690 1.1076 1.1076 32.4412 34.0693 36.3623 34.2608 100001....................................................... 1.5529 0.9046 0.9046 25.2381 24.4060 23.8151 24.4521 100002....................................................... 1.4122 0.9642 0.9642 22.1269 25.3389 26.4462 24.6809 100004....................................................... 0.8962

*

* 16.2637 16.5974

* 16.4390 100006....................................................... 1.6390 0.9409 0.9409 26.2372 26.3789 27.9464 26.8585 100007....................................................... 1.6725 0.9409 0.9409 25.4333 26.5378 28.2465 26.8017 100008....................................................... 1.7204 0.9825 0.9825 25.7377 27.4314 28.9763 27.4811 100009....................................................... 1.4625 0.9825 0.9825 24.4666 25.9381 27.1166 25.8395 100010.......................................................

***

*

* 26.9486

*

* 26.9486 100012....................................................... 1.6806 0.9339 0.9339 24.5762 26.3788 28.0401 26.3901 100014....................................................... 1.3972 0.9397 0.9397 22.3054 24.5862 25.3244 24.0840 100015....................................................... 1.3865 0.9249 0.9249 22.5781 24.6038 25.8553 24.2886 100017....................................................... 1.6159 0.9397 0.9397 22.9545 26.1580 27.5965 25.6638 100018....................................................... 1.6523 0.9935 0.9935 27.8582 28.1481 29.5692 28.5441 100019....................................................... 1.6733 0.9440 0.9440 25.5566 27.6179 28.1170 27.1634 100020.......................................................

***

*

* 23.6106 23.9414 27.1058 24.9057 100022....................................................... 1.6879 1.0470 1.0470 29.0519 29.9345 33.2813 30.8780 100023....................................................... 1.5132 0.9409 0.9409 21.4015 23.0074 24.6790 23.0038 100024....................................................... 1.2661 0.9825 0.9825 27.6476 30.2395 29.4861 29.0764 100025....................................................... 1.6860 0.8609 0.8609 21.1174 22.1580 23.3147 22.2233 100026....................................................... 1.6048 0.8609 0.8609 21.3533 21.4703 22.9234 21.9413 100027....................................................... 0.9126 0.8609 0.8609 12.0314 16.1223 18.8639 15.6138 100028....................................................... 1.3425 0.9440 0.9440 23.7818 26.8661 27.4585 26.0611 100029....................................................... 1.2634 0.9825 0.9825 26.9307 27.5844 28.4463 27.6559 100030....................................................... 1.3103 0.9409 0.9409 22.4887 24.0943 24.7251 23.8482 100032....................................................... 1.7935 0.9249 0.9249 23.0174 25.2450 26.3898 24.9308 100034....................................................... 1.9078 0.9825 0.9825 24.4064 25.9415 27.9305 25.9959 100035....................................................... 1.5645 0.9866 0.9866 25.3590 26.9407 29.2732 27.1757 100038....................................................... 1.9590 1.0470 1.0470 27.4422 29.8583 31.0393 29.4968 100039....................................................... 1.4635 1.0470 1.0470 26.6016 28.4627 29.5742 28.2437 100040....................................................... 1.7080 0.9046 0.9046 23.5372 23.6443 25.9099 24.3687 100043....................................................... 1.3536 0.9249 0.9249 22.8963 25.2273 26.5006 24.9156 100044....................................................... 1.4428 0.9857 0.9857 26.3208 28.3596 29.7123 28.1591 100045....................................................... 1.3397 0.9409 0.9409 23.0520 26.9641 30.5941 27.0017 100046....................................................... 1.2924 0.9249 0.9249 26.6169 26.3673 27.4887 26.8296 100047....................................................... 1.7742 0.9453 0.9453 24.4212 25.0404 26.1017 25.2191

[[Page 24175]]

100048....................................................... 0.9448 0.8609 0.8609 18.3767 18.8771 19.7932 19.0265 100049....................................................... 1.2016 0.8908 0.8908 22.9532 22.9810 23.3622 23.1049 100050....................................................... 1.1313 0.9825 0.9825 20.6893 19.8713 21.7480 20.7633 100051....................................................... 1.3495 0.9409 0.9409 22.3311 23.1940 28.0190 24.4952 100052....................................................... 1.3169 0.8908 0.8908 20.9078 22.3920 23.5420 22.3120 100053....................................................... 1.2474 0.9825 0.9825 27.3383 27.3224 28.0804 27.5770 100054....................................................... 1.2414 0.8654 0.8654 25.7279 28.0512 29.1317 27.5948 100055....................................................... 1.3622 0.9249 0.9249 22.1051 23.5332 25.4970 23.6039 100056.......................................................

***

*

* 25.7945

*

* 25.7945 100057....................................................... 1.5600 0.9409 0.9409 22.6038 25.3897 24.9844 24.3593 100061....................................................... 1.5507 0.9825 0.9825 26.7673 29.2565 31.0039 29.0171 100062....................................................... 1.7063 0.8964 0.8964 24.1413 25.2340 26.5512 25.3312 100063....................................................... 1.2658 0.9249 0.9249 21.5566 24.7026 26.0284 24.1067 100067....................................................... 1.4126 0.9249 0.9249 23.9333 26.1213 26.9257 25.6361 100068....................................................... 1.7656 0.9397 0.9397 24.9025 25.9202 27.0727 25.9472 100069....................................................... 1.3348 0.9249 0.9249 22.4386 24.7442 25.9129 24.3174 100070....................................................... 1.7383 0.9866 0.9866 23.7746 24.8883 27.0935 25.1963 100071....................................................... 1.2411 0.9249 0.9249 23.4176 24.9682 26.4245 25.0038 100072....................................................... 1.3793 0.9397 0.9397 24.2934 26.0459 26.3997 25.6529 100073....................................................... 1.7701 1.0470 1.0470 25.3685 30.3358 30.3162 28.6546 100075....................................................... 1.4953 0.9249 0.9249 23.3503 25.1691 26.0289 24.8882 100076....................................................... 1.2143 0.9825 0.9825 21.0777 21.9483 23.4786 22.0898 100077....................................................... 1.3599 0.9453 0.9453 24.3478 26.0347 29.4683 26.5871 100079....................................................... 1.6395

*

*

*

*

*

* 100080....................................................... 1.8174 0.9642 0.9642 26.3596 27.0126 28.4894 27.3255 100081....................................................... 1.0745 0.8609 0.8609 16.9168 15.6662 16.8158 16.4460 100084....................................................... 1.8081 0.9409 0.9409 25.4140 26.3393 26.7820 26.1607 100086....................................................... 1.2749 1.0470 1.0470 26.4817 28.2641 29.9772 28.2256 100087....................................................... 1.8986 0.9866 0.9866 25.9909 27.1531 30.3527 27.9094 100088....................................................... 1.6439 0.9046 0.9046 24.8729 25.9182 26.1923 25.6760 100090....................................................... 1.5387 0.9046 0.9046 24.0501 24.2422 25.0930 24.4705 100092....................................................... 1.5509 0.9440 0.9440 26.0856 28.4789 27.9279 27.5045 100093....................................................... 1.7611 0.8609 0.8609 21.1547 21.3524 22.2184 21.5835 100098.......................................................

***

*

* 21.2505

*

* 21.2505 100099....................................................... 1.0847 0.8908 0.8908 20.4328 21.3036 24.7212 22.1811 100102....................................................... 1.1374 0.8734 0.8734 22.8850 23.8596 25.3617 24.0415 100103....................................................... 0.9737

*

* 21.7494

*

* 21.7494 100105....................................................... 1.4783 0.9604 0.9604 24.9503 26.8091 29.2659 27.0006 100106....................................................... 0.9711 0.8609 0.8609 20.2882 24.0389 23.8545 22.7821 100107....................................................... 1.2031 0.9339 0.9339 24.4484 26.1337 26.1391 25.5929 100108....................................................... 0.8066 0.8609 0.8609 16.3757 22.0750 21.2176 19.8907 100109....................................................... 1.3164 0.9409 0.9409 23.8836 24.9951 25.9430 24.9469 100110....................................................... 1.6056 0.9409 0.9409 28.3699 29.1494 29.4304 29.0104 100113....................................................... 1.9725 0.9299 0.9299 25.0067 26.3806 27.5595 26.3652 100114....................................................... 1.3113 0.9825 0.9825 27.7413 29.2195 29.2327 28.7304 100117....................................................... 1.1967 0.9046 0.9046 26.0451 26.4536 27.5443 26.7071 100118....................................................... 1.3392 0.9046 0.9046 23.6669 28.0569 28.2361 27.0580 100121....................................................... 1.1021 0.8908 0.8908 24.0937 24.8579 26.5604 25.1840 100122....................................................... 1.2277 0.8654 0.8654 21.2597 23.4751 23.9552 22.8872 100124....................................................... 1.1827 0.8609 0.8609 21.6483 22.7023 25.0550 23.1604 100125....................................................... 1.2466 0.9825 0.9825 25.3532 26.7452 29.5003 27.3520 100126....................................................... 1.3389 0.9249 0.9249 23.2996 24.4515 29.0390 25.6215 100127....................................................... 1.6178 0.9249 0.9249 21.3223 24.4485 26.1506 24.0288 100128....................................................... 2.1100 0.9249 0.9249 25.6763 29.4979 29.8875 28.4604 100130....................................................... 1.1732 0.9642 0.9642 22.8324 24.2046 25.2345 24.0576 100131....................................................... 1.3335 0.9825 0.9825 25.8316 29.2462 28.1549 27.7421 100132....................................................... 1.2373 0.9249 0.9249 23.0428 24.3293 26.2877 24.6022 100134....................................................... 0.9129 0.8609 0.8609 19.5337 20.9244 20.4785 20.3225 100135....................................................... 1.6218 0.9316 0.9316 22.3071 24.0024 28.0900 24.6354 100137....................................................... 1.2238 0.8908 0.8908 23.3692 25.1974 24.6076 24.4568 100139....................................................... 0.8408 0.9299 0.9299 14.5046 17.5489 16.6310 16.2799 100140....................................................... 1.1473 0.9046 0.9046 24.8165 26.4720 26.1383 25.8508 100142....................................................... 1.2230 0.8609 0.8609 20.7219 22.9577 23.8571 22.5245 100150....................................................... 1.3097 0.9825 0.9825 25.7122 26.1990 27.5276 26.4717 100151....................................................... 1.8299 0.9046 0.9046 26.1848 28.1322 30.5977 28.4241 100154....................................................... 1.5669 0.9825 0.9825 26.3703 27.6127 28.2710 27.4772

[[Page 24176]]

100156....................................................... 1.1245 0.8734 0.8734 22.2757 26.7092 27.4848 25.5333 100157....................................................... 1.5980 0.9249 0.9249 25.9133 27.3851 28.9595 27.4711 100160....................................................... 1.2422 0.8609 0.8609 27.2019 26.9851 31.2701 28.5770 100161....................................................... 1.5442 0.9409 0.9409 28.3607 28.8077 28.6336 28.6073 100166....................................................... 1.5055 0.9866 0.9866 24.4251 27.9618 29.6865 27.2716 100167....................................................... 1.2695 1.0470 1.0470 26.8584 30.3694 30.7365 29.3059 100168....................................................... 1.4259 0.9642 0.9642 26.0864 27.1292 27.9334 27.0344 100172....................................................... 1.3322 0.9825 0.9825 18.4651 18.2735 20.8673 19.1957 100173....................................................... 1.7421 0.9249 0.9249 22.4866 24.8721 26.6141 24.6478 100175....................................................... 0.9891 0.8840 0.8840 22.0666 23.5455 24.0790 23.2771 100176....................................................... 1.9676 0.9857 0.9857 29.8326 31.2694 31.0778 30.7413 100177....................................................... 1.2982 0.9440 0.9440 25.3973 26.6781 27.6011 26.6232 100179....................................................... 1.7788 0.9046 0.9046 26.6537 29.5619 29.6646 28.6728 100180....................................................... 1.3332 0.9249 0.9249 26.3299 27.1804 29.2623 27.6555 100181....................................................... 1.0919 0.9825 0.9825 19.5022 21.8540 21.8409 21.1771 100183....................................................... 1.2043 0.9825 0.9825 26.7893 27.4951 28.1843 27.5031 100187....................................................... 1.2393 0.9825 0.9825 26.1394 27.3653 28.0710 27.1892 100189....................................................... 1.2966 1.0470 1.0470 26.5763 28.4136 29.4643 28.2193 100191....................................................... 1.2986 0.9249 0.9249 24.3553 26.6340 27.8297 26.3354 100200....................................................... 1.4276 1.0470 1.0470 28.0926 29.8963 29.9888 29.3614 100204....................................................... 1.5591 0.9299 0.9299 24.4697 25.7537 27.3984 25.9174 100206....................................................... 1.3147 0.9249 0.9249 23.0340 25.2196 26.6863 25.0189 100208.......................................................

***

*

* 24.9854

*

* 24.9854 100209....................................................... 1.3796 0.9825 0.9825 25.0778 26.6246 26.6405 26.1523 100210....................................................... 1.5797 1.0470 1.0470 28.6449 28.9486 29.7288 29.1000 100211....................................................... 1.2015 0.9249 0.9249

* 24.7095 23.9827 24.3359 100212....................................................... 1.5477 0.8964 0.8964 24.2669 24.7566 26.0396 25.0603 100213....................................................... 1.5951 0.9866 0.9866 25.1893 27.1936 27.3982 26.6057 100217....................................................... 1.2343 0.9857 0.9857 25.2635 25.2907 25.9973 25.5366 100220....................................................... 1.6552 0.9339 0.9339 25.0154 26.0905 27.8611 26.3924 100223....................................................... 1.5470 0.8654 0.8654 23.4556 24.7015 25.6022 24.5922 100224....................................................... 1.2356 1.0470 1.0470 23.3593 24.8077 26.1308 24.8045 100225....................................................... 1.2202 1.0470 1.0470 27.9473 28.4316 28.6655 28.3365 100226....................................................... 1.2371 0.9046 0.9046 27.8003 29.3317 28.7732 28.6694 100228....................................................... 1.3987 1.0470 1.0470 27.2873 29.8952 28.4669 28.6149 100230....................................................... 1.3410 1.0470 1.0470 26.3690 28.1703 29.6743 28.0367 100231....................................................... 1.7304 0.8609 0.8609 24.6994 25.5175 26.3337 25.5418 100232 h..................................................... 1.2545 0.9046 0.9046 23.9405 24.9322 27.3158 25.3587 100234....................................................... 1.3964 0.9642 0.9642 25.2574 26.3601 28.2662 26.6107 100236....................................................... 1.4175 0.9453 0.9453 25.9282 26.6585 28.1991 26.9446 100237....................................................... 1.9228 1.0470 1.0470 25.6112 31.3543 32.3006 29.5164 100238....................................................... 1.6275 0.9249 0.9249 27.1748 28.4302 29.9215 28.5609 100239....................................................... 1.2871 0.9866 0.9866 26.9668 27.7592 28.4351 27.7562 100240....................................................... 0.9280 0.9825 0.9825 23.4830 25.3265 25.7112 24.8537 100242....................................................... 1.4467 0.8609 0.8609 21.5130 24.0990 25.8928 23.8355 100243....................................................... 1.5924 0.9249 0.9249 25.2987 26.1131 27.1058 26.2400 100244....................................................... 1.3521 0.9339 0.9339 24.1515 25.2584 26.5235 25.3682 100246....................................................... 1.5959 0.9857 0.9857 27.6382 28.9894 29.9108 28.8806 100248....................................................... 1.5784 0.9249 0.9249 25.9170 27.7797 28.7311 27.5094 100249....................................................... 1.3230 0.9249 0.9249 23.4021 23.2084 24.0596 23.5536 100252....................................................... 1.2232 0.9857 0.9857 24.9860 25.8540 27.0442 25.9795 100253....................................................... 1.3805 0.9642 0.9642 24.4051 25.7121 27.9291 26.0507 100254....................................................... 1.5434 0.9316 0.9316 25.0192 25.7338 26.1147 25.6499 100255....................................................... 1.2809 0.9249 0.9249 22.2341 24.4808 26.3538 24.3804 100256....................................................... 1.8683 0.9249 0.9249 26.0629 28.8856 29.7926 28.2929 100258....................................................... 1.5255 1.0470 1.0470 31.8772 31.2482 31.3505 31.4813 100259....................................................... 1.2692 0.9249 0.9249 24.9404 26.0175 27.1642 26.0636 100260....................................................... 1.3677 0.9857 0.9857 25.2630 27.5188 27.0181 26.6532 100262.......................................................

***

*

* 26.3954

*

* 26.3954 100264....................................................... 1.2637 0.9249 0.9249 25.0250 25.5489 25.9597 25.5115 100265....................................................... 1.3089 0.9249 0.9249 23.4758 24.1454 25.9086 24.5857 100266....................................................... 1.4274 0.8609 0.8609 22.6614 23.2340 23.7655 23.2568 100267....................................................... 1.2996 0.9866 0.9866 26.5059 27.3768 28.7517 27.5078 100268....................................................... 1.1892 0.9642 0.9642 29.8289 29.2898 29.9909 29.7065 100269....................................................... 1.3995 0.9642 0.9642 25.3228 26.7450 27.3632 26.5403 100275....................................................... 1.3040 0.9642 0.9642 24.3059 26.0361 27.0080 25.8478

[[Page 24177]]

100276....................................................... 1.2587 1.0470 1.0470 27.2589 30.0576 31.2531 29.5875 100277....................................................... 1.4104 0.9825 0.9825 47.3905 16.5427 20.7768 22.4551 100279....................................................... 1.3178 0.9339 0.9339 25.4909 26.8606 28.5951 27.0996 100281....................................................... 1.3391 1.0470 1.0470 27.0864 28.6660 29.8789 28.6295 100284....................................................... 1.0591 0.9825 0.9825 22.5927 23.8170 22.3173 22.9046 100285....................................................... 1.2194

*

*

*

*

*

* 100286....................................................... 1.6325 0.9935 0.9935 27.1051 29.4284 28.4751 28.3833 100287....................................................... 1.3417 0.9642 0.9642 28.2229 28.3427 28.2583 28.2764 100288....................................................... 1.5562 0.9642 0.9642 37.4785 33.8141 29.6965 33.2143 100289....................................................... 1.7571 1.0470 1.0470 28.4504 29.2915 29.5902 29.1535 100290....................................................... 1.1732 0.9191 0.9191

* 23.5080 25.1300 24.3178 100291....................................................... 1.3066 0.9440 0.9440

*

* 28.4799 28.4799 100292....................................................... 1.3038 0.8609 0.8609

*

* 26.9608 26.9608 100293.......................................................

***

*

*

*

* 32.7722 32.7722 100294.......................................................

***

*

*

*

* 30.3556 30.3556 100295.......................................................

***

*

*

*

* 26.1791 26.1791 100296....................................................... 1.3555 0.9825 0.9825

*

*

*

* 100298....................................................... 0.8740 0.9316 0.9316

*

*

*

* 100299....................................................... 1.3010 0.9866 0.9866

*

*

*

* 110001....................................................... 1.2775 0.9644 0.9644 25.1164 25.3102 26.6205 25.6873 110002....................................................... 1.3523 0.9644 0.9644 21.8616 25.3897 26.3797 24.5871 110003....................................................... 1.2617 0.9046 0.9046 20.0968 21.4002 22.0049 21.1828 110004....................................................... 1.2789 0.8965 0.8965 22.7929 23.9911 24.4124 23.7130 110005....................................................... 1.2301 0.9761 0.9761 22.3645 22.9000 27.9633 24.5295 110006....................................................... 1.4702 0.9827 0.9827 25.0719 28.6090 28.9119 27.4847 110007....................................................... 1.6002 0.8969 0.8969 30.7430 23.8729 26.3197 26.5387 110008....................................................... 1.2995 0.9761 0.9761 23.4662 27.1711 30.1360 26.9747 110010....................................................... 2.1912 0.9761 0.9761 28.7690 29.7142 31.8635 30.1393 110011....................................................... 1.2378 0.9761 0.9761 25.4620 26.0899 28.0194 26.5176 110015....................................................... 1.1303 0.9761 0.9761 25.5661 26.6610 28.7369 27.0953 110016....................................................... 1.1761 0.7577 0.7577 18.8376 21.7610 20.7638 20.4328 110018....................................................... 1.1832 0.9761 0.9761 25.6485 28.2431 26.4698 26.7925 110020....................................................... 1.3269 0.9761 0.9761 24.8735 26.8501 27.1406 26.3040 110023....................................................... 1.3249 0.9644 0.9644 25.3746 27.3029 30.3424 27.7599 110024....................................................... 1.4064 0.9089 0.9089 23.8091 25.7205 27.3054 25.5765 110025....................................................... 1.4741 0.9046 0.9046 31.5253 26.1311 29.9555 28.9712 110026....................................................... 1.1102 0.7577 0.7577 20.5740 21.2826 21.3621 21.0771 110027....................................................... 1.0741 0.7964 0.7964 19.2323 20.2175 20.8174 20.0273 110028....................................................... 1.8298 0.9681 0.9681 25.1836 28.1619 30.5430 27.9386 110029....................................................... 1.7593 0.9644 0.9644 25.2335 24.8893 26.6096 25.6552 110030....................................................... 1.2303 0.9761 0.9761 25.0842 26.4770 28.1621 26.6637 110031....................................................... 1.2875 0.9761 0.9761 24.1711 24.7874 26.3138 25.1188 110032....................................................... 1.1329 0.7577 0.7577 20.7211 21.9407 22.5419 21.7322 110033....................................................... 1.3719 0.9761 0.9761 25.2326 28.3210 29.6154 27.8235 110034....................................................... 1.6774 0.9681 0.9681 24.4141 26.9986 28.0571 26.5634 110035....................................................... 1.6293 0.9761 0.9761 25.7562 27.4583 28.1179 27.1607 110036....................................................... 1.8177 0.9089 0.9089 25.4854 26.8789 27.7279 26.7470 110038....................................................... 1.4966 0.8101 0.8101 20.5880 21.2138 21.7736 21.2085 110039....................................................... 1.4547 0.9681 0.9681 19.4032 24.7248 25.8629 23.0782 110040....................................................... 1.1223 0.9644 0.9644 18.8744 19.7509 19.1800 19.2690 110041....................................................... 1.2552 0.9707 0.9707 21.5402 23.4074 24.7306 23.1719 110042....................................................... 1.0876 0.9761 0.9761 26.8321 28.6873 34.0887 29.8762 110043....................................................... 1.7925 0.9089 0.9089 25.2788 26.6323 23.9626 25.2951 110044....................................................... 1.1525 0.7577 0.7577 19.6940 20.9654 22.6491 21.0788 110045....................................................... 1.1388 0.9761 0.9761 21.3922 24.9821 23.5532 23.2970 110046....................................................... 1.1557 0.9761 0.9761 24.0022 23.8292 25.5453 24.4504 110049.......................................................

***

*

* 19.8706

*

* 19.8706 110050....................................................... 1.1141 0.9050 0.9050 25.6020 26.1320 28.2504 26.6887 110051....................................................... 1.1491 0.7577 0.7577 19.0995 19.4276

* 19.2687 110054....................................................... 1.4092 0.9644 0.9644 22.2250 25.7085 26.5180 24.8264 110056....................................................... 0.9187

*

* 23.0080

*

* 23.0080 110059....................................................... 1.1352 0.7577 0.7577 18.7097 20.5565 20.6838 19.8951 110063.......................................................

***

*

* 20.3760

*

* 20.3760 110064....................................................... 1.4874 0.8256 0.8256 23.8739 24.2739 23.6909 23.9385 110069....................................................... 1.2898 0.9176 0.9176 22.3006 24.1669 24.9679 23.8522 110071....................................................... 1.0437 0.7577 0.7577 13.3731 18.0224 19.7309 16.8213

[[Page 24178]]

110073....................................................... 1.0751 0.7577 0.7577 16.3610 18.6336 17.5422 17.4505 110074....................................................... 1.5434 0.9827 0.9827 27.5836 27.1207 29.1532 27.9899 110075....................................................... 1.2899 0.8958 0.8958 20.9973 22.0935 22.7715 21.9811 110076....................................................... 1.4276 0.9761 0.9761 25.2424 26.3506 28.1355 26.5899 110078....................................................... 2.0372 0.9761 0.9761 27.8627 29.5779 30.4031 29.3431 110079....................................................... 1.4419 0.9761 0.9761 24.5255 23.1024 26.4675 24.6603 110080....................................................... 1.2829 0.9761 0.9761 21.5482 22.3213 18.4242 20.7532 110082....................................................... 1.9077 0.9761 0.9761 28.9731 29.8366 30.9276 29.9458 110083....................................................... 1.9292 0.9761 0.9761 26.2604 27.8245 30.3920 28.2014 110086....................................................... 1.2886 0.7577 0.7577 20.8557 21.1509 21.2115 21.0747 110087....................................................... 1.4659 0.9761 0.9761 26.2872 28.0471 28.3256 27.5768 110089....................................................... 1.1203 0.7577 0.7577 21.2013 21.9509 22.3332 21.8399 110091....................................................... 1.2844 0.9761 0.9761 26.3857 26.5523 28.9885 27.4113 110092....................................................... 1.0523 0.7577 0.7577 18.7397 18.5527 20.2520 19.1704 110095....................................................... 1.4415 0.8101 0.8101 21.8709 23.4846 25.7326 23.7156 110096....................................................... 0.9724

*

* 19.4498

*

* 19.4498 110100....................................................... 0.9636 0.7577 0.7577 16.5833 16.5600 15.1511 16.0255 110101....................................................... 1.0753 0.7577 0.7577 14.4630 16.4270 18.1778 16.2572 110104....................................................... 1.0503 0.7577 0.7577 19.5575 18.7951 19.1452 19.1709 110105....................................................... 1.3027 0.7577 0.7577 20.6270 21.1077 22.7867 21.5133 110107....................................................... 1.9366 0.9554 0.9554 26.0763 26.2526 28.0519 26.8480 110109....................................................... 1.0020 0.7577 0.7577 20.4726 21.4280 21.8210 21.2959 110111....................................................... 1.1922 0.9681 0.9681 20.5577 29.2190 24.6109 24.2986 110112....................................................... 0.9195 0.7577 0.7577 21.0612 24.2463 21.7411 22.2315 110113....................................................... 1.0319 0.9681 0.9681 16.7641 19.1753 18.9512 18.3153 110115....................................................... 1.7116 0.9761 0.9761 29.8699 32.0197 31.9907 31.3106 110121....................................................... 1.0279 0.7577 0.7577 21.2534 21.6637 22.0498 21.6648 110122....................................................... 1.5567 0.8982 0.8982 22.0210 23.7589 24.7846 23.5480 110124....................................................... 1.0276 0.8005 0.8005 20.9334 22.7058 23.4296 22.3620 110125....................................................... 1.3252 0.9176 0.9176 22.1458 22.4238 23.3281 22.6254 110128....................................................... 1.2532 0.8958 0.8958 23.2576 24.4596 25.6176 24.4945 110129....................................................... 1.5112 0.8256 0.8256 22.4202 23.3631 24.4429 23.4176 110130....................................................... 0.9251 0.7577 0.7577 17.6529 18.7549 18.4928 18.3190 110132....................................................... 1.0227 0.7577 0.7577 18.9927 19.2307 20.1060 19.4424 110135....................................................... 1.2432 0.7577 0.7577 20.0057 20.4411 21.8451 20.8410 110136.......................................................

***

*

* 22.7715 15.8573 18.5125 19.1561 110142....................................................... 0.9652 0.7577 0.7577 17.3328 18.1980 19.4290 18.3479 110143....................................................... 1.3959 0.9761 0.9761 25.4932 27.7055 27.6784 26.9990 110146....................................................... 1.0904 0.8363 0.8363 19.9221 23.9067 24.7255 22.8343 110149.......................................................

***

*

* 24.7686 27.1477 28.2647 26.9026 110150....................................................... 1.2486 0.9644 0.9644 23.8157 22.6624 25.2397 23.8573 110153....................................................... 1.1463 0.9176 0.9176 22.8660 24.5368 24.4107 23.9661 110161....................................................... 1.4911 0.9761 0.9761 27.4435 29.3201 31.2120 29.3628 110163....................................................... 1.3865 0.8969 0.8969 25.5461 26.0764 28.0288 26.5286 110164....................................................... 1.5927 0.9554 0.9554 26.4450 27.0600 28.5216 27.3709 110165....................................................... 1.3817 0.9761 0.9761 24.3897 26.8378 27.1472 26.1300 110166.......................................................

***

*

* 25.2264 26.8070

* 26.0253 110168....................................................... 1.8861 0.9644 0.9644 24.6321 27.0022 28.7602 26.8363 110172....................................................... 1.2080 0.9761 0.9761 27.0240 29.1703 30.7555 29.0077 110177....................................................... 1.7219 0.9681 0.9681 25.0129 26.7504 27.9520 26.6015 110179.......................................................

***

*

* 26.1173 26.0759

* 26.0961 110183....................................................... 1.2204 0.9761 0.9761 27.6020 29.6133 29.9753 29.1744 110184....................................................... 1.1779 0.9761 0.9761 25.5420 26.5240 27.0140 26.4179 110186....................................................... 1.3488 0.8256 0.8256 23.2348 25.0299 26.1373 24.8057 110187....................................................... 1.2445 0.9644 0.9644 22.5730 24.2933 24.4380 23.8234 110189....................................................... 1.1035 0.9644 0.9644 23.9404 26.7653 25.5622 25.4422 110190....................................................... 1.0679 0.7759 0.7759 19.1054 14.2517 22.4774 18.1909 110191....................................................... 1.2940 0.9761 0.9761 25.8409 26.8277 27.2171 26.6346 110192....................................................... 1.3492 0.9761 0.9761 25.7406 26.7852 27.9800 26.8678 110193.......................................................

***

*

* 27.8223 27.3341 27.8180 27.6526 110194....................................................... 0.9325 0.7577 0.7577 16.3148 18.4776 18.8136 17.9305 110198....................................................... 1.3451 0.9761 0.9761 30.8014 31.7748 31.7399 31.4753 110200....................................................... 1.8335 0.8256 0.8256 21.2177 22.3249 24.7384 22.6614 110201....................................................... 1.4386 0.9554 0.9554 27.0388 28.2232 30.6525 28.6696 110203....................................................... 0.9744 0.9761 0.9761 25.8951 26.8768 30.3037 27.7533 110205....................................................... 1.1502 0.9644 0.9644 20.6150 19.7409 21.5043 20.6527

[[Page 24179]]

110209....................................................... 0.5449 0.7577 0.7577 19.1000 19.0450 20.6610 19.6589 110212....................................................... 1.0965 0.8340 0.8340 20.9365 40.5120 23.5240 28.8400 110214.......................................................

***

*

*

*

* 38.0916 38.0916 110215....................................................... 1.2932 0.9761 0.9761 23.9657 25.7886 27.6105 25.8891 110218.......................................................

***

*

* 26.1073

*

* 26.1073 110219....................................................... 1.3711 0.9761 0.9761 27.1880 27.0362 28.9963 27.7481 110220.......................................................

***

*

*

*

* 36.3797 36.3797 110221.......................................................

***

*

*

*

* 27.9342 27.9342 110222.......................................................

***

*

*

*

* 35.6600 35.6600 110224....................................................... 1.2679 0.9554 0.9554

*

*

*

* 110225....................................................... 1.1623 0.9761 0.9761

*

*

*

* 110226....................................................... 1.1684

*

*

*

*

*

* 120001....................................................... 1.7479 1.1066 1.1066 31.7108 34.7715 36.1455 34.2182 120002....................................................... 1.1953 1.0502 1.0502 26.9900 29.9913 31.1454 29.4877 120004....................................................... 1.2414 1.1066 1.1066 28.3569 28.6527 29.8958 28.9336 120005....................................................... 1.2996 1.0502 1.0502 26.9053 29.3405 30.7655 28.9478 120006....................................................... 1.2506 1.1066 1.1066 29.6751 31.2285 31.6553 30.8640 120007....................................................... 1.6798 1.1066 1.1066 28.7964 30.4247 30.8207 30.0248 120010....................................................... 1.8625 1.1066 1.1066 27.1265 30.1659 29.2456 28.7313 120011....................................................... 1.4183 1.1066 1.1066 31.7447 34.1643 37.6638 34.6233 120014....................................................... 1.2906 1.0502 1.0502 28.0786 28.6416 30.9983 29.2759 120016.......................................................

***

*

* 52.1034 19.6034

* 31.3542 120019....................................................... 1.1569 1.0502 1.0502 28.9661 30.3809 30.9024 30.1294 120022....................................................... 1.8414 1.1066 1.1066 24.7875 26.6100 28.3925 26.5859 120024....................................................... 0.8882

*

*

*

*

*

* 120025.......................................................

***

*

* 48.7148 30.2358

* 39.4887 120026....................................................... 1.3774 1.1066 1.1066 28.5048 30.3293 32.6726 30.6338 120027....................................................... 1.3041 1.1066 1.1066 26.4630 28.6717 28.6901 27.9388 120028....................................................... 1.3553 1.1066 1.1066 31.3195 30.3794 32.2641 31.3359 120029....................................................... 2.0189 1.1066 1.1066

*

*

*

* 130002....................................................... 1.4037 0.8674 0.8674 21.6626 23.6078 24.8996 23.4857 130003....................................................... 1.3819 1.0033 1.0033 25.4904 27.6345 29.1686 27.4795 130005.......................................................

***

*

* 25.2550 25.7523

* 25.4954 130006....................................................... 1.7984 0.9404 0.9404 24.3982 25.3221 27.3657 25.7611 130007....................................................... 1.7777 0.9404 0.9404 24.8764 24.9562 28.8562 26.2212 130011....................................................... 1.2032

*

* 22.9336

*

* 22.9336 130013....................................................... 1.3238 0.9404 0.9404 26.3118 27.9209 28.4195 27.5522 130014....................................................... 1.2962 0.9404 0.9404 23.4789 24.3884 26.4165 24.7517 130018....................................................... 1.6875 0.9400 0.9400 23.9798 26.4125 27.5137 26.0217 130021.......................................................

***

*

* 18.9400 16.1658

* 17.6183 130024....................................................... 1.0850 0.8949 0.8949 21.7853 23.3347 24.5799 23.2478 130025....................................................... 1.2211 0.8674 0.8674 19.7066 20.1452 21.7093 20.5485 130026.......................................................

***

*

* 25.4020

*

* 25.4020 130028....................................................... 1.3940 0.9400 0.9400 25.2938 26.3443 27.8274 26.7013 130036.......................................................

***

*

* 16.7907

*

* 16.7907 130049....................................................... 1.5643 1.0284 1.0284 24.5841 26.9749 27.6683 26.4480 130060.......................................................

***

*

* 26.7516

*

* 26.7516 130062....................................................... 0.4992

*

* 16.7951 20.6642 25.4820 20.1910 130063....................................................... 1.3226 0.9404 0.9404 20.9502 22.5904 25.0864 22.8539 130065....................................................... 1.8682 0.9300 0.9300

*

* 21.5260 21.5260 130066....................................................... 2.0225 0.9696 0.9696

*

*

*

* 130067....................................................... 1.1199 0.9300 0.9300

*

*

*

* 140001....................................................... 1.0879 0.8334 0.8334 21.4779 22.3170 22.9464 22.2483 140002....................................................... 1.3285 0.9017 0.9017 24.4908 24.6954 27.0262 25.3949 140003.......................................................

***

*

* 22.6230

*

* 22.6230 140007....................................................... 1.3267 1.0742 1.0742 26.7943 28.3482 30.5555 28.5893 140008....................................................... 1.4514 1.0742 1.0742 27.2211 28.5297 29.4264 28.3893 140010....................................................... 1.5134 1.0742 1.0742 31.5774 35.1024 32.1387 32.9542 140011....................................................... 1.1519 0.8334 0.8334 20.6338 22.4091 23.3923 22.1495 140012....................................................... 1.1895 1.0596 1.0596 24.3675 28.6564 28.7947 27.2494 140013....................................................... 1.4139 0.8973 0.8973 22.6022 23.3065 24.3673 23.3996 140015....................................................... 1.4234 0.8902 0.8902 22.2266 23.0600 24.3516 23.2245 140016....................................................... 1.0295

*

* 17.1372 18.1242

* 17.6389 140018....................................................... 1.4130 1.0742 1.0742 27.3334 27.7548 26.2598 27.1177 140019....................................................... 0.9335 0.8334 0.8334 18.4554 18.9228 20.5469 19.2999 140024....................................................... 1.0391

*

* 16.9672 17.5249

* 17.2349

[[Page 24180]]

140026....................................................... 1.1460 0.8680 0.8680 21.6847 23.0470 25.8658 23.4929 140027.......................................................

***

*

* 22.6208

*

* 22.6208 140029....................................................... 1.5856 1.0742 1.0742 27.7304 28.6565 30.4267 29.0118 140030....................................................... 1.5703 1.0742 1.0742 28.7623 29.7771 30.8539 29.8244 140032....................................................... 1.2542 0.8902 0.8902 22.8157 24.0574 26.3265 24.4078 140033....................................................... 1.2032 1.0596 1.0596 26.1553 25.6068 26.6309 26.1186 140034....................................................... 1.2202 0.8902 0.8902 22.1003 23.0034 24.0132 23.0492 140040....................................................... 1.1819 0.8827 0.8827 20.0269 22.2969 23.0412 21.6957 140043....................................................... 1.2734 0.9773 0.9773 26.0330 26.7996 27.2076 26.6815 140045....................................................... 1.0786

*

* 21.0042 20.6548

* 20.8316 140046....................................................... 1.4780 0.8902 0.8902 22.5022 23.2127 25.1403 23.7433 140048....................................................... 1.2684 1.0742 1.0742 27.0874 28.2222 29.4775 28.2409 140049....................................................... 1.5191 1.0742 1.0742 26.6533 27.4009 29.7853 27.9674 140051....................................................... 1.5347 1.0742 1.0742 27.9935 27.7901 30.9784 28.8784 140052....................................................... 1.2841 0.9017 0.9017 22.2588 23.5662 25.9526 23.9370 140053....................................................... 1.8913 0.8900 0.8900 23.5477 24.8455 27.0098 25.1043 140054....................................................... 1.4870 1.0742 1.0742 31.7265 31.8564 33.1231 32.2061 140058....................................................... 1.2228 0.8902 0.8902 22.1269 22.8423 24.5345 23.1736 140059....................................................... 1.1165 0.9017 0.9017 22.7121 22.4651 22.7978 22.6554 140061....................................................... 1.0739

*

* 30.9925 20.8063

* 25.9797 140062....................................................... 1.2142 1.0742 1.0742 31.2359 34.7704 34.9018 33.6097 140063....................................................... 1.4093 1.0742 1.0742 26.5584 27.8306 28.3171 27.6213 140064....................................................... 1.1938 0.8827 0.8827 21.7470 22.0407 23.6796 22.5242 140065....................................................... 1.3865 1.0742 1.0742 26.1904 29.4678 30.5985 28.7875 140066....................................................... 1.1297 0.9017 0.9017 20.4353 21.9771 21.7172 21.3717 140067....................................................... 1.8182 0.8973 0.8973 23.5906 25.3986 27.3723 25.4762 140068....................................................... 1.1945 1.0742 1.0742 25.8963 27.3956 28.3348 27.2266 140075....................................................... 1.2767 1.0742 1.0742 26.9257 27.9325 27.0069 27.3106 140077....................................................... 1.0393 0.9017 0.9017 19.0922 19.1363 20.5654 19.5779 140079.......................................................

***

*

* 29.3040

*

* 29.3040 140080....................................................... 1.4417 1.0742 1.0742 26.0109 23.2575 28.0751 25.6089 140082....................................................... 1.4773 1.0742 1.0742 26.8077 25.6645 29.2173 27.2244 140083....................................................... 1.0308 1.0742 1.0742 24.6491 26.2972 26.7552 25.9303 140084....................................................... 1.2289 1.0596 1.0596 27.6819 29.2515 30.0397 29.0292 140088....................................................... 1.8500 1.0742 1.0742 31.0364 32.4978 30.8245 31.4341 140089....................................................... 1.1914 0.8334 0.8334 22.1227 23.3401 24.5591 23.2899 140091....................................................... 1.8250 0.9649 0.9649 26.1075 26.8518 27.8742 26.9776 140093....................................................... 1.1831 0.9155 0.9155 22.1540 25.3127 27.5152 24.7343 140094....................................................... 1.0356 1.0742 1.0742 25.3678 27.9273 27.9141 27.1207 140095....................................................... 1.2507 1.0742 1.0742 29.9746 27.6799 26.6424 28.1556 140100....................................................... 1.3030 1.0596 1.0596 32.8743 37.0819 37.2217 35.8092 140101....................................................... 1.1672 1.0742 1.0742 25.4784 28.5365 29.2080 27.8662 140102.......................................................

***

*

* 21.2278

*

* 21.2278 140103....................................................... 1.1961 1.0742 1.0742 21.7512 23.3258 23.8866 22.9977 140105....................................................... 1.2788 1.0742 1.0742 26.3054 27.4531 28.4390 27.3700 140109....................................................... 1.0917

*

* 17.8103 19.5675

* 18.6923 140110....................................................... 1.0910 1.0596 1.0596 25.6561 27.9844 29.3202 27.6755 140113....................................................... 1.5788 0.9649 0.9649 23.5337 26.7969 29.9552 26.5722 140114....................................................... 1.4160 1.0742 1.0742 25.7968 28.3014 28.6458 27.6452 140115....................................................... 1.0851 1.0742 1.0742 26.3677 25.1498 25.8357 25.7964 140116....................................................... 1.2978 1.0742 1.0742 30.5166 31.9902 34.3361 32.3584 140117....................................................... 1.5416 1.0742 1.0742 25.6314 26.8802 27.9774 26.8349 140118....................................................... 1.6195 1.0742 1.0742 27.7392 29.7570 32.2213 29.8836 140119....................................................... 1.7729 1.0742 1.0742 33.6302 36.1419 34.7716 34.8306 140120....................................................... 1.2239 0.8973 0.8973 22.5795 22.7375 24.0981 23.1900 140122....................................................... 1.4330 1.0742 1.0742 26.4991 28.4188 31.0736 28.6341 140124....................................................... 1.3392 1.0742 1.0742 35.2798 36.1327 36.4899 35.9612 140125....................................................... 1.2398 0.9017 0.9017 20.7189 20.4014 22.3436 21.1516 140127....................................................... 1.6317 0.8959 0.8959 22.8172 24.1658 25.0102 23.9945 140130....................................................... 1.2469 1.0596 1.0596 26.3518 29.5247 32.9615 29.7730 140133....................................................... 1.2969 1.0742 1.0742 26.1599 28.0339 30.6892 28.1483 140135....................................................... 1.4756 0.8334 0.8334 21.2104 22.3264 23.0885 22.2454 140137....................................................... 1.0253 0.9017 0.9017 20.5053 21.4700 23.4302 21.8888 140140.......................................................

***

*

* 21.4710

*

* 21.4710 140141....................................................... 1.0512

*

* 23.0515 21.7871

* 22.4305 140143....................................................... 1.2279 0.8827 0.8827 23.8255 26.2954 26.2579 25.4680

[[Page 24181]]

140144.......................................................

***

*

* 27.8046

*

* 27.8046 140145....................................................... 1.0954 0.9017 0.9017 21.6168 23.4608 25.4576 23.5453 140147....................................................... 1.1011 0.8334 0.8334 19.5896 19.8541 21.5005 20.3136 140148....................................................... 1.7345 0.8900 0.8900 23.0022 24.7031 25.6350 24.3700 140150....................................................... 1.6237 1.0742 1.0742 33.9013 35.2711 53.4891 41.2967 140151....................................................... 0.8172 1.0742 1.0742 22.4842 23.4879 25.1381 23.7102 140152....................................................... 1.0879 1.0742 1.0742 29.6882 27.6086 30.5283 29.2513 140155....................................................... 1.2917 1.0032 1.0032 27.6610 28.9724 29.8350 28.8823 140158....................................................... 1.4185 1.0742 1.0742 23.8542 27.0986 27.3765 25.9317 140160....................................................... 1.2622 0.9773 0.9773 22.7002 24.5373 25.6756 24.3339 140161....................................................... 1.1501 1.0596 1.0596 24.1071 23.1647 24.6442 23.9715 140162....................................................... 1.6074 0.8959 0.8959 26.0312 27.4472 28.9571 27.4950 140164....................................................... 1.7902 0.8902 0.8902 22.0424 23.7457 24.3913 23.3924 140165....................................................... 1.0595

*

* 15.9312 16.6304

* 16.2816 140166....................................................... 1.1868 0.8334 0.8334 21.7776 23.1005 26.5696 23.8462 140167....................................................... 1.1260 0.9728 0.9728 19.7610 22.8911 23.2552 21.9523 140168.......................................................

***

*

* 20.0225

*

* 20.0225 140170....................................................... 0.9621

*

* 17.1608

*

* 17.1608 140172....................................................... 1.4090 1.0742 1.0742 27.1121 29.8568 32.0491 29.9831 140174....................................................... 1.4735 1.0742 1.0742 24.7011 27.8131 30.6391 27.6903 140176....................................................... 1.2059 1.0742 1.0742 28.9378 31.3490 32.8367 31.1310 140177....................................................... 0.9899 1.0742 1.0742 19.3328 22.5610 25.4042 22.6360 140179....................................................... 1.3042 1.0742 1.0742 26.3200 27.6376 29.1623 27.7184 140180....................................................... 1.2048 1.0742 1.0742 27.4366 28.3629 29.4449 28.4116 140181....................................................... 1.2002 1.0742 1.0742 23.6034 25.0100 24.7902 24.4674 140182....................................................... 1.5644 1.0742 1.0742 28.0337 28.2211 30.4042 28.7014 140184....................................................... 1.2402 0.8334 0.8334 20.1279 21.1802 24.5927 22.1636 140185....................................................... 1.4592 0.9017 0.9017 22.0222 23.8531 24.9794 23.6400 140186....................................................... 1.5570 1.0032 1.0032 28.1977 30.6951 29.4859 29.5088 140187....................................................... 1.5360 0.9017 0.9017 22.0674 23.2892 24.9822 23.4667 140189....................................................... 1.1691 0.9155 0.9155 25.6954 23.7198 22.2803 23.9070 140190....................................................... 1.0766

*

* 18.8530 19.8297

* 19.3398 140191....................................................... 1.2997 1.0742 1.0742 25.2817 25.8678 28.1849 26.4367 140193.......................................................

***

*

* 22.9443

*

* 22.9443 140197....................................................... 1.3178 1.0742 1.0742 21.8060 23.0684 24.2236 22.9343 140199....................................................... 1.0459

*

* 21.3464 22.0315

* 21.6914 140200....................................................... 1.4752 1.0742 1.0742 24.9217 26.3379 28.3720 26.5054 140202....................................................... 1.5706 1.0596 1.0596 27.4336 29.7870 32.1701 29.9764 140203.......................................................

***

*

* 28.2212

*

* 28.2212 140205....................................................... 1.7126 1.0150 1.0150

*

*

*

* 140206....................................................... 1.0867 1.0742 1.0742 27.5481 30.6561 29.1294 29.1455 140207....................................................... 1.2439 1.0742 1.0742 25.7331 24.1048 25.1473 24.9715 140208....................................................... 1.6564 1.0742 1.0742 27.6586 29.4708 29.7525 28.9886 140209....................................................... 1.5833 0.8973 0.8973 23.3886 24.5376 26.3371 24.7775 140210....................................................... 1.1359 0.8334 0.8334 16.6729 19.2639 20.5812 18.7925 140211....................................................... 1.2974 1.0742 1.0742 29.5114 29.7054 30.7546 30.0426 140213....................................................... 1.2144 1.0742 1.0742 29.1649 30.2945 31.3811 30.2935 140215.......................................................

***

*

* 22.3097

*

* 22.3097 140217....................................................... 1.4968 1.0742 1.0742 29.3711 31.5324 32.7581 31.1722 140223....................................................... 1.4796 1.0742 1.0742 29.2540 30.4923 31.9618 30.5734 140224....................................................... 1.3603 1.0742 1.0742 29.0350 28.2177 29.8867 29.0497 140228....................................................... 1.5725 0.9987 0.9987 25.0074 25.6419 27.7259 26.1206 140231....................................................... 1.4875 1.0742 1.0742 28.3545 30.6410 30.0920 29.7474 140233....................................................... 1.6248 1.0596 1.0596 27.3379 28.6305 28.3631 28.1358 140234....................................................... 1.0969 0.8827 0.8827 23.2604 23.6928 24.7645 23.9187 140239....................................................... 1.5507 0.9987 0.9987 24.2112 29.0092 31.8210 28.3245 140240....................................................... 1.4058 1.0742 1.0742 27.2654 28.7310 30.1439 28.6637 140242....................................................... 1.4891 1.0742 1.0742 30.4005 32.0522 34.4226 32.3743 140245.......................................................

***

*

* 16.0772

*

* 16.0772 140250....................................................... 1.1833 1.0742 1.0742 27.4628 28.5971 29.9198 28.6855 140251....................................................... 1.3420 1.0742 1.0742 26.7266 27.1687 28.4384 27.4435 140252....................................................... 1.3975 1.0742 1.0742 30.2656 33.3351 34.5410 32.7890 140258....................................................... 1.5438 1.0742 1.0742 27.9478 30.2639 33.6353 30.7068 140271....................................................... 0.8939

*

* 18.8535

*

* 18.8535 140275....................................................... 1.3373 0.8569 0.8569 25.2824 26.1473 27.9824 26.4533 140276....................................................... 1.8331 1.0742 1.0742 27.5936 29.8325 31.3200 29.6123

[[Page 24182]]

140280....................................................... 1.4395 0.8569 0.8569 21.9302 23.4447 22.5604 22.6515 140281....................................................... 1.6866 1.0742 1.0742 29.2602 30.4838 33.7817 31.1676 140285.......................................................

***

*

* 17.7824 20.7576

* 19.1679 140286....................................................... 1.1273 1.0742 1.0742 28.4378 29.1543 31.0563 29.5696 140288....................................................... 1.5613 1.0742 1.0742 26.9581 29.3988 31.7089 29.3668 140289....................................................... 1.3194 0.9017 0.9017 22.3274 22.6211 24.5456 23.1903 140290....................................................... 1.3527 1.0742 1.0742 28.6926 31.7341 31.2636 30.6196 140291....................................................... 1.5063 1.0596 1.0596 28.2338 29.8958 31.3199 29.9025 140292....................................................... 1.1567 1.0742 1.0742 26.1781 27.6285 29.2990 27.7701 140294....................................................... 1.1615 0.8334 0.8334 22.6123 23.4504 24.0181 23.3722 140300....................................................... 1.1185 1.0742 1.0742 33.3983 34.8568 35.6231 34.6085 140301....................................................... 1.2721 1.0742 1.0742

* 31.7073 49.7125 37.1819 140303....................................................... 1.8671 1.0742 1.0742

*

* 29.8654 29.8654 140344....................................................... 0.7733

*

*

*

*

*

* 150001....................................................... 1.1131 0.9757 0.9757 27.1021 29.6844 28.3954 28.4082 150002....................................................... 1.4378 1.0596 1.0596 23.3804 25.0063 26.3713 24.8884 150003....................................................... 1.6318 0.8957 0.8957 23.3196 25.3458 27.0406 25.2176 150004....................................................... 1.4953 1.0596 1.0596 24.8884 26.8458 28.0176 26.5920 150005....................................................... 1.1856 0.9757 0.9757 25.4443 27.2369 29.5025 27.5016 150006....................................................... 1.3717 0.9543 0.9543 24.8976 26.4061 26.1674 25.8384 150007....................................................... 1.3603 0.9494 0.9494 23.5841 26.6073 29.4617 26.6700 150008....................................................... 1.4502 1.0596 1.0596 23.6953 26.6928 27.3400 25.9807 150009....................................................... 1.3886 0.9137 0.9137 20.4993 22.2147 24.9618 22.6002 150010....................................................... 1.4176 0.9494 0.9494 23.9740 26.8524 26.1311 25.6410 150011....................................................... 1.1850 0.9582 0.9582 23.2249 24.3490 25.3748 24.3343 150012....................................................... 1.5696 0.9677 0.9677 22.9314 27.3029 27.7477 25.8046 150013....................................................... 1.0122

*

* 19.7689 21.8465

* 20.8053 150014.......................................................

***

*

* 26.5785

*

* 26.5785 150015....................................................... 1.3253 1.0596 1.0596 24.3015 26.2434 27.7478 26.1118 150017....................................................... 1.7827 0.9498 0.9498 23.7180 25.2342 27.1394 25.3937 150018....................................................... 1.6614 0.9421 0.9421 24.7048 26.3289 27.4616 26.1770 150021....................................................... 1.7672 0.9498 0.9498 27.8168 29.6967 29.5355 29.0360 150022....................................................... 1.1171 0.8728 0.8728 22.8035 22.6773 22.9027 22.7977 150023....................................................... 1.5443 0.8663 0.8663 23.1253 23.7159 26.3792 24.2243 150024....................................................... 1.3983 0.9757 0.9757 24.7879 27.1589 27.5637 26.5220 150026....................................................... 1.3092 0.9421 0.9421 23.7185 28.1127 28.7334 26.9980 150027....................................................... 1.0215

*

* 21.2855 17.4862

* 19.1736 150029....................................................... 1.4031 0.9677 0.9677 23.4103 26.9680 27.8939 25.8068 150030....................................................... 1.1595 0.9582 0.9582 24.4361 26.9533 28.0417 26.5118 150033....................................................... 1.6558 0.9757 0.9757 25.8851 27.9995 29.0207 27.6412 150034....................................................... 1.5452 1.0596 1.0596 23.9388 26.0465 28.1138 26.1270 150035....................................................... 1.5489 0.9361 0.9361 26.0952 26.6620 27.1031 26.6373 150037....................................................... 1.3067 0.9757 0.9757 27.7009 28.5451 30.7071 28.9916 150038....................................................... 1.1286 0.9757 0.9757 24.4188 28.8054 29.0433 27.4342 150042....................................................... 1.4612 0.8479 0.8479 21.9917 23.0102 22.3848 22.4673 150044....................................................... 1.3885 0.9137 0.9137 23.1200 23.7065 24.3939 23.7747 150045 h..................................................... 1.0516 0.9914 0.9914 24.2899 25.2225 27.1520 25.569 150046....................................................... 1.4240 0.8663 0.8663 21.0417 21.9369 24.1694 22.4186 150047....................................................... 1.7598 0.9498 0.9498 24.5455 25.8349 25.1553 25.1829 150048....................................................... 1.3838 0.9599 0.9599 24.5864 27.1817 27.4034 26.3728 150049....................................................... 1.2142

*

* 20.2178 22.3370

* 21.2543 150051....................................................... 1.5992 0.9582 0.9582 22.6866 23.7061 25.3577 23.9071 150052....................................................... 1.0642

*

* 19.6073 20.6339

* 20.1223 150056....................................................... 1.9057 0.9757 0.9757 27.6754 28.2842 29.5718 28.5127 150057....................................................... 2.0352 0.9757 0.9757 22.7804 24.8605 29.6310 25.6224 150058....................................................... 1.5547 0.9677 0.9677 26.9753 27.5341 29.3647 28.0150 150059....................................................... 1.5388 0.9757 0.9757 27.0792 28.5715 32.4123 29.3673 150060....................................................... 1.0871

*

* 23.2409 24.8544

* 24.0586 150061....................................................... 1.1363 0.8479 0.8479 21.3640 22.2822 21.7707 21.8139 150062....................................................... 1.0931

*

* 23.5550 24.6088

* 24.0884 150063.......................................................

***

*

* 19.0377

*

* 19.0377 150064....................................................... 1.2156 0.8479 0.8479 21.6370 23.7707 25.1734 23.5270 150065....................................................... 1.2414 0.9582 0.9582 24.4451 25.9461 27.9073 26.1176 150069....................................................... 1.2501 0.9599 0.9599 25.3445 25.2655 25.9517 25.5268 150070.......................................................

***

*

* 22.6260

*

* 22.6260 150072....................................................... 1.1595 0.8479 0.8479 20.3191 20.5111 21.3608 20.7440

[[Page 24183]]

150074....................................................... 1.4564 0.9757 0.9757 24.4374 25.2586 25.6634 25.1233 150075....................................................... 1.0933 0.9498 0.9498 24.2085 24.0745 25.6197 24.6280 150076....................................................... 1.2852 0.9543 0.9543 24.1434 28.1874 28.2428 26.8000 150078....................................................... 1.0122

*

* 21.2476

*

* 21.2476 150079....................................................... 1.1145

*

* 20.6486 21.4067

* 21.0466 150082....................................................... 1.7181 0.8844 0.8844 22.2054 25.5860 28.1847 25.2933 150084....................................................... 1.7659 0.9757 0.9757 28.7722 29.3905 29.5244 29.2252 150086....................................................... 1.2036 0.9599 0.9599 22.4471 23.9404 25.2450 23.9229 150088....................................................... 1.2606 0.9582 0.9582 23.0998 23.6253 26.2241 24.3172 150089....................................................... 1.5861 0.8479 0.8479 22.6545 25.0449 24.6068 24.0532 150090....................................................... 1.5494 1.0596 1.0596 24.6758 26.2899 29.4725 26.7855 150091 h..................................................... 1.1148 1.0071 1.0071 27.8087 30.6209 30.7951 29.8811 150096....................................................... 0.9023

*

* 21.9091

*

* 21.9091 150097....................................................... 1.1238 0.9757 0.9757 24.4179 25.0367 27.1660 25.5838 150100....................................................... 1.7215 0.8844 0.8844 22.2687 24.3530 25.0773 23.8670 150101....................................................... 1.0867 0.9498 0.9498 27.9745 29.1657 29.8966 29.0799 150102....................................................... 1.0400 0.9278 0.9278 22.6870 24.5923 25.3187 24.2235 150104....................................................... 1.0401 0.9757 0.9757 21.8172 25.5871 28.5451 25.2739 150106 h..................................................... 1.0633 0.9498 0.9498 20.9955 20.9387 19.9273 20.5636 150109....................................................... 1.4441 0.8957 0.8957 24.3786 23.5865 26.0186 24.6513 150112....................................................... 1.4182 0.9582 0.9582 24.7455 26.5643 27.6269 26.3492 150113....................................................... 1.2634 0.9582 0.9582 23.0450 24.8760 26.0356 24.6828 150115....................................................... 1.4534 0.8479 0.8479 20.5215 19.3411 22.3372 20.6746 150122....................................................... 1.1613 0.9582 0.9582 24.2471 26.0173

* 25.1559 150123.......................................................

***

*

* 15.3050

*

* 15.3050 150124....................................................... 1.1063

*

* 18.8218 21.3933

* 20.1237 150125....................................................... 1.4997 1.0596 1.0596 24.3872 26.7666 27.1394 26.1113 150126....................................................... 1.4372 1.0596 1.0596 25.5585 26.9887 27.7563 26.7967 150128....................................................... 1.4280 0.9757 0.9757 23.1660 26.4976 28.2773 25.9381 150129....................................................... 1.1690 0.9757 0.9757 35.4311 29.9099 30.1445 31.4914 150130....................................................... 1.0939

*

* 21.5678 21.7399

* 21.6494 150132.......................................................

***

*

* 24.2559 25.6257 27.7474 25.8793 150133....................................................... 1.2322 0.9498 0.9498 21.8839 22.7293 25.1827 23.2488 150134....................................................... 1.0669 0.9137 0.9137 22.1085 23.8526 26.1958 23.9695 150136.......................................................

***

*

* 25.7004 26.2703

* 25.9880 150146....................................................... 1.0555 0.9498 0.9498 26.1168 29.3383 30.2135 28.6444 150147....................................................... 1.2950 1.0596 1.0596 32.3336 22.8456 27.0517 26.4997 150148.......................................................

***

*

* 27.2081

*

* 27.2081 150149....................................................... 1.0182 0.8844 0.8844 23.8554 23.6361 24.7733 24.1065 150150....................................................... 1.2596 0.9498 0.9498 26.5138 25.5331 28.4744 26.8947 150151.......................................................

***

*

*

* 38.1446

* 38.1446 150152.......................................................

***

*

*

* 44.7143

* 44.7143 150153....................................................... 2.4953 0.9757 0.9757

*

* 32.2301 32.2301 150154....................................................... 2.5331 0.9757 0.9757

*

* 29.2863 29.2863 150155.......................................................

***

*

*

*

* 45.0525 45.0525 150156.......................................................

***

*

*

*

* 25.8304 25.8304 150157....................................................... 1.5402 0.9757 0.9757

*

*

*

* 150158....................................................... 1.1799

*

*

*

*

*

* 150159....................................................... 0.9066

*

*

*

*

*

* 150160....................................................... 1.8672

*

*

*

*

*

* 150323....................................................... 0.8865

*

*

*

*

*

* 150325....................................................... 0.8673

*

*

*

*

*

* 160001....................................................... 1.1633 0.8976 0.8976 23.8657 25.1220 25.0365 24.6447 160003....................................................... 0.8939

*

* 19.0037

*

* 19.0037 160005....................................................... 1.1884 0.8696 0.8696 21.1745 21.8950 23.7127 22.2743 160008....................................................... 1.0864 0.8696 0.8696 19.8066 20.7200 22.3526 20.9456 160013....................................................... 1.2716 0.8914 0.8914 23.0163 23.7163 24.6784 23.7825 160014....................................................... 0.9604

*

* 19.2447 20.5882

* 19.9190 160016....................................................... 1.5629 0.8976 0.8976 21.2785 23.3619 24.6900 23.1167 160020....................................................... 1.1096

*

* 19.0043 19.5554

* 19.2901 160024....................................................... 1.6059 0.9136 0.9136 24.2385 26.2392 27.4041 25.9650 160026....................................................... 1.0140

*

* 24.2045 24.7424

* 24.4805 160028....................................................... 1.3221 0.9453 0.9453 26.0052 26.2948 28.0717 26.9016 160029....................................................... 1.6161 0.9726 0.9726 24.9493 27.9277 29.7097 27.5319 160030....................................................... 1.4263 0.9819 0.9819 24.9920 26.7068 28.9474 26.8746 160031....................................................... 0.9870

*

* 18.5281 19.7368

* 19.1263

[[Page 24184]]

160032....................................................... 1.0729 0.8968 0.8968 22.3837 23.4727 25.7041 23.9167 160033....................................................... 1.7593 0.8696 0.8696 23.4148 24.6768 26.5814 24.9317 160034....................................................... 0.9775

*

* 19.4837 19.3503

* 19.4156 160039....................................................... 0.9863

*

* 20.9623 22.1180

* 21.5414 160040....................................................... 1.2803 0.8891 0.8696 21.8187 23.9053 25.6843 23.8388 160044....................................................... 1.1510

*

* 19.5635

*

* 19.5635 160045....................................................... 1.7325 0.8891 0.8891 24.4957 25.4153 26.9819 25.6677 160047....................................................... 1.4056 0.9453 0.9453 24.5000 25.2072 25.6964 25.1382 160048....................................................... 1.0401

*

* 19.5701 19.5832

* 19.5767 160050....................................................... 1.1294

*

* 23.8830 24.5403

* 24.2221 160057....................................................... 1.2446 0.9568 0.9568 22.0472 23.0937 25.1339 23.4637 160058....................................................... 1.9653 0.9726 0.9726 25.5244 27.1646 28.6411 27.1442 160064....................................................... 1.5286 0.9256 0.9256 27.6301 28.6139 28.7718 28.4086 160066....................................................... 1.0600

*

* 21.4631 22.7709

* 22.1300 160067....................................................... 1.3137 0.8891 0.8696 21.9418 23.4060 23.7824 23.1319 160069....................................................... 1.5111 0.9132 0.9132 22.7514 25.3402 27.7295 25.2986 160074....................................................... 1.0989

*

* 20.2418

*

* 20.2418 160076.......................................................

***

*

* 20.9749

*

* 20.9749 160079....................................................... 1.5393 0.8891 0.8891 22.5299 23.7234 25.4508 23.9274 160080....................................................... 1.3064 0.8696 0.8696 23.5721 23.1837 25.9475 24.2696 160081....................................................... 1.1664

*

* 21.3614 23.1930

* 22.2788 160082....................................................... 1.8161 0.9136 0.9136 23.8181 26.4398 27.2896 25.8257 160083....................................................... 1.6913 0.9136 0.9136 25.0617 28.2193 27.3867 26.9189 160089....................................................... 1.2968 0.8976 0.8976 21.5693 22.6551 23.6643 22.6499 160090....................................................... 0.8236

*

* 21.2753

*

* 21.2753 160091....................................................... 0.9377

*

* 18.0630 17.9862

* 18.0240 160092....................................................... 0.9932

*

* 22.0841

*

* 22.0841 160101....................................................... 1.1187 0.9136 0.9136 24.2309 25.1000 23.7690 24.3536 160104....................................................... 1.5181 0.8696 0.8696 24.0075 24.9134 28.0389 25.6671 160106.......................................................

***

*

* 21.4912

*

* 21.4912 160107.......................................................

***

*

* 21.3754

*

* 21.3754 160110....................................................... 1.5282 0.8891 0.8696 24.1762 24.9434 26.9342 25.3634 160112....................................................... 1.2386 0.8696 0.8696 21.8901 23.0672 25.2434 23.4606 160113.......................................................

***

*

* 18.6599

*

* 18.6599 160115....................................................... 1.0432

*

* 19.5764

*

* 19.5764 160116....................................................... 1.0175

*

* 22.2019

*

* 22.2019 160117....................................................... 1.3193 0.9132 0.9132 23.4250 25.0278 25.9502 24.8152 160118.......................................................

***

*

* 18.3322 19.7764

* 19.0436 160122....................................................... 1.1051 0.8696 0.8696 22.9565 22.5872 23.9298 23.1689 160124....................................................... 1.1607 0.8696 0.8696 22.7223 23.1690 23.1591 23.0224 160126....................................................... 1.0173

*

* 20.3748 19.8323

* 20.1046 160140....................................................... 1.0475

*

* 22.5230

*

* 22.5230 160146....................................................... 1.4589 0.9201 0.9201 20.9583 22.9897 22.5441 22.1450 160147....................................................... 1.3443 0.8976 0.8976 26.6577 26.6438 28.6722 27.3688 160153....................................................... 1.6297 0.9201 0.9201 26.3671 28.9881 30.5992 28.6813 160154....................................................... 0.9033

*

*

*

*

*

* 160365....................................................... 0.7586

*

*

*

*

*

* 160366....................................................... 0.8054

*

*

*

*

*

* 170001....................................................... 1.2262 0.8017 0.8017 20.9837 21.9131 23.0583 21.9743 170006....................................................... 1.2593 0.8620 0.8620 20.6460 21.9019 24.5553 22.4217 170009....................................................... 1.0705 0.9501 0.9501 29.1979 29.2588 31.2360 29.8767 170010....................................................... 1.2077 0.8146 0.8146 21.2131 24.0008 24.9889 23.4347 170012....................................................... 1.6500 0.8832 0.8832 22.6869 24.7392 25.8453 24.4008 170013....................................................... 1.5264 0.8832 0.8832 23.1159 25.0419 25.9854 24.7349 170014....................................................... 1.0386 0.9501 0.9501 22.9772 23.5960 24.9156 23.8535 170015....................................................... 1.0240

*

* 19.1902 20.2367

* 19.7243 170016....................................................... 1.6420 0.8738 0.8738 24.2336 25.9482 26.3308 25.5277 170017....................................................... 1.1104 0.9093 0.9093 23.3030 24.7771 26.6342 24.9721 170018....................................................... 0.9385

*

* 17.9497

*

* 17.9497 170019....................................................... 1.1619

*

* 20.3243 22.0251

* 21.1885 170020....................................................... 1.5720 0.8832 0.8832 22.2571 23.1800 22.6799 22.7039 170022....................................................... 1.1286

*

* 22.9313 22.2878

* 22.6058 170023....................................................... 1.4438 0.8832 0.8832 23.2690 23.9808 24.4018 23.8806 170027....................................................... 1.4472 0.8017 0.8017 21.4678 22.5103 22.9256 22.2935 170033....................................................... 1.3383 0.8832 0.8832 20.0801 20.7865 22.0776 20.9737 170039....................................................... 0.9534 0.9093 0.9093 20.1983 21.5203 25.4845 22.1744

[[Page 24185]]

170040....................................................... 1.9280 0.9501 0.9501 27.1771 28.2856 28.9419 28.1702 170049....................................................... 1.4737 0.9501 0.9501 24.1208 24.7895 26.3910 25.1440 170052....................................................... 1.2142

*

* 17.3794 18.5291

* 17.9769 170054.......................................................

***

*

* 17.5500

*

* 17.5500 170058....................................................... 1.0587 0.9501 0.9501 22.0398 23.3398 23.1208 22.8378 170068....................................................... 1.2219 0.9177 0.9177 20.8771 22.6087 22.6765 22.0710 170070....................................................... 0.9818

*

* 16.4767 16.0162

* 16.2556 170074....................................................... 1.2412 0.8017 0.8017 20.4936 21.0565 23.2439 21.6462 170075....................................................... 0.8380 0.8017 0.8017 16.2047 16.5444 18.8919 17.1984 170085....................................................... 0.9089

*

* 18.4867

*

* 18.4867 170086....................................................... 1.5716 0.8738 0.8738 22.7737 24.0812 25.4693 24.1433 170090.......................................................

***

*

* 15.9807

*

* 15.9807 170093....................................................... 0.8381

*

* 16.8710 16.5553

* 16.7116 170094....................................................... 0.9782 0.8017 0.8017 20.3678 21.3887 20.9912 20.9361 170097.......................................................

***

*

* 20.3391

*

* 20.3391 170098....................................................... 0.9894

*

* 20.0078 20.1242

* 20.0657 170103....................................................... 1.2387 0.9093 0.9093 21.4985 22.8707 23.7154 22.7347 170104....................................................... 1.5107 0.9501 0.9501 26.1866 26.9671 27.8829 27.0103 170105....................................................... 1.0190 0.8017 0.8017 19.6687 21.4422 21.9852 21.0428 170109....................................................... 1.0433 0.9501 0.9501 22.7166 23.2626 24.1847 23.3947 170110....................................................... 0.9597 0.8017 0.8017 21.8904 22.9195 22.8693 22.5555 170114....................................................... 0.8804

*

* 18.1610 18.9158

* 18.5532 170116.......................................................

***

*

* 23.1127

*

* 23.1127 170120....................................................... 1.3358 0.8620 0.8620 19.8723 21.0499 22.1507 21.0257 170122....................................................... 1.6367 0.9093 0.9093 24.6532 25.3981 26.6964 25.5707 170123....................................................... 1.6568 0.9093 0.9093 26.4676 27.2239 28.2363 27.2774 170133....................................................... 1.0499 0.9501 0.9501 21.7748 22.9309 22.9094 22.5427 170137....................................................... 1.2403 0.8017 0.8017 22.7676 23.8863 24.7063 23.8048 170142....................................................... 1.3495 0.8591 0.8591 22.4095 22.5778 23.3910 22.8083 170143....................................................... 1.2000

*

* 19.7643 20.4459

* 20.1017 170144.......................................................

***

*

* 24.4259 24.6260

* 24.5144 170145....................................................... 1.0697 0.8017 0.8017 21.4472 21.5756 23.1863 22.0533 170146....................................................... 1.4687 0.9501 0.9501 28.1965 29.1358 30.3055 29.2105 170147....................................................... 2.0068 0.9093 0.9093 23.1610 21.4753 22.7160 22.4146 170150....................................................... 1.1923 0.8017 0.8017 17.4916 18.5744 20.1810 18.7858 170166....................................................... 1.0396 0.8017 0.8017 18.5978 19.2842 19.8233 19.2265 170175....................................................... 1.3814 0.8832 0.8832 23.6262 23.9304 25.8196 24.4660 170176....................................................... 1.5073 0.9501 0.9501 24.2283 26.2366 28.0633 26.1546 170180.......................................................

***

*

*

* 25.1366

* 25.1366 170182....................................................... 1.4744 0.9501 0.9501 24.3820 25.7443 28.2886 26.1597 170183....................................................... 1.9823 0.9093 0.9093 22.8633 24.5539 26.0515 24.4826 170185....................................................... 1.3263 0.9501 0.9501 24.8478 26.7797 29.1199 27.2051 170186....................................................... 2.6919 0.9093 0.9093 30.5157 31.7896 33.0190 31.8475 170187....................................................... 1.4655 0.8017 0.8017 21.0780 23.3702 24.4045 22.9793 170188....................................................... 2.0410 0.9501 0.9501 27.2225 29.9751 31.8257 29.7873 170190....................................................... 1.0729 0.8591 0.8591 22.4865 22.8729 22.9911 22.7762 170191....................................................... 1.6457 0.8017 0.8017 24.9599 21.3069 22.2346 22.8619 170192....................................................... 2.0073 0.9093 0.9093

* 27.9704 27.0735 27.4857 170193....................................................... 1.6307 0.8832 0.8832

* 24.7430 18.4870 21.4458 170194....................................................... 1.3722 0.9501 0.9501

* 27.9904 30.7548 29.6973 170195....................................................... 2.0069 0.9501 0.9501

*

* 30.6081 30.6081 170196....................................................... 2.2556 0.9093 0.9093

*

*

*

* 170332....................................................... 0.7372

*

*

*

*

*

* 170344....................................................... 0.7933

*

*

*

*

*

* 170374....................................................... 0.8095

*

*

*

*

*

* 170375....................................................... 0.7667

*

*

*

*

*

* 180001....................................................... 1.2904 0.9599 0.9599 24.7647 25.4217 27.4380 25.9006 180002....................................................... 1.0856 0.7793 0.7793 21.6843 22.9727 25.5510 23.4521 180004....................................................... 1.0814 0.7793 0.7793 19.0834 19.5437 21.2755 19.9789 180005....................................................... 1.0940 0.8759 0.8759 22.8871 24.5561 24.9313 24.1526 180006....................................................... 0.8701

*

* 15.7136 14.8011

* 15.2405 180007....................................................... 1.4568 0.9168 0.9168 21.8724 22.7606 26.4901 23.7049 180009....................................................... 1.6569 0.9009 0.9009 24.0971 25.3837 26.6728 25.3971 180010....................................................... 1.9267 0.9168 0.9168 26.4116 24.7256 25.7070 25.5805 180011....................................................... 1.3761 0.8928 0.8928 22.3183 22.7364 25.6662 23.5939 180012....................................................... 1.4709 0.9137 0.9137 22.9096 24.6642 25.8098 24.4828

[[Page 24186]]

180013....................................................... 1.4693 0.9571 0.9571 21.4728 22.9512 23.9232 22.7868 180016....................................................... 1.3146 0.9137 0.9137 22.2148 23.1832 24.9302 23.4667 180017....................................................... 1.2778 0.8207 0.8207 19.0694 20.8630 21.9306 20.6221 180018....................................................... 1.3860 0.8928 0.8928 18.3314 19.0992 20.9508 19.4438 180019....................................................... 1.1175 0.9599 0.9599 22.0379 24.1342 24.2365 23.4611 180020....................................................... 1.0710 0.7793 0.7793 22.3477 21.9494 24.3479 22.9113 180021....................................................... 0.9567 0.7793 0.7793 17.9346 18.5966 19.2640 18.6011 180024....................................................... 1.1122 0.9137 0.9137 23.6826 32.1824 31.3281 28.9328 180025....................................................... 1.1108 0.9137 0.9137 17.4781 19.1543 22.8383 19.7600 180026....................................................... 1.0695

*

* 15.8431 18.2120

* 17.0401 180027....................................................... 1.1962 0.8094 0.8094 22.1072 23.8763 21.2891 22.3439 180028....................................................... 0.9346 0.8759 0.8759 21.4766 24.7968 25.4328 23.9001 180029....................................................... 1.3805 0.8062 0.8062 21.2110 23.0536 25.1372 23.1824 180035....................................................... 1.6266 0.9599 0.9599 26.7702 29.8438 31.8857 29.5742 180036....................................................... 1.2029 0.9009 0.9009 23.1636 25.1154 25.8131 24.6472 180037....................................................... 1.2572 0.9137 0.9137 24.4451 25.7361 26.3742 25.5161 180038....................................................... 1.4800 0.8780 0.8780 22.2750 24.6348 25.9911 24.2496 180040....................................................... 2.0538 0.9137 0.9137 24.5590 26.2125 27.7343 26.2542 180041.......................................................

***

*

* 18.5483

*

* 18.5483 180043....................................................... 1.1754 0.7793 0.7793 18.8436 19.0617 20.6947 19.5226 180044....................................................... 1.6181 0.8759 0.8759 21.6837 23.0971 24.6946 23.1584 180045....................................................... 1.3355 0.9599 0.9599 24.5856 25.8349 27.3369 25.9400 180046....................................................... 1.0532 0.9168 0.9168 24.7562 27.2244 27.5609 26.5441 180047....................................................... 0.9169

*

* 20.4768 21.8037

* 21.1276 180048....................................................... 1.2720 0.9137 0.9137 22.3601 21.6571 23.9768 22.6449 180049 h..................................................... 1.3907 0.9744 0.9744 19.4488 23.3407 23.1703 22.0488 180050....................................................... 1.1591 0.7793 0.7793 21.7150 22.6473 25.5270 23.2474 180051....................................................... 1.2771 0.8431 0.8431 19.2100 21.3312 23.0986 21.2619 180053....................................................... 1.0110 0.7793 0.7793 18.6610 19.1578 20.0309 19.3175 180054.......................................................

***

*

* 19.0657

*

* 19.0657 180055....................................................... 1.1340

*

* 21.1989 20.7237

* 20.9496 180056....................................................... 1.1090 0.8844 0.8844 21.4695 22.8910 24.9363 23.0960 180063....................................................... 1.1323

*

* 15.9185 17.9741

* 17.0063 180064....................................................... 1.2625 0.7793 0.7793 15.3819 16.2638 17.2395 16.3222 180066....................................................... 1.1353 0.9571 0.9571 24.6359 24.9543 22.6968 24.0612 180067....................................................... 2.0454 0.9168 0.9168 24.0551 25.4080 27.3195 25.5822 180069....................................................... 1.0900 0.8759 0.8759 20.8797 22.3674 24.8052 22.7309 180070....................................................... 1.1763 0.7793 0.7793 17.4266 20.1308 20.6670 19.4044 180078....................................................... 1.1205 0.8759 0.8759 25.4196 26.2636 27.6613 26.4740 180079....................................................... 1.1252 0.7793 0.7793 19.5783 19.7791 20.0616 19.8220 180080....................................................... 1.2929 0.8278 0.8278 20.1651 21.7380 21.3549 21.0816 180087....................................................... 1.2016 0.7793 0.7793 17.7758 18.4331 19.5444 18.6024 180088....................................................... 1.6372 0.9137 0.9137 24.6053 27.5767 28.1804 26.8275 180092....................................................... 1.1833 0.9168 0.9168 22.4864 22.5679 24.2126 23.0944 180093....................................................... 1.5187 0.8545 0.8545 19.2748 20.5422 21.1607 20.3257 180095....................................................... 1.0540 0.7793 0.7793 17.1354 17.9677 17.9541 17.6956 180101....................................................... 1.1164 0.9168 0.9168 24.2242 25.4796 28.3249 26.0568 180102....................................................... 1.6318 0.8094 0.8094 19.1136 18.4388 21.2737 19.5783 180103....................................................... 2.1888 0.9168 0.9168 25.1577 26.9407 28.4766 26.8190 180104....................................................... 1.6266 0.8094 0.8094 22.8911 24.9441 25.9248 24.6219 180105....................................................... 0.8701 0.7793 0.7793 19.5364 19.7615 19.8581 19.7194 180106....................................................... 0.9335 0.7793 0.7793 15.7851 17.8020 19.1634 17.6990 180115....................................................... 0.9382 0.7793 0.7793 19.9316 20.9831 20.2666 20.3950 180116....................................................... 1.2247 0.8210 0.8210 21.8698 22.7353 23.1396 22.5915 180117....................................................... 0.9727 0.7793 0.7793 20.5952 21.1854 22.4436 21.4051 180124....................................................... 1.3041 0.9571 0.9571 21.4270 23.1917 24.9816 23.2096 180126....................................................... 1.0703

*

* 15.1776

*

* 15.1776 180127....................................................... 1.3028 0.9137 0.9137 21.4633 23.4765 24.8603 23.2919 180128....................................................... 0.9146 0.8075 0.8075 20.5575 20.8406 21.9414 21.1232 180130....................................................... 1.6643 0.9137 0.9137 24.8441 26.0278 27.7053 26.2114 180132....................................................... 1.4816 0.8928 0.8928 22.2101 23.7652 24.5256 23.5331 180134....................................................... 1.0218

*

* 17.3449 18.6779

* 18.0324 180138....................................................... 1.2283 0.9137 0.9137 25.1789 27.3400 28.8157 27.1346 180139....................................................... 1.0399 0.8928 0.8928 21.3797 23.5363 23.3285 22.7513 180141....................................................... 1.8300 0.9137 0.9137 24.3140 25.3042 25.3054 24.9917 180143....................................................... 1.6199 0.9168 0.9168 23.9125 25.1613 28.6078 26.0627

[[Page 24187]]

180144.......................................................

***

*

*

*

* 30.3286 30.3286 180147....................................................... 1.6674 0.8164 0.8164

*

*

*

* 180148....................................................... 1.9111 0.7793 0.7793

*

*

*

* 180325....................................................... 0.6167

*

*

*

*

*

* 190001....................................................... 1.1128 0.8855 0.8855 19.5680 19.7516 21.5505 20.3938 190002....................................................... 1.6807 0.8300 0.8300 21.7000 22.0056 23.3871 22.3593 190003....................................................... 1.4747 0.8300 0.8300 21.8156 23.4977 25.1210 23.4734 190004....................................................... 1.3195 0.8003 0.8003 22.1835 23.3290 24.5339 23.3634 190005....................................................... 1.4444 0.8855 0.8855 20.7987 22.3208 23.3281 22.1604 190006....................................................... 1.3548 0.8300 0.8300 19.4573 22.2467 22.8415 21.4705 190007....................................................... 1.1671 0.7487 0.7487 18.7854 19.7528 21.6654 20.0400 190008....................................................... 1.7539 0.8003 0.8003 21.4137 24.0111 24.7413 23.4477 190009....................................................... 1.1787 0.8028 0.8028 18.8295 19.8404 21.1607 19.8729 190010....................................................... 1.0751

*

* 19.9788 21.6889

* 20.8295 190011....................................................... 1.0542 0.8015 0.8015 18.1525 19.7319 20.7613 19.5483 190013....................................................... 1.5067 0.7934 0.7934 19.6346 20.8626 21.8582 20.7874 190014....................................................... 1.2522 0.7487 0.7487 17.4740 22.4596 22.4213 20.6365 190015....................................................... 1.3280 0.8855 0.8855 22.1046 22.8875 24.0393 23.0562 190017 h..................................................... 1.3326 0.8535 0.8535 18.6962 21.5033 23.9006 21.2079 190019....................................................... 1.7368 0.8028 0.8028 23.0704 23.7168 24.9325 23.9113 190020....................................................... 1.1669 0.8102 0.8102 19.8505 21.6136 21.7393 21.0389 190025....................................................... 1.1904 0.7487 0.7487 20.4651 20.8950 22.7566 21.3808 190026....................................................... 1.5893 0.8028 0.8028 21.3386 22.5087 23.6452 22.5325 190027....................................................... 1.7130 0.7934 0.7934 21.2449 21.2526 24.1159 22.1755 190034....................................................... 1.1212 0.7487 0.7487 17.5002 19.6943 20.1435 19.1254 190036....................................................... 1.7154 0.8855 0.8855 23.7356 24.8152 26.1501 24.8932 190037....................................................... 1.0152 0.7934 0.7934 16.7629 18.6393 19.4805 18.2227 190039....................................................... 1.4789 0.8855 0.8855 23.3105 25.6665 24.8064 24.6160 190040....................................................... 1.3347 0.8855 0.8855 23.8076 26.7428 29.1926 26.4378 190041....................................................... 1.4817 0.8879 0.8879 23.9082 24.6734 28.2604 25.5075 190043....................................................... 0.9762

*

* 16.8944 17.3477

* 17.1195 190044 h..................................................... 1.2847 0.8300 0.8300 19.5304 19.5567 19.6876 19.5901 190045....................................................... 1.6052 0.8855 0.8855 24.0490 25.3854 26.1439 25.2015 190046....................................................... 1.4230 0.8855 0.8855 22.2884 24.2128 24.4763 23.6621 190048....................................................... 1.0930 0.7487 0.7487 18.6148 19.6288 24.1444 20.4885 190049.......................................................

***

*

* 20.1229

*

* 20.1229 190050....................................................... 1.1065 0.7487 0.7487 18.5287 19.1076 20.2752 19.3127 190053....................................................... 1.0904 0.7487 0.7487 15.7258 16.4968 17.0974 16.4674 190054....................................................... 1.3124 0.7594 0.7594 20.3525 20.1108 22.5554 21.0238 190059....................................................... 0.8305

*

* 19.2396

*

* 19.2396 190060....................................................... 1.4882 0.7934 0.7934 22.2517 23.6278 23.7228 23.1972 190064....................................................... 1.5792 0.8102 0.8102 21.5514 23.3617 23.1018 22.6984 190065....................................................... 1.5196 0.8102 0.8102 23.0523 23.7450 23.2052 23.3343 190077....................................................... 0.9219

*

* 18.4043 18.8409

* 18.6185 190078 h..................................................... 1.0622 0.8535 0.8535 21.5782 21.3786 21.4302 21.4587 190079....................................................... 1.2803 0.8855 0.8855 21.8158 21.2546 24.5361 22.5734 190081....................................................... 0.8857 0.7487 0.7487 14.9141 15.6146 17.3888 15.9862 190083....................................................... 0.8253

*

* 19.2683

*

* 19.2683 190086....................................................... 1.2411 0.8015 0.8015 18.8306 19.8823 21.7601 20.1681 190088 h..................................................... 1.0582 0.9584 0.9584 22.5045 22.3480 23.7776 22.8555 190089....................................................... 1.0009

*

* 16.2961

*

* 16.2961 190090....................................................... 1.0399 0.7487 0.7487 20.0745 20.2045 21.9736 20.8003 190095.......................................................

***

*

* 18.7302 18.0174

* 18.3606 190098....................................................... 1.6321 0.8879 0.8879 23.0802 24.6353 25.4941 24.4176 190099....................................................... 0.9927 0.8102 0.8102 21.1657 20.4597 21.4308 21.0206 190102....................................................... 1.5637 0.8300 0.8300 23.4618 25.2267 26.2644 24.9673 190106....................................................... 1.1741 0.8028 0.8028 21.5643 21.7228 22.9793 22.1017 190109....................................................... 1.1062 0.8003 0.8003 17.4842 18.6524 19.7946 18.5909 190110....................................................... 0.9270

*

* 19.0611

*

* 19.0611 190111....................................................... 1.6432 0.8879 0.8879 25.2370 24.4998 26.0669 25.2574 190114....................................................... 1.0698 0.7487 0.7487 14.6258 15.8031 15.8975 15.4576 190115....................................................... 1.1109 0.8879 0.8879 26.0272 26.6295 27.9894 26.8610 190116....................................................... 1.2757 0.7487 0.7487 18.6074 20.3844 21.4300 20.1684 190118....................................................... 0.9548 0.8879 0.8879 19.0200 19.7025 20.6847 19.8213 190122....................................................... 1.2678 0.8102 0.8102 19.3131 23.7082 21.6887 21.4626 190124....................................................... 1.5845 0.8855 0.8855 23.4862 24.6675 26.4280 24.8426

[[Page 24188]]

190125....................................................... 1.6592 0.8015 0.8015 22.3976 23.9649 25.7211 23.9666 190128....................................................... 1.0106 0.8102 0.8102 24.7842 27.9136 28.1804 26.9928 190130....................................................... 1.0390

*

* 16.6910

*

* 16.6910 190131....................................................... 1.1810 0.8855 0.8855 22.5032 25.1917 27.3959 25.0842 190133....................................................... 0.9292 0.7725 0.7725 14.3089 13.6266 17.7890 15.7239 190135....................................................... 1.5040 0.8855 0.8855 26.9920 26.8238 28.2929 27.3619 190140....................................................... 1.0098 0.7487 0.7487 17.0371 17.6936 18.5731 17.7798 190144 h..................................................... 1.1524 0.9584 0.9584 21.1658 21.7547 23.1334 22.0403 190145....................................................... 0.9656 0.7487 0.7487 17.3361 18.9678 18.4810 18.2716 190146....................................................... 1.5838 0.8855 0.8855 23.7721 26.1792 27.6317 25.7618 190148.......................................................

***

*

* 20.8321

*

* 20.8321 190149....................................................... 0.9370

*

* 17.1671 18.8819

* 17.9835 190151....................................................... 0.9812 0.7487 0.7487 17.8741 18.6293 17.5239 18.0074 190152....................................................... 1.3746 0.8855 0.8855 27.4708 27.6099 29.4694 28.1681 190156....................................................... 0.8864

*

* 18.3702

*

* 18.3702 190158....................................................... 1.5509 0.8855 0.8855 26.2352 26.3042 27.1110 26.5427 190160....................................................... 1.5748 0.8015 0.8015 20.0025 21.6740 22.7598 21.4114 190161....................................................... 1.0826 0.7934 0.7934 17.8794 19.1022 22.3359 19.6222 190162.......................................................

***

*

* 22.1781 25.0328 25.7829 24.2603 190164....................................................... 1.0953 0.8028 0.8028 21.4247 22.8599 24.0576 22.8477 190167....................................................... 1.1968 0.7487 0.7487 17.8604 24.3185 25.8153 22.5159 190175....................................................... 1.3812 0.8855 0.8855 24.6790 27.1531 26.1048 26.0265 190176....................................................... 1.7672 0.8855 0.8855 25.8482 25.6997 26.8503 26.1394 190177....................................................... 1.7055 0.8855 0.8855 25.4769 27.4621 27.9703 26.9919 190182....................................................... 1.0531 0.8855 0.8855 25.0837 28.4799 27.5625 26.9440 190183....................................................... 1.1374 0.8003 0.8003 18.3151 19.8084 22.0079 19.9316 190184....................................................... 0.9618 0.7648 0.7648 21.3191 23.9609 22.4219 22.5353 190185....................................................... 1.4457 0.8855 0.8855 24.4176 24.7912 26.1253 25.1793 190190....................................................... 0.8819 0.7648 0.7648 14.0052 16.1195 22.9091 18.5382 190191 h..................................................... 1.3219 0.8102 0.8102 22.3755 23.5734 23.3481 23.1104 190196....................................................... 0.9313 0.8300 0.8300 21.9355 24.7135 24.3478 23.6938 190197....................................................... 1.3995 0.8015 0.8015 22.9631 24.3735 25.2869 24.1817 190199....................................................... 1.1332 0.8102 0.8102 18.5317 14.1410 18.4387 16.8503 190200.......................................................

***

*

* 26.4258 27.5681 29.3041 27.5730 190201....................................................... 1.4773 0.7934 0.7934 22.5588 24.5877 25.3816 24.2106 190202....................................................... 1.3534 0.8102 0.8102 21.8900 24.7944 26.9337 24.6847 190203....................................................... 5.8369 0.8855 0.8855 26.9099 26.8795 28.7207 27.4692 190204....................................................... 1.4705 0.8855 0.8855 28.8777 28.3684 28.9970 28.7443 190205....................................................... 1.7340 0.8300 0.8300 21.7696 24.4540 25.8360 24.0124 190206....................................................... 1.5267 0.8855 0.8855 26.9117 26.0139 26.9116 26.6047 190208....................................................... 0.8148 0.7487 0.7487 24.8409 24.2586 24.8507 24.6578 190218....................................................... 1.1776 0.8715 0.8715 23.9182 25.0356 26.1218 25.0378 190236....................................................... 1.4266 0.8879 0.8879 23.8233 23.6824 25.3463 24.2960 190240.......................................................

***

*

* 13.9888

*

* 13.9888 190241....................................................... 1.4098 0.8003 0.8003 28.9620 23.9700 24.8072 25.7035 190242....................................................... 1.1366 0.8102 0.8102 20.5937 23.0072 24.3809 22.7673 190243.......................................................

***

*

* 30.6060

*

* 30.6060 190245....................................................... 1.6145 0.8015 0.8015

* 27.1786 26.0610 26.6431 190246....................................................... 1.7005 0.7648 0.7648

*

*

*

* 190247.......................................................

***

*

*

*

* 32.6169 32.6169 190248.......................................................

***

*

*

*

* 22.5610 22.5610 190249....................................................... 1.6224 0.8102 0.8102

*

* 19.9654 19.9654 190250....................................................... 2.2982 0.8855 0.8855

*

* 30.7776 30.7776 190251....................................................... 1.3551 0.8102 0.8102

*

* 22.7409 22.7409 190252.......................................................

***

*

*

*

* 23.5958 23.5958 190253....................................................... 1.0067 0.8855 0.8855

*

* 23.2202 23.2202 190254.......................................................

***

*

*

*

* 32.7951 32.7951 190255....................................................... 0.7132 0.8300 0.8300

*

* 23.6948 23.6948 190256....................................................... 1.0318 0.8855 0.8855

*

*

*

* 190257....................................................... 1.6790 0.7487 0.7487

*

* 23.3563 23.3563 190258....................................................... 1.6850 0.8879 0.8879

*

* 31.4217 31.4217 190259....................................................... 1.6898 0.8300 0.8300

*

*

*

* 190260....................................................... 1.4951 0.8855 0.8855

*

*

*

* 190261....................................................... 0.8481 0.8015 0.8015

*

*

*

* 190262....................................................... 1.3581 0.8855 0.8855

*

*

*

* 190263....................................................... 2.3925 0.8300 0.8300

*

*

*

*

[[Page 24189]]

190264....................................................... 0.8475

*

*

*

*

*

* 190265....................................................... 1.7577

*

*

*

*

*

* 190266....................................................... 2.1798

*

*

*

*

*

* 190267....................................................... 1.1686

*

*

*

*

*

* 190268....................................................... 1.0792

*

*

*

*

*

* 190272....................................................... 1.5252

*

*

*

*

*

* 190315....................................................... 0.6227

*

*

*

*

*

* 190319....................................................... 0.6636

*

*

*

*

*

* 190322....................................................... 0.6534

*

*

*

*

*

* 200001....................................................... 1.3968 0.9702 0.9702 23.2210 25.1145 25.2214 24.5549 200002....................................................... 1.1618 0.8528 0.8528 24.1446 25.7478 25.8372 25.2072 200007....................................................... 1.0634

*

* 22.3920

*

* 22.3920 200008....................................................... 1.3499 0.9916 0.9916 25.1741 27.4412 28.1910 26.9280 200009....................................................... 1.9130 0.9916 0.9916 28.1409 31.1056 30.5597 29.9288 200012....................................................... 1.2286

*

* 24.1243 25.7623

* 24.9713 200013....................................................... 1.0902

*

* 23.9048 24.4131

* 24.1576 200018....................................................... 1.3112 0.8399 0.8399 24.3294 23.6337 23.3123 23.7070 200019....................................................... 1.2865 0.9916 0.9916 24.0926 25.1367 25.9081 25.0652 200020....................................................... 1.2500 1.0309 1.0309 28.7351 31.7083 33.4438 31.3595 200021....................................................... 1.2371 0.9916 0.9916 25.1027 24.5519 27.4575 25.7589 200024....................................................... 1.5547 0.9487 0.9487 24.6484 26.0080 26.9002 25.9263 200025....................................................... 1.1601 0.9916 0.9916 24.3646 26.0573 27.0379 25.8101 200026.......................................................

***

*

* 21.9997

*

* 21.9997 200027....................................................... 1.2078

*

* 23.2912 26.3118

* 24.7659 200028....................................................... 1.0082

*

* 24.3061 24.3271

* 24.3172 200031....................................................... 1.2800 0.8399 0.8399 20.6202 21.9489 21.2055 21.2587 200032....................................................... 1.1803 0.8865 0.8865 24.2221 25.5227 26.6057 25.4585 200033....................................................... 1.8640 0.9702 0.9702 26.8727 28.6479 29.5897 28.3730 200034....................................................... 1.3356 0.9487 0.9487 26.1150 26.2926 27.3852 26.6073 200037....................................................... 1.1709 0.8399 0.8399 23.3490 23.2333 24.3927 23.6760 200039....................................................... 1.2856 0.9487 0.9487 24.0474 25.1196 24.9813 24.7257 200040....................................................... 1.2411 0.9916 0.9916 23.6791 25.5405 26.1019 25.0872 200041....................................................... 1.1777 0.8399 0.8399 23.6797 24.5532 24.8537 24.3828 200050....................................................... 1.2158 0.9702 0.9702 25.5233 26.4992 27.7986 26.6203 200052....................................................... 1.1205 0.8399 0.8399 22.7763 21.8726 22.6132 22.4260 200063....................................................... 1.1573 0.9487 0.9487 24.7235 25.0167 25.9508 25.2331 200066....................................................... 1.1290

*

* 21.6354

*

* 21.6354 210001....................................................... 1.4173 0.9211 0.9211 26.3144 27.7561 27.6008 27.2238 210002....................................................... 1.9843 1.0090 1.0090 25.2859 26.4992 32.7693 28.0377 210003....................................................... 1.6774 1.1076 1.1076 32.3042 29.8684 34.2570 32.1281 210004....................................................... 1.4303 1.1068 1.1068 29.4300 34.2392 33.2835 32.3122 210005....................................................... 1.2792 1.1028 1.1028 27.1276 28.7557 28.9736 28.2902 210006....................................................... 1.0955 1.0090 1.0090 25.6396 25.4081 26.5757 25.8788 210007....................................................... 1.9108 1.0090 1.0090 28.4496 30.2548 32.0607 30.2720 210008....................................................... 1.3721 1.0090 1.0090 26.3008 25.2833 24.6380 25.3549 210009....................................................... 1.7671 1.0090 1.0090 24.6332 26.2360 28.7516 26.5487 210010.......................................................

***

*

* 24.5071 25.7775

* 25.1483 210011....................................................... 1.4072 1.0090 1.0090 24.8373 27.5031 29.9956 27.5064 210012....................................................... 1.6687 1.0090 1.0090 25.7934 27.4103 30.3738 27.9884 210013....................................................... 1.3016 1.0090 1.0090 23.9875 25.1348 28.1586 25.7366 210015....................................................... 1.3253 1.0090 1.0090 25.8532 28.2029 30.4000 28.1869 210016....................................................... 1.8484 1.1068 1.1068 28.6992 32.2081 32.9950 31.2873 210017....................................................... 1.2333 0.8946 0.8946 21.3983 23.2168 24.8570 23.1911 210018....................................................... 1.2046 1.1068 1.1068 27.5431 29.1870 29.7414 28.8513 210019....................................................... 1.7934 0.8958 0.8958 24.9252 26.1824 27.6140 26.2446 210022....................................................... 1.3768 1.1068 1.1068 30.1470 33.8015 35.4174 33.0730 210023....................................................... 1.4377 1.0299 1.0299 29.0844 30.4656 32.2959 30.6752 210024....................................................... 1.7307 1.0090 1.0090 27.1756 29.5579 31.0777 29.2823 210025....................................................... 1.2602 0.8946 0.8946 23.8943 26.0771 26.8894 25.5852 210027....................................................... 1.4414 0.8946 0.8946 23.9255 26.0111 25.5623 25.2157 210028....................................................... 1.1079 0.9458 0.9458 24.1265 25.9221 26.5604 25.5493 210029....................................................... 1.2797 1.0090 1.0090 31.2888 27.9741 31.4973 30.1510 210030....................................................... 1.3403 0.8946 0.8946 27.5507 29.5635 27.8221 28.3058 210032....................................................... 1.1400 1.0878 1.0878 25.7138 26.1829 27.3503 26.4352 210033....................................................... 1.1879 1.0090 1.0090 26.6113 29.0420 29.2098 28.3156 210034....................................................... 1.3061 1.0090 1.0090 26.3896 28.4308 30.7435 28.5652

[[Page 24190]]

210035....................................................... 1.2634 1.1076 1.1076 24.5198 26.1082 28.2974 26.3729 210037....................................................... 1.2148 0.8946 0.8946 24.1913 27.0973 27.4321 26.3569 210038....................................................... 1.1762 1.0090 1.0090 28.3414 29.5980 30.2311 29.4259 210039....................................................... 1.1341 1.1076 1.1076 25.8415 27.6940 30.6411 28.0851 210040....................................................... 1.2321 1.0090 1.0090 28.3723 29.3514 28.6883 28.8196 210043....................................................... 1.3335 1.0299 1.0299 24.3070 27.5657 28.0237 26.6189 210044....................................................... 1.3586 1.0090 1.0090 24.8083 28.8700 30.1590 27.9174 210045....................................................... 1.0603 0.8958 0.8958 15.0867 15.6380 14.3656 15.0218 210048....................................................... 1.3049 1.0377 1.0377 25.0617 28.4638 27.3793 27.0126 210049....................................................... 1.2098 1.0090 1.0090 25.9342 26.9656 26.7764 26.5560 210051....................................................... 1.3106 1.1076 1.1076 27.3692 29.2998 30.1862 28.9788 210054....................................................... 1.3557 1.1076 1.1076 24.6658 26.2295 27.6137 26.2370 210055....................................................... 1.2007 1.1076 1.1076 28.0014 29.9708 30.8388 29.6378 210056....................................................... 1.2815 1.0090 1.0090 26.6884 28.6091 30.5354 28.6855 210057....................................................... 1.4141 1.1068 1.1068 29.2233 32.2883 31.9780 31.2261 210058....................................................... 1.0867 1.0090 1.0090 24.8576 29.7841 31.7032 29.0401 210060....................................................... 1.1523 1.1076 1.1076 28.7531 28.5087 28.8466 28.7138 210061....................................................... 1.3223 0.8946 0.8946 24.1369 23.6662 23.0523 23.5621 220001....................................................... 1.2596 1.1318 1.1318 27.3238 29.0014 31.2085 29.1967 220002....................................................... 1.3298 1.1318 1.1318 28.9722 30.3598 32.8760 30.8268 220003....................................................... 1.0758

*

* 20.5790 22.0549

* 21.3294 220006.......................................................

***

*

* 29.5946 30.8599 30.7330 30.4422 220008....................................................... 1.2830 1.0791 1.0791 27.1675 30.1043 30.9345 29.4497 220010....................................................... 1.2555 1.1318 1.1318 27.4161 29.7998 31.4253 29.5798 220011....................................................... 1.1836 1.1318 1.1318 32.6624 34.4064 32.7733 33.3053 220012....................................................... 1.5060 1.2553 1.2553 32.9791 35.7872 37.6096 35.5395 220015....................................................... 1.1800 1.0664 1.0664 25.5449 28.3397 29.7600 27.9761 220016....................................................... 1.1151 1.0664 1.0664 26.8798 28.0609 30.8663 28.6310 220017....................................................... 1.2644 1.1687 1.1687 28.8264 29.7108 31.2550 29.9361 220019....................................................... 1.1472 1.1318 1.1318 22.2294 23.2544 24.9623 23.5079 220020....................................................... 1.1731 1.0791 1.0791 24.2279 26.5305 27.8385 26.2353 220024....................................................... 1.3169 1.0664 1.0664 25.5837 27.3488 28.6898 27.1876 220025....................................................... 1.0713 1.1318 1.1318 24.5186 23.0637 26.0299 24.5351 220028....................................................... 1.5243 1.1318 1.1318 31.3592 32.0980 31.5587 31.6664 220029....................................................... 1.1194 1.1318 1.1318 28.1432 28.6970 31.1099 29.3471 220030....................................................... 1.1049 1.0664 1.0664 23.6257 24.4289 25.9633 24.7095 220031....................................................... 1.6617 1.1687 1.1687 32.2660 34.8183 37.0251 34.7408 220033....................................................... 1.1670 1.1318 1.1318 26.8049 28.2539 31.3862 28.8106 220035....................................................... 1.4035 1.1318 1.1318 27.5533 28.6238 31.2994 29.2385 220036....................................................... 1.5300 1.1687 1.1687 29.6296 31.5184 33.5361 31.6091 220041.......................................................

***

*

* 29.7464

*

* 29.7464 220046....................................................... 1.4404 1.1318 1.0664 27.7726 28.1396 30.3602 28.8066 220049....................................................... 1.2204 1.1318 1.1318 27.0464 27.7517 30.6379 28.5150 220050....................................................... 1.1427 1.0664 1.0664 24.9945 26.3768 28.0886 26.5235 220051....................................................... 1.2556 1.0664 1.0664 26.5575 29.8380 30.6499 28.9958 220052....................................................... 1.1658 1.1687 1.1687 28.0925 29.8577 32.5961 30.0602 220058....................................................... 1.0009 1.1318 1.1318 25.0598 24.9642 26.7206 25.5650 220060....................................................... 1.1942 1.2181 1.2181 30.8242 32.3362 33.0544 32.1202 220062....................................................... 0.5772 1.1318 1.1318 21.9489 24.2779 24.9938 23.7495 220063....................................................... 1.2343 1.1318 1.1318 25.5840 27.3967 29.9941 27.6386 220065....................................................... 1.2426 1.0664 1.0664 24.8737 26.5513 27.5196 26.3247 220066....................................................... 1.3716 1.0664 1.0664 26.2561 27.1317 27.9943 27.1639 220067....................................................... 1.1669 1.1687 1.1687 28.5220 29.8911 30.3267 29.6132 220070....................................................... 1.1708 1.1318 1.1318 28.9100 31.9283 32.8480 31.0719 220071....................................................... 1.8540 1.1687 1.1687 31.8322 32.2936 35.5338 33.2847 220073....................................................... 1.2165 1.0791 1.0791 29.2399 31.3566 33.3418 31.2658 220074....................................................... 1.3020 1.1687 1.1687 27.5763 28.4930 30.0912 28.7684 220075....................................................... 1.5634 1.1687 1.1687 27.9503 29.1588 30.5079 29.2027 220076.......................................................

***

*

* 27.2534 29.7507 27.4339 28.0834 220077....................................................... 1.7189 1.0918 1.0918 28.0935 30.2684 31.1933 29.9019 220080....................................................... 1.2116 1.1318 1.1318 27.1578 28.9835 29.5970 28.6365 220082....................................................... 1.2876 1.1318 1.1318 24.8060 26.9841 29.8247 27.2457 220083....................................................... 1.1521 1.1687 1.1687 29.9001 32.9143 33.7694 32.1442 220084....................................................... 1.2315 1.1318 1.1318 29.0505 32.5711 31.4451 31.0666 220086....................................................... 1.8147 1.1687 1.1687 31.7482 34.3667 33.7988 33.2870 220088....................................................... 1.8495 1.1687 1.1687 28.5711 28.5462 36.0913 30.7044

[[Page 24191]]

220089....................................................... 1.3003 1.1161 1.1161 32.4409 31.1708 32.4915 32.0184 220090....................................................... 1.2011 1.1318 1.1318 29.7945 30.8685 32.9169 31.2935 220095....................................................... 1.1330 1.1318 1.1318 24.9871 27.4273 28.5030 27.0085 220098....................................................... 1.1241 1.1318 1.1318 26.8538 28.8314 30.8540 28.8728 220100....................................................... 1.3422 1.1687 1.1687 28.4848 29.6912 31.4815 29.9431 220101....................................................... 1.2661 1.1318 1.1318 31.0834 33.1690 35.9902 33.5726 220105....................................................... 1.2410 1.1318 1.1318 30.0892 31.9421 33.2654 31.8424 220108....................................................... 1.1449 1.1687 1.1687 29.0804 30.6252 33.0443 30.9170 220110....................................................... 2.0017 1.1687 1.1687 35.4242 36.6084 39.0322 37.0923 220111....................................................... 1.1994 1.1687 1.1687 28.9092 31.1850 33.3309 31.2225 220116....................................................... 1.9564 1.1687 1.1687 32.2337 32.9988 36.5682 33.8543 220119....................................................... 1.1193 1.1687 1.1687 27.8372 30.1056 30.8989 29.6743 220126....................................................... 1.1729 1.1687 1.1687 26.7660 28.7805 31.8676 29.1255 220133.......................................................

***

*

* 31.2981 33.6003

* 32.4924 220135....................................................... 1.3405 1.2553 1.2553 31.3246 33.9866 36.0887 33.8967 220153....................................................... 0.9848 1.0664 1.0664 18.9267

* 14.1334 17.1170 220154....................................................... 0.9336 1.1687 1.1687 30.9009 28.6462 35.5883 31.2859 220163....................................................... 1.6470 1.1318 1.1318 30.5056 33.6484 33.8384 32.5869 220171....................................................... 1.7942 1.1318 1.1318 28.9733 30.4036 32.0101 30.5076 220174....................................................... 1.1988 1.1318 1.1318 30.3356 31.7572 30.7270 30.9243 220176....................................................... 1.5414

*

*

*

*

*

* 230001....................................................... 1.0769

*

* 24.3660

*

* 24.3660 230002....................................................... 1.2952 1.0235 1.0391 27.0305 29.1410 28.6090 28.2640 230003....................................................... 1.2115 1.0737 0.9683 25.2596 26.1278 27.3169 26.2815 230004....................................................... 1.7321 1.0737 0.9961 25.5573 26.7206 29.1937 27.2248 230005 h..................................................... 1.2788 1.0853 1.0853 22.1018 24.1902 26.3043 24.1338 230006....................................................... 1.1218

*

* 22.7656 23.8835

* 23.3472 230013....................................................... 1.3549 1.0685 1.0235 22.7014 23.7822 24.5785 23.6715 230015....................................................... 1.0350 0.9414 0.9414 23.4512 24.6570 27.0741 25.0665 230017....................................................... 1.6823 1.0737 1.0737 27.3259 29.5178 31.7604 29.6143 230019....................................................... 1.5714 1.0685 1.0235 27.6563 28.4575 32.0970 29.3438 230020....................................................... 1.7351 1.0630 1.0391 26.8516 29.2869 29.1241 28.4427 230021....................................................... 1.5640 0.9191 0.9191 23.4663 24.9551 26.4485 24.9904 230022....................................................... 1.2895 0.9823 0.9823 22.2528 23.3000 25.0800 23.5509 230024....................................................... 1.5504 1.0630 1.0391 27.6555 30.0813 31.5988 29.7774 230027....................................................... 1.1269

*

* 22.5736 23.5511

* 23.0457 230029....................................................... 1.6096 1.0685 1.0235 27.9012 29.0935 32.7314 29.8511 230030....................................................... 1.2805 0.9055 0.9055 20.9867 22.3174 23.5494 22.3170 230031....................................................... 1.3726 1.0123 1.0123 23.2910 25.4678 28.9309 25.7151 230034....................................................... 1.3358 0.9055 0.9055 20.9195 26.7967 24.7096 24.1460 230035....................................................... 1.3084 0.9469 0.9469 20.9197 21.2317 24.6410 22.2545 230036....................................................... 1.3873 1.0040 1.0040 26.5854 28.3622 29.2811 28.0601 230037....................................................... 1.2855 1.0630 1.0391 24.7875 26.2000 28.6435 26.5799 230038....................................................... 1.7665 1.0737 0.9469 25.2499 26.3480 27.9064 26.5323 230040....................................................... 1.2170 0.9469 0.9469 21.9813 24.2349 25.5295 23.9840 230041....................................................... 1.5467 1.0139 1.0139 25.2518 26.1760 27.4599 26.3249 230042....................................................... 1.2127

*

* 24.3640 26.2037

* 25.3026 230046....................................................... 1.8770 1.0853 1.0853 29.2683 30.3591 31.8614 30.5717 230047....................................................... 1.4956 1.0235 1.0235 26.2447 28.1351 30.7000 28.4133 230053....................................................... 1.6058 1.0630 1.0391 28.3030 29.8703 32.3593 30.1185 230054....................................................... 2.0040 0.9620 0.9620 24.0137 24.9905 25.8181 24.9538 230055....................................................... 1.2536 0.9055 0.9055 23.7671 25.4143 26.6932 25.2940 230058....................................................... 1.1715 0.9055 0.9055 21.9308 24.0657 26.0394 24.0162 230059....................................................... 1.5561 1.0737 0.9469 23.1451 25.5350 27.6205 25.5084 230060....................................................... 1.2076 0.9055 0.9055 24.5073 25.5015 28.8932 26.2709 230065.......................................................

***

*

* 27.9179 28.4631 32.3190 29.1033 230066....................................................... 1.3089 1.0737 0.9961 25.8517 27.4928 29.8291 27.8691 230069....................................................... 1.1416 1.0630 1.0391 27.6815 29.5556 31.3504 29.5335 230070....................................................... 1.6546 0.9055 0.9055 25.1587 24.2342 25.2886 24.8787 230071....................................................... 0.8889 1.0685 1.0235 24.7707 26.3907 28.1751 26.4737 230072....................................................... 1.4215 1.0737 0.9683 24.1560 24.4933 26.3114 25.0275 230075....................................................... 1.3157 0.9871 0.9871 24.1482 27.6193 28.5212 26.7496 230077....................................................... 2.0406 1.0685 1.0685 27.3117 27.6157 28.3061 27.7598 230078....................................................... 1.0339 0.9055 0.9055 21.9200 23.9901 26.2508 24.1481 230080....................................................... 1.3081 0.9055 0.9055 21.2840 21.2314 24.0443 22.1966 230081....................................................... 1.2045 0.9055 0.9055 20.6777 23.0788 24.5396 22.7915

[[Page 24192]]

230082....................................................... 0.9782

*

* 23.1240 22.2165

* 22.6498 230085....................................................... 1.2286 1.0737 1.0737 22.2569 22.7314 23.3957 22.8121 230086....................................................... 1.1583

*

* 20.8759

*

* 20.8759 230087.......................................................

***

*

*

* 16.9168

* 16.9168 230089....................................................... 1.3507 1.0630 1.0391 23.9486 28.7015 30.4100 27.6217 230092....................................................... 1.3484 0.9823 0.9823 24.3768 26.3584 28.1764 26.3309 230093....................................................... 1.2207 0.9469 0.9469 24.5055 26.4967 26.0513 25.6772 230095....................................................... 1.3595 0.9055 0.9055 19.2244 21.3915 22.4323 21.0375 230096....................................................... 1.1658 1.0737 1.0737 26.7578 28.7681 30.6584 28.7161 230097....................................................... 1.8024 0.9469 0.9469 25.2104 26.5773 28.5361 26.7964 230099....................................................... 1.2294 1.0630 1.0391 25.0390 26.4882 28.7593 26.7894 230100....................................................... 1.2303 0.9055 0.9055 20.4565 21.8895 24.1824 22.1932 230101....................................................... 1.1612 0.9055 0.9055 23.1349 24.3772 25.3781 24.3329 230103....................................................... 1.0731

*

* 18.4304 21.6609

* 19.9258 230104....................................................... 1.6312 1.0630 1.0391 27.8864 30.5570 31.7701 30.0214 230105....................................................... 1.9789 1.0040 1.0040 24.6853 27.2705 32.8773 28.3242 230106....................................................... 1.0982 1.0737 0.9499 24.1128 24.3980 25.6113 24.7279 230108....................................................... 1.1275 0.9055 0.9055 22.4966 18.4063 20.8489 20.4585 230110....................................................... 1.2929 0.9055 0.9055 22.7621 28.7704 24.6324 25.3971 230117....................................................... 1.8782 1.0737 1.0737 29.6361 29.4775 32.3796 30.4251 230118....................................................... 1.0705 0.9055 0.9055 21.4886 22.3636 23.4529 22.4396 230119....................................................... 1.3083 1.0630 1.0391 29.2509 30.2441 30.5690 30.0291 230120....................................................... 1.1170

*

* 21.7894 24.1485

* 22.9553 230121....................................................... 1.2749 0.9823 0.9823 23.4394 24.5220 26.7038 24.8835 230124....................................................... 1.3714

*

* 23.0508

*

* 23.0508 230130....................................................... 1.7526 1.0685 1.0235 26.9907 26.6076 30.4881 28.0695 230132....................................................... 1.4085 1.0978 1.0978 29.9106 30.5318 32.7610 31.0442 230133....................................................... 1.3772 0.9055 0.9055 21.2273 24.3175 24.1542 23.2760 230135....................................................... 1.1854 1.0630 1.0391 23.9000 25.8406 26.3160 25.3904 230141....................................................... 1.6360 1.0978 1.0978 30.4643 28.6326 31.7206 30.2602 230142....................................................... 1.2984 1.0235 1.0391 25.6044 26.9433 27.7390 26.7874 230143....................................................... 1.2854

*

* 19.5387 21.4083

* 20.4663 230144....................................................... 1.5305 1.0853 1.0853

*

*

*

* 230145.......................................................

***

*

* 17.2181

*

* 17.2181 230146....................................................... 1.3093 1.0630 1.0391 24.3891 26.3432 27.0190 25.9632 230149.......................................................

***

*

* 21.4753

*

* 21.4753 230151....................................................... 1.3162 1.0685 1.0235 26.4669 28.2243 27.3926 27.3632 230153....................................................... 0.9954

*

* 22.3404 22.8644

* 22.6169 230155.......................................................

***

*

* 24.0404

*

* 24.0404 230156....................................................... 1.5931 1.0853 1.0853 29.4855 31.1909 33.3966 31.3733 230165....................................................... 1.7163 1.0630 1.0391 27.3164 28.9636 29.3983 28.5661 230167....................................................... 1.5889 1.0096 1.0096 26.6828 27.4562 29.4375 27.8699 230169.......................................................

***

*

* 27.1172 31.8442

* 29.3455 230171.......................................................

***

*

* 22.0635

*

* 22.0635 230172....................................................... 1.2675

*

* 24.0236 25.7402

* 24.8835 230174....................................................... 1.3287 1.0737 0.9683 26.2770 27.6920 30.2951 28.1112 230176....................................................... 1.2860 1.0630 1.0391 25.6777 27.3605 27.8101 27.1746 230180....................................................... 1.0946 0.9055 0.9055 22.5454 24.7358 26.5277 24.6245 230184.......................................................

***

*

* 21.9346 23.6707 34.0691 23.6789 230186.......................................................

***

*

* 27.1126 26.2282

* 26.7039 230189....................................................... 0.9848

*

* 20.8605 23.0099

* 21.9754 230190....................................................... 0.9660 1.0737 1.0737 28.7365 29.9604 32.4001 30.3817 230193....................................................... 1.2369 1.0123 1.0123 24.3181 23.3565 25.2992 24.3281 230195....................................................... 1.4121 1.0235 1.0235 27.1266 28.2892 29.4364 28.3509 230197....................................................... 1.6117 1.0978 1.0978 28.3439 30.0367 32.8265 30.4301 230204....................................................... 1.3256 1.0235 1.0235 25.9871 29.1466 29.7273 28.2022 230207....................................................... 1.3967 1.0685 1.0235 22.2854 24.5201 25.4131 24.0831 230208....................................................... 1.1981 0.9469 0.9469 20.9420 21.9651 23.1625 22.0408 230212....................................................... 1.0156 1.0853 1.0853 27.3686 29.7980 32.5361 29.8062 230216....................................................... 1.6633 1.0123 1.0123 26.1468 27.5230 29.1364 27.6226 230217....................................................... 1.3064 0.9823 0.9823 26.7929 28.6075 29.7609 28.4930 230222 h..................................................... 1.3442 0.9283 0.9283 24.8925 26.9724 30.2084 27.4096 230223....................................................... 1.2478 1.0685 1.0235 27.1503 29.2853 28.7434 28.4016 230227....................................................... 1.5190 1.0235 1.0235 28.1105 29.5798 31.2231 29.6698 230230....................................................... 1.5144 1.0096 1.0096 25.4471 27.9607 30.0898 27.8390 230235....................................................... 0.9813

*

* 19.6046 21.8777

* 20.7318

[[Page 24193]]

230236....................................................... 1.4603 1.0737 0.9469 26.3988 28.4754 30.7222 28.5769 230239....................................................... 1.2296 0.9055 0.9055 21.1643 22.1040 21.2172 21.5040 230241....................................................... 1.2197 1.0123 1.0123 25.8671 27.4890 27.5447 26.9859 230244....................................................... 1.4048 1.0630 1.0391 25.3817 26.4326 28.0406 26.5791 230254....................................................... 1.4614 1.0685 1.0235 26.4431 28.1216 28.9407 27.8278 230257....................................................... 0.9689 1.0235 1.0235 25.4086 27.8197 30.1026 27.6619 230259....................................................... 1.2083 1.0853 1.0853 24.3067 26.8677 27.9433 26.4486 230264....................................................... 2.1504 1.0235 1.0235 19.9992 19.2398 22.3532 20.5167 230269....................................................... 1.4452 1.0685 1.0235 27.4732 28.8187 30.9490 29.1589 230270....................................................... 1.3222 1.0630 1.0391 26.1113 27.8488 25.2072 26.3816 230273....................................................... 1.5273 1.0630 1.0391 30.2209 29.9307 31.5014 30.5474 230275....................................................... 0.4787 0.9055 0.9055 30.2244 23.1095 23.7882 25.8693 230277....................................................... 1.3945 1.0685 1.0235 26.9231 29.1973 29.6262 28.6272 230279....................................................... 0.5318 1.0630 1.0391 23.1636 24.7673 27.1158 24.8848 230283.......................................................

***

*

* 24.9272 26.2622 33.2824 26.4188 230289.......................................................

***

*

*

* 29.7720

* 29.7720 230290.......................................................

***

*

* 29.4792

*

* 29.4792 230291.......................................................

***

*

*

* 30.9655

* 30.9655 230292.......................................................

***

*

*

* 31.8943

* 31.8943 230294.......................................................

***

*

*

*

* 31.3710 31.3710 230295.......................................................

***

*

*

*

* 27.2229 27.2229 230296....................................................... 1.6564 1.0096 1.0096

*

*

*

* 230328....................................................... 0.6608

*

*

*

*

*

* 240001....................................................... 1.5162 1.0943 1.0943 29.9123 31.5753 33.3161 31.6280 240002....................................................... 1.8250 1.0157 1.0157 26.9608 28.9860 30.9011 28.9495 240004....................................................... 1.5995 1.0943 1.0943 27.8796 30.8072 32.7422 30.4106 240006....................................................... 1.0882 1.1246 1.1246 30.2330 30.1950 30.9169 30.4586 240007....................................................... 0.9780

*

* 23.7588

*

* 23.7588 240010....................................................... 2.0356 1.1246 1.1246 30.4139 31.3733 33.5850 31.7910 240011.......................................................

***

*

* 22.9561

*

* 22.9561 240013....................................................... 1.3325

*

* 28.7202 28.3860

* 28.5544 240014....................................................... 1.0328 1.0943 1.0943 28.3788 29.8623 30.0296 29.4562 240016....................................................... 1.2570

*

* 24.9211 26.7814

* 25.9310 240017....................................................... 1.2425 0.9256 0.9256 23.3314 24.4417 24.2138 23.9977 240018....................................................... 1.2809 1.0842 1.0842 27.9218 25.6236 27.9842 27.0238 240019....................................................... 1.0723 1.0157 1.0157 27.5441 28.6723 32.3927 29.5002 240020....................................................... 1.0716 1.0943 1.0943 28.1568 31.2443 32.7931 30.6996 240021....................................................... 0.9533

*

* 23.7096 27.1235

* 25.3021 240022....................................................... 1.1345 0.9256 0.9256 23.7368 25.2066 27.4658 25.4771 240025.......................................................

***

*

* 27.8656

*

* 27.8656 240027....................................................... 0.9013

*

* 20.2531 18.2481

* 19.1090 240029....................................................... 1.1341

*

* 24.3017 25.3568

* 24.8217 240030....................................................... 1.3375 0.9971 0.9971 23.3753 24.7154 26.4497 24.8644 240031....................................................... 0.9645

*

* 26.7242 26.7778

* 26.7517 240036....................................................... 1.6566 1.0842 1.0842 27.0821 28.0812 30.9000 28.6586 240037....................................................... 1.0394

*

* 24.3986

*

* 24.3986 240038....................................................... 1.5532 1.0943 1.0943 29.8465 31.0779 33.2288 31.4072 240040....................................................... 1.0905 1.0157 1.0157 26.3177 27.4895 27.3304 27.0645 240043....................................................... 1.1406 0.9256 0.9256 20.7155 21.8685 23.2097 21.9560 240044....................................................... 1.1339 1.0124 1.0124 24.3009 22.0973 25.1529 23.8283 240045....................................................... 1.0878

*

* 26.1743

*

* 26.1743 240047....................................................... 1.5452 1.0157 1.0157 29.1211 28.8288 28.4908 28.7805 240050....................................................... 1.0908 1.0943 1.0943 26.6687 26.4854 26.8525 26.6732 240052....................................................... 1.2502 0.9256 0.9256 24.9870 26.4256 28.0986 26.5338 240053....................................................... 1.4037 1.0943 1.0943 28.4733 29.5315 31.4458 29.8618 240056....................................................... 1.2278 1.0943 1.0943 30.8619 31.6623 33.3453 31.9671 240057....................................................... 1.8040 1.0943 1.0943 29.4870 30.6258 31.7172 30.6390 240059....................................................... 1.0849 1.0943 1.0943 28.6340 29.7916 31.6035 30.0547 240061....................................................... 1.7796 1.1246 1.1246 30.0031 30.6383 32.8216 31.1991 240063....................................................... 1.5489 1.0943 1.0943 29.9603 32.3487 34.2862 32.2192 240064....................................................... 1.2477 1.0157 1.0157 26.6996 29.9662 33.2930 30.5360 240066....................................................... 1.4590 1.0943 1.0943 30.2716 33.4532 36.4650 33.5054 240069....................................................... 1.1852 1.1246 1.1246 27.4990 28.9496 30.2048 28.9405 240071....................................................... 1.1457 1.1246 1.1246 26.4780 28.0585 29.9094 28.1696 240075....................................................... 1.1523 0.9971 0.9971 26.6607 26.1956 27.9350 26.9347 240076....................................................... 1.0765 1.0943 1.0943 28.4519 29.8562 31.5934 30.0582

[[Page 24194]]

240078....................................................... 1.6631 1.0943 1.0943 30.5339 32.3235 32.6859 31.8480 240079.......................................................

***

*

* 20.9220

*

* 20.9220 240080....................................................... 1.8436 1.0943 1.0943 29.6274 31.6828 32.9636 31.4183 240083....................................................... 1.2072 0.9256 0.9256 25.0214 26.6582 26.9625 26.2728 240084....................................................... 1.1120 1.0157 1.0157 24.7856 26.8142 27.5846 26.3984 240087....................................................... 1.0241

*

* 24.8479

*

* 24.8479 240088....................................................... 1.3204 0.9971 0.9971 27.6323 28.0825 28.0161 27.9149 240093....................................................... 1.3161 1.0842 1.0842 23.7785 25.5805 26.9860 25.4182 240094....................................................... 1.1989

*

* 27.3974

*

* 27.3974 240100....................................................... 1.2983 0.9256 0.9256 25.3269 27.6299 30.4304 27.7995 240101....................................................... 1.1584 0.9256 0.9256 26.6078 25.5355 26.1979 26.0918 240103....................................................... 1.1155

*

* 22.5416 22.7078

* 22.6234 240104....................................................... 1.1722 1.0943 1.0943 30.1392 31.4306 32.5071 31.4775 240106....................................................... 1.5325 1.0943 1.0943 27.5171 29.3455 30.9325 29.3230 240107....................................................... 0.9182

*

* 25.5199

*

* 25.5199 240109....................................................... 0.9469

*

* 15.2076 16.5051

* 15.8386 240115....................................................... 1.6345 1.0943 1.0943 29.0261 31.3869 32.6799 31.0904 240117....................................................... 1.1572 0.9256 0.9256 22.0463 23.6230 23.7271 23.1567 240123....................................................... 1.1119

*

* 20.5755 21.7500

* 21.1868 240124.......................................................

***

*

* 23.9297

*

* 23.9297 240127.......................................................

***

*

* 24.4824

*

* 24.4824 240128....................................................... 1.0253 0.9256 0.9256 21.2638 21.5791 23.2704 22.0363 240132....................................................... 1.3295 1.0943 1.0943 29.5310 31.7139 32.8272 31.3936 240133....................................................... 1.1376

*

* 26.1836

*

* 26.1836 240135.......................................................

***

*

* 16.1837

*

* 16.1837 240137.......................................................

***

*

* 23.8666

*

* 23.8666 240139.......................................................

***

*

* 23.7898

*

* 23.7898 240141....................................................... 1.1289 1.0943 1.0943 26.7173 26.4016 29.8940 27.9382 240143....................................................... 0.8821

*

* 21.1180 21.7416

* 21.4375 240152....................................................... 0.9917

*

* 27.3445 29.6196

* 28.5127 240154....................................................... 1.0591

*

* 23.9643

*

* 23.9643 240162....................................................... 1.1507

*

* 22.3136 22.2721

* 22.2926 240166....................................................... 1.1450 0.9256 0.9256 23.4265 25.7509 27.1602 25.4648 240179.......................................................

***

*

* 20.8449

*

* 20.8449 240187....................................................... 1.2475 1.0842 1.0842 26.5129 27.8811 28.0014 27.4824 240196....................................................... 0.7780 1.0943 1.0943 28.9380 30.7719 32.4098 30.7649 240206....................................................... 0.8192 1.4448 1.4448

*

*

*

* 240207....................................................... 1.1912 1.0943 1.0943 29.2395 31.7665 32.6617 31.2871 240210....................................................... 1.2761 1.0943 1.0943 29.7227 32.1564 33.0565 31.6494 240211....................................................... 0.9917 1.0842 1.0842 44.4214 18.8503 23.5383 24.9982 240213....................................................... 1.3747 1.0943 1.0943 31.3974 32.7532 34.3377 32.9080 240366....................................................... 0.8163

*

*

*

*

*

* 250001....................................................... 1.8600 0.8278 0.8278 21.9176 22.7827 23.7029 22.8415 250002....................................................... 0.9030 0.8008 0.8008 20.1310 23.3845 23.9358 22.3598 250004....................................................... 1.9070 0.9032 0.9032 20.6828 24.1065 24.9720 23.2149 250006....................................................... 1.0729 0.9032 0.9032 21.4038 24.0191 24.9513 23.4457 250007....................................................... 1.2555 0.8914 0.8914 23.6933 25.8710 25.8218 25.1582 250009....................................................... 1.2768 0.8640 0.8640 20.4329 22.2323 22.2900 21.6627 250010....................................................... 1.0392 0.7579 0.7579 19.4130 19.4403 20.8939 19.9016 250012....................................................... 0.9166 0.9367 0.9367 20.0493 20.2921 20.2685 20.2019 250015....................................................... 1.0413 0.7579 0.7579 20.6931 20.7555 21.4605 20.9636 250017....................................................... 1.0388 0.7579 0.7579 18.1013 21.3950 22.0824 20.6762 250018....................................................... 0.8272 0.7579 0.7579 17.0689 16.6294 16.9042 16.8758 250019....................................................... 1.5866 0.8914 0.8914 22.8358 23.9741 26.3257 24.3649 250020....................................................... 0.9684 0.7579 0.7579 19.3390 21.4019 21.3531 20.6951 250021.......................................................

***

*

* 15.1242 20.3559

* 16.1481 250023....................................................... 0.8560 0.8607 0.8607 16.1820 16.2418 17.0598 16.5022 250025....................................................... 1.1161 0.7579 0.7579 20.6892 20.5258 22.4404 21.2459 250027....................................................... 0.9523 0.7579 0.7579 17.3313 17.3481 23.1213 19.2559 250031....................................................... 1.3383 0.8278 0.8278 22.0850 21.4326 24.9777 22.6950 250034....................................................... 1.5646 0.9032 0.9032 20.6752 24.3189 26.4723 23.8164 250035....................................................... 0.8603 0.7579 0.7579 14.6149 17.2045 19.4498 17.1103 250036....................................................... 1.0150 0.8229 0.8229 17.8313 19.1975 19.2912 18.8229 250037....................................................... 0.8531

*

* 17.4463 17.4012

* 17.4232 250038....................................................... 0.9812 0.8278 0.8278 18.0209 18.9050 21.6995 19.5148 250039....................................................... 0.9171

*

* 15.2939 17.3155

* 16.2540

[[Continued on page 24195]]

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

[[pp. 24195-24244]] Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2007 Rates

[[Continued from page 24194]]

[[Page 24195]]

250040....................................................... 1.5081 0.8607 0.8607 21.3451 23.2285 24.9604 23.2173 250042....................................................... 1.1719 0.9032 0.9032 21.4117 23.4135 25.0292 23.2557 250043....................................................... 1.0266 0.7579 0.7579 18.3322 19.8098 18.5069 18.8884 250044....................................................... 1.0422 0.8008 0.8008 21.1198 23.3862 24.1915 22.8737 250045....................................................... 1.1328

*

* 25.0863 26.3831

* 25.7497 250048....................................................... 1.6466 0.8278 0.8278 21.6547 22.9765 25.5576 23.4215 250049....................................................... 0.8984 0.7579 0.7579 17.8154 17.7005 16.6336 17.2912 250050....................................................... 1.2572 0.7579 0.7579 18.3170 19.1467 20.2413 19.2614 250051....................................................... 0.8663 0.7579 0.7579 106908 106095 11.7079 109990 250057....................................................... 1.1351 0.7579 0.7579 19.6789 20.1900 22.5761 20.8199 250058....................................................... 1.2384 0.7579 0.7579 17.5160 18.1704 19.0087 18.2438 250059....................................................... 0.9837 0.7579 0.7579 17.7270 19.2977 20.6556 19.2080 250060....................................................... 0.8378 0.7579 0.7579 20.8115 16.8247 25.4246 20.6969 250061....................................................... 0.8786 0.7579 0.7579 15.2515 12.8174 16.2589 14.6266 250065.......................................................

***

*

* 16.1984

*

* 16.1984 250067....................................................... 1.0700 0.7579 0.7579 20.1261 21.6911 23.4774 21.7391 250068.......................................................

***

*

* 16.9585

*

* 16.9585 250069....................................................... 1.5415 0.7785 0.7785 21.6617 22.8162 16.1304 19.3701 250071.......................................................

***

*

* 17.7149

*

* 17.7149 250072....................................................... 1.5965 0.8278 0.8278 22.9316 24.6587 26.4719 24.7138 250077....................................................... 0.9353 0.7579 0.7579 14.2271 14.7632 17.4410 15.4299 250078 \2\................................................... 1.6824 0.8607 0.8914 18.6563 20.9354 21.3612 20.3108 250079....................................................... 0.8320 0.8278 0.8278 27.2549 38.0031 44.8151 37.9933 250081....................................................... 1.2341 0.7785 0.7785 21.3830 24.7031 23.9285 23.1846 250082....................................................... 1.4493 0.8224 0.8224 20.5212 19.6966 23.1859 21.1022 250083.......................................................

***

*

* 19.9484

*

* 19.9484 250084....................................................... 1.1750 0.7579 0.7579 21.8001 18.5775 19.4461 19.8188 250085....................................................... 0.9867 0.7579 0.7579 18.7367 19.7007 21.3859 19.9851 250093....................................................... 1.1742 0.7579 0.7579 18.8001 21.3237 22.3211 20.8049 250094....................................................... 1.6054 0.8607 0.8607 22.3312 22.7312 24.5599 23.2045 250095....................................................... 1.0280 0.7579 0.7579 19.9553 21.3511 20.0315 20.4379 250096....................................................... 1.1310 0.8278 0.8278 22.7458 22.6298 24.4706 23.2825 250097....................................................... 1.5757 0.8102 0.8102 19.4534 20.1687 22.0566 20.5452 250099....................................................... 1.2588 0.8278 0.8278 19.0333 19.5797 20.5324 19.7105 250100....................................................... 1.4755 0.7785 0.7785 22.0328 24.2209 26.2027 24.1667 250101.......................................................

***

*

* 21.2234 19.3543

* 20.1785 250102....................................................... 1.6047 0.8278 0.8278 22.5518 24.2868 24.3828 23.7712 250104....................................................... 1.4423 0.8278 0.8278 21.4431 22.6591 23.5992 22.6152 250105....................................................... 0.9397

*

* 17.9468 18.1196

* 18.0323 250107....................................................... 0.9189

*

* 16.5369 17.8999

* 17.2381 250112....................................................... 0.9624 0.7579 0.7579 19.6172 21.2824 23.2090 21.4577 250117....................................................... 1.0940 0.8607 0.8607 19.9774 23.3673 22.2965 21.8104 250120....................................................... 1.0796 0.7579 0.7579 22.7607 23.4277 24.5030 23.5079 250122....................................................... 1.0886 0.8607 0.7579 23.7230 24.5854 27.7136 25.3125 250123....................................................... 1.3078 0.8914 0.8914 22.0486 24.5115 25.8310 24.1586 250124....................................................... 0.8426 0.8278 0.8278 15.4343 17.2181 18.4511 17.0346 250125....................................................... 1.3143 0.8914 0.8914 26.8379 27.7077 27.9165 27.4937 250126....................................................... 0.9024 0.9367 0.9367 20.4085 21.7111 24.0142 21.9434 250127....................................................... 0.8488 1.4448 1.4448

*

*

*

* 250128....................................................... 0.8921 0.7579 0.7579 15.9344 17.6269 17.8958 17.1308 250134....................................................... 0.7992 0.8278 0.8278 23.5608 25.8368 23.0509 24.1129 250136....................................................... 1.0417 0.8278 0.8278 22.5832 23.0637 24.6860 23.4511 250138....................................................... 1.3056 0.8278 0.8278 22.7902 23.8861 24.8531 23.8880 250141....................................................... 1.6112 0.9367 0.9367 24.5772 27.6158 29.0066 27.2108 250146....................................................... 0.9041

*

* 17.2328 18.6486

* 17.9106 250149....................................................... 0.8797 0.7579 0.7579 15.0367 15.0641 16.5424 15.5525 250151....................................................... 0.4842 0.7579 0.7579 21.8697 17.2205 19.1595 18.6189 250152....................................................... 0.9050 0.8278 0.8278

* 25.7837 27.1864 26.4345 250153.......................................................

***

*

*

* 29.0461

* 29.0461 250155.......................................................

***

*

*

*

* 22.3917 22.3917 250156....................................................... 1.6598 0.7579 0.7579

*

*

*

* 250159....................................................... 0.8786

*

*

*

*

*

* 250300....................................................... 0.6711

*

*

*

*

*

* 250302....................................................... 0.7681

*

*

*

*

*

* 250306....................................................... 0.8875

*

*

*

*

*

* 250311....................................................... 0.6819

*

*

*

*

*

*

[[Page 24196]]

250314....................................................... 0.8263

*

*

*

*

*

* 250317....................................................... 0.7015

*

*

*

*

*

* 250318....................................................... 0.7989

*

*

*

*

*

* 250319....................................................... 0.7364

*

*

*

*

*

* 250320....................................................... 0.7176

*

*

*

*

*

* 260001....................................................... 1.6784 0.8620 0.8620 25.3084 25.9250 27.1336 26.1147 260002.......................................................

***

*

* 27.2329 26.4879

* 26.9807 260003.......................................................

***

*

* 17.6339

*

* 17.6339 260004....................................................... 0.9693 0.8206 0.8206 16.7742 16.9421 17.2699 17.0026 260005....................................................... 1.4686 0.9017 0.9017 24.6142 26.5773 28.1696 26.5242 260006....................................................... 1.4688 0.8206 0.8206 26.4948 26.7587 30.1186 27.9482 260008.......................................................

***

*

* 17.6040 18.9522

* 18.2612 260009....................................................... 1.2265 0.9501 0.9501 21.2729 22.1816 23.6333 22.3815 260011....................................................... 1.4257 0.8550 0.8550 21.4409 22.7061 24.4077 22.8791 260012....................................................... 1.1452

*

* 19.3389 20.3061

* 19.8719 260013....................................................... 1.0553

*

* 19.2065 20.5007

* 19.8516 260015....................................................... 1.0248 0.8206 0.8206 22.4450 22.5409 23.5052 22.8435 260017....................................................... 1.3611 0.8902 0.8902 21.1359 22.7022 23.3807 22.4549 260018....................................................... 1.0484

*

* 14.8425 17.0434

* 15.9088 260020....................................................... 1.7691 0.9017 0.9017 25.7898 26.0407 27.6200 26.5265 260021....................................................... 1.3788 0.9017 0.9017 27.8332 27.6330 29.3311 28.2357 260022....................................................... 1.2315 0.8696 0.8696 21.7707 22.8085 23.1569 22.5606 260023....................................................... 1.2983 0.9017 0.9017 21.2519 21.2077 23.3349 21.8971 260024....................................................... 1.1077 0.8206 0.8206 17.5351 18.4829 18.9172 18.3027 260025....................................................... 1.3739 0.8902 0.8902 20.0901 22.4645 22.2246 21.6146 260027....................................................... 1.6704 0.9501 0.9501 24.7605 25.3348 26.9815 25.6688 260029....................................................... 1.1287

*

* 22.2892

*

* 22.2892 260031.......................................................

***

*

* 24.2877

*

* 24.2877 260032....................................................... 1.8631 0.9017 0.9017 23.1125 23.9478 25.5746 24.2130 260034....................................................... 0.9620 0.9501 0.9501 23.3034 24.1143 23.7530 23.7269 260035....................................................... 0.9284

*

* 16.8502 17.8741

* 17.3672 260036....................................................... 0.9601

*

* 20.1324 22.1912

* 21.0403 260039....................................................... 1.0479

*

*

*

*

*

* 260040....................................................... 1.6510 0.8490 0.8490 21.9452 23.3566 24.0972 23.1582 260044....................................................... 0.9223

*

* 20.0686

*

* 20.0686 260047....................................................... 1.5031 0.8206 0.8206 22.6169 24.4185 25.0084 24.0413 260048....................................................... 1.2049 0.9501 0.9501 25.8089 24.3906 27.9464 26.0146 260050....................................................... 1.2142 0.9993 0.9993 20.6364 23.6849 25.0389 23.2365 260052....................................................... 1.3392 0.9017 0.9017 22.5809 24.5165 26.1098 24.4028 260053....................................................... 1.1022

*

* 20.0051 21.6607

* 20.8214 260057....................................................... 1.1001 0.9501 0.9501 16.4875 19.3335 20.6191 18.7408 260059....................................................... 1.2035 0.8206 0.8206 18.6379 19.7243 23.1217 20.5682 260061....................................................... 1.1216 0.8206 0.8206 19.6674 21.5264 22.7333 21.2263 260062....................................................... 1.2337 0.9501 0.9501 26.0439 26.4539 27.6932 26.7397 260063.......................................................

***

*

* 22.0826

*

* 22.0826 260064....................................................... 1.3185 0.8550 0.8550 19.1587 19.0543 21.6891 19.9635 260065....................................................... 1.7537 0.8490 0.8490 23.6969 23.0015 26.9359 24.5533 260067....................................................... 0.8877

*

* 16.5364 17.6256

* 17.0827 260068....................................................... 1.7594 0.8550 0.8550 23.9340 24.9504 25.8172 24.9247 260070....................................................... 0.9582 0.8206 0.8206 14.3881 18.4779 22.5048 18.8578 260073....................................................... 0.9941 0.8206 0.8206 19.2744 21.6214 21.9134 20.9434 260074....................................................... 1.2557 0.8550 0.8550 23.9301 24.8654 25.3754 24.7419 260077....................................................... 1.6328 0.9017 0.9017 23.5466 25.5782 26.2056 25.0998 260078....................................................... 1.3444 0.8206 0.8206 18.4017 19.0802 20.2858 19.2623 260080....................................................... 0.9295 0.8206 0.8206 11.2817 14.7774 16.6581 14.1755 260081....................................................... 1.5369 0.9017 0.9017 23.7447 26.3969 28.6641 26.2683 260085....................................................... 1.6015 0.9501 0.9501 24.6046 25.6302 26.9696 25.7362 260086....................................................... 0.8999

*

* 17.1202 19.1702

* 18.1866 260091....................................................... 1.5426 0.9017 0.9017 26.1149 27.2407 28.9307 27.4593 260094....................................................... 1.5689 0.8345 0.8345 20.6805 23.2544 24.0891 22.7688 260095....................................................... 1.3199 0.9501 0.9501 23.8671 25.5668 24.5424 24.6443 260096....................................................... 1.4703 0.9501 0.9501 25.9932 27.5592 29.7166 27.8481 260097....................................................... 1.1816 0.8631 0.8631 21.5077 21.3957 24.3155 22.4793 260102....................................................... 0.9158 0.9501 0.9501 22.9283 24.2368 27.3752 24.9011 260103.......................................................

***

*

* 23.3175

*

* 23.3175 260104....................................................... 1.4999 0.9017 0.9017 24.0038 26.2867 28.5834 26.3843

[[Page 24197]]

260105....................................................... 1.7844 0.9017 0.9017 28.4652 28.8849 30.1547 29.1870 260107....................................................... 1.3536 0.9501 0.9501 24.2001 26.7782 26.1120 25.6719 260108....................................................... 1.8031 0.9017 0.9017 24.0936 24.9880 26.7305 25.3112 260110....................................................... 1.7032 0.8902 0.8902 22.2730 23.7978 24.6033 23.5975 260113....................................................... 1.1184 0.8210 0.8210 19.2467 20.9644 20.3219 20.1880 260115....................................................... 1.1842 0.9017 0.9017 21.7450 21.9859 23.2089 22.3429 260116....................................................... 1.1117 0.8210 0.8210 17.2698 18.5076 20.2843 18.6799 260119....................................................... 1.3503 0.8206 0.8206 22.1588 24.9937 25.3857 24.1933 260122....................................................... 1.0867

*

* 17.3270 20.8015

* 19.0424 260123.......................................................

***

*

* 16.1169

*

* 16.1169 260127....................................................... 0.9496

*

* 22.5328 21.8534

* 22.1664 260134.......................................................

***

*

* 18.1531

*

* 18.1531 260137....................................................... 1.6799 0.8620 0.8620 21.3426 22.7431 23.9849 22.7568 260138....................................................... 1.9860 0.9501 0.9501 27.8229 28.5610 30.1909 28.8843 260141....................................................... 1.8731 0.8550 0.8550 21.1511 22.4886 24.7555 22.6828 260142....................................................... 1.0575 0.8206 0.8206 19.6582 20.3993 21.1102 20.4022 260147....................................................... 0.9163 0.8206 0.8206 17.2291 18.5153 19.8920 18.5887 260159.......................................................

***

*

* 26.8924 23.7427 23.3667 25.0036 260160....................................................... 1.0950 0.8206 0.8206 19.4997 21.0544 23.2474 21.4698 260162....................................................... 1.3128 0.9017 0.9017 24.1246 25.1423 27.0428 25.5018 260163....................................................... 1.1375 0.8206 0.8206 19.2885 20.1949 21.2854 20.2047 260164....................................................... 1.1012

*

* 19.5539 19.7068

* 19.6321 260166....................................................... 1.2031 0.9501 0.9501 25.5151 27.0237 29.7395 27.4350 260172.......................................................

***

*

* 18.1438

*

* 18.1438 260175....................................................... 1.1223 0.9501 0.9501 21.1257 22.6171 24.1261 22.6182 260176....................................................... 1.7007 0.9017 0.9017 29.2184 27.4244 28.7405 28.4251 260177....................................................... 1.2297 0.9501 0.9501 25.0724 26.1178 27.2209 26.1484 260178....................................................... 1.8231 0.8550 0.8550 21.4781 22.2251 25.8033 23.2762 260179....................................................... 1.5349 0.9017 0.9017 24.8541 26.1419 26.6483 25.8935 260180....................................................... 1.5806 0.9017 0.9017 21.9679 26.7461 27.6875 25.4223 260183....................................................... 1.6192 0.8902 0.8902 23.3924 26.0418 27.4529 25.6739 260186....................................................... 1.6356 0.8550 0.8550 23.4317 25.3148 26.7114 25.2113 260189....................................................... 0.5844

*

*

*

*

*

* 260190....................................................... 1.2092 0.9501 0.9501 25.1653 26.4505 28.2087 26.6613 260191....................................................... 1.2955 0.9017 0.9017 22.4369 23.3856 24.3589 23.4174 260193....................................................... 1.1924 0.9501 0.9501 24.4705 26.2979 27.6919 26.2018 260195....................................................... 1.2645 0.8206 0.8206 20.1327 22.3958 22.3215 21.7669 260198....................................................... 1.1484 0.9017 0.9017 27.6116 27.5996 28.1088 27.7785 260200....................................................... 1.2426 0.9017 0.9017 25.1134 24.8624 28.8227 26.3660 260207....................................................... 1.0751 0.8490 0.8490 19.2467 19.7294 20.9045 20.0908 260209....................................................... 1.1133 0.8341 0.8341 21.8396 23.2430 24.8878 23.3114 260210....................................................... 1.2183 0.9017 0.9017

* 25.3782 26.5193 26.0224 260211....................................................... 1.6548 0.9501 0.9501

* 33.9109 39.2576 36.5853 260213....................................................... 1.7185 0.9501 0.9501

*

*

*

* 260214....................................................... 1.1966

*

*

*

*

*

* 260324....................................................... 0.6926

*

*

*

*

*

* 260326....................................................... 0.8398

*

*

*

*

*

* 270002 \2\................................................... 1.2593 0.8909 0.8909 20.7620 22.7322 24.3756 22.6537 270003....................................................... 1.2545 0.8781 0.8781 24.2823 26.4843 28.4192 26.4146 270004....................................................... 1.7115 0.8740 0.8740 22.9081 23.5454 25.1806 23.8999 270011....................................................... 0.9968 0.8781 0.8781 22.0710 22.1394 22.5874 22.2704 270012 \2\................................................... 1.6196 0.8909 0.8909 23.1697 25.2873 25.5002 24.6491 270014....................................................... 1.9153 0.8909 0.8909 25.0650 26.2025 26.3179 25.8695 270017....................................................... 1.3672 0.8909 0.8909 24.6186 27.5483 26.7552 26.3154 270021....................................................... 1.0409

*

* 21.6758 21.7056

* 21.6913 270023....................................................... 1.5356 0.8740 0.8909 25.5525 26.7576 26.4505 26.2685 270032....................................................... 1.0407 0.8740 0.8591 18.2377 19.6212 21.0457 19.6054 270036....................................................... 0.8297

*

* 21.8255 20.4242

* 20.9986 270049....................................................... 1.7342 0.8740 0.8740 24.6556 26.3996 26.8611 25.9770 270050....................................................... 1.1098

*

* 22.4195

*

* 22.4195 270051....................................................... 1.5813 0.8909 0.8909 26.4457 26.6619 25.1706 26.0404 270057....................................................... 1.2530 0.8740 0.8591 22.6251 24.2980 26.5171 24.5339 270060....................................................... 0.9595

*

* 16.6592 17.7564

* 17.1813 270074....................................................... 0.9013 1.4448 1.4448

*

*

*

* 270079.......................................................

***

*

* 21.6382

*

* 21.6382 270081....................................................... 1.0056 0.8591 0.8591 17.3174 17.4862 18.9628 17.9008

[[Page 24198]]

270082.......................................................

***

*

* 19.6173

*

* 19.6173 270084 \2\................................................... 1.0889

*

* 22.2340

*

* 22.2340 270086....................................................... 1.1747 0.8781 0.8781

*

* 23.0672 23.0672 270087....................................................... 1.1805 0.8591 0.8591

*

* 22.8163 22.8163 280003....................................................... 1.7898 1.0084 1.0084 27.2844 29.3921 30.8267 29.2098 280009....................................................... 1.8271 0.9746 0.9746 25.3162 26.7678 27.6871 26.5956 280010.......................................................

***

*

* 22.6516

*

* 22.6516 280013....................................................... 1.7857 0.9453 0.9453 24.5214 26.1908 27.2546 25.9627 280020....................................................... 1.7128 1.0084 1.0084 25.7522 26.5068 27.6978 26.6945 280021....................................................... 1.1344

*

* 22.2864 22.0489

* 22.1652 280023....................................................... 1.3783 0.9746 0.9746 22.7207 22.3230 26.7240 23.8272 280030....................................................... 1.9075 0.9453 0.9453 32.5601 30.7481 30.4696 31.2643 280032....................................................... 1.3256 0.9746 0.9746 22.6510 23.6462 25.0787 23.7853 280040....................................................... 1.6714 0.9453 0.9453 25.2965 26.9827 28.4619 26.9500 280054....................................................... 1.2075

*

* 22.4241 23.5665

* 23.0039 280057....................................................... 0.8525

*

* 23.6793 20.4830

* 21.8581 280060....................................................... 1.6944 0.9453 0.9453 25.2288 26.2139 27.8379 26.5044 280061....................................................... 1.4064 0.9154 0.9154 23.9110 24.9482 25.9246 24.9668 280065....................................................... 1.2249 0.9636 0.9636 27.9937 26.0135 28.3954 27.4121 280077....................................................... 1.3131 0.9453 0.9453 24.0516 25.5624 27.0934 25.5691 280081....................................................... 1.5886 0.9453 0.9453 25.1973 26.0541 28.7505 26.6763 280105....................................................... 1.2640 0.9453 0.9453 25.0445 26.7555 28.0693 26.7054 280108....................................................... 1.0675

*

* 22.5584 23.2502

* 22.8979 280111....................................................... 1.1778 0.8691 0.8691 22.1424 23.4770 24.5663 23.4937 280117....................................................... 1.1313

*

* 22.0611 24.1521

* 23.1088 280119....................................................... 0.8523 1.4448 1.4448

*

*

*

* 280123....................................................... 0.9112 0.8828 0.8828 27.5207

* 12.1758 18.1112 280125....................................................... 1.4971 0.8816 0.8816 21.8385 21.7658 22.3025 21.9721 280127....................................................... 1.8457 1.0084 1.0084

*

* 31.8278 31.8278 280128....................................................... 3.0322 1.0084 1.0084

*

* 28.9234 28.9234 280129....................................................... 1.9223 0.9453 0.9453

*

*

*

* 280130....................................................... 1.3422 0.9453 0.9453

*

*

*

* 290001....................................................... 1.8273 1.1975 1.1975 27.3105 31.1981 35.3981 31.2171 290002....................................................... 0.9183 0.9569 0.9569 16.8433 18.3469 17.0514 17.4394 290003....................................................... 1.7512 1.1417 1.1417 27.1099 28.1625 30.4639 28.5720 290005....................................................... 1.4855 1.1417 1.1417 27.1531 27.6697 28.5735 27.8244 290006....................................................... 1.2047 1.1524 1.1524 26.3617 27.9502 30.0265 28.0763 290007....................................................... 1.6530 1.1417 1.1417 35.4193 37.5559 38.9568 37.2981 290008....................................................... 1.1651 0.9421 0.9421 26.4086 27.9714 28.3311 27.5573 290009....................................................... 1.7714 1.1975 1.1975 27.6011 29.8019 36.2577 31.1439 290010....................................................... 1.0541

*

* 23.8733 23.9654

* 23.9192 290012....................................................... 1.3212 1.1417 1.1417 27.2675 31.0843 33.4690 30.7038 290016....................................................... 1.2257

*

* 25.1726 26.1925

* 25.6684 290019....................................................... 1.3891 1.1524 1.1524 27.2484 28.6158 29.6855 28.5533 290020 h..................................................... 1.0427 1.1417 1.1417 21.3094 21.6993 20.9481 21.3644 290021....................................................... 1.7971 1.1417 1.1417 28.3837 33.2116 33.9446 31.8430 290022....................................................... 1.5768 1.1417 1.1417 29.8144 29.4422 30.4581 29.9084 290027....................................................... 0.9025 0.8967 0.8967 17.8850 15.1448 21.6128 18.3839 290032....................................................... 1.4163 1.1975 1.1975 29.4164 31.7105 32.0495 31.1084 290039....................................................... 1.5419 1.1417 1.1417 29.6801 31.2941 33.6718 31.6289 290041....................................................... 1.3158 1.1417 1.1417 30.1346 33.9878 35.5146 33.3938 290042....................................................... 0.4555 1.1417 1.1417

*

*

*

* 290044.......................................................

***

*

*

*

* 38.1320 38.1320 290045....................................................... 1.5773 1.1417 1.1417 26.9319 30.9612 34.4022 31.2459 290046....................................................... 1.2702 1.1417 1.1417

*

*

*

* 290047....................................................... 1.4129 1.1417 1.1417

*

*

*

* 290049....................................................... 1.3499 1.0054 1.0054

*

*

*

* 290050....................................................... 1.1705

*

*

*

*

*

* 290051....................................................... 1.5597

*

*

*

*

*

* 300001....................................................... 1.5726 1.1665 1.1665 29.4130 27.5032 28.8432 28.5481 300003....................................................... 2.0572 1.1665 1.1665 27.8059 33.3560 34.5310 31.9387 300005....................................................... 1.3969 1.1665 1.1665 25.1869 25.6699 26.7123 25.8743 300006....................................................... 1.2070

*

* 20.6787 23.3200

* 21.9235 300007....................................................... 1.2792

*

* 25.3125

*

* 25.3125 300010....................................................... 1.1835

*

* 26.9346 27.5028

* 27.2341 300011....................................................... 1.2737 1.1665 1.1665 27.3325 28.4044 31.6428 29.1783

[[Page 24199]]

300012....................................................... 1.3755 1.1665 1.1665 28.4234 30.5198 30.3374 29.7075 300013.......................................................

***

*

* 23.1529

*

* 23.1529 300014....................................................... 1.1978 1.1665 1.1665 25.5059 27.5151 29.2605 27.5032 300015....................................................... 1.0767

*

* 24.0620

*

* 24.0620 300016.......................................................

***

*

* 24.5498

*

* 24.5498 300017....................................................... 1.2321 1.1665 1.1665 28.3959 29.6957 30.3051 29.4733 300018....................................................... 1.3845 1.1665 1.1665 28.0308 29.7209 29.6873 29.1985 300019....................................................... 1.2862 1.1665 1.1665 25.3845 25.9656 27.2631 26.2544 300020....................................................... 1.2090 1.1665 1.1665 26.8402 28.6723 30.5485 28.7305 300022....................................................... 1.0801

*

* 23.5948

*

* 23.5948 300023....................................................... 1.3630 1.1665 1.1665 25.4873 28.6309 30.9871 28.5288 300024....................................................... 1.6816

*

* 23.9205

*

* 23.9205 300029....................................................... 1.7658 1.1665 1.1665 26.9484 29.0806 29.9138 28.7021 300034....................................................... 2.0425 1.1665 1.1665 28.5375 29.7484 31.5753 29.9856 300308....................................................... 0.6393

*

*

*

*

*

* 300309....................................................... 0.7909

*

*

*

*

*

* 300310....................................................... 0.6299

*

*

*

*

*

* 310001....................................................... 1.7499 1.3215 1.3215 33.9360 35.3612 41.8952 37.1034 310002....................................................... 1.8830 1.3038 1.3008 35.4567 37.3461 38.9875 37.2295 310003....................................................... 1.2035 1.3215 1.3215 31.1040 32.8935 35.3962 33.1810 310005....................................................... 1.3045 1.1886 1.1886 27.5690 29.0084 31.6992 29.4759 310006....................................................... 1.1997 1.3215 1.3215 27.0436 27.4545 28.9780 27.8274 310008....................................................... 1.3218 1.3215 1.3215 29.5857 31.2579 32.2471 31.0509 310009....................................................... 1.2680 1.3038 1.3008 29.7760 32.7384 33.9105 32.0940 310010....................................................... 1.2806 1.1318 1.1318 25.3139 28.5852 33.1613 29.0668 310011....................................................... 1.2514 1.1341 1.1341 28.5241 30.8612 31.0823 30.1687 310012....................................................... 1.6373 1.3215 1.3215 33.1622 34.6882 38.1712 35.4125 310013....................................................... 1.2295 1.3038 1.3008 28.5016 30.6248 31.4496 30.2036 310014....................................................... 1.9216 1.1226 1.1226 32.7222 29.7204 30.9277 30.9970 310015....................................................... 1.9678 1.3038 1.3008 32.4980 36.4776 37.1869 35.4178 310016....................................................... 1.3082 1.3215 1.3215 28.9788 33.9862 34.3751 32.6794 310017....................................................... 1.3290 1.3038 1.3008 28.0930 30.9233 32.0816 30.4154 310018....................................................... 1.1885 1.3038 1.3008 26.9399 30.3381 31.1747 29.5340 310019....................................................... 1.6374 1.3215 1.3215 31.0524 29.6592 30.9463 30.5778 310020....................................................... 1.5424 1.3215 1.3215 29.3392 30.6722 32.7089 30.8843 310021....................................................... 1.6517 1.1886 1.1886 29.6308 31.3410 33.1764 31.3692 310022....................................................... 1.2444 1.1226 1.1226 26.1914 28.2024 28.9633 27.8379 310024....................................................... 1.3630 1.1886 1.1886 27.5278 30.9171 33.3774 30.6108 310025....................................................... 1.3032 1.3215 1.3215 27.7960 31.1274 34.3920 31.3534 310026....................................................... 1.1807 1.3215 1.3215 25.3970 27.5171 29.3348 27.4955 310027....................................................... 1.3584 1.1886 1.1886 27.0982 28.8314 29.1626 28.5991 310028....................................................... 1.2686 1.3038 1.1886 29.1101 31.3849 31.8631 30.8364 310029....................................................... 1.9437 1.1226 1.1226 29.1439 30.7707 33.7099 31.2185 310031....................................................... 3.0821 1.1242 1.1242 30.2345 33.9685 35.3478 33.2165 310032....................................................... 1.3129 1.1226 1.1226 27.8754 27.5232 29.1612 28.2024 310034....................................................... 1.3412 1.1242 1.1242 27.8517 29.9162 31.8300 29.8876 310037....................................................... 1.3580 1.3215 1.3215 32.1471 35.0329 38.0377 35.1550 310038....................................................... 2.0170 1.3038 1.3008 32.1977 33.4822 35.8746 33.9362 310039....................................................... 1.2537 1.3038 1.3008 27.1054 28.8292 31.8657 29.2627 310040....................................................... 1.3533 1.3215 1.3215 28.0068 34.1113 34.5838 32.1930 310041....................................................... 1.2800 1.1242 1.1242 29.7335 32.8085 33.3980 31.9565 310042.......................................................

***

*

* 29.0207 30.7358 34.0717 31.1859 310044....................................................... 1.3686 1.1318 1.1318 27.7752 31.3206 31.9267 30.3672 310045....................................................... 1.7345 1.3215 1.3215 32.6359 34.1060 37.3128 34.7199 310047....................................................... 1.2988 1.1736 1.1736 28.3415 32.7880 35.2527 32.2796 310048....................................................... 1.3238 1.1886 1.1886 28.4715 30.2025 32.4064 30.4056 310049.......................................................

***

*

* 32.7666 27.8564

* 30.6033 310050....................................................... 1.2381 1.3038 1.3008 27.2276 27.3033 29.5929 28.0821 310051....................................................... 1.3966 1.3038 1.1886 32.0113 33.7168 36.1453 33.9634 310052....................................................... 1.3415 1.1242 1.1242 28.1498 30.8036 32.8650 30.5913 310054....................................................... 1.2940 1.3038 1.3008 30.6905 34.1860 35.7990 33.5435 310057....................................................... 1.3251 1.1226 1.1226 26.4606 29.5221 28.6219 28.2552 310058....................................................... 1.0596 1.3215 1.3215 26.4816 28.0815 27.3745 27.2978 310060....................................................... 1.2437 1.3038 1.1226 23.2146 25.1575 27.6986 25.4776 310061....................................................... 1.2606 1.1226 1.1226 27.5400 28.2129 31.7646 29.1214 310063....................................................... 1.3618 1.1886 1.1886 28.3457 31.4884 32.1212 30.6378

[[Page 24200]]

310064....................................................... 1.5601 1.1736 1.1736 29.5979 33.4440 35.3987 32.8719 310067.......................................................

***

*

* 26.8068

*

* 26.8068 310069....................................................... 1.2815 1.1226 1.1226 27.9656 28.1681 29.9598 28.7705 310070....................................................... 1.4011 1.3038 1.3008 32.1806 33.2310 33.7936 33.1015 310072.......................................................

***

*

* 26.3520

*

* 26.3520 310073....................................................... 1.8401 1.1242 1.1242 29.6611 32.0329 33.2615 31.6839 310074....................................................... 1.2542 1.3215 1.3215 28.4361 29.4834 35.6666 31.1493 310075....................................................... 1.3069 1.1242 1.1242 26.2479 31.6870 31.9433 29.9126 310076....................................................... 1.6706 1.3038 1.3008 34.9428 36.4280 38.0720 36.4875 310077.......................................................

***

*

* 30.7465 32.6644 34.0345 32.4516 310078.......................................................

***

*

* 26.9589 29.8014 30.7927 29.2238 310081....................................................... 1.2351 1.1226 1.1226 26.4259 26.6136 29.8217 27.6431 310083....................................................... 1.2916 1.3038 1.3008 24.6563 28.2392 30.0128 27.5631 310084....................................................... 1.2146 1.1242 1.1242 29.9437 32.9001 34.3249 32.2493 310086....................................................... 1.2372 1.1226 1.1226 27.3601 29.3058 30.7666 29.1619 310088....................................................... 1.1889 1.1736 1.1736 25.5274 26.4966 29.0942 27.0316 310090....................................................... 1.2738 1.1886 1.1886 27.1661 30.8941 33.3364 30.3968 310091....................................................... 1.1950 1.1226 1.1226 27.1115 27.7204 28.8503 27.8956 310092....................................................... 1.4321 1.1318 1.1318 25.7071 29.4999 29.3843 28.2367 310093....................................................... 1.1892 1.3038 1.3008 25.8727 28.0401 29.9026 28.0649 310096....................................................... 2.0353 1.3038 1.3008 30.3675 34.4275 36.4988 33.8387 310105....................................................... 1.2260 1.3215 1.3215 30.9968 31.9769 29.9797 30.9490 310108....................................................... 1.3646 1.3038 1.3008 29.1548 30.1002 33.0791 30.7872 310110....................................................... 1.2908 1.1318 1.1318 27.8707 31.2164 33.2096 31.0583 310111....................................................... 1.2002 1.1242 1.1242 28.8692 30.7475 31.9533 30.6096 310112....................................................... 1.2755 1.1242 1.1242 28.9928 30.4192 30.9671 30.1683 310113....................................................... 1.2386 1.1242 1.1242 27.5203 29.6079 31.9823 29.7520 310115....................................................... 1.2894 1.3038 1.1226 26.2803 29.6020 30.6848 28.9374 310116....................................................... 1.2313 1.3215 1.3215 26.6287 25.6976 29.5404 27.2633 310118....................................................... 1.3298 1.3215 1.3215 28.1238 28.8797 31.9920 29.6477 310119....................................................... 1.8293 1.3038 1.3008 35.6786 37.7876 42.6911 38.8840 310120....................................................... 1.0683 1.3038 1.1886 27.2010 31.4110 29.5849 29.3345 310122....................................................... 1.8284 1.1242 1.1242

*

*

*

* 310123....................................................... 2.4750 1.2237 1.2237

*

*

*

* 310124....................................................... 1.7405 1.1592 1.1592

*

*

*

* 310125....................................................... 3.0573 1.1886 1.1886

*

*

*

* 320001....................................................... 1.5398 0.9477 0.9477 26.1962 26.9434 28.3114 27.2210 320002....................................................... 1.4251 1.0821 1.0821 28.6963 30.5158 32.0322 30.4616 320003....................................................... 1.1829 0.8982 0.8982 22.3911 28.1402 27.4758 25.7749 320004....................................................... 1.3224 0.8353 0.8353 24.0362 24.9481 24.7427 24.6089 320005....................................................... 1.3413 0.9477 0.9477 21.2164 23.8264 25.4686 23.5378 320006....................................................... 1.3228 0.9814 0.9814 22.5615 24.2812 26.6616 24.5380 320009....................................................... 1.5558 0.9477 0.9477 24.4237 22.8293 31.2529 25.5999 320011....................................................... 1.1211 0.8795 0.8795 23.1539 24.2279 25.6322 24.4026 320013....................................................... 1.1009 0.9814 0.9814 27.8671 28.9276 22.6383 25.9594 320014....................................................... 1.1072 0.9270 0.9270 26.7112 24.5310 26.0108 25.6452 320016....................................................... 1.1409 0.8353 0.8353 21.7001 23.5040 24.8595 23.3847 320017....................................................... 1.1564 0.9477 0.9477 23.6861 25.0286 31.3764 26.3396 320018....................................................... 1.4337 0.9333 0.9333 23.0915 23.2360 26.8414 24.1413 320019....................................................... 1.6146 0.9477 0.9477 31.2250 31.5192 29.5311 30.6451 320021....................................................... 1.6483 0.9477 0.9477 28.5620 27.2357 26.6064 27.3101 320022....................................................... 1.1318 0.8353 0.8353 22.1492 23.7160 24.3131 23.3995 320030....................................................... 1.0412 0.8353 0.8353 18.0990 22.1971 20.9229 20.3256 320033....................................................... 1.2017 0.9814 0.9814 24.1185 27.6393 32.4689 27.9429 320037....................................................... 1.1385 0.9477 0.9477 21.6080 23.3999 25.1973 23.4459 320038....................................................... 1.2203 0.8353 0.8353 21.2181 20.1533 21.5104 20.9623 320046....................................................... 1.1831

*

* 22.9114 24.3534

* 23.6315 320057....................................................... 0.8052 1.4448 1.4448

*

*

*

* 320058....................................................... 0.8101 1.4448 1.4448

*

*

*

* 320059....................................................... 0.8615 1.4448 1.4448

*

*

*

* 320060....................................................... 0.9188 1.4448 1.4448

*

*

*

* 320061....................................................... 0.8690 1.4448 1.4448

*

*

*

* 320062....................................................... 0.8781 1.4448 1.4448

*

*

*

* 320063....................................................... 1.2764 0.9737 0.9737 24.9141 24.4696 25.1341 24.8572 320065....................................................... 1.1554 0.9737 0.9737 21.6189 26.6603 26.9856 25.3295 320067....................................................... 0.8883 0.8353 0.8353 20.4431 23.7745 23.0640 22.5148

[[Page 24201]]

320069....................................................... 1.1144 0.8353 0.8353 19.7296 20.9167 22.2717 20.9948 320070....................................................... 0.9190 1.4448 1.4448

*

*

*

* 320074....................................................... 1.1380 0.9477 0.9477 35.5980 22.2175 31.3214 29.3022 320079....................................................... 1.0890 0.9477 0.9477 23.8092 25.2105 25.7148 24.9372 320083....................................................... 2.5979 0.9477 0.9477

* 28.2114 24.0257 25.7289 320084....................................................... 0.9804 0.8353 0.8353

* 17.2511 17.5258 17.4008 320085....................................................... 1.6874 0.9333 0.9333

* 24.8752 28.5627 26.8570 330001.......................................................

***

*

* 31.3735 33.4718

* 32.4179 330002....................................................... 1.5005 1.3215 1.3215 29.3459 31.1924 30.4429 30.3409 330003....................................................... 1.3482 0.8753 0.8753 21.6506 22.9945 23.8448 22.8408 330004....................................................... 1.2620 1.0583 1.0583 23.9959 26.0445 27.5850 25.9379 330005....................................................... 1.5873 0.9475 0.9475 25.9287 29.0124 30.5004 28.4063 330006....................................................... 1.2604 1.3215 1.3215 29.7509 31.5370 32.4887 31.2785 330008....................................................... 1.1431 0.9475 0.9475 21.3269 21.8198 23.2197 22.1194 330009....................................................... 1.2062 1.3215 1.3215 35.8367 35.4986 35.4703 35.5997 330010.......................................................

***

*

* 17.9178 19.6920 20.6440 19.2176 330011....................................................... 1.3098 0.8816 0.8816 20.3641 21.8008 24.9644 22.3720 330013....................................................... 1.9972 0.8753 0.8753 23.9070 24.5162 26.1086 24.8688 330014....................................................... 1.3121 1.3215 1.3215 35.4053 38.8123 41.9904 38.6661 330016....................................................... 0.9857 0.8267 0.8267 18.9388 28.4392 21.7319 22.2994 330019....................................................... 1.2870 1.3215 1.3215 32.3413 34.8266 36.2560 34.4888 330023 \2\................................................... 1.5742 1.3038 1.3215 29.2669 31.6208 35.2521 32.2225 330024....................................................... 1.8005 1.3215 1.3215 36.5648 37.8398 42.0169 38.6703 330025....................................................... 1.0804 0.9475 0.9475 19.7561 20.2775 21.2619 20.4337 330027....................................................... 1.4373 1.3038 1.3008 35.1325 39.0717 41.6731 38.5866 330028....................................................... 1.4210 1.3215 1.3215 33.5312 34.2709 36.1977 34.6170 330029....................................................... 0.4427 0.9475 0.9475 18.6623 19.1589 22.2943 19.8291 330030....................................................... 1.2380 0.9007 0.9007 22.4368 22.9937 24.1393 23.1393 330033....................................................... 1.1423 0.8267 0.8267 21.3762 22.5681 24.4951 22.7923 330036....................................................... 1.1271 1.3215 1.3215 27.6813 28.9409 28.6763 28.4126 330037....................................................... 1.1107 0.9007 0.9007 19.6385 20.6904 22.5429 20.9676 330041....................................................... 1.2505 1.3215 1.3215 36.2481 36.0286 36.9040 36.3905 330043....................................................... 1.3834 1.2701 1.2701 34.1039 34.7480 38.4138 35.7957 330044....................................................... 1.2969 0.8422 0.8422 23.1450 24.1907 25.2654 24.2192 330045....................................................... 1.3331 1.2701 1.2701 34.4956 36.1893 38.2951 36.3647 330046....................................................... 1.4281 1.3215 1.3215 42.0900 44.8494 49.9508 45.5451 330047 h..................................................... 1.2132 0.8753 0.8753 21.1244 24.0678 24.2099 23.2219 330049....................................................... 1.4505 1.3038 1.0913 25.7022 29.2904 29.7258 28.2859 330053....................................................... 1.0625 0.9007 0.9007 19.6807 18.5290 20.0581 19.4166 330055....................................................... 1.5596 1.3215 1.3215 35.1393 38.4839 41.2383 38.3132 330056....................................................... 1.4423 1.3215 1.3215 32.9295 37.8444 35.4120 35.3946 330057....................................................... 1.7075 0.8753 0.8753 22.6519 24.4680 26.1030 24.4281 330058....................................................... 1.3449 0.9007 0.9007 19.5520 21.3727 22.2270 21.0700 330059....................................................... 1.5303 1.3215 1.3215 38.1019 39.7386 41.0950 39.6782 330061....................................................... 1.2227 1.3215 1.3215 32.7427 33.2848 35.0321 33.7280 330062....................................................... 1.0487

*

* 21.4270 21.0464

* 21.2306 330064....................................................... 1.2592 1.3215 1.3215 38.5719 36.4276 37.5279 37.4900 330065....................................................... 1.0539 0.9475 0.9475 21.9192 23.9128 24.8627 23.5400 330066....................................................... 1.3403 0.8753 0.8753 23.0916 24.7941 28.5116 25.5240 330067 \2\................................................... 1.4381 1.3038 1.3215 34.8416 26.4243 27.2479 28.9882 330072....................................................... 1.3269 1.3215 1.3215 32.7905 36.4336 37.1569 35.4529 330073....................................................... 1.1317 0.9007 0.9007 19.0781 20.1490 22.3706 20.5067 330074....................................................... 1.2195 0.9007 0.9007 20.2874 21.4274 22.6971 21.4576 330075....................................................... 1.1127 0.9723 0.9723 22.0240 22.4188 23.0741 22.5194 330078....................................................... 1.4671 0.9475 0.9475 22.7762 23.3981 25.5249 23.9158 330079....................................................... 1.2417 0.9974 0.9974 22.1064 22.5237 24.6828 23.1380 330080....................................................... 1.1802 1.3215 1.3215 36.1171 39.1724 39.0128 38.1206 330084....................................................... 1.0859 0.8267 0.8267 22.6365 21.5455 21.8844 22.0141 330085....................................................... 1.1463 0.9428 0.9428 23.2927 23.9568 24.6752 23.9772 330086....................................................... 1.3556 1.3215 1.3215 28.8424 29.1784 32.4300 30.1863 330088....................................................... 1.0121 1.2701 1.2701 31.2631 31.3973 33.6229 32.0964 330090....................................................... 1.4380 0.8267 0.8267 22.7721 23.6174 25.2379 23.8595 330091....................................................... 1.3451 0.9475 0.9475 22.5796 23.8063 25.1750 23.8763 330094....................................................... 1.2611 0.9058 0.9058 22.1495 23.0001 24.7488 23.2787 330095.......................................................

***

*

* 28.9914 31.9872 46.3616 32.4322 330096....................................................... 1.2346 0.8267 0.8267 22.4895 22.0337 22.9866 22.5018

[[Page 24202]]

330097....................................................... 1.1683

*

* 19.2233 20.3189

* 19.7495 330100....................................................... 0.9820 1.3215 1.3215 32.8406 34.4621 37.3387 34.9547 330101....................................................... 1.9087 1.3215 1.3215 39.2601 38.7503 40.4612 39.5161 330102....................................................... 1.3915 0.9475 0.9475 23.6141 24.8184 25.2287 24.5563 330103....................................................... 1.0850 0.8330 0.8330 18.8763 21.1452 22.5242 20.8126 330104....................................................... 1.3440 1.3215 1.3215 33.7556 32.8818 33.1903 33.2697 330106....................................................... 1.7400 1.4485 1.3008 39.8554 41.4561 42.8789 41.4391 330107....................................................... 1.2734 1.2701 1.2701 31.8528 31.3888 34.1234 32.4908 330108....................................................... 1.1383 0.8267 0.8267 21.4680 22.2607 22.7058 22.1280 330111....................................................... 1.0558 0.9475 0.9475 17.6185 20.9387 19.9803 19.4680 330115....................................................... 1.1814 0.9723 0.9723 20.5101 23.3043 25.2327 23.0156 330119....................................................... 1.7645 1.3215 1.3215 36.5873 39.1114 38.4828 38.0489 330121....................................................... 0.9476

*

* 19.7388

*

* 19.7388 330122.......................................................

***

*

* 26.3849

*

* 26.3849 330125....................................................... 1.7528 0.9007 0.9007 24.6945 26.7118 26.7047 26.0770 330126....................................................... 1.2994 1.3038 1.1473 28.8299 31.6370 35.1728 33.1208 330127....................................................... 1.3343 1.3215 1.3215 43.7479 44.6103 44.4572 44.2717 330128....................................................... 1.2870 1.3215 1.3215 34.5289 37.7166 39.5738 37.2581 330132....................................................... 1.0988 0.8267 0.8267 16.3088 17.4946 20.2593 18.3351 330133....................................................... 1.3735 1.3215 1.3215 44.0704 36.6962 40.0269 40.0358 330135....................................................... 1.1836 1.3038 1.1473 26.9969 29.0837 28.2828 28.1734 330136....................................................... 1.4932 0.9428 0.9428 22.5447 24.2010 25.7642 24.2296 330140....................................................... 1.7494 0.9723 0.9723 23.5774 25.7573 27.0648 25.4535 330141....................................................... 1.3524 1.2701 1.2701 30.6616 34.8902 37.7577 34.5697 330144....................................................... 1.0534 0.8267 0.8267 20.1805 20.9935 22.9269 21.3429 330148....................................................... 1.0140

*

* 18.5443

*

* 18.5443 330151....................................................... 1.1572 0.8267 0.8267 17.6782 19.1841 21.5978 19.3648 330152....................................................... 1.2920 1.3215 1.3215 32.0616 36.5136 36.5762 35.0673 330153....................................................... 1.7108 0.8753 0.8753 21.9935 24.5219 26.2638 24.3225 330157....................................................... 1.3554 0.9428 0.9428 23.6939 25.2312 26.7341 25.2451 330158....................................................... 1.5438 1.3215 1.3215 33.0067 32.2990 37.6639 34.3802 330159....................................................... 1.4177 0.9723 0.9723 24.1916 28.9094 28.5063 27.1433 330160....................................................... 1.5992 1.3215 1.3215 34.0373 34.1960 35.8958 34.7339 330162....................................................... 1.3033 1.3215 1.3215 31.3812 32.1783 34.4443 32.6472 330163....................................................... 1.1712 0.9475 0.9475 22.4644 24.0200 27.0659 24.5702 330164....................................................... 1.4565 0.9007 0.9007 24.4306 28.8481 27.2894 26.8505 330166 h..................................................... 1.0648 0.8267 0.8267 18.8777 19.4360 20.4318 19.5757 330167....................................................... 1.7599 1.2838 1.3008 33.7365 34.4748 36.1041 34.7272 330169....................................................... 1.4208 1.3215 1.3215 38.3498 39.3361 44.3462 40.5303 330171....................................................... 1.1942 1.3215 1.3215 27.7810 30.0122 30.0593 29.2106 330175....................................................... 1.1464 0.8267 0.8267 21.1944 22.2067 23.7714 22.4153 330177....................................................... 1.0045 0.8267 0.8267 20.1850 19.6100 19.9735 19.9338 330180....................................................... 1.2313 0.8753 0.8753 21.9641 22.1920 23.7235 22.6242 330181....................................................... 1.3007 1.2838 1.3008 35.9334 38.5351 40.9623 38.5235 330182....................................................... 2.3224 1.3038 1.3008 36.3831 39.6038 40.0238 38.7114 330184....................................................... 1.4427 1.3215 1.3215 33.2843 34.4044 35.1901 34.3420 330185....................................................... 1.2291 1.2701 1.2701 31.0179 32.3466 34.2430 32.5908 330188....................................................... 1.2590 0.9475 0.9475 22.6803 23.9210 25.5586 24.0883 330189....................................................... 1.0679 0.8753 0.8753 19.2538 21.6229 22.9867 21.2142 330191....................................................... 1.2924 0.8753 0.8753 22.3719 24.0232 24.7436 23.7211 330193....................................................... 1.2808 1.3215 1.3215 36.9866 37.1807 38.7230 37.6472 330194....................................................... 1.8228 1.3215 1.3215 39.9177 43.9910 44.2515 42.7636 330195....................................................... 1.7332 1.3215 1.3215 38.6867 40.0206 39.5538 39.5038 330196....................................................... 1.3705 1.3215 1.3215 32.5883 33.2171 35.7930 33.8609 330197....................................................... 1.0633 0.8267 0.8267 22.3117 23.4291 26.7687 24.1549 330198....................................................... 1.3856 1.2838 1.3008 29.5359 30.5485 32.7085 30.9857 330199....................................................... 1.1511 1.3215 1.3215 32.7870 35.0059 38.2030 35.2594 330201....................................................... 1.6395 1.3215 1.3215 33.3215 39.3682 37.4511 36.6531 330202....................................................... 1.2806 1.3215 1.3215 34.3545 38.0129 36.6670 36.3901 330203....................................................... 1.4512 0.9723 0.9723 26.2459 26.5882 31.9331 28.1724 330204....................................................... 1.3265 1.3215 1.3215 30.3273 37.6849 38.9990 35.5345 330205....................................................... 1.2915 1.3038 1.1473 30.0101 32.1617 32.4144 31.6042 330208....................................................... 1.1799 1.3215 1.3215 28.2667 29.6282 31.4344 29.9593 330209.......................................................

***

*

* 28.7213 29.7988 30.1376 29.5534 330211....................................................... 1.1264 0.8267 0.8267 21.1094 22.9966 24.3905 22.8006 330212.......................................................

***

*

* 27.0585 27.2232

* 27.1435

[[Page 24203]]

330213....................................................... 1.0844 0.8267 0.8267 21.7208 22.5191 24.9647 23.1508 330214....................................................... 1.9477 1.3215 1.3215 33.7670 37.8500 42.1291 37.8343 330215....................................................... 1.2755 0.8422 0.8422 20.6343 22.6744 23.3466 22.2273 330218....................................................... 1.0776 0.9723 0.9723 21.4095 24.1106 26.2793 23.9406 330219....................................................... 1.7056 0.9475 0.9475 27.7400 29.3644 29.8772 28.9747 330221....................................................... 1.3793 1.3215 1.3215 34.7033 36.5539 39.1877 36.8432 330222....................................................... 1.2774 0.8753 0.8753 25.9825 23.9746 25.6286 25.1525 330223....................................................... 1.0219 0.8267 0.8267 18.4291 19.4229 23.6690 20.4211 330224....................................................... 1.3174 1.0583 1.0583 23.9379 25.7850 28.0293 25.9885 330225....................................................... 1.1580 1.2838 1.3008 28.9952 29.2719 31.9981 30.1465 330226....................................................... 1.3178 0.9007 0.9007 23.4783 21.8977 24.1599 23.1859 330229 h..................................................... 1.2036 0.8360 0.8360 19.5670 20.6095 21.8375 20.6728 330230....................................................... 0.9991 1.3215 1.3215 32.1101 33.3175 35.7536 33.6689 330231....................................................... 1.0210 1.3215 1.3215 33.9324 36.9619 39.1585 36.5993 330232....................................................... 1.1885 0.8753 0.8753 21.4765 24.4531 26.2367 24.0703 330233....................................................... 1.4774 1.3215 1.3215 41.9968 45.5132 46.4011 44.6873 330234....................................................... 2.2633 1.3215 1.3215 36.8500 40.6314 48.6802 41.8211 330235....................................................... 1.1768 0.9428 0.9428 22.1217 23.3866 25.6714 23.6691 330236....................................................... 1.5550 1.3215 1.3215 32.9391 35.6347 38.6055 35.7449 330238....................................................... 1.1812 0.9007 0.9007 19.2407 20.8639 21.8941 20.6562 330239 h..................................................... 1.2433 0.8360 0.8360 20.4936 21.5397 22.3783 21.4691 330240....................................................... 1.2427 1.3215 1.3215 40.7478 39.9450 42.8856 41.1747 330241....................................................... 1.8668 0.9723 0.9723 27.7213 29.0882 30.2601 29.0836 330242....................................................... 1.3276 1.3215 1.3215 32.2178 33.6926 36.2068 34.0089 330245....................................................... 1.8252 0.8422 0.8422 21.6857 22.8003 25.2401 23.2687 330246....................................................... 1.3306 1.2701 1.2701 31.6763 34.6329 36.8581 34.3345 330247....................................................... 0.7996 1.3215 1.3215 32.1733 32.2300 35.2706 33.1804 330249....................................................... 1.2670 0.9723 0.9723 21.4345 22.9834 24.5819 23.0385 330250....................................................... 1.3135 0.9355 0.9355 23.0641 25.1664 26.8227 25.0299 330259....................................................... 1.4044 1.2838 1.3008 30.0488 31.9152 33.2686 31.7934 330261....................................................... 1.3009 1.3215 1.3215 30.9356 30.7942 33.5583 31.7945 330263....................................................... 1.0260 0.8267 0.8267 20.8456 22.4675 23.6060 22.3341 330264....................................................... 1.2873 1.2701 1.1473 28.1501 30.0139 31.0746 29.7061 330265....................................................... 1.1926 0.9007 0.9007 19.9414 20.4635 21.6198 20.6587 330267....................................................... 1.4008 1.3215 1.3215 30.3709 31.5478 33.1643 31.7213 330268....................................................... 0.9452 0.8267 0.8267 18.9142 20.9720 25.6319 21.7316 330270....................................................... 2.0124 1.3215 1.3215 38.2605 42.2111 53.8973 44.3875 330273....................................................... 1.3585 1.3215 1.3215 29.5106 30.4720 36.3643 32.1579 330276....................................................... 1.1335 0.8330 0.8330 21.7826 22.2353 23.8846 22.6430 330277....................................................... 1.1855 0.9439 0.9439 25.1438 25.3582 26.5151 25.7061 330279....................................................... 1.4992 0.9475 0.9475 23.4816 25.2130 26.7728 25.2467 330285....................................................... 2.0268 0.9007 0.9007 27.1260 27.9018 29.9511 28.3309 330286....................................................... 1.3541 1.2701 1.2701 32.3244 33.3552 34.4498 33.4062 330290....................................................... 1.7641 1.3215 1.3215 36.3764 36.9981 40.0375 37.7918 330293.......................................................

***

*

* 19.0290

*

* 19.0290 330304....................................................... 1.3150 1.3215 1.3215 33.4431 34.5761 36.2311 34.7931 330306....................................................... 1.4598 1.3215 1.3215 30.7551 35.6640 36.3448 34.3198 330307....................................................... 1.2821 0.9883 0.9883 25.4128 27.5699 29.2568 27.4840 330314....................................................... 1.2414 1.2701 1.2701 26.0150 25.5597 25.8968 25.8297 330316....................................................... 1.2614 1.3215 1.3215 33.1512 34.8623 35.1243 34.3638 330331....................................................... 1.2609 1.2838 1.3008 34.7052 36.1630 38.8882 36.6631 330332....................................................... 1.2980 1.2838 1.3008 31.8389 33.3050 34.7704 33.3802 330333.......................................................

***

*

* 33.7637 26.1917

* 29.6102 330338.......................................................

***

*

* 27.3859 31.3761 37.2825 32.0071 330339....................................................... 0.9158 0.8753 0.8753 22.2812 22.6569 24.0829 23.0041 330340....................................................... 1.2406 1.2701 1.2701 31.4322 33.9358 36.7304 34.0134 330350....................................................... 1.4882 1.3215 1.3215 39.3541 36.6250 43.5699 39.8450 330353....................................................... 1.1878 1.3215 1.3215 38.6962 37.6549 43.9114 40.1352 330357....................................................... 1.2787 1.3215 1.3215 34.3965 35.5975 37.5781 35.8277 330372....................................................... 1.2829 1.2838 1.3008 30.1505 32.6721 34.7591 32.6538 330385....................................................... 1.1485 1.3215 1.3215 42.6671 46.3221 47.0402 45.3358 330386....................................................... 1.2241 1.0583 1.0583 25.9228 27.9943 28.7592 27.5994 330389....................................................... 1.8452 1.3215 1.3215 34.7552 34.7669 36.9478 35.4956 330390....................................................... 1.2447 1.3215 1.3215 33.2628 36.0573 34.5945 34.5746 330393....................................................... 1.7531 1.2701 1.2701 34.8213 34.8095 37.6074 35.7608 330394....................................................... 1.6481 0.8816 0.8816 23.3505 25.2229 26.6945 25.0944

[[Page 24204]]

330395....................................................... 1.3957 1.3215 1.3215 35.4619 37.3096 35.7217 36.1690 330396....................................................... 1.3725 1.3215 1.3215 32.5345 35.0297 36.8429 34.7966 330397....................................................... 1.3754 1.3215 1.3215 34.5110 38.4741 36.7459 36.5053 330399....................................................... 1.1594 1.3215 1.3215 33.6753 32.3688 34.5604 33.5258 330401....................................................... 1.3754 1.2701 1.2701 35.7435 40.6249 37.3189 37.8874 330402.......................................................

***

*

* 21.3302

*

* 21.3302 330403.......................................................

***

*

*

* 23.1887 25.2042 24.1429 330404....................................................... 0.8753

*

*

*

*

*

* 330405....................................................... 0.8833

*

*

*

*

*

* 330406....................................................... 0.8810

*

*

*

*

*

* 340001....................................................... 1.5157 0.9520 0.9520 23.2436 25.0041 27.2111 25.1005 340002....................................................... 1.7808 0.9520 0.9110 25.1099 27.3349 28.4571 27.0078 340003....................................................... 1.1318 0.8607 0.8607 21.5562 23.3066 24.1238 22.9768 340004....................................................... 1.4174 0.9129 0.9129 24.2055 25.4474 26.6506 25.4397 340005....................................................... 1.0032

*

* 22.9830 22.3814

* 22.6704 340007.......................................................

***

*

* 21.1519

*

* 21.1519 340008....................................................... 1.1135 0.9520 0.9520 24.2089 26.6314 26.2698 25.7197 340010....................................................... 1.3600 0.9570 0.9570 23.1349 24.5666 27.1894 24.9795 340011....................................................... 1.0750 0.8607 0.8607 18.1843 19.9484 20.0476 19.3757 340012....................................................... 1.3275 0.8607 0.8607 22.0583 22.7189 23.2312 22.6747 340013....................................................... 1.2343 0.9286 0.9286 22.4787 23.0261 24.3059 23.2775 340014....................................................... 1.5855 0.8992 0.8992 24.4831 25.1872 27.1685 25.6433 340015 h..................................................... 1.3320 0.9787 0.9787 24.3870 26.2276 28.1772 26.2865 340016....................................................... 1.2923 0.8607 0.8607 22.7574 23.0359 23.7376 23.1810 340017....................................................... 1.3200 0.9110 0.9110 22.8879 23.8229 22.7039 23.1314 340018....................................................... 1.2060

*

* 20.3840 23.7243

* 21.9193 340019.......................................................

***

*

* 17.8768

*

* 17.8768 340020....................................................... 1.2238 0.8814 0.8814 24.1955 23.7995 26.1419 24.7053 340021....................................................... 1.2885 0.9520 0.9520 23.6884 26.0995 29.3286 26.4057 340023....................................................... 1.3674 0.9286 0.9286 23.2844 24.4897 26.2541 24.6946 340024....................................................... 1.1513 0.8607 0.8607 21.2671 22.2521 23.8742 22.4843 340025....................................................... 1.2791 0.9110 0.9110 20.9915 21.2276 23.1272 21.8404 340027....................................................... 1.1485 0.9300 0.9300 22.6107 23.6326 25.2357 23.8877 340028....................................................... 1.5457 0.8962 0.8962 24.6836 26.3298 26.5301 25.8563 340030....................................................... 2.0383 0.9805 0.9805 27.4664 29.0122 30.0506 28.8550 340032....................................................... 1.4184 0.9520 0.9520 24.8031 26.7475 27.7578 26.5096 340035....................................................... 1.0842 0.8607 0.8607 21.2407 23.5476 24.5596 23.1461 340036....................................................... 1.3160 0.9855 0.9855 22.2089 25.2077 26.3904 24.6981 340037....................................................... 1.0334 0.8823 0.8823 22.5089 21.6411 25.2974 23.1980 340038....................................................... 1.2308 0.8607 0.8607 14.0203 14.0713 23.1194 16.2732 340039....................................................... 1.2931 0.9520 0.9520 25.6605 27.1275 27.9102 26.9345 340040....................................................... 1.9365 0.9427 0.9427 24.1523 26.3325 27.9072 26.1644 340041....................................................... 1.2470 0.9029 0.9029 23.0497 23.6600 24.3510 23.7190 340042....................................................... 1.1867 0.8607 0.8607 22.1107 23.0236 24.3666 23.1693 340044....................................................... 1.0102

*

* 21.7089

*

* 21.7089 340045....................................................... 0.9486

*

* 14.5004 23.1918

* 18.3297 340047....................................................... 1.8343 0.8992 0.8992 25.3727 25.0605 27.8038 26.1074 340049....................................................... 1.8974 0.9805 0.9805 22.3082 30.4827 31.2630 28.1162 340050....................................................... 1.0680 0.8962 0.8962 21.4511 24.2533 25.6210 23.7875 340051....................................................... 1.2225 0.8901 0.8901 21.9069 23.4091 24.0706 23.1553 340053....................................................... 1.5721 0.9520 0.9520 26.9361 27.7261 28.5758 27.7590 340055....................................................... 1.2438 0.9029 0.9029 24.3728 24.1057 26.4405 24.9504 340060....................................................... 1.1227 0.8992 0.8992 22.4303 22.8657 22.3770 22.5569 340061....................................................... 1.7759 0.9805 0.9805 26.6657 27.5594 27.2893 27.1830 340064....................................................... 1.0805 0.8607 0.8607 22.3631 22.9143 23.9195 23.0608 340065.......................................................

***

*

* 20.8413

*

* 20.8413 340068....................................................... 1.1865 0.9516 0.9516 20.8600 21.8830 22.4484 21.7271 340069....................................................... 1.8892 0.9805 0.9805 27.5045 27.4473 29.8633 28.2974 340070....................................................... 1.2950 0.8992 0.8992 23.6045 24.9033 25.6875 24.7454 340071....................................................... 1.0908 0.9570 0.9570 22.1854 25.4537 26.0452 24.6143 340072....................................................... 1.1732 0.8607 0.8607 21.3320 23.1163 24.8367 23.0580 340073....................................................... 1.4358 0.9805 0.9805 29.4189 30.2061 31.2882 30.3321 340075....................................................... 1.2096 0.9029 0.9029 24.1297 26.0225 25.4646 25.1678 340084....................................................... 1.1470 0.9520 0.9520 21.3227 21.2580 21.3338 21.3047 340085 h..................................................... 1.2078 0.9369 0.9369 23.0890 23.9793 25.8265 24.2485 340087....................................................... 1.2104 0.8607 0.8607 18.4202 22.0070 22.5608 20.8741

[[Page 24205]]

340088.......................................................

***

*

* 24.3299

*

* 24.3299 340090....................................................... 1.3172 0.9855 0.9855 21.7173 23.4542 25.8788 23.8260 340091....................................................... 1.5502 0.9129 0.9129 24.9411 25.8266 26.0698 25.6286 340096 h..................................................... 1.2065 0.9369 0.9369 23.6345 25.2169 25.0546 24.6415 340097....................................................... 1.1989 0.8607 0.8607 22.5775 24.2127 25.6227 24.1152 340098....................................................... 1.4802 0.9520 0.9520 25.4823 27.3308 28.7253 27.1943 340099....................................................... 1.2462 0.8607 0.8607 20.0178 20.3683 21.6077 20.6547 340104....................................................... 0.8626 0.8823 0.8823 14.3252 15.7521 16.5594 15.5520 340106....................................................... 1.1004 0.8607 0.8607 22.6979 22.4894 25.2139 23.4325 340107....................................................... 1.1924 0.8869 0.8869 22.5583 22.9698 24.4751 23.3459 340109....................................................... 1.2610 0.8840 0.8840 22.3826 23.4419 25.4826 23.8242 340113....................................................... 1.8335 0.9520 0.9520 26.0776 28.2568 28.6890 27.7109 340114....................................................... 1.6228 0.9805 0.9805 25.4533 26.6813 28.7016 26.9713 340115....................................................... 1.6156 0.9805 0.9805 25.1907 25.0212 27.0359 25.7751 340116....................................................... 1.7312 0.9029 0.9029 26.1641 25.3213 27.1898 26.2312 340119....................................................... 1.2061 0.9520 0.9520 22.4821 24.2287 24.9657 23.9376 340120....................................................... 1.0248 0.8607 0.8607 21.8548 23.0916 24.7598 23.2664 340121....................................................... 1.0763 0.9840 0.9840 20.3701 21.7576 22.6663 21.6117 340123....................................................... 1.2907 0.8992 0.8992 23.1879 26.1083 25.6790 24.9990 340124....................................................... 1.0333 0.9570 0.9570 18.3866 20.8018 22.2436 20.3584 340126 h..................................................... 1.2954 0.9570 0.9570 23.5405 25.0189 26.8953 25.1845 340127....................................................... 1.1826 0.9805 0.9805 24.6096 25.7831 26.6726 25.7092 340129....................................................... 1.2866 0.9520 0.9520 24.1356 25.4902 26.3540 25.4160 340130....................................................... 1.3338 0.9520 0.9520 23.0937 25.2941 26.6451 25.1555 340131....................................................... 1.5363 0.9300 0.9300 25.2989 27.9358 27.8063 27.0592 340132....................................................... 1.1937 0.8607 0.8607 20.4222 21.3521 22.9792 21.6047 340133....................................................... 1.0422 0.8915 0.8915 22.1588 22.5558 22.8049 22.5184 340137....................................................... 0.9094 0.9029 0.9029 29.9903 21.0642 22.2880 25.0275 340138....................................................... 0.8891 0.9805 0.9805 27.4767 21.3670

* 24.4228 340141....................................................... 1.6287 0.9840 0.9840 24.8132 27.3355 29.5610 27.3178 340142....................................................... 1.2086 0.8607 0.8607 22.1298 22.9907 24.4531 23.2199 340143....................................................... 1.5034 0.9029 0.9029 24.8904 25.3633 28.6528 26.2974 340144....................................................... 1.2673 0.9520 0.9520 25.6538 27.2686 26.6107 26.5141 340145....................................................... 1.3036 0.9520 0.9520 23.7028 23.7131 25.4851 24.3247 340146.......................................................

***

*

* 18.8354

*

* 18.8354 340147....................................................... 1.3166 0.9570 0.9570 23.9998 25.4534 26.6789 25.4056 340148....................................................... 1.5957 0.8992 0.8992 22.4205 23.5880 25.8143 23.9131 340151....................................................... 1.0985 0.8607 0.8607 22.2613 22.0052 22.6662 22.3143 340153....................................................... 1.8446 0.9520 0.9520 25.7078 26.4896 28.2013 26.7972 340155....................................................... 1.4243 0.9805 0.9805 28.8758 30.4940 30.5341 30.0011 340156....................................................... 0.8336 1.4448 1.4448

*

*

*

* 340158....................................................... 1.1327 0.9840 0.9840 23.4724 26.4849 28.1593 25.9520 340159....................................................... 1.1318 0.9805 0.9805 22.1872 23.2991 24.4603 23.3300 340160....................................................... 1.3065 0.8607 0.8607 19.1330 20.7525 21.8503 20.6086 340166....................................................... 1.3370 0.9520 0.9520 25.7398 26.0557 27.8366 26.5981 340168....................................................... 0.3885 0.9840 0.9840 16.8076 17.3249

* 17.0785 340171....................................................... 1.1788 0.9520 0.9520 27.2074 28.2734 29.1675 28.2636 340173....................................................... 1.2716 0.9805 0.9805 26.6128 27.5072 29.0996 27.8382 340177....................................................... 1.1493 0.8607 0.8607

* 24.7471 26.9929 25.8488 340178.......................................................

***

*

*

* 28.7219

* 28.7219 340179.......................................................

***

*

*

*

* 34.2396 34.2396 340182.......................................................

***

*

*

*

* 28.2372 28.2372 340183....................................................... 1.1100

*

*

*

*

*

* 340322....................................................... 0.7923

*

*

*

*

*

* 350002....................................................... 1.7713 0.8485 0.7255 20.6474 22.0283 22.4948 21.7317 350003....................................................... 1.2047 0.7255 0.7255 25.3076 21.8061 23.7797 23.5084 350004.......................................................

***

*

* 27.5891

*

* 27.5891 350006....................................................... 1.6121 0.7255 0.7255 19.5870 19.4985 20.7196 19.9754 350009....................................................... 1.1099 0.8485 0.8485 20.7014 23.0873 23.8524 22.5660 350010....................................................... 1.1294 0.8485 0.7237 18.5682 19.1965 20.2900 19.3694 350011....................................................... 2.0043 0.8485 0.8485 22.3896 23.1947 23.9046 23.2095 350014....................................................... 0.9021 0.8485 0.7237 18.5360 17.7565 17.9617 18.0556 350015....................................................... 1.6873 0.8485 0.7255 18.6381 20.1161 20.4658 19.8222 350017....................................................... 1.3520 0.8485 0.7237 20.1943 21.0243 21.8203 21.0001 350019 \2\................................................... 1.6973 0.8485 0.9256 24.2382 22.1960 23.6479 23.3102 350027.......................................................

***

*

* 14.2262

*

* 14.2262

[[Page 24206]]

350030....................................................... 0.9937 0.8485 0.7237 19.2282 18.9978 20.0738 19.4364 350043.......................................................

***

*

* 20.9732

*

* 20.9732 350061....................................................... 1.0456

*

* 18.6546 22.0515

* 20.3874 350063....................................................... 0.8764 1.4448 1.4448

*

*

*

* 350064....................................................... 0.8725 1.4448 1.4448

*

*

*

* 350070....................................................... 2.0130 0.8485 0.8485 24.4464 25.2836 25.9959 25.2624 360001....................................................... 1.4368 0.9599 0.9599 23.7750 23.9101 26.5234 24.7144 360002....................................................... 1.2119 0.8673 0.8673 22.6923 24.5789 25.2297 24.2006 360003....................................................... 1.8456 0.9599 0.9599 26.3180 27.5029 28.8816 27.5641 360006....................................................... 1.9839 1.0119 1.0119 25.7041 28.1698 30.8441 28.2373 360008....................................................... 1.3028 0.8759 0.8759 23.2545 24.5714 25.7859 24.5599 360009....................................................... 1.6056 0.9060 0.9060 23.2659 23.1012 24.8430 23.7552 360010....................................................... 1.2454 0.8737 0.8737 22.0262 23.1178 23.6797 22.9911 360011....................................................... 1.3176 0.9919 0.9919 22.4482 25.5340 27.0031 24.9499 360012....................................................... 1.3422 1.0119 1.0119 25.5913 27.5470 29.9512 27.8791 360013....................................................... 1.1193 0.9060 0.9060 25.1588 26.8129 27.2317 26.4104 360014....................................................... 1.1293 0.9919 0.9919 23.8305 25.3861 26.8524 25.3890 360016....................................................... 1.4722 0.9599 0.9599 24.6587 26.1283 27.7608 26.1961 360017....................................................... 1.8024 1.0119 1.0119 25.4969 27.2910 29.9598 27.6052 360019....................................................... 1.3228 0.9212 0.9212 24.1105 25.5926 26.9051 25.5454 360020....................................................... 1.6244 0.9212 0.9212 22.3795 24.4343 23.8636 23.5858 360024.......................................................

***

*

* 24.0612 23.5793

* 23.9138 360025....................................................... 1.4743 0.9212 0.9212 23.6574 25.5633 27.6127 25.8025 360026....................................................... 1.3027 0.9049 0.9049 22.3303 23.5898 25.4053 23.7441 360027....................................................... 1.6825 0.9212 0.9212 24.7093 25.4894 27.1811 25.7999 360029....................................................... 1.1410 0.9588 0.9588 20.8778 22.7785 24.6599 22.7997 360031.......................................................

***

*

* 24.4324

*

* 24.4324 360032 h..................................................... 1.1695 0.9060 0.9060 22.9759 23.2638 25.2551 23.8405 360034.......................................................

***

*

* 25.1366

*

* 25.1366 360035....................................................... 1.7700 1.0119 1.0119 25.6895 27.5220 29.8683 27.7932 360036....................................................... 1.2134 0.9212 0.9212 25.0910 27.6094 28.4712 27.1094 360037....................................................... 1.4154 0.9378 0.9378 25.1615 24.3982 28.3912 25.9007 360038....................................................... 1.5182 0.9599 0.9599 24.8294 22.8009 23.6986 23.7742 360039....................................................... 1.4811 0.9919 0.9919 22.5921 24.0218 24.2491 23.6541 360040....................................................... 1.1486 0.8673 0.8673 22.8729 24.0942 25.2894 24.0903 360041....................................................... 1.4912 0.9378 0.9378 23.2625 24.1080 25.5889 24.3654 360044....................................................... 1.1134 0.8673 0.8673 20.4724 21.8411 21.8857 21.4070 360046....................................................... 1.2112 0.9599 0.9599 23.8918 25.0775 25.7145 24.9194 360047....................................................... 1.0125

*

* 17.1973 21.7248

* 19.5322 360048....................................................... 1.8468 0.9588 0.9588 27.2274 28.8107 29.1376 28.3862 360049.......................................................

***

*

* 24.2605 25.8367 26.2059 25.4083 360051....................................................... 1.7024 0.9049 0.9049 25.1785 25.7556 27.0097 26.0022 360052....................................................... 1.6267 0.9049 0.9049 23.3285 24.5405 25.8613 24.5908 360054....................................................... 1.3415 0.8759 0.8759 20.3176 23.0376 23.1854 22.1915 360055....................................................... 1.4208 0.8815 0.8815 25.1475 26.3112 27.3781 26.2760 360056....................................................... 1.6221 0.9599 0.9599 23.4638 23.1024 27.1657 24.5328 360058....................................................... 1.0757 0.8673 0.8673 22.7943 23.4429 24.6591 23.6483 360059....................................................... 1.5786 0.9378 0.9378 25.5222 25.3516 28.8091 26.6068 360062....................................................... 1.4901 1.0119 1.0119 26.8091 28.6518 31.8334 29.2317 360064....................................................... 1.6168 0.8815 0.8815 22.8729 22.2393 25.2315 23.4351 360065....................................................... 1.2521 0.9212 0.9212 24.0868 26.3036 28.1088 26.2426 360066....................................................... 1.5217 0.9060 0.9060 25.2316 27.3362 27.8899 26.8407 360068....................................................... 1.8902 0.9588 0.9588 23.7895 25.8414 26.5008 25.3817 360069....................................................... 1.2137

*

* 25.7032 24.2444

* 24.9438 360070....................................................... 1.6590 0.9088 0.9088 23.1687 24.8863 26.4994 24.8533 360071 h..................................................... 1.1279 0.9060 0.9060 21.6176 22.0786 22.9101 22.1868 360072....................................................... 1.4686 1.0119 1.0119 23.0464 24.4332 25.5498 24.3891 360074....................................................... 1.2447 0.9588 0.9588 23.6172 24.9055 26.1751 24.8987 360075....................................................... 1.1859 0.9378 0.9378 24.7610 26.8453 27.1558 26.3365 360076....................................................... 1.4726 0.9599 0.9599 22.5943 25.9369 27.3636 25.2933 360077....................................................... 1.5136 0.9378 0.9378 24.7086 25.6505 29.2165 26.5561 360078....................................................... 1.3049 0.9212 0.9212 24.6821 26.1313 26.1568 25.6598 360079....................................................... 1.8031 0.9599 0.9599 25.8762 26.0935 26.1253 26.0376 360080....................................................... 1.1259 0.8673 0.8673 19.5436 20.8309 21.0795 20.5175 360081....................................................... 1.3277 0.9588 0.9588 25.1439 27.5695 30.4888 27.5972 360082....................................................... 1.3704 0.9378 0.9378 27.4264 27.1197 29.4729 28.0495

[[Page 24207]]

360084....................................................... 1.5807 0.8737 0.8737 25.2059 25.8415 27.7366 26.2609 360085....................................................... 2.1063 1.0119 1.0119 27.5792 29.0081 31.6756 29.4421 360086....................................................... 1.5487 0.9049 0.9049 22.3005 22.1859 24.8676 23.1200 360087....................................................... 1.3826 0.9378 0.9378 25.9131 25.4040 29.6489 27.0082 360089....................................................... 1.0966 0.8673 0.8673 21.0253 22.7951 25.4796 23.0814 360090....................................................... 1.5300 0.9588 0.9588 24.4291 26.7717 28.6236 26.5744 360091....................................................... 1.3038 0.9378 0.9378 26.0541 27.5067 26.2518 26.6013 360092....................................................... 1.2227 1.0119 1.0119 23.5100 25.6618 25.6879 24.9879 360093....................................................... 1.0458

*

* 24.1238

*

* 24.1238 360094.......................................................

***

*

* 27.1864 26.6348

* 26.9890 360095....................................................... 1.3013 0.9588 0.9588 24.6984 26.1275 26.3654 25.7726 360096....................................................... 1.1174 0.8815 0.8815 22.2333 24.6317 25.6497 24.1705 360098....................................................... 1.3974 0.9378 0.9378 23.6413 24.8447 25.7314 24.7628 360100....................................................... 1.2146 0.9088 0.9088 19.0616 23.0561 25.3775 22.1813 360101....................................................... 1.3459 0.9378 0.9378 27.7584 26.6208 28.7561 27.7335 360106....................................................... 1.1149

*

* 21.6450 24.1588

* 22.9406 360107....................................................... 1.0901 0.9588 0.9588 24.5365 25.9697 25.0899 25.1975 360109....................................................... 1.0676 0.8673 0.8673 24.3236 25.4184 26.4649 25.4240 360112....................................................... 1.9284 0.9588 0.9588 26.7880 28.6784 31.4146 28.9038 360113....................................................... 1.2716 0.9599 0.9599 23.5138 25.6493 26.8972 25.2973 360115....................................................... 1.2507 0.9378 0.9378 24.0232 24.0052 25.4614 24.5372 360116....................................................... 1.2486 0.9599 0.9599 23.4049 18.0655 25.1390 22.2554 360118....................................................... 1.5454 0.9298 0.9298 24.2526 27.7289 27.5254 26.5502 360121....................................................... 1.2601 1.0630 1.0391 25.2037 24.5592 27.5575 25.7699 360123....................................................... 1.4622 0.9378 0.9378 24.1761 22.6523 27.1080 24.5618 360125....................................................... 1.2312 0.9212 0.9212 22.6871 22.1096 23.6342 22.8051 360128....................................................... 0.9991

*

* 18.5954 21.0066

* 19.7451 360129....................................................... 0.8850

*

* 19.5336

*

* 19.5336 360130....................................................... 1.4172 0.9378 0.9378 21.7015 22.9762 25.4768 23.6048 360131....................................................... 1.2611 0.9088 0.9088 23.1730 24.0495 25.7134 24.3448 360132....................................................... 1.3086 0.9599 0.9599 25.7991 25.9453 27.4285 26.3954 360133....................................................... 1.6046 0.9049 0.9049 23.9457 24.6208 28.9439 25.8164 360134....................................................... 1.7646 0.9599 0.9599 25.3013 29.2975 28.4609 27.6989 360137....................................................... 1.6613 0.9378 0.9378 25.7647 26.9522 25.1870 25.9473 360141....................................................... 1.5955 0.8815 0.8815 31.0127 27.7085 30.1241 29.6138 360142....................................................... 1.0183

*

* 21.2084 22.1610

* 21.6897 360143....................................................... 1.3785 0.9378 0.9378 23.8938 24.6306 28.4811 25.7432 360144....................................................... 1.2995 0.9378 0.9378 26.7160 25.7079 28.7129 27.0896 360145....................................................... 1.7603 0.9378 0.9378 23.4743 25.8268 26.3634 25.2160 360147....................................................... 1.4037 0.8673 0.8673 22.7172 24.1953 25.2136 24.0757 360148....................................................... 1.0686 0.8673 0.8673 24.4873 26.1946 26.3049 25.7083 360150....................................................... 1.2404 0.9212 0.9212 25.8703 24.7667 25.2592 25.2945 360151....................................................... 1.6537 0.9088 0.9088 22.2179 24.8629 26.0020 24.3233 360152....................................................... 1.5944 1.0119 1.0119 24.9894 27.9147 30.0354 27.4637 360153....................................................... 1.0121 0.8673 0.8673 19.0844 19.0226 19.1349 19.0821 360154.......................................................

***

*

* 17.1274

*

* 17.1274 360155....................................................... 1.5025 0.9378 0.9378 23.9466 25.3909 26.8044 25.3987 360156....................................................... 1.1867 0.8886 0.8886 22.6709 24.0510 25.3478 24.0344 360159....................................................... 1.2285 0.9919 0.9919 25.7108 33.1613 28.6988 28.9897 360161....................................................... 1.3481 0.8815 0.8815 22.6005 24.3792 25.7944 24.2437 360163....................................................... 1.8980 0.9599 0.9599 25.7966 26.9728 29.1497 27.2933 360170....................................................... 1.2814 1.0119 1.0119 22.9359 24.3620 27.3245 25.1144 360172....................................................... 1.4157 0.9378 0.9378 23.4727 26.3501 27.9941 25.9423 360174....................................................... 1.2911 0.9049 0.9049 22.8167 24.9990 26.5821 24.8252 360175....................................................... 1.2853 0.9919 0.9919 24.6152 26.5949 27.7409 26.3745 360177....................................................... 1.1829

*

* 23.4256 24.4712

* 23.9572 360179....................................................... 1.6031 0.9599 0.9599 25.9429 28.8645 30.2960 28.4358 360180....................................................... 2.2529 0.9378 0.9378 26.8720 26.1514 29.5742 27.5212 360185....................................................... 1.2223 0.8815 0.8815 21.8641 23.7173 24.8364 23.4838 360187....................................................... 1.6071 0.9049 0.9049 23.8362 24.8173 25.1844 24.6459 360189....................................................... 1.1205 1.0119 1.0119 24.2512 24.2136 26.6418 25.0335 360192....................................................... 1.3080 0.9378 0.9378 26.2976 26.7577 26.6802 26.5811 360194....................................................... 1.4943

*

* 22.3297

*

* 22.3297 360195....................................................... 1.1127 0.9378 0.9378 25.8043 26.1280 25.5865 25.8335 360197....................................................... 1.1514 0.9919 0.9919 24.7539 27.0896 28.6572 26.8812 360203....................................................... 1.1904 0.8673 0.8673 21.5564 22.1414 23.2702 22.3580

[[Page 24208]]

360210....................................................... 1.1799 1.0119 1.0119 26.5665 27.8415 28.7970 27.7707 360211....................................................... 1.5528 0.8673 0.8673 23.0884 22.5449 25.6367 23.6870 360212....................................................... 1.3402 0.9378 0.9378 24.5310 25.2756 26.3396 25.4049 360218....................................................... 1.1646 1.0119 1.0119 24.4720 27.4288 29.1835 27.0945 360230....................................................... 1.5362 0.9378 0.9378 26.6444 27.0223 29.3334 27.7442 360234....................................................... 1.3735 0.9599 0.9599 23.3325 24.3625 26.6945 24.6936 360236....................................................... 1.2075 0.9599 0.9599 21.3795 35.8144 25.7297 25.5205 360239....................................................... 1.3163 0.9049 0.9049 24.4398 25.2474 25.9671 25.2853 360241.......................................................

***

*

* 24.8089 24.7001 23.4843 24.1955 360245....................................................... 0.5410 0.9212 0.9212 18.7966 19.1885 20.0683 19.3751 360247....................................................... 0.3827 1.0119 1.0119 25.1083 19.8892 19.3874 21.2446 360253....................................................... 2.3855 0.9599 0.9599 28.2555 30.4276 31.4677 30.0805 360257.......................................................

***

*

* 17.9652

*

* 17.9652 360258....................................................... 1.4162

*

*

*

*

*

* 360259....................................................... 1.2048 0.9588 0.9588

* 25.1338 26.3472 25.7673 360260.......................................................

***

*

*

* 27.3903

* 27.3903 360261....................................................... 1.7902 0.9009 0.9009

* 22.5431 23.2578 22.9224 360262....................................................... 1.3180 0.9588 0.9588

* 27.1680 29.8320 28.5152 360263....................................................... 1.6984 0.9060 0.9060

* 20.8884 22.6737 21.7835 360264.......................................................

***

*

*

*

* 36.4427 36.4427 360265.......................................................

***

*

*

*

* 36.5621 36.5621 360266....................................................... 2.0048 1.0119 1.0119

*

*

*

* 360268....................................................... 2.3692 0.9049 0.9049

*

*

*

* 360269....................................................... 1.8533

*

*

*

*

*

* 360270....................................................... 1.0574

*

*

*

*

*

* 360271....................................................... 1.2708

*

*

*

*

*

* 360272....................................................... 1.3839

*

*

*

*

*

* 360319....................................................... 0.7559

*

*

*

*

*

* 360325....................................................... 0.8727

*

*

*

*

*

* 360327....................................................... 0.8846

*

*

*

*

*

* 360328....................................................... 0.6787

*

*

*

*

*

* 360330....................................................... 0.7444

*

*

*

*

*

* 370001....................................................... 1.7930 0.8146 0.8146 26.2391 27.7245 24.5650 26.1351 370002....................................................... 1.1799 0.7663 0.7663 19.7718 20.1479 21.1078 20.3588 370004....................................................... 1.0870 0.8620 0.8620 24.7694 25.3919 26.9577 25.6751 370006....................................................... 1.2934 0.8017 0.8017 16.9469 20.1063 22.7149 19.9948 370007....................................................... 1.0616 0.7663 0.7663 17.2084 17.6547 18.3587 17.7447 370008....................................................... 1.4174 0.8857 0.8857 22.7419 24.2978 25.3440 24.2102 370011....................................................... 0.9999 0.8857 0.8857 19.2266 19.7821 21.7538 20.1606 370013....................................................... 1.5053 0.8857 0.8857 22.6451 24.9295 26.7257 24.7559 370014....................................................... 1.0129 0.8376 0.8376 24.8138 25.3576 25.6283 25.2744 370015....................................................... 0.9407 0.8146 0.8146 21.1833 23.6693 24.1384 22.9965 370016 h..................................................... 1.5363 0.8857 0.8857 24.2737 25.4062 26.2547 25.3515 370018....................................................... 1.4528 0.8146 0.8146 23.4286 23.5336 25.0566 24.0042 370019....................................................... 1.2391 0.7663 0.7663 19.6761 21.4474 21.8628 20.9956 370020....................................................... 1.3420 0.7663 0.7663 17.4835 18.5046 19.0473 18.3584 370022....................................................... 1.2433 0.8116 0.8116 18.4217 19.6495 23.6102 20.4747 370023....................................................... 1.2712 0.7747 0.7747 20.6002 21.5762 23.0397 21.7646 370025....................................................... 1.2655 0.8146 0.8146 22.0287 23.5659 24.0174 23.2102 370026 h..................................................... 1.5216 0.8857 0.8857 22.5734 23.0848 25.8863 23.8389 370028....................................................... 1.8296 0.8857 0.8857 24.8661 26.6153 27.3471 26.2811 370029....................................................... 1.0748 0.7663 0.7663 22.1163 23.9956 26.2124 24.0953 370030....................................................... 1.0261 0.7663 0.7663 20.3315 23.3037 23.5362 22.4100 370032....................................................... 1.4505 0.8857 0.8857 21.6029 23.4843 24.9755 23.3829 370034....................................................... 1.2289 0.7663 0.7663 17.6247 18.2341 18.7092 18.1945 370036....................................................... 1.0525 0.7663 0.7663 16.9222 17.7576 18.8545 17.8650 370037....................................................... 1.6593 0.8857 0.8857 23.1256 23.9685 25.2235 24.1678 370039....................................................... 1.1293 0.8146 0.8146 21.0793 21.8220 23.1526 22.0252 370040....................................................... 1.0032 0.7761 0.7761 21.1061 22.4048 22.4840 21.9813 370041....................................................... 0.8640 0.8146 0.8146 22.0082 22.3496 21.1950 21.8627 370042....................................................... 0.8638

*

* 15.3613

*

* 15.3613 370043.......................................................

***

*

* 21.5588

*

* 21.5588 370045.......................................................

***

*

* 14.6370

*

* 14.6370 370047....................................................... 1.4165 0.8376 0.8376 19.7112 20.4657 23.1490 21.1519 370048....................................................... 1.1155 0.7663 0.7663 17.7273 19.2464 20.7363 19.2180 370049....................................................... 1.3251 0.8857 0.8857 21.6878 23.2171 23.8712 22.9296

[[Page 24209]]

370051....................................................... 1.0947 0.7663 0.7663 14.6254 17.2618 18.0757 16.5780 370054....................................................... 1.2331 0.7663 0.7663 21.5521 21.5043 22.3399 21.8038 370056....................................................... 1.8115 0.8116 0.8116 21.7647 22.0312 23.9116 22.5937 370057....................................................... 0.9668 0.8146 0.8146 18.0426 19.7284 19.2372 19.0104 370060....................................................... 0.9205 0.8146 0.8146 23.8007 18.7592 18.0984 20.1632 370064....................................................... 0.9620

*

* 14.1879 14.2053

* 14.1969 370065....................................................... 1.0168 0.7784 0.7784 20.6537 20.0226 20.4496 20.3712 370072....................................................... 0.7997 0.7663 0.7663 14.6387

99616 101559 109922 370076.......................................................

***

*

* 21.5461

*

* 21.5461 370078....................................................... 1.5644 0.8146 0.8146 23.9507 25.4068 26.2455 25.2147 370080....................................................... 0.8779 0.7663 0.7663 17.4857 18.0665 18.5141 17.9718 370083....................................................... 0.9436 0.7663 0.7663 15.3447 16.8836 17.8617 16.5924 370084....................................................... 0.9721 0.7663 0.7663 17.2735 16.6514 17.2101 17.0695 370089....................................................... 1.1406 0.7663 0.7663 19.9021 20.4699 20.8401 20.4021 370091....................................................... 1.5557 0.8146 0.8146 22.9893 23.3357 24.0027 23.4438 370093....................................................... 1.5136 0.8857 0.8857 25.7296 26.9774 26.8853 26.5217 370094....................................................... 1.3850 0.8857 0.8857 22.0591 23.1191 23.7154 22.9859 370095....................................................... 0.9994

*

* 16.5310

*

* 16.5310 370097....................................................... 1.2947 0.8116 0.8116 21.7150 22.3267 24.1980 22.8129 370099....................................................... 1.0477 0.8146 0.8146 20.5217 20.5075 23.8980 21.5269 370100....................................................... 0.9904 0.7663 0.7663 14.1883 14.7712 15.5623 14.8564 370103....................................................... 0.9691 0.8003 0.8003 16.1408 17.8018 17.5353 17.2277 370105....................................................... 1.8529 0.8857 0.8857 22.1584 23.8978 25.8829 24.0992 370106....................................................... 1.3478 0.8857 0.8857 24.2393 26.5867 28.0721 26.3986 370112....................................................... 0.9375 0.7761 0.7761 15.4941 15.4471 16.0671 15.6827 370113....................................................... 1.1592 0.8599 0.8599 23.3011 25.3565 27.2827 25.2470 370114....................................................... 1.5625 0.8146 0.8146 21.0603 21.7880 22.5180 21.8058 370123.......................................................

***

*

* 22.8174 25.4733

* 24.1041 370125....................................................... 0.8725

*

* 17.2013 17.1361

* 17.1678 370138....................................................... 1.0856 0.7663 0.7663 19.8308 18.3113 19.9220 19.3246 370139....................................................... 0.9531 0.7663 0.7663 17.8900 18.5225 18.3822 18.2581 370148....................................................... 1.5590 0.8857 0.8857 24.6194 25.2348 27.4012 25.7936 370149 h..................................................... 1.2268 0.9213 0.9213 21.0608 22.3537 23.1753 22.3280 370153....................................................... 1.0613 0.7663 0.7663 18.5417 19.8349 20.5204 19.6637 370156....................................................... 0.9835 0.7663 0.7663 16.6572 19.4743 22.3167 19.3770 370158....................................................... 1.0107 0.8857 0.8857 17.3161 18.5578 19.5733 18.4941 370166....................................................... 0.9240 0.8146 0.8146 21.9070 23.1681 22.8021 22.6015 370169....................................................... 0.9628 0.7663 0.7663 15.7686 15.8002 16.3268 15.9549 370170....................................................... 0.9292 1.4448 1.4448

*

*

*

* 370171....................................................... 0.8716 1.4448 1.4448

*

*

*

* 370172....................................................... 0.8898 1.4448 1.4448

*

*

*

* 370173....................................................... 0.8800 1.4448 1.4448

*

*

*

* 370174....................................................... 0.8491 1.4448 1.4448

*

*

*

* 370176....................................................... 1.1636 0.8146 0.8146 23.0324 25.0509 25.4392 24.5212 370177....................................................... 0.9561

*

* 15.6723 14.7193

* 15.1880 370178....................................................... 0.8982 0.7663 0.7663 14.9767 14.6070 14.9388 14.8411 370179....................................................... 0.9100

*

* 22.8322 23.5794

* 23.1700 370180....................................................... 1.1306 1.4448 1.4448

*

*

*

* 370183....................................................... 0.9428 0.8146 0.8146 20.5025 21.8147 24.2286 22.1884 370190....................................................... 1.3439 0.8146 0.8146 24.9455 33.1137 29.7322 29.3472 370192....................................................... 1.9008 0.8857 0.8857 26.1338 31.4930 27.7061 28.3751 370196....................................................... 0.8029 0.8857 0.8857 29.4383 22.6824 22.4776 24.9992 370199....................................................... 0.8699 0.8857 0.8857 23.7340 26.0451 25.0077 24.9496 370200....................................................... 1.2036 0.7663 0.7663 18.1008 17.6317 20.2539 18.6878 370201....................................................... 1.5499 0.8857 0.8857 23.1240 23.3550 25.7424 24.0321 370202....................................................... 1.5608 0.8146 0.8146 24.4920 25.1181 25.9091 25.2121 370203....................................................... 1.9071 0.8857 0.8857 21.2426 23.5190 23.1328 22.6893 370206....................................................... 1.6057 0.8857 0.8857 27.4495 26.0912 26.1889 26.4826 370209.......................................................

***

*

* 32.8278

*

* 32.8278 370210....................................................... 2.0675 0.8146 0.8146 20.0360 21.2682 22.8799 21.4986 370211....................................................... 1.0016 0.8857 0.8857

* 26.5344 27.6884 27.1417 370212....................................................... 1.5926 0.8857 0.8857

* 21.0758 19.8743 20.4250 370213.......................................................

***

*

*

* 29.3777

* 29.3777 370214....................................................... 1.0348 0.7663 0.7663

*

* 19.9843 19.9843 370215....................................................... 2.4607 0.8857 0.8857

* 32.3589 32.1819 32.2582 370216....................................................... 1.9400 0.8146 0.8146

*

* 26.6205 26.6205

[[Page 24210]]

370217.......................................................

***

*

*

*

* 26.0370 26.0370 370218....................................................... 2.5671 0.8146 0.8146

*

*

*

* 370219....................................................... 1.9097

*

*

*

*

*

* 370220....................................................... 1.8202

*

*

*

*

*

* 370222....................................................... 1.5520

*

*

*

*

*

* 370223....................................................... 0.8668

*

*

*

*

*

* 380001....................................................... 1.3171 1.1405 1.1405 27.8554 30.0103 30.4600 29.5050 380002....................................................... 1.2551 0.9956 0.9956 26.3348 27.1861 30.2136 27.9532 380004....................................................... 1.7168 1.1405 1.1405 28.2466 30.5172 33.6461 30.8486 380005....................................................... 1.3327 1.0836 1.0836 28.0682 30.2211 31.3173 29.9539 380006.......................................................

***

*

* 26.0475

*

* 26.0475 380007....................................................... 1.9152 1.1405 1.1405 31.5207 33.9969 34.7305 33.4267 380008....................................................... 1.2553

*

* 25.4494 25.8356

* 25.6457 380009....................................................... 1.9941 1.1405 1.1405 30.4198 31.7042 32.6878 31.6241 380010.......................................................

***

*

* 27.5291 30.2957 35.0551 30.7377 380014....................................................... 1.9349 1.1536 1.1536 27.7255 29.9648 34.1502 30.6441 380017....................................................... 1.8577 1.1405 1.1405 31.7440 32.2447 34.4728 32.7888 380018....................................................... 1.9551 1.0836 1.0836 27.8952 28.0701 31.2271 29.1079 380020....................................................... 1.3797 1.0877 1.0877 25.8320 28.3563 30.3555 28.2037 380021....................................................... 1.4905 1.1405 1.1405 29.3001 29.3295 29.8854 29.5193 380022....................................................... 1.2577 1.1175 1.1175 27.8683 29.2642 30.8763 29.3903 380023....................................................... 1.2202

*

* 23.7073 26.5439

* 25.1052 380025....................................................... 1.3250 1.1405 1.1405 30.2628 33.2105 35.9576 33.1887 380026....................................................... 1.1244

*

* 26.5217

*

* 26.5217 380027....................................................... 1.2795 1.0525 1.0525 23.8758 25.5161 26.1995 25.2490 380029....................................................... 1.2944 1.0527 1.0527 26.2070 26.9966 29.4873 27.6967 380033....................................................... 1.7377 1.0877 1.0877 29.7995 30.8767 32.8129 31.1892 380035.......................................................

***

*

* 26.4784

*

* 26.4784 380037....................................................... 1.3326 1.1405 1.1405 27.1884 30.5818 33.5871 30.5447 380038....................................................... 1.3226 1.1405 1.1405 30.5903 34.2303 36.0814 33.6061 380039.......................................................

***

*

* 30.1544 32.3959 38.8009 33.4979 380040....................................................... 1.2511 0.9826 0.9826 28.4373 32.0103 32.4278 31.1380 380047....................................................... 1.7738 1.0749 1.0749 27.8385 29.8627 31.7128 29.8785 380050....................................................... 1.4281 1.0450 1.0450 24.2416 25.6190 26.9246 25.6371 380051....................................................... 1.5533 1.0527 1.0527 28.1305 29.7219 31.3732 29.7992 380052....................................................... 1.3106 0.9826 0.9826 22.6799 24.9476 26.0940 24.5630 380056....................................................... 1.0282 1.0527 1.0527 25.0068 25.1475 27.0740 25.8845 380060....................................................... 1.4189 1.1405 1.1405 30.2507 30.7041 32.3036 31.1160 380061....................................................... 1.6466 1.1405 1.1405 29.5145 29.8217 32.7612 30.7533 380066.......................................................

***

*

* 27.5412

*

* 27.5412 380071....................................................... 1.3347 1.1405 1.1405 29.5740 30.2304 32.7599 30.8825 380072.......................................................

***

*

* 22.5275

*

* 22.5275 380075....................................................... 1.3200 1.0836 1.0836 27.4795 29.0368 33.8954 30.0591 380081....................................................... 1.1954 0.9826 0.9826 21.0708 21.8850 26.7699 23.2864 380082....................................................... 1.2101 1.1405 1.1405 30.2721 32.3002 36.3613 33.0576 380089....................................................... 1.3636 1.1405 1.1405 30.8396 33.4214 35.0697 33.0748 380090....................................................... 1.2605 1.0525 1.0525 33.6822 34.4536 33.0782 33.7148 380091....................................................... 1.3973 1.1405 1.1405 35.7002 33.8950 40.6515 36.7344 380100....................................................... 1.7000

*

*

*

*

*

* 390001....................................................... 1.6581 0.9927 0.8503 22.4407 22.5309 24.2592 23.0730 390002....................................................... 1.2561 0.8671 0.8671 23.0113 22.4388 24.6765 23.3793 390003 h..................................................... 1.1504 0.9927 0.8503 21.3182 21.6478 23.1149 22.0126 390004....................................................... 1.6415 0.9413 0.9413 23.4063 24.3249 24.8914 24.2683 390005....................................................... 0.9824

*

* 19.0318

*

* 19.0318 390006....................................................... 1.8717 0.9263 0.9263 23.3960 25.1216 26.9964 25.2038 390008 h..................................................... 1.1526 0.8671 0.8671 21.0021 22.2680 23.1784 22.1394 390009....................................................... 1.7280 0.8705 0.8705 24.2789 25.5482 26.4813 25.4517 390010....................................................... 1.1892 0.8671 0.8671 21.6273 23.5390 24.0078 23.0255 390011....................................................... 1.2880 0.8633 0.8633 19.8602 21.9279 21.5963 21.1099 390012....................................................... 1.2958 1.1009 1.1009

* 28.5076 30.8519 29.6959 390013....................................................... 1.2264 0.9263 0.9263 23.3180 24.0044 24.9820 24.0935 390016 h..................................................... 1.2685 0.8671 0.8671 19.9899 21.9549 23.1263 21.8591 390017.......................................................

***

*

* 20.6575

*

* 20.6575 390019....................................................... 1.1329 0.9927 0.9927 21.5137 23.4636 24.4718 23.1613 390022.......................................................

***

*

* 31.0971 29.0710 31.6841 30.5765 390023....................................................... 1.2172 1.1009 1.1009 27.1600 31.7149 34.4844 31.2591

[[Page 24211]]

390024....................................................... 0.9546 1.1009 1.1009 37.4330 35.3959 31.7173 34.4317 390025....................................................... 0.5440 1.1009 1.1009 15.0282 17.2977 18.1275 16.8452 390026....................................................... 1.2123 1.1009 1.1009 27.0802 29.5157 31.6801 29.4675 390027....................................................... 1.5991 1.1009 1.1009 28.9159 35.8381 35.9249 33.5685 390028....................................................... 1.5682 0.8671 0.8671 23.6616 25.7246 27.8863 25.7953 390029.......................................................

***

*

* 24.4276

*

* 24.4276 390030....................................................... 1.1912 0.9927 0.9927 20.9859 22.1581 23.3532 22.1863 390031....................................................... 1.2239 0.9534 0.9534 21.2949 22.6828 25.7851 23.2238 390032....................................................... 1.1807 0.8671 0.8671 20.9971 22.7205 24.1017 22.5468 390035....................................................... 1.2551 1.1009 1.1009 24.7281 26.2647 28.4959 26.5693 390036....................................................... 1.4696 0.8671 0.8671 23.3858 24.6032 22.6528 23.5100 390037....................................................... 1.3125 0.8671 0.8671 22.9008 24.7820 26.1465 24.6214 390039 h..................................................... 1.1700 0.8621 0.8621 17.8461 20.3787 21.9402 20.0570 390040.......................................................

***

*

* 23.1807

*

* 23.1807 390041....................................................... 1.3108 0.8671 0.8671 20.6789 21.5925 23.2044 21.7988 390042....................................................... 1.3745 0.8671 0.8671 23.9632 25.6328 27.9366 25.8129 390043....................................................... 1.2148 0.8330 0.8330 20.9835 22.2549 23.4652 22.2302 390044....................................................... 1.6474 0.9842 0.9842 24.2586 27.1505 28.4484 26.6625 390045....................................................... 1.6290 0.8330 0.8330 22.2582 23.0712 24.0257 23.1327 390046....................................................... 1.6172 0.9768 0.9768 25.0825 27.2630 29.4366 27.2659 390048....................................................... 1.1056 0.9263 0.9263 23.6622 24.9759 27.4528 25.4111 390049....................................................... 1.6272 0.9927 0.9927 25.4056 27.1366 29.2676 27.3436 390050....................................................... 1.9670 0.8671 0.8671 24.5424 26.6931 27.8306 26.3967 390052....................................................... 1.1532 0.8330 0.8330 21.6736 23.3474 24.7791 23.2785 390054....................................................... 1.2022 0.9768 0.8503 21.4983 22.8087 24.6768 22.9563 390055.......................................................

***

*

* 25.5675 25.6945

* 25.6356 390056....................................................... 1.0719 0.8372 0.8372

* 19.5537 23.5619 21.4544 390057....................................................... 1.3152 1.1009 1.1009 25.1901 27.9583 30.2759 27.8737 390058....................................................... 1.3058 0.9413 0.9413 25.3415 27.4799 26.7884 26.4926 390061....................................................... 1.4913 0.9768 0.9768 25.5012 28.4538 28.6399 27.5670 390062....................................................... 1.1330 0.8717 0.8717 19.0692 21.4052 21.7605 20.7628 390063....................................................... 1.7744 0.8705 0.8705 23.5469 24.7614 25.8275 24.7403 390065....................................................... 1.3030 1.1076 1.1076 23.4021 25.2188 28.1081 25.5499 390066....................................................... 1.2757 0.9263 0.9263 23.0891 24.2087 26.3047 24.5398 390067....................................................... 1.8178 0.9413 0.9413 25.4576 26.3287 28.9773 26.8680 390068....................................................... 1.3160 0.9768 0.9768 25.9890 25.8291 26.8043 26.1705 390070....................................................... 1.4291 1.1009 1.1009 26.9235 30.9499 34.2332 30.7526 390071....................................................... 0.9947 0.8330 0.8330 20.9443 21.8366 25.0434 22.4830 390072 h..................................................... 1.0662 0.9927 0.8503 22.0155 24.9388 24.8220 23.8819 390073....................................................... 1.6664 0.8717 0.8717 24.8013 26.3698 26.1445 25.7871 390074....................................................... 1.1018 0.8671 0.8671 21.0941 22.8545 23.9206 22.6224 390075.......................................................

***

*

* 22.6530 24.6359

* 23.6261 390076....................................................... 1.3847 1.1009 1.1009 18.1276 27.9004 31.8947 25.1241 390079....................................................... 1.8657 0.8499 0.8499 21.4323 23.3053 22.3152 22.3289 390080....................................................... 1.2658 1.1009 1.1009 25.0921 27.2616 29.3486 27.3026 390081....................................................... 1.2210 1.0878 1.0878 28.7974 30.3840 32.2244 30.4889 390084....................................................... 1.1741 0.8330 0.8330 20.7799 19.8605 21.8951 20.8513 390086....................................................... 1.7187 0.8361 0.8361 20.7383 22.5317 23.6719 22.3560 390090....................................................... 1.8335 0.8671 0.8671 20.7474 25.2014 27.8713 24.6921 390091....................................................... 1.1438 0.8671 0.8671 20.8243 21.5586 22.0398 21.4679 390093....................................................... 1.2262 0.8330 0.8330 21.0427 21.4401 22.8098 21.7808 390095....................................................... 1.1833 0.9927 0.8503 21.0754 23.6240 21.9985 22.1929 390096....................................................... 1.5833 0.9842 0.9842 24.4145 27.0763 28.7966 26.8107 390097....................................................... 1.2509 1.1009 1.1009 25.3012 25.6660 26.8698 25.9841 390100....................................................... 1.7379 0.9768 0.9768 26.7267 27.7208 28.9921 27.8855 390101....................................................... 1.2730 0.9514 0.9514 20.1694 21.9418 22.6003 21.6003 390102....................................................... 1.4104 0.8671 0.8671 21.6629 24.8898 25.2152 24.0444 390103....................................................... 0.9404 0.8671 0.8671 18.6703 20.6775 20.7796 20.0065 390104....................................................... 1.0839 0.8330 0.8330 19.1803 19.6428 19.2769 19.3701 390107....................................................... 1.3848 0.8671 0.8671 23.1023 24.1386 24.5076 23.9477 390108....................................................... 1.2431 1.1009 1.1009 24.7486 27.2661 27.2284 26.4403 390109....................................................... 1.0688

*

* 18.7558 19.9156

* 19.3329 390110....................................................... 1.6421 0.8671 0.8671 23.3355 23.9808 27.8192 24.9894 390111....................................................... 2.0459 1.1009 1.1009 30.6809 32.6510 34.1737 32.5475 390112 h..................................................... 1.1876 0.8621 0.8621 16.6113 19.2126 20.1316 18.6193 390113....................................................... 1.3210 0.8673 0.8673 21.7729 22.2591 23.2491 22.4294

[[Page 24212]]

390114....................................................... 1.3855 0.8671 0.8671 22.6630 24.0473 26.9445 24.5624 390115....................................................... 1.4625 1.1009 1.1009 26.4751 27.7333 29.2480 27.8215 390116....................................................... 1.2624 1.1009 1.1009 28.5563 30.2722 31.7572 30.2754 390117....................................................... 1.1777 0.8330 0.8330 20.0040 20.3946 21.0086 20.4770 390118....................................................... 1.1753 0.8330 0.8330 19.3332 21.5001 20.4058 20.3988 390119....................................................... 1.2890 0.9927 0.8503 21.2761 22.2746 22.7221 22.1033 390121....................................................... 1.7647 0.8717 0.8717 22.0556 23.1408 26.3071 23.7780 390122....................................................... 1.1273 0.8330 0.8330 21.6981 22.5785 23.9861 22.7470 390123....................................................... 1.1806 1.1009 1.1009 25.2209 28.6269 32.0389 28.5662 390125....................................................... 1.2652 0.8330 0.8330 19.4406 20.9456 21.8553 20.7713 390127....................................................... 1.2773 1.1009 1.1009 28.9238 30.9374 32.5496 30.8978 390128....................................................... 1.1996 0.8671 0.8671 21.8837 23.1539 24.3440 23.1405 390130....................................................... 1.2097 0.8633 0.8633 21.0694 24.0685 23.7197 22.9210 390131....................................................... 1.3556 0.8671 0.8671 21.2164 22.6306 22.8611 22.2247 390132....................................................... 1.4330 1.1009 1.1009 26.8153 27.7250 28.9482 27.8442 390133....................................................... 1.6813 1.1009 1.1009 26.1458 28.7162 29.6905 28.2740 390135.......................................................

***

*

*

* 24.4738

* 24.4738 390136.......................................................

***

*

* 24.8042 22.1415 24.2200 23.7599 390137....................................................... 1.4828 0.9927 0.8503 21.8830 23.4877 24.4118 23.2305 390138....................................................... 1.2362 0.8330 0.8330 22.7210 24.2769 25.8021 24.2858 390139....................................................... 1.3183 1.1009 1.1009 28.2089 30.4246 33.4122 30.7557 390142....................................................... 1.4259 1.1009 1.1009 32.0827 32.5786 33.7285 32.8151 390145....................................................... 1.4891 0.8671 0.8671 22.4255 23.8041 24.9495 23.7235 390146....................................................... 1.2802 0.8330 0.8330 22.3260 25.2460 22.6594 23.4555 390147....................................................... 1.3039 0.8671 0.8671 23.6380 25.0971 26.5534 25.0934 390150....................................................... 1.1581 0.8330 0.8330 24.5256 24.1855 23.5572 24.0979 390151....................................................... 1.3329 1.1028 1.1028 25.1422 27.1539 29.9832 27.4878 390152.......................................................

***

*

* 11.7774

*

* 11.7774 390153....................................................... 1.4275 1.1009 1.1009 27.5167 30.0586 32.4096 30.1880 390154....................................................... 1.2257 0.8330 0.8330 20.4408 20.6982 23.0482 21.3878 390156....................................................... 1.3466 1.0878 1.0878 27.8096 31.2571 32.2600 30.3947 390157....................................................... 1.3458 0.8671 0.8671 22.0222 22.7493 21.6936 22.1545 390160....................................................... 1.1891 0.8671 0.8671 19.5942 21.4877 24.3824 21.8172 390162....................................................... 1.4444 1.0127 1.0127

* 30.0900 35.4117 32.5988 390163....................................................... 1.2443 0.8671 0.8671 19.8863 22.1741 23.0960 21.6744 390164....................................................... 2.1047 0.8671 0.8671 25.1277 26.4971 26.4272 26.0933 390166....................................................... 1.1405 0.8671 0.8671 20.9510 24.9810 21.2366 22.3853 390168....................................................... 1.4614 0.8671 0.8671 21.9344 24.5820 26.1248 24.3161 390169....................................................... 1.4501 0.9927 0.8503 24.1682 27.2242 32.0181 27.6964 390173....................................................... 1.1370 0.8330 0.8330 21.6562 22.8220 24.2832 22.9513 390174....................................................... 1.6414 1.1009 1.1009 30.3725 32.6265 34.7231 32.5879 390176....................................................... 1.1087 0.8671 0.8671 17.1387

* 24.2733 19.5548 390178....................................................... 1.3316 0.8815 0.8815 19.2731 20.7270 22.5141 20.8263 390179....................................................... 1.4585 1.1009 1.1009 24.8350 27.2222 28.3835 26.8460 390180....................................................... 1.4150 1.0878 1.0878 30.4264 32.4375 35.3578 32.7463 390181....................................................... 1.0829 0.8330 0.8330 25.7357 24.4573 26.0384 25.3889 390183....................................................... 1.1072 0.8330 0.8330 22.0117 25.6554 27.5253 24.9187 390184....................................................... 1.2051 0.8671 0.8671 21.3407 22.5519 23.0254 22.3289 390185....................................................... 1.2931 0.9768 0.8503 21.8871 23.0202 25.8770 23.6157 390189....................................................... 1.1310 0.8330 0.8330 21.2711 22.3722 23.2078 22.3630 390191....................................................... 1.1347

*

* 19.2308 20.8761

* 20.0637 390192....................................................... 1.0319 0.9927 0.8503 20.0395 21.2620 21.2310 20.8428 390193.......................................................

***

*

* 18.5516 20.1024

* 19.3425 390194....................................................... 1.1231 0.9927 0.9927 23.1814 25.4235 27.5277 25.4082 390195....................................................... 1.5955 1.1009 1.1009 28.3480 31.0019 33.2707 30.9412 390197....................................................... 1.3853 0.9927 0.9927 24.9234 25.7739 26.2868 25.6606 390198....................................................... 1.1139 0.8705 0.8705 16.8529 18.7222 20.8448 18.7246 390199....................................................... 1.1937 0.8330 0.8330 19.9653 21.3157 22.4727 21.2413 390200.......................................................

***

*

* 23.1486 23.7471

* 23.4231 390201....................................................... 1.2935 0.8330 0.8330 24.8222 26.3658 27.5466 26.2970 390203....................................................... 1.6839 1.1009 1.1009 28.2741 28.9054 30.2714 29.1517 390204....................................................... 1.2831 1.1009 1.1009 25.6342 28.6829 29.6658 28.0375 390211....................................................... 1.2440 0.8815 0.8815 22.4472 23.1450 24.3990 23.3310 390215.......................................................

***

*

* 26.4180 28.0402

* 27.0961 390217....................................................... 1.2022 0.8671 0.8671 21.3281 24.3610 23.6716 23.0524 390219....................................................... 1.3065 0.8671 0.8671 22.8559 25.1705 25.2892 24.4016

[[Page 24213]]

390220....................................................... 1.0838 1.1009 1.1009 24.7553 41.6138 28.3573 30.6553 390222....................................................... 1.2542 1.0878 1.0878 27.0954 28.7488 30.5995 28.8443 390223....................................................... 1.9980 1.1009 1.1009 28.2538 27.6407 29.4647 28.4678 390224....................................................... 0.8611

*

* 18.1226 18.7624

* 18.4428 390225....................................................... 1.1891 0.9768 0.9768 23.4945 24.9391 27.2964 25.3940 390226....................................................... 1.7575 1.1009 1.1009 27.0061 28.5890 32.2766 29.3055 390228....................................................... 1.3685 0.8671 0.8671 22.5999 23.3078 24.5021 23.4828 390231....................................................... 1.4447 1.1009 1.1009 27.0576 29.2653 30.8464 29.0891 390233....................................................... 1.3526 0.9514 0.9514 22.8667 24.8690 25.3424 24.3814 390236....................................................... 1.1748 0.8330 0.8330 21.9199 21.9169 22.6902 22.1761 390237....................................................... 1.5683 0.9927 0.8503 24.6316 26.9533 27.0591 26.1468 390238.......................................................

***

*

* 26.4748

*

* 26.4748 390246....................................................... 1.1657 0.8330 0.8330 23.3275 20.1581 25.5357 22.7908 390256....................................................... 1.8697 0.9413 0.9413 24.2331 26.3619 28.6363 26.4469 390258....................................................... 1.5418 1.1009 1.1009 27.2038 29.4626 30.3079 29.0897 390263....................................................... 1.4554 0.9927 0.9927 23.4202 26.0170 27.8037 25.8192 390265....................................................... 1.4944 0.8671 0.8671 21.6751 23.4836 24.6360 23.2649 390266....................................................... 1.1801 0.8815 0.8815 19.2836 20.3918 21.2245 20.3113 390267....................................................... 1.1852 0.8671 0.8671 22.5464 23.1051 24.4937 23.3733 390268....................................................... 1.3621 0.8804 0.8804 24.2050 25.0021 26.0621 25.1256 390270....................................................... 1.4700 0.9768 0.8503 24.0837 24.1496 25.6462 24.6744 390272....................................................... 0.5282 1.1009 1.1009

*

*

*

* 390278....................................................... 0.5405 1.1009 1.1009 21.6893 23.6843 24.1725 23.1303 390279....................................................... 1.1033

*

* 15.3569 17.0012

* 16.1698 390285....................................................... 1.4961 1.1009 1.1009 33.5347 35.0427 37.2793 35.2062 390286....................................................... 1.1710 1.1009 1.1009 27.4090 28.1761 29.6638 28.3830 390287.......................................................

***

*

* 35.7147 37.6569 38.9525 37.4292 390288.......................................................

***

*

* 28.5267 29.7287 30.9493 29.7053 390289.......................................................

***

*

* 28.4577 28.8826 30.7464 29.2939 390290....................................................... 1.9127 1.1009 1.1009 36.4991 37.9040 37.9834 37.4690 390291.......................................................

***

*

* 21.3015

*

* 21.3015 390298.......................................................

***

*

* 26.8290

*

* 26.8290 390299.......................................................

***

*

* 31.9423

*

* 31.9423 390300.......................................................

***

*

* 40.4697

*

* 40.4697 390301.......................................................

***

*

*

* 30.9838

* 30.9838 390302....................................................... 2.1291

*

*

*

*

*

* 390303.......................................................

***

*

*

*

* 27.8974 27.8974 390304....................................................... 1.2893 1.1009 1.1009

*

* 30.8572 30.8572 390307....................................................... 2.0672 0.8815 0.8815

*

*

*

* 390308....................................................... 0.8968 1.1009 1.1009

*

*

*

* 390309....................................................... 1.1904 1.1009 1.1009

*

*

*

* 390310....................................................... 2.5154 0.8330 0.8330

*

*

*

* 400001....................................................... 1.3197 0.4396 0.4396 16.1114 13.1847 13.9703 14.2429 400002....................................................... 1.7815 0.4852 0.4852 14.8607 16.7583 15.8300 15.7293 400003....................................................... 1.2707 0.4852 0.4852 13.0776 12.8329 14.2278 13.3681 400004....................................................... 1.2677 0.4396 0.4396 104716 14.3108 12.0952 12.1371 400005....................................................... 1.1979 0.4396 0.4396 102878 107207 108193 106148 400006....................................................... 1.1645 0.4396 0.4396

89919

92265

81860

87958 400007....................................................... 1.2128 0.4396 0.4396

87152

92463 102084

93717 400009....................................................... 1.0167 0.3242 0.3242

92007

93116

93834

93007 400010....................................................... 0.8436 0.3917 0.3917 109354 100962 100781 103657 400011....................................................... 1.0360 0.4396 0.4396

85868

85534

97022

89770 400012....................................................... 1.4590 0.4396 0.4396

83580

83802 11.9435

93674 400013....................................................... 1.2317 0.4396 0.4396

95584 103347 108428 102803 400014....................................................... 1.3296 0.3856 0.3856 11.7023 12.2169 105871 11.4707 400015....................................................... 1.3552 0.4396 0.4396 15.6066 15.6349 13.7075 14.9492 400016....................................................... 1.4419 0.4396 0.4396 15.3497 14.7607 16.5449 15.5555 400017....................................................... 1.1236 0.4396 0.4396 101238 102734 103148 102269 400018....................................................... 1.1948 0.4396 0.4396 107948 11.6165 11.7496 11.4151 400019....................................................... 1.4382 0.4396 0.4396 14.9892 12.8029 12.8992 13.4598 400021....................................................... 1.3198 0.4884 0.4884 13.8643 14.1533 14.4649 14.1568 400022....................................................... 1.3733 0.4852 0.4852 16.0539 15.9246 15.3806 15.7699 400024....................................................... 0.8278 0.3856 0.3856

91316 12.4649 105851 104594 400026....................................................... 1.0863 0.3242 0.3242 5.2085 5.8200

99034 6.4832 400028....................................................... 1.2282 0.4852 0.4852 103354 109808 11.4583 109391 400032....................................................... 1.1613 0.4396 0.4396 107195 102652 103523 104470

[[Page 24214]]

400044....................................................... 1.2533 0.4852 0.4852 107890 13.7509 15.0643 13.2982 400048....................................................... 1.1305 0.4396 0.4396 14.0887 104266

96590 11.4085 400061....................................................... 1.8741 0.4396 0.4396 15.1639 18.9123 18.1083 17.4205 400079....................................................... 1.1751 0.3917 0.3917

94218 12.7825

97136 104627 400087....................................................... 1.2553 0.4396 0.4396

95860 106849 11.1382 104923 400094.......................................................

***

*

*

88646

*

*

88646 400098....................................................... 1.3208 0.4396 0.4396 13.7938 12.8230 14.0632 13.4998 400102....................................................... 1.2898 0.4396 0.4396 101795 102677 105904 103382 400103....................................................... 1.6742 0.3856 0.3856 12.8288

93859 108059 106890 400104....................................................... 1.1455 0.4396 0.4396

82758

93854 11.4349

97084 400105....................................................... 1.1547 0.4396 0.4396 12.7725 14.0219 15.6682 14.1165 400106....................................................... 1.1415 0.4396 0.4396

96902 11.4507 107533 106057 400109....................................................... 1.4063 0.4396 0.4396 14.2169 14.2111 14.3015 14.2434 400110....................................................... 1.1588 0.3861 0.3861 11.8458 12.3449 11.4297 11.8994 400111....................................................... 1.0981 0.3917 0.3917 13.4777 14.5029 14.5980 14.1786 400112....................................................... 1.1494 0.4396 0.4396

89469 19.3945 101536 11.4865 400113....................................................... 1.2376 0.4852 0.4852 100830

96778 108360 101888 400114....................................................... 1.1480 0.4396 0.4396 12.1920 11.5478 101147 11.2106 400115....................................................... 1.1597 0.4396 0.4396

91132 13.7392 12.3253 11.4989 400117....................................................... 1.1245 0.4396 0.4396 102911 12.7600 102910 11.0109 400118....................................................... 1.2557 0.4396 0.4396 11.9324 12.5743 12.8655 12.4718 400120....................................................... 1.3081 0.4396 0.4396 11.9714 12.7955 13.5787 12.8169 400121....................................................... 1.0060 0.4396 0.4396

86665

82197

97450

88283 400122....................................................... 1.9098 0.4396 0.4396

96463 11.2325

89500 101687 400123....................................................... 1.2218 0.3856 0.3856 11.8135 12.3041 13.1036 12.4082 400124....................................................... 2.9200 0.4396 0.4396 17.2258 16.1812 17.5453 16.9794 400125....................................................... 1.1716 0.4047 0.4047 107425 11.6386 11.9805 11.4266 400126....................................................... 1.2506 0.4884 0.4884 13.3932

98008 14.4278 11.9045 400127....................................................... 1.6978 0.4396 0.4396

*

*

*

* 400128....................................................... 1.0326

*

*

*

*

*

* 410001....................................................... 1.2798 1.0791 1.0791 27.0309 28.0816 28.7232 27.9407 410004....................................................... 1.2554 1.0791 1.0791 25.4578 27.4209 29.8160 27.5282 410005....................................................... 1.2518 1.0791 1.0791 27.1171 30.1606 28.0170 28.4104 410006....................................................... 1.3408 1.0791 1.0791 27.1842 29.4395 30.4938 29.0529 410007....................................................... 1.6795 1.0791 1.0791 30.1360 31.8548 33.2082 31.8053 410008....................................................... 1.2437 1.0791 1.0791 28.4245 29.6092 30.7042 29.5882 410009....................................................... 1.2546 1.0791 1.0791 27.7337 29.4094 31.8827 29.7343 410010....................................................... 1.2153 1.1318 1.1318 30.7826 32.8599 33.1837 32.3515 410011....................................................... 1.3425 1.0791 1.0791 28.5875 30.3787 34.1277 30.9611 410012....................................................... 1.7592 1.1318 1.1318 32.1679 32.6009 34.2578 33.0696 410013....................................................... 1.2452 1.2020 1.2020 31.7482 35.4624 36.1627 34.4667 420002....................................................... 1.5071 0.9520 0.9520 27.9312 28.2848 29.6120 28.6309 420004....................................................... 1.9971 0.9168 0.9168 26.0279 27.2620 28.2541 27.2127 420005....................................................... 1.0520 0.8604 0.8604 19.8167 23.1943 24.2198 22.4053 420006.......................................................

***

*

* 22.8920 24.0811 24.5609 23.8460 420007....................................................... 1.6133 0.9286 0.9286 25.0395 25.2650 27.2262 25.8946 420009....................................................... 1.4085 0.9286 0.9286 23.8668 25.5079 27.3791 25.6316 420010....................................................... 1.1727 0.8604 0.8604 21.6478 23.4562 24.2841 23.1799 420011....................................................... 1.2007 0.9708 0.9708 20.8895 21.4030 21.7568 21.3667 420014.......................................................

***

*

* 21.5658

*

* 21.5658 420015....................................................... 1.3233 0.9708 0.9708 24.7383 26.2154 21.2872 23.9502 420016....................................................... 0.9804 0.8604 0.8604 17.3837 17.1229 20.8597 18.3791 420018....................................................... 1.7486 0.8604 0.8604 23.6356 24.8024 21.8989 23.4144 420019....................................................... 1.0789 0.8604 0.8604 20.5472 22.5312 21.4165 21.4730 420020....................................................... 1.2657 0.9168 0.9168 24.6592 25.8883 27.8386 26.1025 420023....................................................... 1.7023 0.9708 0.9708 25.1035 26.7263 27.9657 26.5640 420026....................................................... 1.9244 0.8604 0.8604 29.2961 27.4814 28.0609 28.2225 420027....................................................... 1.6213 0.9286 0.9286 22.8322 25.1692 26.4925 24.8853 420030....................................................... 1.2546 0.9168 0.9168 24.2847 26.0079 27.0672 25.7933 420033....................................................... 1.1348 0.9708 0.9708 27.5740 31.8759 31.3764 30.3043 420036....................................................... 1.2159 0.9520 0.9520 21.9641 22.8294 23.9791 22.9381 420037....................................................... 1.3078 0.9708 0.9708 26.8750 29.4156 30.4783 28.9942 420038....................................................... 1.2810 0.9708 0.9708 22.6741 24.2259 26.1603 24.3482 420039....................................................... 1.0969 0.9192 0.9192 24.0637 25.1148 27.2085 25.4527 420043 h..................................................... 1.1624 0.9369 0.9369 22.9764 23.0555 23.3824 23.1477 420048....................................................... 1.2633 0.8604 0.8604 23.1515 24.1923 26.0899 24.4888

[[Page 24215]]

420049....................................................... 1.2698 0.8819 0.8819 23.2156 23.9722 25.5048 24.2429 420051....................................................... 1.5632 0.8604 0.8604 23.9455 24.8026 24.8652 24.5591 420053....................................................... 1.1371 0.8604 0.8604 21.1177 22.2825 22.7135 22.0833 420054....................................................... 1.0765 0.8604 0.8604 24.0653 24.8931 24.8011 24.5877 420055....................................................... 1.0631 0.8604 0.8604 20.3599 21.9764 23.3168 21.9025 420056....................................................... 1.3401 0.8604 0.8604 21.1640 21.6963 23.9218 22.2405 420057....................................................... 1.2668 0.8604 0.8604 19.7653 23.4311 22.2186 21.7975 420059....................................................... 1.0763

*

* 21.4260

*

* 21.4260 420061.......................................................

***

*

* 20.8684

*

* 20.8684 420062....................................................... 1.0673 0.8739 0.8739 25.6683 25.9526 26.9629 26.2354 420064....................................................... 1.2144 0.8819 0.8819 22.1290 23.3610 24.2786 23.2388 420065....................................................... 1.4215 0.9168 0.9168 22.8674 24.5715 25.3741 24.2923 420066....................................................... 0.9904 0.8604 0.8604 20.5893 23.9048 24.4148 22.9867 420067....................................................... 1.3417 0.8958 0.8958 24.6038 25.0345 25.3722 25.0243 420068....................................................... 1.3345 0.9554 0.9554 22.2638 23.4248 25.2900 23.6594 420069....................................................... 1.1105 0.8604 0.8604 19.6959 20.5546 21.6426 20.6460 420070....................................................... 1.3141 0.8604 0.8604 22.4370 23.4355 23.9471 23.3117 420071....................................................... 1.4059 0.9286 0.9286 23.1727 24.9418 25.6422 24.6317 420072....................................................... 1.0863 0.8604 0.8604 17.5899 18.6742 17.2143 17.8091 420073....................................................... 1.3790 0.8604 0.8604 24.0274 24.5813 25.8074 24.8472 420075....................................................... 0.9046

*

* 16.4816

*

* 16.4816 420078....................................................... 1.8782 0.9708 0.9708 25.3032 28.9112 30.1670 28.1072 420079....................................................... 1.5771 0.9168 0.9168 25.2939 25.4935 26.9725 25.9340 420080....................................................... 1.4619 0.8958 0.8958 28.4569 28.4734 29.0327 28.6601 420082....................................................... 1.5148 0.9681 0.9681 26.1221 29.8528 30.7503 28.8866 420083....................................................... 1.4829 0.9286 0.9286 25.3043 27.1322 26.9176 26.4627 420085....................................................... 1.5804 0.9516 0.9516 25.3180 26.8692 27.7993 26.6577 420086....................................................... 1.4224 0.8604 0.8604 25.1372 25.8869 21.7594 24.0808 420087....................................................... 1.8048 0.9168 0.9168 23.2230 24.3609 25.4810 24.3588 420088.......................................................

***

*

* 23.1273

*

* 23.1273 420089....................................................... 1.3305 0.9168 0.9168 25.2729 26.0074 28.9297 26.7899 420091....................................................... 1.3534 0.8604 0.8604 23.4710 26.9214 26.0435 25.5227 420093.......................................................

***

*

* 25.1457 27.4766 28.6727 27.2207 420097.......................................................

***

*

* 24.7809

*

* 24.7809 420098....................................................... 1.1589 0.8639 0.8639

*

* 31.3940 31.3940 420100....................................................... 1.9085

*

*

*

*

*

* 420101....................................................... 1.0458

*

*

*

*

*

* 430005....................................................... 1.3298 1.0359 0.8485 19.9454 22.3272 23.0896 21.7517 430008 \2\................................................... 1.0746 0.9456 0.9559 20.9442 23.3790 24.6127 22.8729 430011.......................................................

***

*

* 20.6597

*

* 20.6597 430012....................................................... 1.2579 0.9456 0.9456 22.7530 24.0850 24.9285 23.9166 430013 \2\................................................... 1.1791 0.9456 0.9559 22.9675 25.1378 26.5894 24.8973 430014....................................................... 1.3196 0.8485 0.8485 25.5387 26.4964 27.4732 26.5372 430015....................................................... 1.1709 0.9456 0.8485 23.2035 22.7947 23.8702 23.2928 430016....................................................... 1.6875 0.9559 0.9559 26.1495 27.8453 30.2136 28.0429 430027....................................................... 1.7911 0.9559 0.9559 23.8477 26.2139 26.9443 25.7330 430029....................................................... 0.8746

*

* 20.2708

*

* 20.2708 430031 \2\................................................... 0.9582

*

* 15.6112 16.0346

* 15.8232 430043.......................................................

***

*

* 17.2722

*

* 17.2722 430047....................................................... 1.0053

*

* 21.9116 18.8982

* 20.4712 430048....................................................... 1.3110 0.9456 0.8485 21.1718 23.0783 24.1611 22.8614 430060....................................................... 0.9031 0.9456 0.8485 102704

* 11.7945 109543 430064....................................................... 1.0621 0.9456 0.8485 16.4314 17.5376 17.2636 17.0895 430077....................................................... 1.7585 0.9456 1.0359 23.4835 25.1763 31.1834 26.6659 430081....................................................... 0.8530 1.4448 1.4448

*

*

*

* 430082....................................................... 0.7949 1.4448 1.4448

*

*

*

* 430083....................................................... 0.8473 1.4448 1.4448

*

*

*

* 430084....................................................... 0.9005 1.4448 1.4448

*

*

*

* 430085....................................................... 0.8408 1.4448 1.4448

*

*

*

* 430089....................................................... 1.6831 0.9201 0.9201 21.1109 22.5625 23.6025 22.5500 430090....................................................... 1.4802 0.9559 0.9559 26.0851 25.8460 28.9461 27.1155 430091....................................................... 2.1668 0.9456 1.0359 23.8897 24.3021 25.8667 24.7276 430092....................................................... 1.8623 0.8485 0.8485 20.2570 20.9486 23.4758 21.5566 430093....................................................... 0.9304 1.0359 1.0359 23.1526 29.5244 30.0783 27.8638 430094....................................................... 1.4722 0.9154 0.9154 18.5429 18.9099 22.5333 19.9282 430095....................................................... 2.4917 0.9559 0.9559 24.7074 28.1749 29.8113 27.7110

[[Page 24216]]

430096....................................................... 1.9427 0.8485 0.8485

* 21.6998 22.6901 22.1655 440001....................................................... 1.1169 0.8070 0.8070 17.4802 19.3100 20.2649 19.0060 440002....................................................... 1.7066 0.9032 0.9032 23.2177 24.6664 25.9742 24.6541 440003....................................................... 1.2347 0.9853 0.9853 24.5168 25.9209 28.8489 26.4731 440006....................................................... 1.4887 0.9853 0.9853 26.7983 28.5951 29.6894 28.3900 440007....................................................... 0.9516 0.7957 0.7957 13.7042 25.8236 19.4053 18.8359 440008....................................................... 1.0250 0.8640 0.8640 22.1405 23.4301 23.3316 22.9571 440009....................................................... 1.1899 0.7957 0.7957 21.1274 21.5970 23.1758 22.0061 440010....................................................... 0.9646 0.7957 0.7957 16.9060 17.1803 18.2555 17.4628 440011....................................................... 1.3341 0.8278 0.8278 21.6861 22.5068 23.9451 22.7588 440012....................................................... 1.5557 0.8078 0.8078 21.4769 22.3029 23.7400 22.4984 440015....................................................... 1.8501 0.8278 0.8278 22.5583 23.7422 25.0126 23.7907 440016....................................................... 1.0145 0.7957 0.7957 20.0982 22.1646 22.6177 21.6373 440017....................................................... 1.8336 0.8078 0.8078 22.5313 22.9364 24.4189 23.3049 440018....................................................... 1.1147 0.8070 0.8070 21.7239 23.3444 23.3049 22.8330 440019....................................................... 1.7779 0.8278 0.8278 23.8802 25.2553 25.8265 24.9572 440020....................................................... 1.0317 0.8829 0.8829 23.1718 23.9475 23.5480 23.5575 440023....................................................... 0.9906

*

* 17.0335

*

* 17.0335 440024....................................................... 1.3361 0.8841 0.8841 20.3658 23.2716 23.6564 22.4300 440025....................................................... 1.1289 0.8607 0.8607 19.5995 20.6798 21.4831 20.6130 440026....................................................... 0.6849

*

* 26.9149 26.8986 28.1548 27.3132 440029....................................................... 1.3750 0.9853 0.9853 25.8538 28.0779 29.2583 27.8141 440030....................................................... 1.3551 0.8013 0.8013 20.0586 22.1217 23.8651 22.0702 440031....................................................... 1.1563 0.7957 0.7957 18.0944 19.6685 20.3131 19.3798 440032....................................................... 1.1223 0.8062 0.8062 16.0734 18.5277 19.6994 18.1087 440033....................................................... 1.0675 0.7957 0.7957 18.7749 20.7917 20.0504 19.8739 440034....................................................... 1.6231 0.8278 0.8278 23.1121 23.5403 24.4772 23.7187 440035....................................................... 1.3627 0.9571 0.9571 22.3230 24.3752 26.2379 24.3199 440039....................................................... 2.1248 0.9853 0.9853 26.4647 28.4678 29.9015 28.3486 440040....................................................... 0.9305 0.7957 0.7957 17.7647 17.8510 18.2335 17.9564 440041....................................................... 0.9605

*

* 17.4074 17.9409

* 17.6972 440046....................................................... 1.1823 0.9853 0.9853 25.5329 26.1341 27.6435 26.4633 440047....................................................... 0.8929 0.8456 0.8456 20.4812 21.4280 22.3132 21.4112 440048....................................................... 1.8553 0.9367 0.9367 24.3283 27.7560 29.3776 27.0718 440049....................................................... 1.6271 0.9367 0.9367 22.9755 25.3043 26.9042 25.0712 440050....................................................... 1.3256 0.9110 0.9110 21.8972 23.1362 24.6283 23.2518 440051....................................................... 0.9873 0.8061 0.8061 20.7948 21.9108 23.7561 22.1363 440052....................................................... 1.0493 0.7957 0.7957 20.1875 21.1133 21.8224 21.0640 440053....................................................... 1.2859 0.9853 0.9853 23.9083 25.4345 27.2143 25.5366 440054....................................................... 1.1108 0.7957 0.7957 20.5992 21.4400 22.9137 21.6206 440056....................................................... 1.1517 0.8278 0.8278 20.4088 22.1068 22.6402 21.8021 440057....................................................... 1.0894 0.7957 0.7957 14.6242 16.4451 16.2043 15.7807 440058....................................................... 1.1733 0.8841 0.8841 22.6014 22.9263 24.5733 23.3536 440059....................................................... 1.5230 0.9571 0.9571 23.9301 26.3551 27.0398 25.7416 440060....................................................... 1.1113 0.8640 0.8640 22.7133 23.3014 24.2289 23.4440 440061....................................................... 1.0612 0.7957 0.7957 21.2085 21.8274 23.7972 22.1762 440063....................................................... 1.5519 0.8081 0.8081 21.8578 22.3256 24.2436 22.8424 440064....................................................... 1.0269 0.8965 0.8965 20.9742 22.0955 23.2881 22.0874 440065....................................................... 1.2273 0.9853 0.9853 21.4794 22.3247 24.5839 22.8185 440067....................................................... 1.1704 0.8278 0.8278 22.1410 23.1089 23.6433 22.9820 440068....................................................... 1.1108 0.8841 0.8841 23.1705 24.5971 25.5084 24.4008 440070....................................................... 0.9767 0.7957 0.7957 19.0240 19.4372 19.0125 19.1532 440072....................................................... 1.1510 0.9032 0.9032 20.9294 27.1443 24.1118 23.7250 440073....................................................... 1.4478 0.9571 0.9571 22.2959 23.9198 26.0153 24.0664 440081 h..................................................... 1.1987 0.8278 0.8278 19.0328 19.7878 20.6628 19.8630 440082....................................................... 2.1349 0.9853 0.9853 28.7828 27.9724 30.5997 29.1230 440083....................................................... 0.9462 0.7957 0.7957 16.0956 17.3329 23.4452 18.9853 440084....................................................... 1.2049 0.7957 0.7957 15.2825 16.3738 17.5206 16.4229 440091....................................................... 1.6877 0.8965 0.8965 26.1122 25.6797 26.8144 26.2154 440102....................................................... 1.1120 0.7957 0.7957 17.5140 17.5261 20.0410 18.3603 440104....................................................... 1.8282 0.8965 0.8965 23.3731 25.3739 26.5346 25.1499 440105....................................................... 1.0151 0.8081 0.8081 20.7821 22.3438 22.6923 21.9737 440109....................................................... 0.9889 0.7957 0.7957 18.2508 18.6720 19.6599 18.8870 440110....................................................... 1.1019 0.8278 0.8278 20.9039 21.3287 21.2955 21.1604 440111....................................................... 1.2995 0.9853 0.9853 25.8821 28.5705 29.5053 27.9706 440114....................................................... 1.0157

*

* 21.4271 24.0147

* 22.7665

[[Page 24217]]

440115....................................................... 0.9925 0.8456 0.8456 20.0642 21.7830 22.4307 21.4405 440120....................................................... 1.5709 0.8278 0.8278 23.9003 25.5961 26.0172 25.1825 440125....................................................... 1.6399 0.8278 0.8278 21.9337 22.4196 22.9618 22.4439 440130....................................................... 1.1653 0.7957 0.7957 21.6480 23.4517 24.3338 23.1392 440131....................................................... 1.1555 0.9367 0.9367 22.4119 24.9598 26.2835 24.5883 440132....................................................... 1.2915 0.7957 0.7957 20.5716 21.5085 23.0374 21.6966 440133....................................................... 1.6608 0.9853 0.9853 27.5019 26.2422 28.9034 27.5284 440135....................................................... 1.0517 0.7957 0.7957 25.3928 26.6615 28.4307 26.8611 440137....................................................... 1.0820 0.7957 0.7957 18.2073 20.6663 21.9678 20.1924 440141....................................................... 1.0091 0.7957 0.7957 19.4528 21.3313 22.2645 21.1533 440143....................................................... 0.9346

*

* 21.0374

*

* 21.0374 440144....................................................... 1.2554 0.7957 0.7957 22.3671 23.3828 23.6094 23.1261 440145....................................................... 0.9924

*

* 20.9863 20.7875

* 20.8882 440147.......................................................

***

*

* 28.9038 31.4012 33.3608 31.2464 440148....................................................... 1.1184 0.9571 0.9571 23.0697 24.6412 24.2554 23.9966 440149....................................................... 1.0243

*

* 19.8020 20.4562

* 20.1312 440150....................................................... 1.3664 0.9853 0.9853 25.4952 26.8308 28.3249 26.8782 440151....................................................... 1.0878 0.9571 0.9571 23.3037 23.9808 26.7603 24.6946 440152....................................................... 1.8573 0.9367 0.9367 25.9495 26.5513 27.0829 26.5411 440153....................................................... 1.0530 0.7964 0.7964 22.7744 22.2846 22.7501 22.6002 440156....................................................... 1.5372 0.8965 0.8965 25.6333 26.9689 27.8265 26.8113 440159....................................................... 1.4567 0.9367 0.9367 21.1073 22.8645 24.4882 22.9041 440161....................................................... 1.7891 0.9853 0.9853 28.6774

* 29.5526 29.1459 440162.......................................................

***

*

* 16.5305 21.1418 28.0859 21.5406 440166.......................................................

***

*

* 27.1355 31.0779 35.4275 30.5015 440168....................................................... 0.9738 0.9367 0.9367 22.1764 22.8768 27.8781 24.3442 440173....................................................... 1.6130 0.8278 0.8278 20.8723 22.8846 22.9918 22.2791 440174....................................................... 0.8839 0.8329 0.8329 20.7960 22.0974 24.1697 22.3179 440175....................................................... 1.0159 0.9571 0.9571 24.0005 22.7299 24.6413 23.7639 440176....................................................... 1.2251 0.8078 0.8078 22.0079 23.6659 23.1222 22.9749 440180....................................................... 1.2535 0.8278 0.8278 21.9781 23.3808 25.2167 23.6141 440181....................................................... 0.9526 0.8364 0.8364 21.1406 22.7150 24.3293 22.7527 440182....................................................... 0.9870 0.7957 0.7957 20.2630 22.3612 23.2013 21.9586 440183....................................................... 1.6248 0.9367 0.9367 27.7769 27.1515 28.8310 27.9092 440184....................................................... 1.0336 0.8081 0.8081 20.8219 22.3475 24.3699 22.4690 440185....................................................... 1.1495 0.8841 0.8841 23.4172 23.9052 25.1022 24.2246 440186....................................................... 1.0327 0.9853 0.9853 24.6773 25.7445 27.3448 25.9302 440187....................................................... 1.1095 0.7957 0.7957 21.7637 21.3252 22.8652 21.9897 440189....................................................... 1.3834 0.8860 0.8860 24.7851 27.5435 27.8595 26.7516 440192....................................................... 1.0715 0.9571 0.9571 25.1119 25.7495 26.7266 25.8889 440193....................................................... 1.2853 0.9853 0.9853 24.3911 24.4299 24.8439 24.5603 440194....................................................... 1.3338 0.9853 0.9853 26.2498 26.6527 29.9809 27.7279 440197....................................................... 1.3107 0.9853 0.9853 26.4999 27.1534 29.6975 27.7361 440200....................................................... 0.9957 0.9853 0.9853 17.0633 17.7491 19.9962 18.2529 440203....................................................... 0.9226 0.7957 0.7957 17.7639 19.3864 23.2355 19.8845 440217....................................................... 1.3383 0.9367 0.9367 25.9667 28.5968 29.4892 28.0654 440218....................................................... 1.7741 0.9853 0.9853 26.3741 24.6465 24.3645 25.3056 440222....................................................... 0.9844 0.9367 0.9367 28.3879 29.7292 29.2515 29.1278 440225....................................................... 0.8475 0.8278 0.8278

*

* 26.4444 26.4444 440226....................................................... 1.5408 0.8278 0.8278

*

* 26.5721 26.5721 440227....................................................... 1.2278 0.9853 0.9853

*

*

*

* 440228....................................................... 1.3652 0.9367 0.9367

*

*

*

* 450002....................................................... 1.4375 0.9101 0.9101 25.4975 25.7171 28.0968 26.4037 450005....................................................... 1.0954 0.8612 0.8612 23.4049 23.5576 24.8874 23.9095 450007....................................................... 1.3241 0.8859 0.8859 19.2875 20.7321 22.7681 20.9365 450008....................................................... 1.2987 0.9131 0.9131 22.0934 22.9669 25.4507 23.5297 450010....................................................... 1.6039 0.8790 0.8360 22.4133 23.7529 25.0592 23.7488 450011....................................................... 1.7202 0.9064 0.9064 24.1576 24.8831 27.0743 25.3503 450014.......................................................

***

*

* 22.5001

*

* 22.5001 450015....................................................... 1.5860 1.0087 1.0087 24.0730 27.4012 29.3737 26.9851 450016.......................................................

***

*

* 22.1368

*

* 22.1368 450018....................................................... 1.5062 1.0030 1.0030 24.6443 26.7999 28.5226 26.6104 450020....................................................... 0.9622

*

* 17.7148 18.3047

* 18.0203 450021....................................................... 1.8322 1.0087 1.0087 28.5578 29.1350 30.1831 29.2883 450023....................................................... 1.4320 0.8554 0.8554 20.9278 22.0558 25.5410 22.7444 450024....................................................... 1.4841 0.9101 0.9101 22.4178 24.4195 25.4622 24.1268

[[Page 24218]]

450028....................................................... 1.5344 0.9474 0.9474 25.6030 26.8250 27.7693 26.7175 450029....................................................... 1.5535 0.8003 0.8003 23.9709 23.2995 23.7005 23.6494 450031....................................................... 1.4013 1.0087 1.0087 27.0328 27.9626 29.4827 28.2223 450032....................................................... 1.1925 0.8715 0.8715 20.8306 27.0748 21.2720 22.8525 450033....................................................... 1.6629 0.9474 0.9474 29.0541 28.4781 28.5174 28.6719 450034....................................................... 1.5793 0.8612 0.8612 23.4615 24.1589 26.2069 24.5798 450035....................................................... 1.5477 1.0030 1.0030 25.4580 26.2838 28.3361 26.6364 450037....................................................... 1.5982 0.8905 0.8905 23.1176 24.2684 26.3292 24.6149 450039....................................................... 1.3819 0.9870 0.9870 23.3034 24.7347 26.2041 24.8293 450040....................................................... 1.7828 0.8626 0.8626 23.8047 24.9590 25.9125 24.8722 450042....................................................... 1.7951 0.8653 0.8653 22.6936 24.1181 26.6885 24.5021 450044....................................................... 1.7267 1.0087 1.0087 25.8403 29.4308 32.4768 29.3230 450046....................................................... 1.5874 0.8578 0.8578 22.0695 23.4907 25.3629 23.6516 450047....................................................... 0.8361 0.9474 0.9474 22.7242 19.8221 21.2384 21.2173 450050....................................................... 0.9114

*

* 21.6933 23.3044

* 22.5039 450051....................................................... 1.8871 1.0087 1.0087 27.2523 28.0411 29.5795 28.3261 450052....................................................... 0.9776 0.8003 0.8003 19.7185 19.7774 21.1995 20.1263 450053....................................................... 0.9826 0.8003 0.8003 19.4978 21.9082 20.4980 20.6324 450054....................................................... 1.7608 0.9131 0.9131 25.1229 24.2782 27.7869 25.6677 450055....................................................... 1.1174 0.8003 0.8003 20.5235 22.1979 22.4127 21.7257 450056....................................................... 1.8144 0.9360 0.9360 25.6685 27.0530 28.2252 26.8936 450058....................................................... 1.5775 0.8859 0.8859 24.7442 25.9653 26.8533 25.8582 450059....................................................... 1.3376 0.9360 0.9360 26.8209 26.6535 27.4391 26.9795 450064....................................................... 1.4386 0.9870 0.9870 24.2920 23.8748 27.5350 25.2944 450068....................................................... 2.0792 1.0030 1.0030 26.2864 27.9633 29.9491 28.0965 450072....................................................... 1.1764 1.0030 1.0030 22.5010 24.0166 25.3658 23.9560 450073....................................................... 0.9681 0.8051 0.8051 20.0464 21.7337 24.6840 22.0875 450078....................................................... 0.9553 0.8003 0.8003 17.2196 15.8968 18.2067 17.0494 450079....................................................... 1.6954 1.0087 1.0087 27.0443 28.1096 29.8969 28.2854 450080....................................................... 1.2691 0.8905 0.8905 21.2482 22.9835 27.2213 23.6862 450082....................................................... 1.0789 0.8003 0.8003 20.9113 22.0442 23.3125 22.0908 450083....................................................... 1.7780 0.8854 0.8854 24.9182 25.8214 27.2160 26.0725 450085....................................................... 1.0382 0.8003 0.8003 19.4524 22.0840 23.4732 21.7012 450087....................................................... 1.4483 0.9870 0.9870 26.4203 29.1587 30.0371 28.5792 450090....................................................... 1.2044 0.8003 0.8003 17.6506 19.4244 20.9803 19.3653 450092....................................................... 1.2084 0.8003 0.8003 20.4921 23.2071 23.9641 22.5714 450094.......................................................

***

*

* 25.3618 25.2434

* 25.3030 450096....................................................... 1.4283 0.8612 0.8612 22.8722 24.1619 26.1563 24.3175 450097....................................................... 1.4526 1.0030 1.0030 24.9380 26.4965 28.2316 26.5557 450098....................................................... 0.9594

*

* 22.9005 22.6626

* 22.7778 450099....................................................... 1.2289 0.9177 0.9177 24.0293 26.6796 28.8288 26.4791 450101....................................................... 1.5872 0.8653 0.8653 20.6575 23.6905 24.8496 23.0430 450102....................................................... 1.8228 0.8854 0.8854 23.1773 24.5503 25.3756 24.3986 450104....................................................... 1.2091 0.8859 0.8859 22.5165 23.8469 23.3944 23.2732 450107....................................................... 1.4218 0.9101 0.9101 23.8770 25.9326 27.9184 25.8765 450108....................................................... 1.1901 0.8859 0.8859 19.3561 19.4935 20.2479 19.7198 450112.......................................................

***

*

* 22.5552

*

* 22.5552 450113.......................................................

***

*

*

* 54.6681

* 54.6681 450119....................................................... 1.2924 0.8790 0.8790 24.1392 25.7008 27.6154 25.8461 450121....................................................... 1.4829 0.9870 0.9870 25.8826 25.7051 29.0897 26.9221 450123....................................................... 1.0580 0.8612 0.8612 19.5872 21.2154 23.0469 21.1313 450124....................................................... 1.8874 0.9360 0.9360 26.0280 27.4198 28.1018 27.2284 450126....................................................... 1.3432 1.0030 1.0030 27.3021 28.3033 28.8116 28.2181 450128....................................................... 1.2314 0.8790 0.8790 21.4190 23.3633 24.1195 22.9163 450130....................................................... 1.2180 0.8859 0.8859 20.2777 21.5226 23.5398 21.8292 450131.......................................................

***

*

* 23.2317 23.7098 26.3279 24.2678 450132....................................................... 1.5414 1.0119 1.0119 26.8476 28.6954 30.2134 28.5936 450133....................................................... 1.6337 0.9802 0.9802 25.0972 26.8344 29.2478 27.1707 450135....................................................... 1.6922 0.9870 0.9870 24.3858 26.0755 27.9663 26.2251 450137....................................................... 1.6056 0.9870 0.9870 27.0081 30.4254 31.4048 29.7868 450140.......................................................

***

*

* 22.4695

*

* 22.4695 450143....................................................... 1.0146 0.9360 0.9360 19.7487 21.8705 22.5280 21.4534 450144....................................................... 1.0731 0.9737 0.9737 20.9599 21.3289 25.6368 22.5854 450147....................................................... 1.4387 0.8554 0.8554 24.6203 23.9771 25.0247 24.5527 450148....................................................... 1.1848 0.9870 0.9870 23.5037 25.3498 27.5125 25.5034 450151....................................................... 1.2027 0.8003 0.8003 20.1356 22.2915 23.2545 21.9494

[[Page 24219]]

450152....................................................... 1.2274 0.9131 0.9131 21.6351 22.7463 24.1970 22.8540 450154....................................................... 1.3702 0.8003 0.8003 18.6058 21.2021 20.7952 20.1904 450155....................................................... 1.0271 0.8003 0.8003 17.9306 18.0589 21.3482 19.0936 450157.......................................................

***

*

* 17.8812

*

* 17.8812 450160....................................................... 0.8255

*

* 21.9118

*

* 21.9118 450162....................................................... 1.3087 0.8626 0.8626 31.0645 30.9903 31.9964 31.3817 450163....................................................... 1.0883 0.8137 0.8137 20.3280 23.1400 23.4148 22.2842 450165....................................................... 1.0794 0.8859 0.8859 20.2414 24.3242 27.6487 24.0511 450176....................................................... 1.3564 0.8790 0.8790 20.9392 20.9297 23.6030 21.8256 450177....................................................... 1.1934 0.8003 0.8003 19.7657 21.3322 22.6615 21.2531 450178....................................................... 0.9382 0.8003 0.8003 20.2992 24.7301 23.9597 22.8868 450184....................................................... 1.5480 1.0030 1.0030 25.3935 26.7821 28.4921 26.9217 450185.......................................................

***

*

* 15.5838

*

* 15.5838 450187....................................................... 1.1744 1.0030 1.0030 24.2400 25.6786 28.2045 26.0900 450188....................................................... 0.9551 0.8003 0.8003 18.9586 20.4070 21.4250 20.3073 450191....................................................... 1.1747 0.9360 0.9360 25.9078 26.0298 27.2533 26.4251 450192....................................................... 1.1719 0.9870 0.9870 22.5118 22.5880 23.8534 22.9951 450193....................................................... 2.0371 1.0030 1.0030 29.2751 32.2964 34.3517 32.0480 450194....................................................... 1.3875 0.9870 0.9870 22.3348 24.8972 23.5660 23.5448 450196....................................................... 1.4334 0.9870 0.9870 23.6170 24.7557 24.6006 24.3267 450200....................................................... 1.4680 0.8133 0.8133 22.0923 23.5344 24.2489 23.3064 450201....................................................... 0.9908 0.8003 0.8003 20.3350 20.9809 21.3642 20.8932 450203....................................................... 1.1593 0.9591 0.9591 23.3953 24.1675 25.9236 24.5529 450209....................................................... 1.9505 0.9177 0.9177 24.4977 26.0958 27.3634 25.9724 450210....................................................... 0.9811 0.8003 0.8003 19.6340 19.9832 21.1245 20.2859 450211....................................................... 1.3657 1.0030 1.0030 20.7982 23.8230 26.8071 23.6708 450213....................................................... 1.7804 0.8859 0.8859 21.7930 23.9676 25.1261 23.6580 450214....................................................... 1.1756 1.0030 1.0030 23.9112 25.9598 27.1030 25.6581 450219....................................................... 0.9943 0.8003 0.8003 20.8255 21.7934 22.0150 21.5883 450221....................................................... 1.1342 0.8003 0.8003 20.6887 20.3186 18.7121 19.9030 450222....................................................... 1.6242 1.0030 1.0030 26.2975 27.4426 30.3939 28.0745 450224....................................................... 1.3688 0.8854 0.8854 22.2250 24.1956 26.8950 24.3799 450229....................................................... 1.6311 0.8051 0.8051 19.8279 21.4459 23.2333 21.5168 450231....................................................... 1.6305 0.9177 0.9177 23.9532 25.2852 26.9729 25.4493 450234....................................................... 1.0419 0.8003 0.8003 23.6695 18.4451 19.9093 20.4175 450235....................................................... 1.0212 0.8003 0.8003 19.1453 21.5138 22.5969 21.1410 450236....................................................... 1.1103 0.8003 0.8003 19.2987 22.0788 22.4149 21.2880 450237....................................................... 1.6433 0.8859 0.8859 25.1504 24.8901 26.2898 25.4597 450239....................................................... 0.9627 0.9131 0.9131 21.8595 21.1945 21.1113 21.3735 450241....................................................... 1.0459 0.8003 0.8003 18.1155 18.7957 19.3886 18.7815 450243....................................................... 0.9884 0.8003 0.8003 14.0589 15.4636 13.3360 14.2632 450249.......................................................

***

*

* 16.5616

*

* 16.5616 450253....................................................... 0.9522 1.0030 1.0030 19.6379 20.6124 23.1000 21.1869 450264.......................................................

***

*

* 15.4111

*

* 15.4111 450269.......................................................

***

*

* 14.8204

*

* 14.8204 450270....................................................... 1.2028 0.8003 0.8003 15.0879 14.4325 14.7319 14.7323 450271....................................................... 1.1409 0.9591 0.9591 19.4299 21.7719 23.0668 21.5257 450272....................................................... 1.2287 0.9360 0.9360 23.7933 25.7392 26.1100 25.2204 450276....................................................... 0.9774

*

* 16.0264 16.6319

* 16.3591 450280....................................................... 1.4735 1.0087 1.0087 27.4523 28.7233 29.7601 28.6474 450283....................................................... 1.0773 0.9870 0.9870 20.0069 20.9680 22.1481 21.1023 450289....................................................... 1.3615 1.0030 1.0030 27.3864 28.5665 31.2375 29.0702 450292....................................................... 1.2387 1.0087 1.0087 23.5330 25.0411 26.9725 25.1945 450293....................................................... 0.9057 0.8003 0.8003 20.0898 21.3136 21.3044 20.9173 450296....................................................... 1.0558 1.0030 1.0030 29.2006 27.9690 29.3120 28.8474 450299....................................................... 1.5796 0.9064 0.9064 25.8183 26.4933 28.2325 26.8807 450306....................................................... 0.9244 0.8051 0.8051 14.6699 15.9854 18.7874 16.2370 450315....................................................... 2.5813

*

* 27.9780

* 37.5788 29.8209 450324....................................................... 1.5411 0.8677 0.8677 23.6362 24.9128 25.2508 24.6392 450330....................................................... 1.1740 1.0030 1.0030 24.4310 25.5820 26.3863 25.4943 450340....................................................... 1.4257 0.8385 0.8385 22.7826 24.0636 24.9329 23.9318 450346....................................................... 1.4440 0.8612 0.8612 21.9717 22.2469 23.2733 22.5272 450347....................................................... 1.1769 1.0030 1.0030 22.8133 27.2203 28.3157 26.0371 450348....................................................... 1.0382 0.8003 0.8003 17.0198 18.7675 20.1752 18.7139 450351....................................................... 1.3031 0.9591 0.9591 23.5895 25.6859 27.1819 25.5145 450352....................................................... 1.1235 1.0087 1.0087 23.4297 24.8012 26.8535 24.9931

[[Page 24220]]

450353.......................................................

***

*

* 20.9271 24.4454 26.2804 23.7695 450358....................................................... 1.9767 1.0030 1.0030 29.3408 30.4280 31.6216 30.5511 450362....................................................... 1.0967

*

* 22.0223 25.4372

* 23.7705 450369....................................................... 1.0336 0.8003 0.8003 17.5360 18.4848 18.6148 18.2736 450370....................................................... 1.2149 0.8261 0.8261 22.6815 20.0832 23.1229 21.8052 450372....................................................... 1.3337 1.0087 1.0087 26.8019 28.3359 31.1141 28.7696 450373....................................................... 0.9464 0.8003 0.8003 20.5789 22.2213 24.4712 22.5214 450374....................................................... 0.9179

*

* 17.4509 23.2285

* 19.8412 450378....................................................... 1.4503 1.0030 1.0030 29.5108 30.7684 31.4184 30.5485 450379....................................................... 1.3615 1.0087 1.0087 31.1573 30.6072 33.2816 31.6637 450381....................................................... 0.8992

*

* 20.9200 22.0482

* 21.4845 450388....................................................... 1.6213 0.8859 0.8859 24.1598 25.8674 26.9369 25.8147 450389....................................................... 1.2133 0.9870 0.9870 22.3803 23.8764 25.8283 24.1448 450393....................................................... 0.6586

*

* 24.6872 18.4551 21.5604 21.5244 450395....................................................... 1.0000 1.0030 1.0030 23.9689 24.8656 25.9571 25.0000 450399....................................................... 0.9374 0.8003 0.8003 19.5928 18.2074 19.0372 18.9411 450400....................................................... 1.2473 0.8653 0.8653 22.0103 23.1739 23.2029 22.8044 450403....................................................... 1.3393 1.0087 1.0087 27.8138 29.3063 29.0923 28.7792 450411....................................................... 0.9521 0.8003 0.8003 17.6570 19.6086 19.9183 19.1051 450417....................................................... 0.8854

*

* 17.8078 20.0350

* 18.9286 450418....................................................... 1.1696 1.0030 1.0030 27.0283 26.8434 28.2373 27.2737 450419....................................................... 1.2390 0.9870 0.9870 28.4122 31.0404 32.0315 30.5226 450422....................................................... 0.8834 1.0087 1.0087 29.5592 30.6659 33.8259 31.3662 450424....................................................... 1.3624 1.0030 1.0030 23.1253 28.3149 28.0195 26.6839 450431....................................................... 1.5063 0.9360 0.9360 24.7346 25.2477 26.9028 25.6684 450438....................................................... 1.1610 1.0030 1.0030 22.0476 21.9351 24.2571 22.6852 450446....................................................... 0.6285 1.0030 1.0030 14.9983 14.3132 17.4158 15.4882 450447....................................................... 1.2969 0.9870 0.9870 22.5602 23.5047 25.6376 23.9060 450451....................................................... 1.0902 0.9591 0.9591 22.3834 23.3042 24.3091 23.3428 450460....................................................... 0.9462 0.8003 0.8003 19.5709 20.5812 20.8068 20.3488 450462....................................................... 1.6945 1.0087 1.0087 25.6952 27.8923 29.2836 27.6909 450465....................................................... 1.1297 0.8438 0.8438 23.0130 22.4183 25.7148 23.7820 450469....................................................... 1.5249 0.8677 0.8677 26.6781 28.7890 25.4635 27.0045 450475....................................................... 1.0410 0.8905 0.8905 20.7983 23.5596 22.5480 22.3012 450484....................................................... 1.3812 0.8905 0.8905 23.0604 25.3527 27.0061 25.1666 450488....................................................... 1.0576 0.8905 0.8905 22.3949 23.9144 21.6331 22.6563 450489....................................................... 1.0092 0.8003 0.8003 19.6884 21.4771 21.5002 20.9158 450497....................................................... 1.0331 0.8003 0.8003 17.6614 18.8344 20.3909 18.9764 450498....................................................... 0.8847 0.8003 0.8003 16.4358 17.7822 17.2624 17.1563 450508....................................................... 1.4788 0.8854 0.8854 23.5066 23.9572 27.4558 25.0231 450514....................................................... 1.1107 0.8612 0.8612 21.4034 22.6552 25.9817 23.3480 450517....................................................... 0.9001

*

* 15.2707

*

* 15.2707 450518....................................................... 1.5203 0.8612 0.8612 22.2587 24.1194 27.9953 24.8239 450523.......................................................

***

*

* 28.6387

*

* 28.6387 450530....................................................... 1.2387 1.0030 1.0030 26.1998 28.7451 28.7154 27.9282 450534.......................................................

***

*

* 20.4715

*

* 20.4715 450535.......................................................

***

*

* 29.4427

*

* 29.4427 450537....................................................... 1.4256 1.0087 1.0087 23.9256 27.5856 29.2821 26.9543 450539....................................................... 1.1901 0.8003 0.8003 20.0343 21.0442 22.4081 21.1538 450545.......................................................

***

*

* 22.8130

*

* 22.8130 450547....................................................... 0.9991 0.9870 0.9870 21.8106 21.6542 23.5794 22.4240 450558....................................................... 1.8627 0.8051 0.8051 25.0837 26.1551 27.2223 26.1445 450563....................................................... 1.4314 0.9870 0.9870 27.9427 28.7289 31.4753 29.4391 450565....................................................... 1.3311 0.8489 0.8489 22.1971 23.8847 25.0379 23.7440 450571....................................................... 1.5740 0.8385 0.8385 20.9651 22.7703 24.7674 22.8421 450573....................................................... 1.1346 0.8003 0.8003 21.6974 20.1479 21.0286 20.9450 450578....................................................... 0.9184 0.8003 0.8003 20.0454 20.2695 22.5427 20.9417 450580....................................................... 1.0999 0.8003 0.8003 20.4293 21.1574 21.0151 20.8713 450584....................................................... 1.0160 0.8003 0.8003 19.0373 21.0808 20.0078 20.0299 450586....................................................... 0.9542 0.8003 0.8003 14.6574 16.1003 16.9880 15.9586 450587....................................................... 1.2144 0.8003 0.8003 19.9712 20.4512 22.8245 21.1183 450591....................................................... 1.1954 1.0030 1.0030 22.4991 23.9992 24.9309 23.8280 450596 h..................................................... 1.2159 1.0399 1.0399 24.7477 25.3317 27.4357 25.8078 450597....................................................... 0.9663 0.8080 0.8080 22.9337 23.1711 24.0480 23.3921 450604....................................................... 1.3085 0.8003 0.8003 20.5273 20.9514 23.5413 21.7183 450605....................................................... 1.0415 0.8578 0.8578 23.8820 22.2205 21.2497 22.3978

[[Page 24221]]

450609.......................................................

***

*

* 18.3856

*

* 18.3856 450610....................................................... 1.6427 1.0030 1.0030 22.5451 26.8710 28.0329 25.7712 450615....................................................... 0.9957 0.8003 0.8003 18.2166 20.3028 20.8595 19.8661 450617....................................................... 1.5118 1.0030 1.0030 25.2211 26.5026 28.0634 26.6443 450620....................................................... 0.9569 0.8003 0.8003 18.1819 17.7138 18.2630 18.0543 450623....................................................... 1.1273

*

* 28.3354 28.3552

* 28.3456 450626....................................................... 0.8874

*

* 21.4445 26.8375

* 23.9299 450630....................................................... 1.5750 1.0030 1.0030 27.8856 29.6796 29.5706 29.0278 450631.......................................................

***

*

* 24.5409

*

* 24.5409 450634....................................................... 1.6821 1.0087 1.0087 27.0412 28.1705 28.8277 28.0452 450638....................................................... 1.6272 1.0030 1.0030 29.5385 29.6184 31.5382 30.2289 450639....................................................... 1.4555 0.9870 0.9870 27.3593 29.2669 30.5176 29.1141 450641....................................................... 1.0274 0.8003 0.8003 17.0805 17.5845 18.0724 17.5796 450643....................................................... 1.3388 0.8003 0.8003 20.9674 21.1205 22.0843 21.4069 450644....................................................... 1.5418 1.0030 1.0030 27.2047 29.0186 30.0261 28.8421 450646....................................................... 1.3775 0.9101 0.9101 22.6541 23.8908 25.2251 23.9445 450647....................................................... 1.8824 1.0087 1.0087 28.8881 30.7334 31.6069 30.4271 450648.......................................................

***

*

* 18.2826

*

* 18.2826 450649.......................................................

***

*

* 18.1118

*

* 18.1118 450651....................................................... 1.5268 1.0087 1.0087 28.9829 32.4822 31.4063 30.9883 450653....................................................... 1.1680 0.9602 0.9602 21.8654 23.2603 24.9719 23.3175 450654....................................................... 0.9380 0.8003 0.8003 19.6054 19.9992 20.3563 20.0116 450656....................................................... 1.4785 0.8854 0.8854 22.7284 23.8280 24.8352 23.7707 450658....................................................... 0.9159 0.8003 0.8003 19.9597 20.5398 22.5532 21.0378 450659....................................................... 1.4296 1.0030 1.0030 28.8671 30.1727 30.9251 30.0073 450661....................................................... 1.0957 1.0119 1.0119 21.5537 23.2989 30.1358 25.0485 450662....................................................... 1.5098 0.9474 0.9474 24.5815 28.0913 28.8369 27.1837 450665....................................................... 0.9162

*

* 17.2566 18.6054

* 17.9420 450668....................................................... 1.5089 0.9101 0.9101 26.4508 26.2375 28.4134 27.0380 450669....................................................... 1.2095 1.0087 1.0087 25.6411 27.4507 28.4801 27.2455 450670....................................................... 1.3966 1.0030 1.0030 22.0495 25.1575 25.6979 24.2873 450672....................................................... 1.7679 0.9870 0.9870 26.7785 27.6359 29.8113 28.0976 450673.......................................................

***

*

* 19.4030

*

* 19.4030 450674....................................................... 0.9764 1.0030 1.0030 26.8081

* 29.9733 28.3959 450675....................................................... 1.4004 0.9870 0.9870 26.1555 28.7765 29.1940 28.1661 450677....................................................... 1.3370 0.9870 0.9870 24.0218 27.3728 26.2333 25.8722 450678....................................................... 1.4692 1.0087 1.0087 30.1134 30.1500 31.5997 30.6214 450683....................................................... 1.1779 1.0087 1.0087 24.0080 24.6609 27.8588 25.4486 450684....................................................... 1.2365 1.0030 1.0030 26.2906 27.6789 29.5071 27.8823 450686....................................................... 1.6848 0.8626 0.8626 21.0565 23.2367 24.1869 22.8496 450688....................................................... 1.1915 1.0087 1.0087 23.7796 27.9057 27.1644 26.2965 450690....................................................... 1.4400 0.8854 0.8854 28.7529 28.2531 26.2559 27.8629 450694....................................................... 1.0611 1.0030 1.0030 22.3081 23.5790 23.7874 23.2343 450697....................................................... 1.4245 0.8859 0.8859 21.2662 23.7155 25.2110 23.5525 450698....................................................... 0.8804 0.8003 0.8003 18.5436 18.6494 18.9770 18.7269 450700....................................................... 0.9190

*

* 18.6373

*

* 18.6373 450702....................................................... 1.5435 0.8905 0.8905 24.8628 25.6147 27.5215 26.0104 450709....................................................... 1.2686 1.0030 1.0030 25.0932 25.4855 27.0908 25.8993 450711....................................................... 1.5506 0.8790 0.8790 24.8277 28.0104 26.9466 26.5934 450713....................................................... 1.5698 0.9360 0.9360 26.7190 27.2801 28.2291 27.4332 450715....................................................... 1.2907 1.0087 1.0087 16.1897 28.0365 16.2866 18.8856 450716....................................................... 1.2709 1.0030 1.0030 28.8043 30.8440 32.5978 30.7792 450718....................................................... 1.2315 0.9360 0.9360 27.6672 27.3408 28.2838 27.7793 450723....................................................... 1.4898 1.0087 1.0087 27.0055 28.0812 29.0905 28.0969 450730....................................................... 1.1844 1.0087 1.0087 30.7567 29.9430 31.7101 30.8172 450733.......................................................

***

*

* 25.5624 26.4976

* 26.0340 450742....................................................... 1.2041 1.0087 1.0087 26.3414 26.1190 26.9752 26.5000 450743....................................................... 1.5163 1.0087 1.0087 24.7397 27.3213 28.8273 27.0434 450746....................................................... 0.9459 0.8003 0.8003 16.9209 12.4748 18.6717 15.8396 450747....................................................... 1.2804 0.9870 0.9870 24.2674 22.2870 24.3035 23.6023 450749....................................................... 1.0008 0.8003 0.8003 18.4095 17.8227 19.0712 18.4140 450751.......................................................

***

*

* 22.9070 19.3265 18.5972 20.2183 450754....................................................... 0.9187 0.8003 0.8003 21.3043 20.8968 21.5435 21.2570 450755....................................................... 0.9654 0.8626 0.8626 19.5168 18.0092 18.3374 18.5256 450758....................................................... 1.9150 1.0087 1.0087 24.0226 25.6548 29.3846 26.3194 450760....................................................... 1.0178 0.9101 0.9101 25.7453 24.6349 24.2669 24.8052

[[Page 24222]]

450761....................................................... 0.8560

*

* 16.2605 15.7483

* 16.0004 450763....................................................... 1.0996

*

* 21.4171 22.4905

* 21.9641 450766....................................................... 1.9890 1.0087 1.0087 28.8576 30.0441 31.9184 30.2287 450770....................................................... 1.1856 0.9360 0.9360 20.1763 20.3656 23.9370 21.5080 450771....................................................... 1.7688 1.0087 1.0087 26.0618 31.3924 31.8002 29.9828 450774....................................................... 1.8338 1.0030 1.0030 24.8562 24.9683 28.2450 26.1216 450775....................................................... 1.2578 1.0030 1.0030 25.3924 24.4006 28.4183 25.9897 450779....................................................... 1.2479 0.9870 0.9870 22.5857 26.9908 29.7868 26.4311 450780....................................................... 1.8456 0.8859 0.8859 22.8688 23.9516 25.9821 24.3116 450788....................................................... 1.5907 0.8578 0.8578 24.2643 25.4172 26.4470 25.3993 450795....................................................... 1.4008 1.0030 1.0030 28.1448 23.7510 24.1271 24.947 450796....................................................... 1.8052 0.9177 0.9177 24.7564 27.9734 33.1303 28.4434 450797.......................................................

***

*

* 23.8708 20.5379 25.4943 23.0765 450801....................................................... 1.4998 0.8133 0.8133 22.2426 23.0373 24.0387 23.1400 450803....................................................... 1.1764 1.0030 1.0030 26.3054 30.6093 28.7427 28.4813 450804....................................................... 1.8999 1.0030 1.0030 26.0003 26.0980 27.6508 26.5919 450808....................................................... 1.5092 0.9360 0.9360 22.8247 23.8067 23.2037 23.2780 450809....................................................... 1.5817 0.9360 0.9360 24.7763 26.3659 26.8214 26.0351 450811....................................................... 1.7444 0.8790 0.8790 23.1022 25.8491 27.3501 25.5331 450813....................................................... 1.1556 0.8859 0.8859 22.1326 25.5949 19.7649 22.3615 450820....................................................... 1.2973 1.0030 1.0030 27.9187 30.5288 31.7443 30.4578 450822....................................................... 1.2957 1.0087 1.0087 29.7067 31.1431 32.3722 31.1755 450824....................................................... 2.5318 0.9360 0.9360

* 26.7803 29.4735 28.1465 450825....................................................... 1.4848 0.8790 0.8790 18.7069 20.2959 20.8107 19.9847 450827....................................................... 1.3902 0.8360 0.8360 21.1788 20.9704 21.6247 21.2706 450828....................................................... 1.2653 0.8003 0.8003 21.4128 22.3667 23.8184 22.5374 450829.......................................................

***

*

* 18.2860 19.5014 20.2816 19.3397 450830....................................................... 0.9567 0.9737 0.9737 26.9917 28.1617 27.4306 27.5236 450831....................................................... 1.5156 1.0030 1.0030 20.0581 22.7885 23.2295 22.2337 450832....................................................... 1.1631 1.0030 1.0030 26.4725 26.6628 27.5752 26.9176 450833....................................................... 1.1639 1.0087 1.0087 26.1256 26.0044 26.7732 26.3344 450834....................................................... 1.5529 0.9064 0.9064 22.7691 21.2204 21.6657 21.8609 450838....................................................... 1.1295 0.8003 0.8003 15.0454 15.8026 18.9487 16.8622 450839....................................................... 0.9411 0.8715 0.8715 21.1905 22.9711 24.5796 22.8436 450840....................................................... 1.0994 1.0087 1.0087 29.5215 31.1914 31.7263 30.9017 450841....................................................... 1.6187 0.9474 0.9474 17.6635 18.9468 21.5306 19.5628 450842.......................................................

***

*

* 23.0945

*

* 23.0945 450844....................................................... 1.3022 1.0030 1.0030 34.4235 28.7296 30.9678 30.6606 450845....................................................... 1.9081 0.9101 0.9101 26.5040 27.7461 29.4977 28.0285 450846.......................................................

***

*

* 24.0791

*

* 24.0791 450847....................................................... 1.2480 1.0030 1.0030 26.8892 27.6854 29.1327 27.9406 450848....................................................... 1.2400 1.0030 1.0030 26.5609 27.8100 29.8391 28.0986 450849....................................................... 2.1291

*

*

*

*

*

* 450850....................................................... 1.2694 0.9802 0.9802

* 22.1334 21.4794 21.7993 450851....................................................... 2.5587 1.0087 1.0087

* 30.1213 32.3361 31.2575 450852.......................................................

***

*

*

* 30.0191

* 30.0191 450853....................................................... 1.9067 1.0087 1.0087

*

* 36.5119 36.5119 450854.......................................................

***

*

*

*

* 26.3165 26.3165 450855....................................................... 1.5514 0.9474 0.9474

*

* 29.0580 29.0580 450856....................................................... 1.7966 0.8859 0.8859

*

* 35.3051 35.3051 450857.......................................................

***

*

*

*

* 31.2379 31.2379 450860....................................................... 2.0577 1.0030 1.0030

*

* 23.8491 23.8491 450861.......................................................

***

*

*

*

* 34.7198 34.7198 450862....................................................... 1.2197 1.0030 1.0030

*

* 31.8895 31.8895 450863.......................................................

***

*

*

*

* 24.9637 24.9637 450864....................................................... 2.0286 0.8854 0.8854

*

* 23.3931 23.3931 450865....................................................... 1.1195 0.9360 0.9360

*

* 30.1339 30.1339 450866.......................................................

***

*

*

*

* 15.5314 15.5314 450867....................................................... 1.3274 0.9360 0.9360

*

* 28.5160 28.5160 450868....................................................... 1.8150 1.0119 1.0119

*

* 28.5693 28.5693 450869....................................................... 1.9116 0.8790 0.8790

*

* 22.5945 22.5945 450870.......................................................

***

*

*

*

* 37.1748 37.1748 450871....................................................... 1.8656 0.9360 0.9360

*

*

*

* 450872....................................................... 1.4150 0.9870 0.9870

*

*

*

* 450874....................................................... 1.4412 1.0087 1.0087

*

*

*

* 450875....................................................... 1.6727 0.9177 0.9177

*

*

*

*

[[Page 24223]]

450876....................................................... 2.2693 0.8626 0.8626

*

*

*

* 450877....................................................... 1.4111 0.9101 0.9101

*

*

*

* 450878....................................................... 2.7773 0.8859 0.8859

*

*

*

* 450879....................................................... 1.2140 0.8003 0.8003

*

*

*

* 450880....................................................... 1.6144 0.9870 0.9870

*

*

*

* 450881....................................................... 1.1914 0.8578 0.8578

*

*

*

* 450882....................................................... 1.7221 0.8854 0.8854

*

*

*

* 450883....................................................... 1.7263 1.0087 1.0087

*

*

*

* 450884....................................................... 1.0379 0.8905 0.8905

*

*

*

* 450885....................................................... 1.4615 1.0087 1.0087

*

*

*

* 450886....................................................... 1.5918

*

*

*

*

*

* 450887....................................................... 1.4961

*

*

*

*

*

* 450888....................................................... 1.3795

*

*

*

*

*

* 450889....................................................... 1.0565

*

*

*

*

*

* 450890....................................................... 2.0428

*

*

*

*

*

* 450891....................................................... 1.3902

*

*

*

*

*

* 450892....................................................... 1.5347

*

*

*

*

*

* 450893....................................................... 1.4462

*

*

*

*

*

* 450895....................................................... 1.4125

*

*

*

*

*

* 460001....................................................... 1.8808 0.9537 0.9537 25.6932 27.0757 28.7686 27.1707 460003....................................................... 1.5603 0.9421 0.9421 24.3527 26.1372 31.2768 27.1512 460004....................................................... 1.7146 0.9421 0.9421 25.2191 26.4498 27.8490 26.5381 460005....................................................... 1.3478 0.9421 0.9421 22.6809 23.5633 24.6804 23.6496 460006....................................................... 1.3807 0.9421 0.9421 24.4350 25.4787 26.8666 25.6213 460007....................................................... 1.3872 0.9295 0.9295 24.2875 25.6686 26.9107 25.6767 460008....................................................... 1.3859 0.9421 0.9421 24.4453 26.5672 29.9748 26.8870 460009....................................................... 1.8418 0.9421 0.9421 25.0984 26.2833 26.7990 26.0960 460010....................................................... 2.0585 0.9421 0.9421 26.2331 27.4648 28.9206 27.5686 460011....................................................... 1.2849 0.9537 0.9537 22.3601 23.4023 25.0983 23.5591 460013....................................................... 1.4239 0.9537 0.9537 23.4765 25.2448 27.5186 25.4104 460014....................................................... 1.0606 0.9421 0.9421 23.9400 24.1412 27.2777 25.1819 460015....................................................... 1.3717 0.9049 0.9049 24.0939 25.6576 27.1745 25.6692 460017....................................................... 1.3339 0.8555 0.8555 21.7082 23.0388 24.4174 22.9891 460018 h..................................................... 0.9103 1.1611 1.1611 18.8942 20.3755 20.3940 19.9191 460019....................................................... 1.3095 0.8163 0.8163 20.3625 19.9900 23.5051 21.2559 460020....................................................... 1.0267 0.8163 0.8163 19.4960 19.5669 19.3185 19.4673 460021....................................................... 1.7313 1.1240 1.1240 24.9725 26.3420 27.5173 26.3816 460023....................................................... 1.2110 0.9537 0.9537 25.0376 25.3094 26.8796 25.7898 460025.......................................................

***

*

* 18.7978

*

* 18.7978 460026....................................................... 1.0018 0.8163 0.8163 22.7589 24.1547 26.3509 24.3848 460030....................................................... 1.2733 0.8163 0.8163 22.6129 23.4679 23.7148 23.2667 460032.......................................................

***

*

* 22.8987

*

* 22.8987 460033....................................................... 0.8966 0.8163 0.8163 22.7816 22.0248 23.5580 22.7910 460035....................................................... 0.9428 0.8163 0.8163 16.9019 17.5723 19.3857 18.0032 460036....................................................... 1.2276

*

* 25.2647 27.2865

* 26.2960 460037....................................................... 0.9296

*

* 19.8478 21.1035

* 20.4672 460039....................................................... 1.0985 0.9021 0.9021 27.5912 28.5656 29.9657 28.7173 460041....................................................... 1.3476 0.9421 0.9421 24.0431 25.2744 26.7893 25.3668 460042....................................................... 1.3789 0.9421 0.9421 23.5819 22.9949 24.7532 23.7828 460043....................................................... 1.2960 0.9537 0.9537 26.6870 28.2089 29.4175 28.1330 460044....................................................... 1.3067 0.9421 0.9421 25.7342 26.6795 27.5967 26.7083 460047....................................................... 1.6867 0.9421 0.9421 25.1721 25.7920 28.0524 26.3519 460049....................................................... 1.9512 0.9421 0.9421 23.0683 24.5164 26.6558 24.8008 460051....................................................... 1.1320 0.9421 0.9421 23.4970 25.5881 27.8380 25.7324 460052....................................................... 1.4773 0.9537 0.9537 24.0797 25.3163 26.8923 25.5154 460054....................................................... 1.7394 0.9049 0.9049 23.5227 25.8668 25.1386 24.8669 470001....................................................... 1.2603 1.1381 1.1381 24.5499 27.7329 29.1057 27.1069 470003....................................................... 1.9722 1.1318 1.0986 24.6660 26.4919 28.1869 26.4264 470005....................................................... 1.3563 1.0986 1.0986 25.7288 29.8255 32.5203 29.3642 470006....................................................... 1.1527

*

* 26.0884 26.9651

* 26.5397 470008....................................................... 1.2850

*

* 21.8951

*

* 21.8951 470010....................................................... 1.2545

*

* 22.9777 26.1273

* 24.5339 470011....................................................... 1.1897 1.0986 1.0986 25.9246 28.3911 29.2637 27.8893 470012....................................................... 1.2567 1.0986 1.0986 22.9159 24.3425 25.6468 24.3436 470018....................................................... 1.1212

*

* 25.9300 28.3419

* 27.1737 470023.......................................................

***

*

* 26.7486

*

* 26.7486

[[Page 24224]]

470024....................................................... 1.2067 1.0986 1.0986 23.7745 25.2427 27.3942 25.5325 470302....................................................... 0.9778

*

*

*

*

*

* 490001....................................................... 1.0802 0.8716 0.7966 21.7111 21.9953 22.9269 22.2279 490002....................................................... 1.0693 0.7966 0.7966 18.5220 19.5613 20.6251 19.6010 490003.......................................................

***

*

* 23.8112 27.3456

* 25.4279 490004....................................................... 1.3075 0.9732 0.9732 24.4580 25.4597 26.9175 25.6513 490005....................................................... 1.6397 1.1076 1.1076 27.6425 28.5744 29.8963 28.7056 490006.......................................................

***

*

* 16.7679

*

* 16.7679 490007....................................................... 2.2239 0.8840 0.8840 24.9533 26.2481 27.6665 26.3324 490009....................................................... 2.0155 1.0140 1.0140 27.5905 29.0740 30.6705 29.0947 490011....................................................... 1.4501 0.8840 0.8840 22.4410 24.5687 26.3250 24.4894 490012....................................................... 1.0263 0.7966 0.7966 18.3697 19.2275 20.4238 19.3376 490013....................................................... 1.3599 0.8716 0.8716 21.4838 22.4772 23.9524 22.6144 490015.......................................................

***

*

* 22.5641

*

* 22.5641 490017....................................................... 1.4225 0.8840 0.8840 22.9632 24.6845 25.5899 24.4194 490018....................................................... 1.2773 0.9732 0.9732 23.2215 24.5196 25.5210 24.4582 490019 h..................................................... 1.1723 1.2316 1.2316 24.4524 25.9761 26.7428 25.7803 490020....................................................... 1.2380 0.9174 0.9174 23.6611 24.8001 26.6396 25.0712 490021....................................................... 1.4653 0.8716 0.8716 23.5930 24.6440 26.1509 24.8426 490022....................................................... 1.4931 1.1076 1.1076 25.0277 28.0749 32.2985 28.4160 490023....................................................... 1.2456 1.1076 1.1076 28.8354 29.7774 31.1609 29.9671 490024....................................................... 1.7466 0.8483 0.8677 21.7268 23.0982 25.7005 23.5054 490027....................................................... 1.1045 0.7966 0.7966 19.8345 18.9409 23.7402 20.7964 490031.......................................................

***

*

* 22.4300 22.0579

* 22.2427 490032....................................................... 1.9877 0.9174 0.9174 22.8942 25.1381 25.6281 24.5660 490033....................................................... 1.0717 1.1076 1.1076 27.6355 30.0909 31.5482 29.8331 490037....................................................... 1.1924 0.7966 0.7966 19.0583 21.3035 23.3679 21.2221 490038....................................................... 1.2207 0.7988 0.7988 19.6427 22.3976 22.3842 21.4601 490040....................................................... 1.5159 1.1076 1.1076 30.1820 32.8738 33.5638 32.1968 490041....................................................... 1.3928 0.8840 0.8840 22.2955 24.5738 26.1445 24.3175 490042....................................................... 1.3030 0.8677 0.8677 20.5845 21.8749 24.4229 22.3975 490043....................................................... 1.1470 1.1076 1.1076 28.2969 30.8871 31.2740 30.3070 490044....................................................... 1.4671 0.8840 0.8840 22.1324 20.8351 23.3012 22.0713 490045....................................................... 1.2905 1.1076 1.1076 27.2132 28.8279 32.4604 29.4320 490046....................................................... 1.5680 0.8840 0.8840 24.6391 25.6328 26.6811 25.6856 490047....................................................... 1.0319

*

* 21.9156 22.5424

* 22.2282 490048....................................................... 1.4274 0.8716 0.8716 24.1639 25.0097 25.8371 25.0464 490050....................................................... 1.4890 1.1076 1.1076 29.4660 30.5037 31.8461 30.6123 490052....................................................... 1.6157 0.8840 0.8840 21.4035 22.8889 23.7544 22.6886 490053....................................................... 1.2486 0.8062 0.8062 20.9367 21.8432 22.7902 21.8500 490057....................................................... 1.6003 0.8840 0.8840 25.1898 26.1128 26.9303 26.0974 490059....................................................... 1.6024 0.9174 0.9174 26.1518 28.7276 28.7481 27.9332 490060....................................................... 1.0394 0.7966 0.7966 21.0828 22.4200 23.6087 22.3825 490063....................................................... 1.8203 1.1076 1.1076 29.4216 30.3632 32.4155 30.7714 490066....................................................... 1.3509 0.8840 0.8840 23.3835 24.7146 28.4793 25.5572 490067....................................................... 1.1965 0.9174 0.9174 21.8730 22.9188 24.5806 23.1010 490069....................................................... 1.5765 0.9174 0.9174 24.4542 26.8791 27.7682 26.4176 490071....................................................... 1.3096 0.9174 0.9174 27.0374 28.4381 29.7235 28.4129 490073....................................................... 1.7271 1.1076 1.1076 25.2859 31.7743 34.4692 29.6891 490075....................................................... 1.4710 0.8483 0.8483 22.8303 23.8191 25.1134 23.9198 490077....................................................... 1.4157 1.0140 1.0140 24.8309 26.0800 27.1434 26.0560 490079....................................................... 1.2785 0.8992 0.8992 19.8100 23.4728 23.3244 22.0780 490084....................................................... 1.1836 0.8133 0.8133 22.7945 24.5965 25.5067 24.2420 490088....................................................... 1.0918 0.8716 0.8716 21.4818 22.4186 24.1339 22.6632 490089....................................................... 1.0530 0.8677 0.8677 21.2123 22.6461 24.5879 22.9250 490090....................................................... 1.1113 0.7966 0.7966 21.3410 22.2907 24.3011 22.5541 490092....................................................... 1.0744 0.9174 0.9174 21.6466 23.8656 23.2472 22.8995 490093....................................................... 1.4535 0.8840 0.8840 23.6779 25.0751 26.1524 25.0724 490094....................................................... 0.9768 0.9174 0.9174 26.0755 26.5726 28.7249 27.1409 490097....................................................... 1.0622 0.7966 0.7966 23.5366 23.8005 25.7117 24.3445 490098....................................................... 1.1704 0.7966 0.7966 20.9805 21.7231 23.3102 22.0052 490101....................................................... 1.3361 1.1076 1.1076 30.1800 30.4285 31.9879 30.8879 490104....................................................... 0.8061 0.9174 0.9174 33.1215 17.3295

* 22.8307 490105....................................................... 0.9463 0.8062 0.8062 38.2813 24.7923 25.7327 29.8754 490106....................................................... 0.9937 0.9732 0.9732 30.1492 23.0199 23.7549 26.2572 490107....................................................... 1.3553 1.1076 1.1076 28.7296 29.7000 31.8461 30.1409

[[Page 24225]]

490108....................................................... 0.9836 0.8716 0.8716 27.9090 22.4345 22.7419 24.3793 490109....................................................... 0.9090 0.9174 0.9174 28.0548 21.9878 22.9347 24.2712 490110....................................................... 1.2759 0.8324 0.8324 21.3126 22.5974 24.4586 22.8433 490111....................................................... 1.2769 0.7966 0.7966 20.6373 22.0199 22.2094 21.6419 490112....................................................... 1.6505 0.9174 0.9174 25.8312 26.6453 27.5555 26.7023 490113....................................................... 1.2628 1.1076 1.1076 29.1786 29.5698 32.8354 30.5878 490114....................................................... 1.0602 0.7966 0.7966 20.0555 20.9116 21.8633 20.9404 490115....................................................... 1.1886 0.7966 0.7966 20.3615 21.4666 22.0483 21.3080 490116....................................................... 1.1906 0.8242 0.8242 21.3083 22.9017 24.2616 22.8382 490117....................................................... 1.1508 0.7966 0.7966 17.4111 18.0277 19.2372 18.2401 490118....................................................... 1.6833 0.9174 0.9174 26.8810 27.4050 28.6297 27.7063 490119....................................................... 1.2525 0.8840 0.8840 23.7813 25.2549 27.1954 25.4840 490120....................................................... 1.3625 0.8840 0.8840 23.1535 24.4434 26.2560 24.6055 490122....................................................... 1.4721 1.1076 1.1076 28.7020 31.0449 32.5825 30.7435 490123....................................................... 1.0815 0.7966 0.7966 22.9511 23.9233 25.0086 23.9568 490124.......................................................

***

*

* 29.7939

*

* 29.7939 490126....................................................... 1.2231 0.7966 0.7966 23.1423 22.2859 22.9757 22.7925 490127....................................................... 1.1735 0.7966 0.7966 19.4005 20.4289 21.4512 20.3942 490130....................................................... 1.2008 0.8840 0.8840 22.0769 22.8512 24.2270 23.0561 490133.......................................................

***

*

*

* 26.5683

* 26.5683 490134....................................................... 0.8128 0.7966 0.7966

*

*

*

* 490135....................................................... 0.6911 0.8677 0.8677

*

*

*

* 490136....................................................... 1.0827

*

*

*

*

*

* 500001....................................................... 1.6186 1.1438 1.1438 26.7502 29.3707 31.2869 29.1920 500002....................................................... 1.4423 1.0440 1.0440 25.0665 25.3347 27.7842 26.0658 500003....................................................... 1.3380 1.1255 1.1255 28.4174 29.6341 31.5127 29.8891 500005....................................................... 1.7822 1.1438 1.1438 31.4415 32.0972 33.3329 32.2891 500007....................................................... 1.3787 1.0722 1.0722 26.1318 28.0476 30.0980 28.1844 500008....................................................... 1.9554 1.1438 1.1438 31.0128 31.8837 33.3228 32.1022 500011....................................................... 1.3253 1.1438 1.1438 28.3391 30.6508 32.0074 30.3834 500012....................................................... 1.6684 1.0440 1.0440 29.2045 30.6856 30.4076 30.0653 500014....................................................... 1.6420 1.1438 1.1438 30.1061 33.7536 36.3225 33.4938 500015....................................................... 1.4667 1.1438 1.1438 30.1596 32.0592 34.5308 32.3201 500016....................................................... 1.7023 1.1255 1.1255 29.3634 31.4221 31.8609 30.9249 500019....................................................... 1.2686 1.0653 1.0653 26.9702 28.6669 30.4632 28.6734 500021....................................................... 1.3488 1.1255 1.1255 28.5926 30.1690 30.0500 29.6659 500023....................................................... 1.2010

*

* 27.3823

*

* 27.3823 500024....................................................... 1.7921 1.0907 1.0907 29.3946 30.7917 32.9554 31.0696 500025....................................................... 1.7858 1.1438 1.1438 31.7335 34.7252 38.5672 34.8346 500026....................................................... 1.4412 1.1438 1.1438 31.4152 33.2937 34.0225 32.9380 500027....................................................... 1.5753 1.1438 1.1438 29.5939 34.2175 35.7683 33.2591 500030....................................................... 1.7399 1.1088 1.1088 30.5926 32.7446 32.8247 32.0831 500031....................................................... 1.2764 1.0440 1.0440 28.5398 31.2186 33.2070 31.0095 500033....................................................... 1.3088 1.0440 1.0440 26.6704 29.4627 30.0929 28.7252 500036....................................................... 1.3769 1.0440 1.0440 26.0223 27.0072 28.5158 27.2093 500037....................................................... 1.0398 1.0440 1.0440 24.6548 26.9969 28.6509 26.6844 500039....................................................... 1.4810 1.1255 1.1255 27.9651 29.8809 32.3485 30.1316 500041....................................................... 1.3811 1.1405 1.1405 26.9101 26.7829 29.6411 27.7279 500044....................................................... 1.9738 1.0448 1.0448 26.9323 30.3164 28.5880 28.6194 500049....................................................... 1.3205 1.0440 1.0440 25.6104 27.1819 28.3014 27.1121 500050....................................................... 1.4378 1.1405 1.1405 26.8971 29.9791 32.5722 29.8732 500051....................................................... 1.7550 1.1438 1.1438 29.0100 31.9406 33.4078 31.5494 500052....................................................... 1.4362 1.1438 1.1438

*

*

*

* 500053....................................................... 1.2978 1.0440 1.0440 26.8074 28.4130 29.2529 28.1462 500054....................................................... 1.9895 1.0448 1.0448 28.8062 30.8067 32.1392 30.6203 500057.......................................................

***

*

* 21.4393

*

* 21.4393 500058....................................................... 1.6738 1.0440 1.0440 28.4247 30.4699 31.3325 30.1884 500060....................................................... 1.3057 1.0440 1.0440 33.5169 34.1523 37.1307 34.9415 500064....................................................... 1.7930 1.1438 1.1438 31.1459 31.5371 32.0554 31.6041 500065.......................................................

***

*

* 26.0960

*

* 26.0960 500072....................................................... 1.2016 1.1255 1.1255 29.3087 33.4863 31.8127 31.5390 500077....................................................... 1.4749 1.0448 1.0448 27.8819 29.4199 30.9414 29.4486 500079....................................................... 1.3526 1.1255 1.1255 28.4934 29.6623 31.8986 30.0378 500084....................................................... 1.3269 1.1438 1.1438 27.6306 29.3484 31.1336 29.4235 500088....................................................... 1.4147 1.1438 1.1438 31.2757 33.4302 34.7384 33.2062 500092.......................................................

***

*

* 23.2466

*

* 23.2466

[[Page 24226]]

500104....................................................... 1.1367

*

* 27.0034

*

* 27.0034 500108....................................................... 1.6392 1.1255 1.1255 28.7206 29.4244 31.8504 30.0479 500110.......................................................

***

*

* 25.4785

*

* 25.4785 500118....................................................... 1.0815

*

* 28.1074

*

* 28.1074 500119....................................................... 1.3571 1.0448 1.0448 27.2335 30.9999 29.2153 29.1384 500122....................................................... 1.2515

*

* 27.4405 30.1396

* 28.8217 500124....................................................... 1.3893 1.1438 1.1438 28.6598 31.5438 32.2351 30.8456 500129....................................................... 1.5958 1.1255 1.1255 30.0223 30.7536 32.5779 31.1547 500134....................................................... 0.5017 1.1438 1.1438 24.2990 26.8608 25.0035 25.4134 500139....................................................... 1.5171 1.0907 1.0907 29.2357 31.6591 34.6120 31.8023 500141....................................................... 1.3234 1.1438 1.1438 30.7478 30.5456 32.1853 31.2034 500143....................................................... 0.4565 1.1119 1.1119 20.7093 22.1419 22.6867 21.8786 500147....................................................... 0.9626

*

* 16.3669 24.5807

* 16.9814 500148....................................................... 1.1035 1.0440 1.0440 18.2168 22.2161 27.0350 21.6967 500150....................................................... 1.1543

*

*

*

*

*

* 500329....................................................... 0.7676

*

*

*

*

*

* 500334....................................................... 0.6580

*

*

*

*

*

* 500337....................................................... 0.8865

*

*

*

*

*

* 510001....................................................... 1.8662 0.8671 0.8671 22.9351 23.4477 24.9395 23.8162 510002....................................................... 1.2073 0.8677 0.8677 22.4751 25.9597 24.0032 24.1436 510006....................................................... 1.3300 0.8671 0.8671 22.2947 23.5727 24.5450 23.4754 510007....................................................... 1.6577 0.9009 0.9009 24.3499 25.2835 25.2802 24.9834 510008....................................................... 1.2502 0.9082 0.9082 24.5293 24.6959 25.5366 24.9190 510012....................................................... 0.9616 0.7637 0.7637 18.5816 18.2845 18.8211 18.5638 510013....................................................... 1.1563 0.7637 0.7637 19.9710 20.8782 22.7404 21.1637 510018....................................................... 1.0576 0.8294 0.8294 21.8475 20.5556 22.8201 21.7432 510022....................................................... 1.8746 0.8559 0.8559 24.1481 24.2125 26.2125 24.8409 510023....................................................... 1.3100 0.8072 0.8072 19.4321 20.4908 20.7734 20.2347 510024....................................................... 1.8007 0.8671 0.8671 23.3115 24.0444 25.2181 24.1883 510026....................................................... 0.9938 0.7637 0.7637 18.0855 16.6192 17.3777 17.2853 510028....................................................... 0.9801

*

* 23.0518 21.7134

* 22.3847 510029....................................................... 1.2865 0.8559 0.8559 21.7527 22.4556 23.3861 22.5557 510030....................................................... 1.1233 0.8449 0.8449 22.3658 21.5583 23.3535 22.4378 510031....................................................... 1.4609 0.8559 0.8559 21.6294 21.7637 23.0714 22.1614 510033....................................................... 1.5615 0.7964 0.7964 21.0707 23.0305 22.5839 22.2245 510038....................................................... 1.0077 0.7637 0.7637 16.8744 17.2832 19.0992 17.7660 510039....................................................... 1.2424 0.7749 0.7749 19.1280 19.5468 19.9164 19.5208 510043.......................................................

***

*

* 16.0586

*

* 16.0586 510046....................................................... 1.3517 0.8294 0.8294 21.2792 21.2540 21.5642 21.3655 510047....................................................... 1.1634 0.8671 0.8671 23.2093 24.0954 26.2033 24.4801 510048....................................................... 1.1421 0.7637 0.7637 17.6785 17.5096 19.0606 18.0744 510050....................................................... 1.5568 0.7749 0.7749 20.1943 19.9766 20.8188 20.3257 510053....................................................... 1.1301 0.7637 0.7637 20.7538 20.8609 22.6334 21.4364 510055....................................................... 1.5283 0.9009 0.9009 29.3962 30.7868 29.1387 29.7610 510058....................................................... 1.3632 0.7964 0.7964 21.9352 22.6976 23.0760 22.5822 510059....................................................... 1.2304 0.8559 0.8559 18.8712 21.9550 21.8993 20.7922 510061.......................................................

***

*

* 15.3355

*

* 15.3355 510062....................................................... 1.1472 0.8294 0.8294 21.1568 23.3216 24.8582 23.0758 510067....................................................... 1.1583 0.7637 0.7637 22.1582 21.2099 24.1938 22.5714 510068....................................................... 1.1019

*

* 20.0007 23.1011

* 21.5379 510070....................................................... 1.2161 0.8294 0.8294 21.1895 23.2382 23.1691 22.5946 510071....................................................... 1.2876 0.8294 0.8294 21.5439 23.1685 23.8043 22.8368 510072....................................................... 1.0728 0.7637 0.7637 19.7990 20.1997 20.8822 20.3279 510077....................................................... 1.1020 0.8759 0.8759 22.8104 23.6585 24.6316 23.7056 510082....................................................... 1.0846 0.7637 0.7637 16.4742 19.1878 19.8764 18.3863 510085....................................................... 1.3124 0.8559 0.8559 22.6563 23.7173 25.8288 24.1309 510086....................................................... 1.1062 0.7637 0.7637 17.8234 17.5933 19.0144 18.1416 510088.......................................................

***

*

* 18.3401

*

* 18.3401 510089.......................................................

***

*

*

* 27.7062

* 27.7062 510090....................................................... 2.2681

*

*

*

*

*

* 520002....................................................... 1.3605 0.9625 0.9625 23.7316 24.9950 26.5869 25.1359 520003.......................................................

***

*

* 21.8662

*

* 21.8662 520004....................................................... 1.4679 0.9466 0.9466 24.4711 25.4639 27.0690 25.6990 520008....................................................... 1.5872 1.0241 1.0241 27.8127 29.8354 31.0949 29.6152 520009....................................................... 1.7236 0.9466 0.9466 23.4265 26.1503 27.7845 25.7871 520010....................................................... 1.1151

*

* 28.5569

*

* 28.5569

[[Page 24227]]

520011....................................................... 1.3314 0.9466 0.9466 23.7785 25.2747 27.1311 25.4700 520013....................................................... 1.4452 0.9644 0.9644 24.4766 26.6225 29.2111 26.8019 520014.......................................................

***

*

* 22.1064

*

* 22.1064 520015.......................................................

***

*

* 23.0403

*

* 23.0403 520017....................................................... 1.1783 0.9644 0.9644 23.4044 24.6676 28.0839 25.3651 520019....................................................... 1.3160 0.9466 0.9466 24.9871 26.7433 29.3066 27.0110 520021....................................................... 1.3354 1.0596 1.0596 25.4872 26.6935 28.1218 26.8573 520024....................................................... 1.0407

*

* 18.5072

*

* 18.5072 520026.......................................................

***

*

* 26.1056

*

* 26.1056 520027....................................................... 1.2653 1.0241 1.0241 26.2516 27.6771 30.8126 28.3796 520028....................................................... 1.2954 1.0502 1.0502 25.7778 25.4164 26.5754 25.9267 520030....................................................... 1.7625 0.9799 0.9799 25.3807 27.0185 29.0074 27.1779 520032....................................................... 1.1081

*

* 25.3059

*

* 25.3059 520033....................................................... 1.2354 0.9466 0.9466 23.9791 25.0854 27.3306 25.5391 520034....................................................... 1.2062 0.9466 0.9466 23.6563 23.9850 25.9625 24.5645 520035....................................................... 1.3268 0.9543 0.9543 23.2625 24.7767 26.8252 24.9975 520037....................................................... 1.8330 0.9625 0.9625 28.6984 29.7234 28.7221 29.0476 520038....................................................... 1.2465 1.0241 1.0241 24.6650 26.6470 29.7288 27.0582 520040....................................................... 1.4799 1.0241 1.0241 23.8501 27.2325 28.7706 26.5424 520041....................................................... 1.0916 1.0731 1.0731 22.8236 22.7596 23.3086 22.9766 520042....................................................... 1.0028

*

* 24.0788

*

* 24.0788 520044....................................................... 1.3404 0.9543 0.9543 24.9387 26.0191 27.4740 26.1760 520045....................................................... 1.5980 0.9466 0.9466 24.5844 26.0030 27.9444 26.1871 520047.......................................................

***

*

* 25.5346

*

* 25.5346 520048....................................................... 1.6307 0.9466 0.9466 23.1653 25.1724 27.0266 25.0694 520049....................................................... 2.1099 0.9791 0.9791 24.1083 25.9256 27.4599 25.7460 520051....................................................... 1.6916 1.0241 1.0241 28.8249 28.4880 31.5274 29.7523 520057....................................................... 1.2115 0.9584 0.9584 23.3205 25.3745 27.6395 25.5004 520059....................................................... 1.2603 1.0408 1.0408 26.5596 28.0906 29.8632 28.1945 520060....................................................... 1.2808 0.9489 0.9489 22.0132 23.8817 24.7482 23.5443 520062....................................................... 1.2708 1.0241 1.0241 24.9988 28.2215 29.4194 27.5670 520063....................................................... 1.1386 1.0241 1.0241 25.3674 27.4101 28.9251 27.2413 520064....................................................... 1.5155 1.0241 1.0241 27.1120 28.6101 30.2879 28.6292 520066....................................................... 1.4918 1.0502 1.0502 25.8812 27.1657 28.3573 27.1367 520068....................................................... 0.9097

*

* 23.4746 24.8184

* 24.1554 520070....................................................... 1.7287 0.9644 0.9644 23.9908 24.8935 27.5457 25.5329 520071....................................................... 1.2004 1.0098 1.0098 26.3154 27.6202 29.3878 27.7380 520075....................................................... 1.4697 0.9791 0.9791 26.0600 27.1699 29.8136 27.6374 520076....................................................... 1.2383 1.0502 1.0502 24.0879 26.1698 28.1355 26.1183 520078....................................................... 1.5311 1.0241 1.0241 25.7662 27.5989 29.6321 27.7034 520083....................................................... 1.7261 1.0731 1.0731 27.0012 28.8407 31.3634 29.1629 520084.......................................................

***

*

* 25.5777

*

* 25.5777 520087....................................................... 1.7272 0.9466 0.9466 24.5280 27.3374 28.2823 26.6696 520088....................................................... 1.2906 1.0098 1.0098 26.0882 26.9936 29.8417 27.7181 520089....................................................... 1.5216 1.0731 1.0731 26.6013 30.0448 33.3398 30.0450 520091....................................................... 1.2880 0.9466 0.9466 24.8269 24.6320 25.9623 25.1681 520092.......................................................

***

*

* 23.4043

*

* 23.4043 520094.......................................................

***

*

* 25.3166 25.7567

* 25.5399 520095....................................................... 1.2375 1.0502 1.0502 28.6376 26.7863 28.5877 27.9986 520096....................................................... 1.3505 1.0098 1.0098 22.9929 24.5758 26.8566 25.0076 520097....................................................... 1.3955 0.9791 0.9791 25.1135 26.3321 29.8400 27.1169 520098....................................................... 1.9798 1.0731 1.0731 28.0730 30.6150 31.9008 30.2555 520100....................................................... 1.2806 0.9685 0.9685 24.5914 26.2161 29.0461 26.6330 520102....................................................... 1.1190 1.0098 1.0098 25.6146 26.8234 28.8280 27.1398 520103....................................................... 1.5698 1.0241 1.0241 25.5361 27.9147 29.8746 27.9295 520107....................................................... 1.2555 0.9620 0.9620 27.7413 28.3431 29.2809 28.4726 520109....................................................... 1.0588 0.9466 0.9466 22.4048 23.3271 24.2510 23.3292 520111.......................................................

***

*

* 26.3095

*

* 26.3095 520112.......................................................

***

*

* 20.4034

*

* 20.4034 520113....................................................... 1.2862 0.9620 0.9620 26.7926 27.4135 30.6517 28.3197 520114.......................................................

***

*

* 22.0536

*

* 22.0536 520116....................................................... 1.2845 1.0098 1.0098 26.3057 26.9902 28.3092 27.2488 520117.......................................................

***

*

* 22.0023

*

* 22.0023 520123.......................................................

***

*

* 22.2430

*

* 22.2430 520132....................................................... 0.9607 0.9543 0.9543 21.6025 23.1941 24.6842 23.1837 520135.......................................................

***

*

* 18.5618

*

* 18.5618

[[Page 24228]]

520136....................................................... 1.6741 1.0241 1.0241 25.5145 27.7703 30.5973 27.9356 520138....................................................... 1.8704 1.0241 1.0241 26.9047 28.4394 30.1937 28.5333 520139....................................................... 1.2833 1.0241 1.0241 25.4424 26.5110 28.5712 26.9062 520140....................................................... 1.6566 1.0241 1.0241 26.1616 28.4433 30.7141 28.4902 520148....................................................... 1.3242

*

* 26.2258

*

* 26.2258 520151.......................................................

***

*

* 22.9592

*

* 22.9592 520152....................................................... 1.0783 0.9466 0.9466 23.2493 24.9392 28.9787 25.8522 520154.......................................................

***

*

* 23.7160

*

* 23.7160 520156.......................................................

***

*

* 24.9258

*

* 24.9258 520160....................................................... 1.8305 0.9466 0.9466 24.3528 25.7588 28.0219 26.0815 520161.......................................................

***

*

* 24.0673

*

* 24.0673 520170....................................................... 1.4056 1.0241 1.0241 25.6124 27.2221 29.9758 27.6579 520173....................................................... 1.1252 1.0157 1.0157 26.2224 28.0995 29.7080 28.0206 520177....................................................... 1.6429 1.0241 1.0241 28.4663 30.7317 31.0104 30.1346 520178....................................................... 0.9970

*

* 23.0419 20.2666

* 21.6760 520189....................................................... 1.1658 1.0596 1.0596 26.3172 28.4720 28.1690 27.7706 520193....................................................... 1.6544 0.9791 0.9791

* 26.0885 28.6187 27.4400 520194....................................................... 1.3272 1.0241 1.0241

* 24.9408 31.0546 27.9475 520195.......................................................

***

*

*

* 36.6973 36.6166 36.6568 520196....................................................... 1.6814 0.9644 0.9644

* 35.1043 40.4421 37.6718 520197....................................................... 2.6191 1.0241 1.0241

*

*

*

* 520198....................................................... 1.3597 0.9466 0.9466

*

*

*

* 520199....................................................... 2.3566 1.0241 1.0241

*

*

*

* 520200....................................................... 1.5982

*

*

*

*

*

* 520343....................................................... 0.8070

*

*

*

*

*

* 520344....................................................... 0.6245

*

*

*

*

*

* 520353....................................................... 0.6538

*

*

*

*

*

* 530002....................................................... 1.0826 0.9303 0.9303 25.2983 26.8356 28.6510 26.9256 530006....................................................... 1.1645 0.9303 0.9303 22.8344 24.9318 27.3112 24.9372 530007.......................................................

***

*

* 19.3476 20.4391

* 19.9218 530008 \2\................................................... 1.1146 0.9303 0.9303 23.8271 23.8589 23.8665 23.8511 530009....................................................... 0.9305 0.9303 0.9303 24.2426 26.8316 25.4972 25.5320 530010 \2\................................................... 1.2318 0.9303 0.9303 23.9255 25.8482 26.3785 25.3803 530011....................................................... 1.1121 0.9303 0.9303 24.1396 24.8245 27.8493 25.6567 530012....................................................... 1.6973 0.9303 0.9303 24.3454 25.2526 27.0939 25.5544 530014....................................................... 1.5419 0.9303 0.9303 23.6907 24.5947 26.8898 25.0653 530015....................................................... 1.2091 0.9303 0.9303 26.3107 27.6876 30.4674 28.1564 530016.......................................................

***

*

* 21.6575

*

* 21.6575 530017....................................................... 0.9926 0.9303 0.9303 23.5415 25.3362 27.8927 25.7008 530023.......................................................

***

*

* 24.1493 21.3813

* 22.6795 530025....................................................... 1.2442 0.9594 0.9594 27.7988 28.6938 28.0007 28.1645 530031.......................................................

***

*

* 16.3472

*

* 16.3472 530032.......................................................

*** 0.9303 0.9303 22.6584 25.7728 23.6562 23.9700

\1\ Based on salaries adjusted for occupational mix, according to the calculation in section III.G. of the preamble to this proposed rule. \2\ These hospitals are assigned a wage index value under a special exceptions policy (FY 2005 IPPS final rule, 69 FR 49105). \3\ The case-mix index is based on the billed DRGs in the FY 2005 MedPAR. It is not transfer adjusted. h These hospitals are assigned a wage index value under the rural hold harmless transition discussed in section III.H.3. of the preamble of the FY 2006 IPPS final rule (70 FR 47378). * Denotes wage data not available for the provider for that year. ** Based on the sum of the salaries and hours computed for Federal FYs 2005, 2006, and 2007. *** Denotes MedPAR data not available for the provider for FY 2005.

Table 3A.--FY 2007 and 3-Year Average Hourly Wage for Urban Areas by CBSA [*Based on the salaries and hours computed for Federal Fiscal Years 2005, 2006, and 2007]

FY 2007 3-year CBSA code

Urban area

average average hourly wage hourly wage

10180.............. Abilene, TX.............. 23.7864 22.2341 10380.............. Aguadilla-Isabela-San

11.5958 11.9816 Sebastian, PR. 10420.............. Akron, OH................ 25.5401 24.8498 10500.............. Albany, GA............... 26.5516 26.5372 10580.............. Albany-Schenectady-Troy, 25.9108 24.3176 NY. 10740.............. Albuquerque, NM.......... 28.0546 27.6389

[[Page 24229]]

10780.............. Alexandria, LA........... 23.7639 22.6218 10900.............. Allentown-Bethlehem-

29.3872 27.4903 Easton, PA-NJ. 11020.............. Altoona, PA.............. 25.8056 24.3129 11100.............. Amarillo, TX............. 27.1670 25.6933 11180.............. Ames, IA................. 28.9474 26.8746 11260.............. Anchorage, AK............ 35.6559 33.7320 11300.............. Anderson, IN............. 26.1417 24.4749 11340.............. Anderson, SC............. 26.4925 24.8853 11460.............. Ann Arbor, MI............ 32.1288 30.6219 11500.............. Anniston-Oxford, AL...... 23.3427 21.9251 11540.............. Appleton, WI............. 27.9303 25.9663 11700.............. Asheville, NC............ 26.9690 25.7974 12020.............. Athens-Clarke County, GA. 29.0907 27.8508 12060.............. Atlanta-Sandy Springs-

28.8960 27.5475 Marietta, GA. 12100.............. Atlantic City, NJ........ 34.7415 32.0814 12220.............. Auburn-Opelika, AL....... 24.0249 22.8346 12260.............. Augusta-Richmond County, 28.6584 26.7093 GA-SC. 12420.............. Austin-Round Rock, TX.... 27.7087 26.5210 12540.............. Bakersfield, CA.......... 31.4405 29.2570 12580.............. Baltimore-Towson, MD..... 29.8705 27.9108 12620.............. Bangor, ME............... 28.7200 27.6266 12700.............. Barnstable Town, MA...... 37.1619 35.0590 12940.............. Baton Rouge, LA.......... 23.9840 23.3500 12980.............. Battle Creek, MI......... 28.7918 26.6912 13020.............. Bay City, MI............. 27.4599 26.3249 13140.............. Beaumont-Port Arthur, TX. 25.4926 23.9070 13380.............. Bellingham, WA........... 32.8247 32.0831 13460.............. Bend, OR................. 31.8191 30.0560 13644.............. Bethesda-Gaithersburg-

32.2704 31.0786 Frederick, MD. 13740.............. Billings, MT............. 25.8722 24.7779 13780.............. Binghamton, NY........... 26.0978 24.1488 13820.............. Birmingham-Hoover, AL.... 26.4036 25.2200 13900.............. Bismarck, ND............. 21.4773 20.8617 13980.............. Blacksburg-Christiansburg- 24.3978 22.6378 Radford, VA. 14020.............. Bloomington, IN.......... 25.3577 23.9071 14060.............. Bloomington-Normal, IL... 26.5223 25.3191 14260.............. Boise City-Nampa, ID..... 27.8382 25.9580 14484.............. Boston-Quincy, MA........ 34.5981 32.6876 14500.............. Boulder, CO.............. 30.6928 28.2498 14540.............. Bowling Green, KY........ 24.1674 22.8806 14740.............. Bremerton-Silverdale, WA. 32.3485 30.1316 14860.............. Bridgeport-Stamford-

37.5692 35.6119 Norwalk, CT. 15180.............. Brownsville-Harlingen, TX 28.0460 27.4783 15260.............. Brunswick, GA............ 29.9555 28.9712 15380.............. Buffalo-Niagara Falls, NY 28.0487 26.4035 15500.............. Burlington, NC........... 25.6875 24.7454 15540.............. Burlington-South

28.0878 26.3208 Burlington, VT. 15764.............. Cambridge-Newton-

32.3023 31.0383 Framingham, MA. 15804.............. Camden, NJ............... 30.7780 29.4794 15940.............. Canton-Massillon, OH..... 26.8199 25.1102 15980.............. Cape Coral-Fort Myers, FL 27.6466 26.1863 16180.............. Carson City, NV.......... 29.6855 28.5533 16220.............. Casper, WY............... 27.0939 25.5544 16300.............. Cedar Rapids, IA......... 26.3211 24.9097 16580.............. Champaign-Urbana, IL..... 28.5638 26.8316 16620.............. Charleston, WV........... 25.3369 24.1265 16700.............. Charleston-North

27.0907 25.9477 Charleston, SC. 16740.............. Charlotte-Gastonia-

28.1830 27.0104 Concord, NC-SC. 16820.............. Charlottesville, VA...... 30.0162 28.5508 16860.............. Chattanooga, TN-GA....... 26.5381 25.4499 16940.............. Cheyenne, WY............. 26.8898 25.0653 16974.............. Chicago-Naperville-

31.7996 30.2340 Joliet, IL. 17020.............. Chico, CA................ 32.7893 29.9719 17140.............. Cincinnati-Middletown, OH- 28.4143 26.7824 KY-IN. 17300.............. Clarksville, TN-KY....... 24.9567 23.0900 17420.............. Cleveland, TN............ 24.0739 22.5520 17460.............. Cleveland-Elyria-Mentor, 27.7626 26.3460 OH. 17660.............. Coeur d'Alene, ID........ 27.6683 26.4480 17780.............. College Station-Bryan, TX 26.8320 25.3789

[[Page 24230]]

17820.............. Colorado Springs, CO..... 28.7059 26.9783 17860.............. Columbia, MO............. 25.3105 23.5598 17900.............. Columbia, SC............. 23.7907 24.6287 17980.............. Columbus, GA-AL.......... 24.4401 23.7713 18020.............. Columbus, IN............. 27.6269 26.4443 18140.............. Columbus, OH............. 29.9564 27.7794 18580.............. Corpus Christi, TX....... 25.3934 24.0550 18700.............. Corvallis, OR............ 34.1502 30.6441 19060.............. Cumberland, MD-WV........ 26.1797 24.9454 19124.............. Dallas-Plano-Irving, TX.. 29.8607 28.3711 19140.............. Dalton, GA............... 26.7899 25.7890 19180.............. Danville, IL............. 27.5152 24.7343 19260.............. Danville, VA............. 25.1134 23.9198 19340.............. Davenport-Moline-Rock

25.2896 24.2728 Island, IA-IL. 19380.............. Dayton, OH............... 26.7881 25.5826 19460.............. Decatur, AL.............. 24.3313 23.8254 19500.............. Decatur, IL.............. 24.2290 22.7819 19660.............. Deltona-Daytona Beach-

27.4687 25.7159 Ormond Beach, FL. 19740.............. Denver-Aurora, CO........ 32.3384 30.3491 19780.............. Des Moines-West Des

27.0441 26.1907 Moines,IA. 19804.............. Detroit-Livonia-Dearborn, 30.2990 28.9283 MI. 20020.............. Dothan, AL............... 22.1225 21.2814 20100.............. Dover, DE................ 29.3258 27.6577 20220.............. Dubuque, IA.............. 27.0318 25.1096 20260.............. Duluth, MN-WI............ 29.7746 28.5452 20500.............. Durham, NC............... 29.0174 28.2855 20740.............. Eau Claire, WI........... 28.5480 26.1872 20764.............. Edison, NJ............... 33.1853 31.3795 20940.............. El Centro, CA............ 27.0989 25.2992 21060.............. Elizabethtown, KY........ 25.8098 24.4828 21140.............. Elkhart-Goshen, IN....... 27.8902 26.4406 21300.............. Elmira, NY............... 24.3652 23.2597 21340.............. El Paso, TX.............. 26.9405 25.4867 21500.............. Erie, PA................. 25.7679 24.3509 21604.............. Essex County, MA......... 30.8807 29.5199 21660.............. Eugene-Springfield, OR... 32.2004 30.4380 21780.............. Evansville, IN-KY........ 26.1797 24.1900 21820.............. Fairbanks, AK............ 32.7496 31.3425 21940.............. Fajardo, PR.............. 11.9805 11.2321 22020.............. Fargo, ND-MN............. 24.4385 24.0588 22140.............. Farmington, NM........... 25.4686 23.5378 22180.............. Fayetteville, NC......... 26.5301 25.8728 22220.............. Fayetteville-Springdale- 25.9870 24.3862 Rogers, AR-MO. 22380.............. Flagstaff, AZ............ 34.3731 32.2119 22420.............. Flint, MI................ 32.4969 30.5849 22500.............. Florence, SC............. 24.9953 24.5176 22520.............. Florence-Muscle Shoals,

23.6570 22.5629 AL. 22540.............. Fond du Lac, WI.......... 29.8417 27.7181 22660.............. Fort Collins-Loveland, CO 28.2139 27.8290 22744.............. Ft Lauderdale-Pompano

30.0138 28.6681 Beach-Deerfield. 22900.............. Fort Smith, AR-OK........ 22.9758 22.6470 23020.............. Fort Walton Beach-

25.6192 24.5301 Crestview-Destin, FL. 23060.............. Fort Wayne, IN........... 28.1177 27.1394 23104.............. Fort Worth-Arlington, TX. 28.3931 26.7339 23420.............. Fresno, CA............... 32.5994 30.1075 23460.............. Gadsden, AL.............. 23.9989 22.5094 23540.............. Gainesville, FL.......... 27.5283 26.2765 23580.............. Gainesville, GA.......... 26.6096 25.6552 23844.............. Gary, IN................. 27.4642 26.1115 24020.............. Glens Falls, NY.......... 24.7436 23.7211 24140.............. Goldsboro, NC............ 27.1894 24.9795 24220.............. Grand Forks, ND-MN....... 23.6479 23.2868 24300.............. Grand Junction, CO....... 28.7625 27.2627 24340.............. Grand Rapids-Wyoming, MI. 28.0304 26.4158 24500.............. Great Falls, MT.......... 25.4356 24.6351 24540.............. Greeley, CO.............. 28.5246 26.7856 24580.............. Green Bay, WI............ 28.9831 27.0003 24660.............. Greensboro-High Point, NC 25.9172 25.2493 24780.............. Greenville, NC........... 27.9072 26.1644

[[Page 24231]]

24860.............. Greenville, SC........... 28.7379 27.2856 25020.............. Guayama, PR.............. 09.5985 09.6952 25060.............. Gulfport-Biloxi, MS...... 26.3877 24.9138 25180.............. Hagerstown-Martinsburg,

26.8867 26.4121 MD-WV. 25260.............. Hanford-Corcoran, CA..... 30.1059 27.7628 25420.............. Harrisburg-Carlisle, PA.. 27.8666 26.2093 25500.............. Harrisonburg, VA......... 26.9175 25.6513 25540.............. Hartford-West Hartford-

32.3195 30.8426 East Hartford, C. 25620.............. Hattiesburg, MS.......... 22.0583 20.9235 25860.............. Hickory-Lenoir-Morganton, 26.7289 25.6097 NC. 25980.............. \1\ Hinesville-Fort

........... ........... Stewart, GA. 26100.............. Holland-Grand Haven, MI.. 27.3564 25.9294 26180.............. Honolulu, HI............. 32.7585 31.0670 26300.............. Hot Springs, AR.......... 26.0849 25.2942 26380.............. Houma-Bayou Cane-

23.6912 22.0451 Thibodaux, LA. 26420.............. Houston-Sugar Land-

29.6912 28.0218 Baytown, TX. 26580.............. Huntington-Ashland, WV-KY- 26.6703 26.1438 OH. 26620.............. Huntsville, AL........... 26.7216 25.2160 26820.............. Idaho Falls, ID.......... 26.8982 25.7696 26900.............. Indianapolis-Carmel, IN.. 28.8843 27.7580 26980.............. Iowa City, IA............ 28.7929 27.2014 27060.............. Ithaca, NY............... 29.2568 27.4840 27100.............. Jackson, MI.............. 28.3070 26.0872 27140.............. Jackson, MS.............. 24.5054 23.2406 27180.............. Jackson, TN.............. 26.2283 24.9470 27260.............. Jacksonville, FL......... 26.7802 26.0119 27340.............. Jacksonville, NC......... 24.3666 23.1693 27500.............. Janesville, WI........... 28.6711 26.9103 27620.............. Jefferson City, MO....... 24.6931 23.4008 27740.............. Johnson City, TN......... 23.8898 22.5898 27780.............. Johnstown, PA............ 25.5195 23.6154 27860.............. Jonesboro, AR............ 22.6678 22.1975 27900.............. Joplin, MO............... 25.5168 24.1603 28020.............. Kalamazoo-Portage, MI.... 31.7833 29.6496 28100.............. Kankakee-Bradley, IL..... 29.6189 29.2729 28140.............. Kansas City, MO-KS....... 28.1260 26.6597 28420.............. Kennewick-Richland-Pasco, 30.6359 29.2912 WA. 28660.............. Killeen-Temple-Fort Hood, 27.0302 25.1082 TX. 28700.............. Kingsport-Bristol-

23.5950 22.6623 Bristol, TN-VA. 28740.............. Kingston, NY............. 27.7882 25.8209 28940.............. Knoxville, TN............ 24.5065 23.6085 29020.............. Kokomo, IN............... 28.1040 26.2399 29100.............. La Crosse, WI-MN......... 27.9055 26.3466 29140.............. Lafayette, IN............ 26.5151 24.9248 29180.............. Lafayette, LA............ 24.5278 23.3229 29340.............. Lake Charles, LA......... 23.4856 22.1071 29404.............. Lake County-Kenosha

30.8117 29.1933 County, IL-WI. 29460.............. Lakeland, FL............. 26.3688 25.0264 29540.............. Lancaster, PA............ 28.5843 27.3304 29620.............. Lansing-East Lansing, MI. 29.8859 27.5256 29700.............. Laredo, TX............... 23.2381 23.0084 29740.............. Las Cruces, NM........... 27.4404 24.7091 29820.............. Las Vegas-Paradise, NV... 33.7979 31.9159 29940.............. Lawrence, KS............. 24.7063 23.8048 30020.............. Lawton, OK............... 24.0253 22.6783 30140.............. Lebanon, PA.............. 26.3047 24.5398 30300.............. Lewiston, ID-WA.......... 29.1686 26.9241 30340.............. Lewiston-Auburn, ME...... 27.0588 26.1610 30460.............. Lexington-Fayette, KY.... 27.1389 25.7178 30620.............. Lima, OH................. 26.7593 25.7193 30700.............. Lincoln, NE.............. 29.8510 28.4796 30780.............. Little Rock-North Little 26.3993 24.7894 Rock, AR. 30860.............. Logan, UT-ID............. 26.7880 25.5328 30980.............. Longview, TX............. 26.0655 24.6081 31020.............. Longview, WA............. 29.6411 27.7279 31084.............. Los Angeles-Long Beach-

34.8198 32.9747 Santa Ana, CA. 31140.............. Louisville-Jefferson

27.0486 25.7096 County, KY-IN. 31180.............. Lubbock, TX.............. 25.5361 24.4128 31340.............. Lynchburg, VA............ 25.8004 24.6790

[[Page 24232]]

31420.............. Macon, GA................ 28.2812 27.0212 31460.............. Madera, CA............... 24.1895 23.7007 31540.............. Madison, WI.............. 31.7670 29.6038 31700.............. Manchester-Nashua, NH.... 30.3488 29.1140 31900.............. Mansfield, OH............ 27.5254 26.5502 32420.............. Mayaguez, PR............. 11.4161 11.4868 32580.............. McAllen-Edinburg-Mission, 26.0218 24.4402 TX. 32780.............. Medford, OR.............. 32.0766 29.5178 32820.............. Memphis, TN-MS-AR........ 27.7288 26.1237 32900.............. Merced, CA............... 33.8080 30.8250 33124.............. Miami-Miami Beach-

29.0857 27.5003 Kendall, FL. 33140.............. Michigan City-La Porte,

26.9182 25.9742 IN. 33260.............. Midland, TX.............. 29.0179 26.8535 33340.............. Milwaukee-Waukesha-West

30.3159 28.4862 Allis, WI. 33460.............. Minneapolis-St. Paul-

32.3959 30.8366 Bloomington, MN-WI. 33540.............. Missoula, MT............. 26.3724 26.0288 33660.............. Mobile, AL............... 23.5488 22.1987 33700.............. Modesto, CA.............. 34.3892 33.1922 33740.............. Monroe, LA............... 23.7257 22.3272 33780.............. Monroe, MI............... 28.7593 26.7894 33860.............. Montgomery, AL........... 23.7850 23.2495 34060.............. Morgantown, WV........... 25.0126 23.9182 34100.............. Morristown, TN........... 23.5331 22.1874 34580.............. Mount Vernon-Anacortes,

31.1247 29.4347 WA. 34620.............. Muncie, IN............... 24.6068 24.0532 34740.............. Muskegon-Norton Shores,

29.4886 27.5164 MI. 34820.............. Myrtle Beach-Conway-North 26.1078 24.9580 Myrtle Beach,. 34900.............. Napa, CA................. 39.9176 36.1438 34940.............. Naples-Marco Island, FL.. 29.4100 28.5222 34980.............. Nashville-Davidson--

29.1670 27.6979 Murfreesboro, TN. 35004.............. Nassau-Suffolk, NY....... 37.5989 35.8100 35084.............. Newark-Union, NJ-PA...... 35.1861 33.0916 35300.............. New Haven-Milford, CT.... 35.5112 33.3802 35380.............. New Orleans-Metairie-

26.2137 25.1311 Kenner, LA. 35644.............. New York-White Plains-

39.1188 37.0666 Wayne, NY-NJ. 35660.............. Niles-Benton Harbor, MI.. 26.4279 24.9042 35980.............. Norwich-New London, CT... 35.4758 32.7007 36084.............. Oakland-Fremont-Hayward, 45.5784 42.9783 CA. 36100.............. Ocala, FL................ 26.3570 25.2302 36140.............. Ocean City, NJ........... 31.0823 30.1687 36220.............. Odessa, TX............... 29.9544 27.9474 36260.............. Ogden-Clearfield, UT..... 26.6673 25.4290 36420.............. Oklahoma City, OK........ 26.2178 25.1040 36500.............. Olympia, WA.............. 32.8460 30.8309 36540.............. Omaha-Council Bluffs, NE- 27.9830 26.8115 IA. 36740.............. Orlando-Kissimmee, FL.... 27.8531 26.6896 36780.............. Oshkosh-Neenah, WI....... 27.5278 25.6702 36980.............. Owensboro, KY............ 25.9911 24.2496 37100.............. Oxnard-Thousand Oaks-

34.2883 32.1061 Ventura, CA. 37340.............. Palm Bay-Melbourne-

27.9443 27.0172 Titusville, FL. 37460.............. Panama City-Lynn Haven,

23.9351 22.6108 FL. 37620.............. Parkersburg-Marietta-

23.5762 22.9231 Vienna, WV-OH. 37700.............. Pascagoula, MS........... 24.3614 22.7858 37860.............. Pensacola-Ferry Pass-

23.6805 22.7437 Brent, FL. 37900.............. Peoria, IL............... 26.5635 24.9170 37964.............. Philadelphia, PA......... 32.5912 30.7325 38060.............. Phoenix-Mesa-Scottsdale, 30.5119 28.4597 AZ. 38220.............. Pine Bluff, AR........... 24.9343 24.0918 38300.............. Pittsburgh, PA........... 25.6688 24.4659 38340.............. Pittsfield, MA........... 30.4192 28.8465 38540.............. Pocatello, ID............ 27.8274 26.4330 38660.............. Ponce, PR................ 14.3623 13.8007 38860.............. Portland-South Portland- 29.3543 28.3363 Biddeford, ME. 38900.............. Portland-Vancouver-

33.7621 31.7618 Beaverton, OR-WA. 38940.............. Port St. Lucie-Fort

29.1805 28.0566 Pierce, FL. 39100.............. Poughkeepsie-Newburgh-

32.3052 30.9565 Middletown, NY. 39140.............. Prescott, AZ............. 29.1830 27.7138 39300.............. Providence-New Bedford-

31.9448 30.5097 Fall River, RI-M. 39340.............. Provo-Orem, UT........... 28.2332 26.6782

[[Page 24233]]

39380.............. Pueblo, CO............... 25.3116 24.2019 39460.............. Punta Gorda, FL.......... 27.9209 26.2796 39540.............. Racine, WI............... 27.2461 25.4815 39580.............. Raleigh-Cary, NC......... 29.1738 27.5962 39660.............. Rapid City, SD........... 30.6665 26.5155 39740.............. Reading, PA.............. 28.5418 26.7025 39820.............. Redding, CA.............. 39.0919 34.6214 39900.............. Reno-Sparks, NV.......... 35.4486 31.1844 40060.............. Richmond, VA............. 27.1570 25.9892 40140.............. Riverside-San Bernardino- 32.3625 30.7856 Ontario, CA. 40220.............. Roanoke, VA.............. 25.6872 23.8222 40340.............. Rochester, MN............ 33.2903 31.5856 40380.............. Rochester, NY............ 26.6628 25.5814 40420.............. Rockford, IL............. 29.5658 27.6241 40484.............. Rockingham County, NH.... 30.0790 28.7345 40580.............. Rocky Mount, NC.......... 26.2562 25.0051 40660.............. Rome, GA................. 27.5523 25.7704 40900.............. Sacramento--Arden-Arcade-- 39.5208 35.6723 Roseville, CA. 40980.............. Saginaw-Saginaw Township 26.4685 26.0187 North, MI. 41060.............. St. Cloud, MN............ 30.9000 28.6361 41100.............. St. George, UT........... 27.5173 26.3816 41140.............. St. Joseph, MO-KS........ 30.1186 27.9482 41180.............. St. Louis, MO-IL......... 26.6920 25.2435 41420.............. Salem, OR................ 30.9397 29.3934 41500.............. Salinas, CA.............. 42.7963 39.6031 41540.............. Salisbury, MD............ 26.5170 25.2945 41620.............. Salt Lake City, UT....... 27.8903 26.5336 41660.............. San Angelo, TX........... 24.8207 23.1919 41700.............. San Antonio, TX.......... 26.2255 25.0650 41740.............. San Diego-Carlsbad-San

33.6627 31.8471 Marcos, CA. 41780.............. Sandusky, OH............. 27.6127 25.5029 41884.............. San Francisco-San Mateo- 44.5507 41.8255 Redwood City, CA. 41900.............. San German-Cabo Rojo, PR. 14.4590 13.7105 41940.............. San Jose-Sunnyvale-Santa 45.2357 42.1510 Clara, CA. 41980.............. San Juan-Caguas-Guaynabo, 13.0139 12.7401 PR. 42020.............. San Luis Obispo-Paso

34.3866 31.7461 Robles, CA. 42044.............. Santa Ana-Anaheim-Irvine, 33.3993 32.1497 CA. 42060.............. Santa Barbara-Santa

32.7438 31.2878 Maria, CA. 42100.............. Santa Cruz-Watsonville,

45.9115 42.4999 CA. 42140.............. Santa Fe, NM............. 32.0322 30.4616 42220.............. Santa Rosa-Petaluma, CA.. 42.8035 38.1447 42260.............. Sarasota-Bradenton-

29.2047 27.1715 Venice, FL. 42340.............. Savannah, GA............. 26.9048 26.1364 42540.............. Scranton--Wilkes-Barre,

25.1702 23.8157 PA. 42644.............. Seattle-Bellevue-Everett, 33.8592 32.2085 WA. 42680.............. Sebastian-Vero Beach,FL.. 28.4305 26.6512 43100.............. Sheboygan, WI............ 26.8090 25.1793 43300.............. Sherman-Denison, TX...... 25.2237 25.7451 43340.............. Shreveport-Bossier City, 26.2834 24.9546 LA. 43580.............. Sioux City, IA-NE-SD..... 27.2365 25.7643 43620.............. Sioux Falls, SD.......... 28.2963 26.7140 43780.............. South Bend-Mishawaka, IN- 28.6471 26.9212 MI. 43900.............. Spartanburg, SC.......... 27.2103 26.0456 44060.............. Spokane, WA.............. 30.9283 29.8346 44100.............. Springfield, IL.......... 26.3463 24.5714 44140.............. Springfield, MA.......... 29.8434 28.5001 44180.............. Springfield, MO.......... 25.1318 23.6337 44220.............. Springfield, OH.......... 25.0325 23.8848 44300.............. State College, PA........ 26.0621 23.8363 44700.............. Stockton, CA............. 33.9933 31.2290 44940.............. Sumter, SC............... 23.9471 23.3117 45060.............. Syracuse, NY............. 28.7825 26.8883 45104.............. Tacoma, WA............... 31.9839 30.4570 45220.............. Tallahassee, FL.......... 27.5786 24.8630 45300.............. Tampa-St. Petersburg-

27.2651 25.7804 Clearwater, FL. 45460.............. Terre Haute, IN.......... 25.6447 23.6038 45500.............. Texarkana, TX-Texarkana, 24.0388 23.1664 AR. 45780.............. Toledo, OH............... 28.3827 26.7423 45820.............. Topeka, KS............... 25.8676 24.7876

[[Page 24234]]

45940.............. Trenton-Ewing, NJ........ 32.1787 29.9319 46060.............. Tucson, AZ............... 27.3501 25.4760 46140.............. Tulsa, OK................ 24.0631 23.6948 46220.............. Tuscaloosa, AL........... 25.5886 23.9087 46340.............. Tyler, TX................ 26.1668 25.6693 46540.............. U a-Rome, NY............. 24.9320 23.4183 46660.............. Valdosta, GA............. 24.6888 23.8783 46700.............. Vallejo-Fairfield, CA.... 44.8596 41.7866 47020.............. Victoria, TX............. 25.3226 23.4143 47220.............. Vineland-Millville-

29.1612 28.2024 Bridgeton, NJ. 47260.............. Virginia Beach-Norfolk-

26.1678 24.8408 Newport News, VA. 47300.............. Visalia-Porterville, CA.. 29.6516 28.2016 47380.............. Waco, TX................. 25.6153 23.6453 47580.............. Warner Robins, GA........ 24.8717 23.8719 47644.............. Warren-Troy-Farmington-

29.9684 28.0982 Hills, MI. 47894.............. Washington-Arlington-

32.7894 30.8030 Alexandria DC-VA. 47940.............. Waterloo-Cedar Falls, IA. 24.9273 23.9407 48140.............. Wausau, WI............... 29.0074 27.1779 48260.............. Weirton-Steubenville, WV- 23.8952 22.5028 OH. 48300.............. Wenatchee, WA............ 30.6283 27.7041 48424.............. West Palm Beach-Boca

28.5424 27.9681 Raton-Boynton FL. 48540.............. Wheeling, WV-OH.......... 20.7847 20.1450 48620.............. Wichita, KS.............. 26.9190 25.8412 48660.............. Wichita Falls, TX........ 24.7483 23.3505 48700.............. Williamsport, PA......... 24.0257 23.2070 48864.............. Wilmington, DE-MD-NJ..... 31.8188 30.2275 48900.............. Wilmington, NC........... 29.1306 26.7990 49020.............. Winchester, VA-WV........ 29.8963 28.7056 49180.............. Winston-Salem, NC........ 27.5311 25.8316 49340.............. Worcester, MA............ 31.8136 30.5516 49420.............. Yakima, WA............... 29.1929 28.2566 49500.............. Yauco, PR................ 11.4297 11.8994 49620.............. York-Hanover, PA......... 27.8747 26.0746 49660.............. Youngstown-Warren-

26.0937 24.8356 Boardman, OH-PA. 49700.............. Yuba City, CA............ 31.8777 29.9596 49740.............. Yuma, AZ................. 27.1721 25.5234

\1\ This area has no average hourly wage because there are no short- term, acute care hospitals in the area.

Table 3B.--FY 2007 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 2005, 2006, and 2007]

FY 2007 3-year CBSA code

Urban area

average average hourly wage hourly wage

01................. Alabama.................. 22.7063 21.2325 02................. Alaska................... 31.5838 32.0136 03................. Arizona.................. 26.4457 24.8708 04................. Arkansas................. 21.7888 20.7414 05................. California............... 33.4249 30.5217 06................. Colorado................. 27.6222 26.1254 07................. Connecticut.............. 34.7826 33.0280 08................. Delaware................. 28.7837 26.9334 10................. Florida.................. 25.4848 24.0976 11................. Georgia.................. 22.4296 21.4509 12................. Hawaii................... 31.0888 29.5623 13................. Idaho.................... 24.1337 22.6410 14................. Illinois................. 24.6699 23.2118 15................. Indiana.................. 25.0993 23.9775 16................. Iowa..................... 25.7422 23.7781 17................. Kansas................... 23.6947 22.4420 18................. Kentucky................. 23.0690 21.7676 19................. Louisiana................ 22.1373 20.7518 20................. Maine.................... 24.8632 24.4350 21................. Maryland................. 26.4816 25.6822 22................. Massachusetts \1\........ ........... ........... 23................. Michigan................. 26.8050 24.9080 24................. Minnesota................ 27.1347 25.6682

[[Page 24235]]

25................. Mississippi.............. 22.4345 21.3758 26................. Missouri................. 23.5321 22.0469 27................. Montana.................. 25.4332 24.2378 28................. Nebraska................. 25.7283 24.5703 29................. Nevada................... 26.5440 25.4110 30................. New Hampshire............ 31.9560 29.2334 31................. New Jersey \1\........... ........... ........... 32................. New Mexico............... 24.7274 23.9765 33................. New York................. 24.4634 22.9464 34................. North Carolina........... 25.4805 24.0022 35................. North Dakota............. 21.4222 20.7057 36................. Ohio..................... 25.6736 24.4091 37................. Oklahoma................. 22.6848 21.4287 38................. Oregon................... 28.8984 27.3817 39................. Pennsylvania............. 24.6593 23.2635 40................. Puerto Rico \1\.......... ........... ........... 41................. Rhode Island \1\......... ........... ........... 42................. South Carolina........... 25.4710 24.2433 43................. South Dakota............. 25.1178 23.6533 44................. Tennessee................ 23.2955 22.0862 45................. Texas.................... 23.6920 22.3956 46................. Utah..................... 24.1638 22.8805 47................. Vermont.................. 29.3826 26.8610 49................. Virginia................. 23.5825 22.4069 50................. Washington............... 30.4489 28.8509 51................. West Virginia............ 22.6063 21.6759 52................. Wisconsin................ 28.0229 26.4234 53................. Wyoming.................. 27.5393 25.7950

\1\ All counties in the State or Territory are classified as urban, with the exception of Massachusetts. Massachusetts has area(s) designated as rural. However, no short-term, acute care hospitals were located in Rural Massachusetts during FY 2003, the base year for the FY 2007 wage index.

TABLE 4A-1.--Wage Index and Capital Geographic Adjustment Factor (GAF) for Urban Areas By CBSA--FY 2007

Urban area (constituent Wage CBSA code

counties)

index GAF

10180................ Abilene, TX................ 0.8051 0.8620 Callahan County, TX....... Jones County, TX.......... Taylor County, TX......... 10380................ Aguadilla-Isabela-San

0.3917 0.5263 Sebasti[aacute]n, PR. Aguada Municipio, PR...... Aguadilla Municipio, PR... A[ntilde]asco Municipio, PR. Isabela Municipio, PR..... Lares Municipio, PR....... Moca Municipio, PR........ Rinc[oacute]n Municipio, PR. San Sebasti[aacute]n Municipio, PR. 10420................ Akron, OH.................. 0.8737 0.9117 Portage County, OH........ Summit County, OH......... 10500................ Albany, GA................. 0.8969 0.9282 Baker County, GA.......... Dougherty County, GA...... Lee County, GA............ Terrell County, GA........ Worth County, GA.......... 10580................ Albany-Schenectady-Troy, NY 0.8753 0.9128 Albany County, NY......... Rensselaer County, NY..... Saratoga County, NY....... Schenectady County, NY.... Schoharie County, NY...... 10740................ Albuquerque, NM............ 0.9477 0.9639 Bernalillo County, NM.....

[[Page 24236]]

Sandoval County, NM....... Torrance County, NM....... Valencia County, NM....... 10780................ Alexandria, LA............. 0.8028 0.8603 Grant Parish, LA.......... Rapides Parish, LA........ 10900................ Allentown-Bethlehem-Easton, 0.9927 0.9950 PA-NJ (PA Hospitals). Warren County, NJ......... Carbon County, PA......... Lehigh County, PA......... Northampton County, PA.... 10900................ \2\ Allentown-Bethlehem-

1.1226 1.0824 Easton, PA-NJ (NJ Hospitals). Warren County, NJ......... Carbon County, PA......... Lehigh County, PA......... Northampton County, PA.... 11020................ Altoona, PA................ 0.8717 0.9103 Blair County, PA.......... 11100................ Amarillo, TX............... 0.9177 0.9429 Armstrong County, TX...... Carson County, TX......... Potter County, TX......... Randall County, TX........ 11180................ Ames, IA................... 0.9779 0.9848 Story County, IA.......... 11260................ Anchorage, AK.............. 1.2062 1.1370 Anchorage Municipality, AK Matanuska-Susitna Borough, AK. 11300................ Anderson, IN............... 0.8831 0.9184 Madison County, IN........ 11340................ Anderson, SC............... 0.8949 0.9268 Anderson County, SC....... 11460................ \3\ Ann Arbor, MI.......... 1.0853 1.0577 Washtenaw County, MI...... 11500................ Anniston-Oxford, AL........ 0.7978 0.8567 Calhoun County, AL........ 11540................ \2\ Appleton, WI........... 0.9466 0.9631 Calumet County, WI........ Outagamie County, WI...... 11700................ Asheville, NC.............. 0.9110 0.9382 Buncombe County, NC....... Haywood County, NC........ Henderson County, NC...... Madison County, NC........ 12020................ Athens-Clarke County, GA... 0.9827 0.9881 Clarke County, GA......... Madison County, GA........ Oconee County, GA......... Oglethorpe County, GA..... 12060................ \1\ Atlanta-Sandy Springs- 0.9761 0.9836 Marietta, GA. Barrow County, GA......... Bartow County, GA......... Butts County, GA.......... Carroll County, GA........ Cherokee County, GA....... Clayton County, GA........ Cobb County, GA........... Coweta County, GA......... Dawson County, GA......... DeKalb County, GA......... Douglas County, GA........ Fayette County, GA........ Forsyth County, GA........ Fulton County, GA......... Gwinnett County, GA....... Haralson County, GA....... Heard County, GA.......... Henry County, GA.......... Jasper County, GA......... Lamar County, GA..........

[[Page 24237]]

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.......... 1.1736 1.1159 Atlantic County, NJ....... 12220................ Auburn-Opelika, AL......... 0.8116 0.8668 Lee County, AL............ 12260................ Augusta-Richmond County, GA- 0.9681 0.9780 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.. 0.9360 0.9557 Bastrop County, TX........ Caldwell County, TX....... Hays County, TX........... Travis County, TX......... Williamson County, TX..... 12540................ \2\ Bakersfield, CA........ 1.1291 1.0867 Kern County, CA........... 12580................ \1\ Baltimore-Towson, MD... 1.0090 1.0062 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................. 0.9702 0.9795 Penobscot County, ME...... 12700................ Barnstable Town, MA........ 1.2553 1.1685 Barnstable County, MA..... 12940................ Baton Rouge, LA............ 0.8102 0.8658 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........... 0.9726 0.9812 Calhoun County, MI........ 13020................ Bay City, MI............... 1.0040 1.0027 Bay County, MI............ 13140................ Beaumont-Port Arthur, TX... 0.8612 0.9027 Hardin County, TX......... Jefferson County, TX...... Orange County, TX......... 13380................ Bellingham, WA............. 1.1088 1.0733 Whatcom County, WA........ 13460................ Bend, OR................... 1.0749 1.0507 Deschutes County, OR...... 13644................ \1\ Bethesda-Gaithersburg- 1.1028 1.0693 Frederick, MD. Frederick County, MD...... Montgomery County, MD..... 13740................ Billings, MT............... 0.8740 0.9119 Carbon County, MT......... Yellowstone County, MT.... 13780................ Binghamton, NY............. 0.8816 0.9173 Broome County, NY......... Tioga County, NY..........

[[Page 24238]]

13820................ \1\ Birmingham-Hoover, AL.. 0.8919 0.9246 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............... 0.7255 0.8027 Burleigh County, ND....... Morton County, ND......... 13980................ Blacksburg-Christiansburg- 0.8242 0.8760 Radford, VA. Giles County, VA.......... Montgomery County, VA..... Pulaski County, VA........ Radford City, VA.......... 14020................ Bloomington, IN............ 0.8566 0.8994 Greene County, IN......... Monroe County, IN......... Owen County, IN........... 14060................ Bloomington-Normal, IL..... 0.8959 0.9275 McLean County, IL......... 14260................ Boise City-Nampa, ID....... 0.9404 0.9588 Ada County, ID............ Boise County, ID.......... Canyon County, ID......... Gem County, ID............ Owyhee County, ID......... 14484................ \1\ Boston-Quincy, MA...... 1.1687 1.1127 Norfolk County, MA........ Plymouth County, MA....... Suffolk County, MA........ 14500................ Boulder, CO................ 1.0368 1.0251 Boulder County, CO........ 14540................ Bowling Green, KY.......... 0.8164 0.8703 Edmonson County, KY....... Warren County, KY......... 14740................ Bremerton-Silverdale, WA... 1.0927 1.0626 Kitsap County, WA......... 14860................ Bridgeport-Stamford-

1.2691 1.1773 Norwalk, CT. Fairfield County, CT...... 15180................ Brownsville-Harlingen, TX.. 0.9474 0.9637 Cameron County, TX........ 15260................ Brunswick, GA.............. 1.0119 1.0081 Brantley County, GA....... Glynn County, GA.......... McIntosh County, GA....... 15380................ \1\ Buffalo-Niagara Falls, 0.9475 0.9637 NY. Erie County, NY........... Niagara County, NY........ 15500................ Burlington, NC............. 0.8677 0.9074 Alamance County, NC....... 15540................ \2\ Burlington-South

1.0986 1.0665 Burlington, VT. Chittenden County, VT..... Franklin County, VT....... Grand Isle County, VT..... 15764................ \1\ Cambridge-Newton-

1.0912 1.0616 Framingham, MA. Middlesex County, MA...... 15804................ \1\ Camden, NJ............. 1.1226 1.0824 Burlington County, NJ..... Camden County, NJ......... Gloucester County, NJ..... 15940................ Canton-Massillon, OH....... 0.9060 0.9346 Carroll County, OH........ Stark County, OH.......... 15980................ Cape Coral-Fort Myers, FL.. 0.9339 0.9542 Lee County, FL............ 16180................ Carson City, NV............ 1.0028 1.0019 Carson City, NV........... 16220................ \2\ Casper, WY............. 0.9303 0.9517

[[Page 24239]]

Natrona County, WY........ 16300................ Cedar Rapids, IA........... 0.8891 0.9227 Benton County, IA......... Jones County, IA.......... Linn County, IA........... 16580................ Champaign-Urbana, IL....... 0.9649 0.9758 Champaign County, IL...... Ford County, IL........... Piatt County, IL.......... 16620................ Charleston, WV............. 0.8559 0.8989 Boone County, WV.......... Clay County, WV........... Kanawha County, WV........ Lincoln County, WV........ Putnam County, WV......... 16700................ Charleston-North

0.9168 0.9422 Charleston, SC. Berkeley County, SC....... Charleston County, SC..... Dorchester County, SC..... 16740................ \1\ Charlotte-Gastonia-

0.9520 0.9669 Concord, NC-SC. Anson County, NC.......... Cabarrus County, NC....... Gaston County, NC......... Mecklenburg County, NC.... Stanly County, NC......... Union County, NC.......... York County, SC........... 16820................ Charlottesville, VA........ 1.0140 1.0096 Albemarle County, VA...... Fluvanna County, VA....... Greene County, VA......... Nelson County, VA......... Charlottesville City, VA.. 16860................ Chattanooga, TN-GA......... 0.8965 0.9279 Catoosa County, GA........ Dade County, GA........... Walker County, GA......... Hamilton County, TN....... Marion County, TN......... Sequatchie County, TN..... 16940................ \2\ Cheyenne, WY........... 0.9303 0.9517 Laramie County, WY........ 16974................ \1\ Chicago-Naperville-

1.0742 1.0502 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.............. 1.1291 1.0867 Butte County, CA.......... 17140................ \1\ Cincinnati-Middletown, 0.9599 0.9724 OH-KY-IN. Dearborn County, IN....... Franklin County, IN....... Ohio County, IN........... Boone County, KY.......... Bracken County, KY........ Campbell County, KY....... Gallatin County, KY....... Grant County, KY.......... Kenton County, KY......... Pendleton County, KY...... Brown County, OH.......... Butler County, OH......... Clermont County, OH....... Hamilton County, OH....... Warren County, OH......... 17300................ Clarksville, TN-KY......... 0.8431 0.8897

[[Page 24240]]

Christian County, KY...... Trigg County, KY.......... Montgomery County, TN..... Stewart County, TN........ 17420................ Cleveland, TN.............. 0.8132 0.8680 Bradley County, TN........ Polk County, TN........... 17460................ \1\ Cleveland-Elyria-

0.9378 0.9570 Mentor, OH. Cuyahoga County, OH....... Geauga County, OH......... Lake County, OH........... Lorain County, OH......... Medina County, OH......... 17660................ Coeur d'Alene, ID.......... 0.9347 0.9548 Kootenai County, ID....... 17780................ College Station-Bryan, TX.. 0.9064 0.9349 Brazos County, TX......... Burleson County, TX....... Robertson County, TX...... 17820................ Colorado Springs, CO....... 0.9697 0.9792 El Paso County, CO........ Teller County, CO......... 17860................ Columbia, MO............... 0.8550 0.8983 Boone County, MO.......... Howard County, MO......... 17900................ \2\ Columbia, SC........... 0.8604 0.9022 Calhoun County, SC........ Fairfield County, SC...... Kershaw County, SC........ Lexington County, SC...... Richland County, SC....... Saluda County, SC......... 17980................ Columbus, GA-AL............ 0.8256 0.8770 Russell County, AL........ Chattahoochee County, GA.. Harris County, GA......... Marion County, GA......... Muscogee County, GA....... 18020................ Columbus, IN............... 0.9333 0.9538 Bartholomew County, IN.... 18140................ \1\ Columbus, OH........... 1.0119 1.0081 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......... 0.8578 0.9003 Aransas County, TX........ Nueces County, TX......... San Patricio County, TX... 18700................ Corvallis, OR.............. 1.1536 1.1028 Benton County, OR......... 19060................ \2\ Cumberland, MD-WV (MD 0.8946 0.9266 Hospitals). Allegany County, MD....... Mineral County, WV........ 19060................ Cumberland, MD-WV (WV

0.8844 0.9193 Hospitals). Allegany County, MD....... Mineral County, WV........ 19124................ \1\ Dallas-Plano-Irving, TX 1.0087 1.0059 Collin County, TX......... Dallas County, TX......... Delta County, TX.......... Denton County, TX......... Ellis County, TX.......... Hunt County, TX........... Kaufman County, TX........ Rockwall County, TX.......

[[Page 24241]]

19140................ Dalton, GA................. 0.9050 0.9339 Murray County, GA......... Whitfield County, GA...... 19180................ Danville, IL............... 0.9295 0.9512 Vermilion County, IL...... 19260................ Danville, VA............... 0.8483 0.8935 Pittsylvania County, VA... Danville City, VA......... 19340................ \2\ Davenport-Moline-Rock 0.8696 0.9088 Island, IA-IL (IA Hospitals). Henry County, IL.......... Mercer County, IL......... Rock Island County, IL.... Scott County, IA.......... 19340................ Davenport-Moline-Rock

0.8569 0.8996 Island, IA-IL (IL Hospitals). Henry County, IL.......... Mercer County, IL......... Rock Island County, IL.... Scott County, IA.......... 19380................ Dayton, OH................. 0.9049 0.9339 Greene County, OH......... Miami County, OH.......... Montgomery County, OH..... Preble County, OH......... 19460................ Decatur, AL................ 0.8220 0.8744 Lawrence County, AL....... Morgan County, AL......... 19500................ \2\ Decatur, IL............ 0.8334 0.8827 Macon County, IL.......... 19660................ Deltona-Daytona Beach-

0.9279 0.9500 Ormond Beach, FL. Volusia County, FL........ 19740................ \1\ Denver-Aurora, CO...... 1.0924 1.0624 Adams County, CO.......... Arapahoe County, CO....... Broomfield County, CO..... Clear Creek County, CO.... Denver County, CO......... Douglas County, CO........ Elbert County, CO......... Gilpin County, CO......... Jefferson County, CO...... Park County, CO........... 19780................ Des Moines-West Des Moines, 0.9136 0.9400 IA. Dallas County, IA......... Guthrie County, IA........ Madison County, IA........ Polk County, IA........... Warren County, IA......... 19804................ \1\ Detroit-Livonia-

1.0235 1.0160 Dearborn, MI. Wayne County, MI.......... 20020................ \2\ Dothan, AL............. 0.7670 0.8339 Geneva County, AL......... Henry County, AL.......... Houston County, AL........ 20100................ Dover, DE.................. 0.9906 0.9936 Kent County, DE........... 20220................ Dubuque, IA................ 0.9132 0.9397 Dubuque County, IA........ 20260................ Duluth, MN-WI.............. 1.0157 1.0107 Carlton County, MN........ St. Louis County, MN...... Douglas County, WI........ 20500................ Durham, NC................. 0.9805 0.9866 Chatham County, NC........ Durham County, NC......... Orange County, NC......... Person County, NC......... 20740................ Eau Claire, WI............. 0.9644 0.9755 Chippewa County, WI....... Eau Claire County, WI..... 20764................ \1\ Edison, NJ............. 1.1242 1.0835

[[Page 24242]]

Middlesex County, NJ...... Monmouth County, NJ....... Ocean County, NJ.......... Somerset County, NJ....... 20940................ \2\ El Centro, CA.......... 1.1291 1.0867 Imperial County, CA....... 21060................ Elizabethtown, KY.......... 0.8719 0.9104 Hardin County, KY......... Larue County, KY.......... 21140................ Elkhart-Goshen, IN......... 0.9421 0.9600 Elkhart County, IN........ 21300................ \2\ Elmira, NY............. 0.8267 0.8778 Chemung County, NY........ 21340................ El Paso, TX................ 0.9101 0.9375 El Paso County, TX........ 21500................ Erie, PA................... 0.8705 0.9094 Erie County, PA........... 21604................ \2\ Essex County, MA....... 1.0664 1.0450 Essex County, MA.......... 21660................ Eugene-Springfield, OR..... 1.0877 1.0593 Lane County, OR........... 21780................ Evansville, IN-KY.......... 0.8844 0.9193 Gibson County, IN......... Posey County, IN.......... Vanderburgh County, IN.... Warrick County, IN........ Henderson County, KY...... Webster County, KY........ 21820................ Fairbanks, AK.............. 1.1063 1.0716 Fairbanks North Star Borough, AK. 21940................ Fajardo, PR................ 0.4047 0.5382 Ceiba Municipio, PR....... Fajardo Municipio, PR..... Luquillo Municipio, PR.... 22020................ Fargo, ND-MN (ND Hospitals) 0.8485 0.8936 Clay County, MN........... Cass County, ND........... 22020................ \2\ Fargo, ND-MN (MN

0.9256 0.9484 Hospitals). Clay County, MN........... Cass County, ND........... 22140................ Farmington, NM............. 0.8603 0.9021 San Juan County, NM....... 22180................ Fayetteville, NC........... 0.8962 0.9277 Cumberland County, NC..... Hoke County, NC........... 22220................ Fayetteville-Springdale-

0.8779 0.9147 Rogers, AR-MO. Benton County, AR......... Madison County, AR........ Washington County, AR..... McDonald County, MO....... 22380................ Flagstaff, AZ.............. 1.1611 1.1077 Coconino County, AZ....... 22420................ Flint, MI.................. 1.0978 1.0660 Genesee County, MI........ 22500................ \2\ Florence, SC........... 0.8604 0.9022 Darlington County, SC..... Florence County, SC....... 22520................ Florence-Muscle Shoals, AL. 0.8008 0.8589 Colbert County, AL........ Lauderdale County, AL..... 22540................ Fond du Lac, WI............ 1.0081 1.0055 Fond du Lac County, WI.... 22660................ Fort Collins-Loveland, CO.. 0.9594 0.9720 Larimer County, CO........ 22744................ \1\ Fort Lauderdale-Pompano 1.0470 1.0320 Beach-Deerfield Beach, FL. Broward County, FL........ 22900................ Fort Smith, AR-OK.......... 0.7761 0.8407 Crawford County, AR....... Franklin County, AR....... Sebastian County, AR......

[[Page 24243]]

Le Flore County, OK....... Sequoyah County, OK....... 23020................ Fort Walton Beach-Crestview- 0.8654 0.9057 Destin, FL. Okaloosa County, FL....... 23060................ Fort Wayne, IN............. 0.9498 0.9653 Allen County, IN.......... Wells County, IN.......... Whitley County, IN........ 23104................ \1\ Fort Worth-Arlington, 0.9591 0.9718 TX. Johnson County, TX........ Parker County, TX......... Tarrant County, TX........ Wise County, TX........... 23420................ \2\ Fresno, CA............. 1.1291 1.0867 Fresno County, CA......... 23460................ Gadsden, AL................ 0.8107 0.8661 Etowah County, AL......... 23540................ Gainesville, FL............ 0.9299 0.9514 Alachua County, FL........ Gilchrist County, FL...... 23580................ Gainesville, GA............ 0.8989 0.9296 Hall County, GA........... 23844................ Gary, IN................... 0.9278 0.9500 Jasper County, IN......... Lake County, IN........... Newton County, IN......... Porter County, IN......... 24020................ Glens Falls, NY............ 0.8359 0.8845 Warren County, NY......... Washington County, NY..... 24140................ Goldsboro, NC.............. 0.9185 0.9434 Wayne County, NC.......... 24220................ Grand Forks, ND-MN (ND

0.7988 0.8574 Hospitals). Polk County, MN........... Grand Forks County, ND.... 24220................ \2\ Grand Forks, ND-MN (MN 0.9256 0.9484 Hospitals). Polk County, MN........... Grand Forks County, ND.... 24300................ Grand Junction, CO......... 1.0037 1.0025 Mesa County, CO........... 24340................ Grand Rapids-Wyoming, MI... 0.9469 0.9633 Barry County, MI.......... Ionia County, MI.......... Kent County, MI........... Newaygo County, MI........ 24500................ Great Falls, MT............ 0.8781 0.9148 Cascade County, MT........ 24540................ Greeley, CO................ 0.9636 0.9749 Weld County, CO........... 24580................ Green Bay, WI.............. 0.9791 0.9856 Brown County, WI.......... Kewaunee County, WI....... Oconto County, WI......... 24660................ Greensboro-High Point, NC.. 0.8992 0.9298 Guilford County, NC....... Randolph County, NC....... Rockingham County, NC..... 24780................ Greenville, NC............. 0.9427 0.9604 Greene County, NC......... Pitt County, NC........... 24860................ Greenville, SC............. 0.9708 0.9799 Greenville County, SC..... Laurens County, SC........ Pickens County, SC........ 25020................ Guayama, PR................ 0.3242 0.4624 Arroyo Municipio, PR...... Guayama Municipio, PR..... Patillas Municipio, PR.... 25060................ Gulfport-Biloxi, MS........ 0.8914 0.9243 Hancock County, MS........

[[Page 24244]]

Harrison County, MS....... Stone County, MS.......... 25180................ Hagerstown-Martinsburg, MD- 0.9082 0.9362 WV. Washington County, MD..... Berkeley County, WV....... Morgan County, WV......... 25260................ \2\ Hanford-Corcoran, CA... 1.1291 1.0867 Kings County, CA.......... 25420................ Harrisburg-Carlisle, PA.... 0.9413 0.9594 Cumberland County, PA..... Dauphin County, PA........ Perry County, PA.......... 25500................ Harrisonburg, VA........... 0.9093 0.9370 Rockingham County, VA..... Harrisonburg City, VA..... 25540................ \1\ \2\ Hartford-West

1.1750 1.1168 Hartford-East Hartford, CT. Hartford County, CT....... Litchfield County, CT..... Middlesex County, CT...... Tolland County, CT........ 25620................ \2\ Hattiesburg, MS........ 0.7579 0.8271 Forrest County, MS........ Lamar County, MS.......... Perry County, MS.......... 25860................ Hickory-Lenoir-Morganton, 0.9029 0.9324 NC. Alexander County, NC...... Burke County, NC.......... Caldwell County, NC....... Catawba County, NC........ 25980................ Hinesville-Fort Stewart, GA 0.7577 0.8270 Liberty County, GA........ Long County, GA........... 26100................ Holland-Grand Haven, MI.... 0.9241 0.9474 Ottawa County, MI......... 26180................ Honolulu, HI............... 1.1066 1.0718 Honolulu County, HI....... 26300................ Hot Springs, AR............ 0.8812 0.9170 Garland County, AR........ 26380................ Houma-Bayou Cane-Thibodaux, 0.8003 0.8585 LA. Lafourche Parish, LA...... Terrebonne Parish, LA..... 26420................ \1\ Houston-Sugar Land-

1.0030 1.0021 Baytown, TX. Austin County, TX......... Brazoria County, TX....... Chambers County, TX....... Fort Bend County, TX...... Galveston County, TX...... Harris County, TX......... Liberty County, TX........ Montgomery County, TX..... San Jacinto County, TX.... Waller County, TX......... 26580................ Huntington-Ashland, WV-KY- 0.9009 0.9310 OH. Boyd County, KY........... Greenup County, KY........ Lawrence County, OH....... Cabell County, WV......... Wayne County, WV.......... 26620................ Huntsville, AL............. 0.9027 0.9323 Limestone County, AL...... Madison County, AL........ 26820................ Idaho Falls, ID............ 0.9300 0.9515 Bonneville County, ID..... Jefferson County, ID...... 26900................ \1\ Indianapolis-Carmel, IN 0.9757 0.9833 Boone County, IN.......... Brown County, IN.......... Hamilton County, IN....... Hancock County, IN........ Hendricks County, IN......

[[Continued on page 24245]]

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

[[pp. 24245-24294]] Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2007 Rates

[[Continued from page 24244]]

[[Page 24245]]

Johnson County, IN........ Marion County, IN......... Morgan County, IN......... Putnam County, IN......... Shelby County, IN......... 26980................ Iowa City, IA.............. 0.9726 0.9812 Johnson County, IA........ Washington County, IA..... 27060................ Ithaca, NY................. 0.9883 0.9920 Tompkins County, NY....... 27100................ Jackson, MI................ 0.9562 0.9698 Jackson County, MI........ 27140................ Jackson, MS................ 0.8278 0.8786 Copiah County, MS......... Hinds County, MS.......... Madison County, MS........ Rankin County, MS......... Simpson County, MS........ 0.8860 0.9205 27180................ Jackson, TN................ Chester County, TN........ Madison County, TN........ 27260................ \1\ Jacksonville, FL....... 0.9046 0.9336 Baker County, FL.......... Clay County, FL........... Duval County, FL.......... Nassau County, FL......... St. Johns County, FL...... 27340................ \2\ Jacksonville, NC....... 0.8607 0.9024 Onslow County, NC......... 27500................ Janesville, WI............. 0.9685 0.9783 Rock County, WI........... 27620................ Jefferson City, MO......... 0.8341 0.8832 Callaway County, MO....... Cole County, MO........... Moniteau County, MO....... Osage County, MO.......... 27740................ Johnson City, TN........... 0.8070 0.8634 Carter County, TN......... Unicoi County, TN......... Washington County, TN..... 27780................ Johnstown, PA.............. 0.8621 0.9034 Cambria County, PA........ 27860................ Jonesboro, AR.............. 0.7952 0.8548 Craighead County, AR...... Poinsett County, AR....... 27900................ Joplin, MO................. 0.8620 0.9033 Jasper County, MO......... Newton County, MO......... 28020................ Kalamazoo-Portage, MI...... 1.0737 1.0499 Kalamazoo County, MI...... Van Buren County, MI...... 28100................ Kankakee-Bradley, IL....... 1.0005 1.0003 Kankakee County, IL....... 28140................ \1\ Kansas City, MO-KS..... 0.9501 0.9656 Franklin County, KS....... Johnson County, KS........ Leavenworth County, KS.... Linn County, KS........... Miami County, KS.......... Wyandotte County, KS...... Bates County, MO.......... Caldwell County, MO....... Cass County, MO........... Clay County, MO........... Clinton County, MO........ Jackson County, MO........ Lafayette County, MO...... Platte County, MO......... Ray County, MO............ 28420................ \2\ Kennewick-Richland-

1.0440 1.0299 Pasco, WA.

[[Page 24246]]

Benton County, WA......... Franklin County, WA....... 28660................ Killeen-Temple-Fort Hood, 0.9131 0.9396 TX. Bell County, TX........... Coryell County, TX........ Lampasas County, TX....... 28700................ Kingsport-Bristol-Bristol, 0.8062 0.8628 TN-VA. Hawkins County, TN........ Sullivan County, TN....... Bristol City, VA.......... Scott County, VA.......... Washington County, VA..... 28740................ Kingston, NY............... 0.9387 0.9576 Ulster County, NY......... 28940................ Knoxville, TN.............. 0.8278 0.8786 Anderson County, TN....... Blount County, TN......... Knox County, TN........... Loudon County, TN......... Union County, TN.......... 29020................ Kokomo, IN................. 0.9494 0.9651 Howard County, IN......... Tipton County, IN......... 29100................ \2\ La Crosse, WI-MN (WI

0.9466 0.9631 Hospitals). Houston County, MN........ La Crosse County, WI...... 29100................ La Crosse, WI-MN (MN

0.9427 0.9604 Hospitals). Houston County, MN........ La Crosse County, WI...... 29140................ Lafayette, IN.............. 0.8957 0.9273 Benton County, IN......... Carroll County, IN........ Tippecanoe County, IN..... 29180................ Lafayette, LA.............. 0.8300 0.8802 Lafayette Parish, LA...... St. Martin Parish, LA..... 29340................ Lake Charles, LA........... 0.7934 0.8534 Calcasieu Parish, LA...... Cameron Parish, LA........ 29400................ Lake County-Kenosha County, 1.0408 1.0278 IL-WI. Lake County, IL........... Kenosha County, WI........ 29460................ Lakeland, FL............... 0.8908 0.9239 Polk County, FL........... 29540................ Lancaster, PA.............. 0.9768 0.9841 Lancaster County, PA...... 29620................ Lansing-East Lansing, MI... 1.0096 1.0066 Clinton County, MI........ Eaton County, MI.......... Ingham County, MI......... 29700................ \2\ Laredo, TX............. 0.8003 0.8585 Webb County, TX........... 29740................ Las Cruces, NM............. 0.9270 0.9494 Dona Ana County, NM....... 29820................ \1\ Las Vegas-Paradise, NV. 1.1417 1.0950 Clark County, NV.......... 29940................ Lawrence, KS............... 0.8346 0.8835 Douglas County, KS........ 30020................ Lawton, OK................. 0.8116 0.8668 Comanche County, OK....... 30140................ Lebanon, PA................ 0.8886 0.9223 Lebanon County, PA........ 30300................ Lewiston, ID-WA (ID

0.9853 0.9899 Hospitals). Nez Perce County, ID...... Asotin County, WA......... 30300................ \2\ Lewiston, ID-WA (WA

1.0440 1.0299 Hospitals). Nez Perce County, ID...... Asotin County, WA......... 30340................ Lewiston-Auburn, ME........ 0.9141 0.9403 Androscoggin County, ME...

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30460................ Lexington-Fayette, KY...... 0.9168 0.9422 Bourbon County, KY........ Clark County, KY.......... Fayette County, KY........ Jessamine County, KY...... Scott County, KY.......... Woodford County, KY....... 30620................ Lima, OH................... 0.9060 0.9346 Allen County, OH.......... 30700................ Lincoln, NE................ 1.0084 1.0057 Lancaster County, NE...... Seward County, NE......... 30780................ Little Rock-North Little

0.8918 0.9246 Rock, AR. Faulkner County, AR....... Grant County, AR.......... Lonoke County, AR......... Perry County, AR.......... Pulaski County, AR........ Saline County, AR......... 30860................ Logan, UT-ID............... 0.9049 0.9339 Franklin County, ID....... Cache County, UT.......... 30980................ Longview, TX............... 0.8905 0.9237 Gregg County, TX.......... Rusk County, TX........... Upshur County, TX......... 31020................ \2\ Longview, WA........... 1.0440 1.0299 Cowlitz County, WA........ 31084................ \1\ \3\ Los Angeles-Long

1.1762 1.1175 Beach-Glendale, CA. Los Angeles County, CA.... 31140................ \1\ Louisville-Jefferson

0.9137 0.9401 County, KY-IN. Clark County, IN.......... Floyd County, IN.......... Harrison County, IN....... Washington County, IN..... Bullitt County, KY........ Henry County, KY.......... Jefferson County, KY...... Meade County, KY.......... Nelson County, KY......... Oldham County, KY......... Shelby County, KY......... Spencer County, KY........ Trimble County, KY........ 31180................ Lubbock, TX................ 0.8626 0.9037 Crosby County, TX......... Lubbock County, TX........ 31340................ Lynchburg, VA.............. 0.8716 0.9102 Amherst County, VA........ Appomattox County, VA..... Bedford County, VA........ Campbell County, VA....... Bedford City, VA.......... Lynchburg City, VA........ 31420................ Macon, GA.................. 0.9554 0.9692 Bibb County, GA........... Crawford County, GA....... Jones County, GA.......... Monroe County, GA......... Twiggs County, GA......... 31460................ \2\ Madera, CA............. 1.1291 1.0867 Madera County, CA......... 31540................ Madison, WI................ 1.0731 1.0495 Columbia County, WI....... Dane County, WI........... Iowa County, WI........... 31700................ \2\ Manchester-Nashua, NH.. 1.1665 1.1112 Hillsborough County, NH... Merrimack County, NH...... 31900................ Mansfield, OH.............. 0.9298 0.9514

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Richland County, OH....... 32420................ Mayag[uuml]ez, PR.......... 0.3856 0.5207 Hormigueros Municipio, PR. Mayag[uuml]ez Municipio, PR. 32580................ McAllen-Edinburg-Mission, 0.8790 0.9155 TX. Hidalgo County, TX........ 32780................ Medford, OR................ 1.0836 1.0565 Jackson County, OR........ 32820................ \1\ Memphis, TN-MS-AR...... 0.9367 0.9562 Crittenden County, AR..... DeSoto County, MS......... Marshall County, MS....... Tate County, MS........... Tunica County, MS......... Fayette County, TN........ Shelby County, TN......... Tipton County, TN......... 32900................ Merced, CA................. 1.1421 1.0953 Merced County, CA......... 33124................ \1\ Miami-Miami Beach-

0.9825 0.9880 Kendall, FL. Miami-Dade County, FL..... 33140................ Michigan City-La Porte, IN. 0.9093 0.9370 LaPorte County, IN........ 33260................ Midland, TX................ 0.9802 0.9864 Midland County, TX........ 33340................ \1\ Milwaukee-Waukesha-West 1.0241 1.0164 Allis, WI. Milwaukee County, WI...... Ozaukee County, WI........ Washington County, WI..... Waukesha County, WI....... 33460................ \1\ Minneapolis-St. Paul- 1.0943 1.0637 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............... 0.8909 0.9239 Missoula County, MT....... 33660................ Mobile, AL................. 0.7955 0.8550 Mobile County, AL......... 33700................ Modesto, CA................ 1.1731 1.1155 Stanislaus County, CA..... 33740................ Monroe, LA................. 0.8015 0.8594 Ouachita Parish, LA....... Union Parish, LA.......... 33780................ Monroe, MI................. 0.9715 0.9804 Monroe County, MI......... 33860................ Montgomery, AL............. 0.8035 0.8609 Autauga County, AL........ Elmore County, AL......... Lowndes County, AL........ Montgomery County, AL..... 34060................ Morgantown, WV............. 0.8449 0.8910 Monongalia County, WV..... Preston County, WV........ 34100................ \2\ Morristown, TN......... 0.7957 0.8551 Grainger County, TN....... Hamblen County, TN........ Jefferson County, TN...... 34580................ Mount Vernon-Anacortes, WA. 1.0514 1.0349 Skagit County, WA......... 34620................ \2\ Muncie, IN............. 0.8479 0.8932

[[Page 24249]]

Delaware County, IN....... 34740................ \3\ Muskegon-Norton Shores, 0.9961 0.9973 MI. Muskegon County, MI....... 34820................ Myrtle Beach-Conway-North 0.8819 0.9175 Myrtle Beach, SC. Horry County, SC.......... 34900................ Napa, CA................... 1.3484 1.2272 Napa County, CA........... 34940................ Naples-Marco Island, FL.... 0.9935 0.9955 Collier County, FL........ 34980................ \1\ Nashville-Davidson-

0.9853 0.9899 Murfreesboro, TN. Cannon County, TN......... Cheatham County, TN....... Davidson County, TN....... Dickson County, TN........ Hickman County, TN........ Macon County, TN.......... Robertson County, TN...... Rutherford County, TN..... Smith County, TN.......... Sumner County, TN......... Trousdale County, TN...... Williamson County, TN..... Wilson County, TN......... 35004................ \1\ \3\ Nassau-Suffolk, NY. 1.2701 1.1779 Nassau County, NY......... Suffolk County, NY........ 35080................ \1\ Newark-Union, NJ-PA.... 1.1886 1.1256 Essex County, NJ.......... Hunterdon County, NJ...... Morris County, NJ......... Sussex County, NJ......... Union County, NJ.......... Pike County, PA........... 35300................ New Haven-Milford, CT...... 1.2093 1.1390 New Haven County, CT...... 35380................ \1\ New Orleans-Metairie- 0.8855 0.9201 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\ \3\ New York-White

1.3215 1.2103 Plains-Wayne, NY-NJ. Bergen County, NJ......... Hudson County, NJ......... Passaic County, NJ........ Bronx County, NY.......... Kings County, NY.......... New York County, NY....... Putnam County, NY......... Queens County, NY......... Richmond County, NY....... Rockland County, NY....... Westchester County, NY.... 35660................ \2\ Niles-Benton Harbor, MI 0.9055 0.9343 Berrien County, MI........ 35980................ Norwich-New London, CT.... 1.2020 1.1343 New London County, CT..... 36084................ \1\ Oakland-Fremont-

1.5669 1.3601 Hayward, CA. Alameda County, CA........ Contra Costa County, CA... 36100................ Ocala, FL.................. 0.8904 0.9236 Marion County, FL......... 36140................ \2\ Ocean City, NJ......... 1.1226 1.0824 Cape May County, NJ....... 36220................ Odessa, TX................. 1.0119 1.0081 Ector County, TX.......... 36260................ Ogden-Clearfield, UT....... 0.9021 0.9319 Davis County, UT..........

[[Page 24250]]

Morgan County, UT......... Weber County, UT.......... 36420................ \1\ Oklahoma City, OK...... 0.8857 0.9202 Canadian County, OK....... Cleveland County, OK...... Grady County, OK.......... Lincoln County, OK........ Logan County, OK.......... McClain County, OK........ Oklahoma County, OK....... 36500................ Olympia, WA................ 1.1096 1.0738 Thurston County, WA....... 36540................ Omaha-Council Bluffs, NE-IA 0.9453 0.9622 Harrison County, IA....... Mills County, IA.......... Pottawattamie County, IA.. Cass County, NE........... Douglas County, NE........ Sarpy County, NE.......... Saunders County, NE....... Washington County, NE..... 36740................ \1\ Orlando-Kissimmee, FL.. 0.9409 0.9591 Lake County, FL........... Orange County, FL......... Osceola County, FL........ Seminole County, FL....... 36780................ \2\ Oshkosh-Neenah, WI..... 0.9466 0.9631 Winnebago County, WI...... 36980................ Owensboro, KY.............. 0.8780 0.9148 Daviess County, KY........ Hancock County, KY........ McLean County, KY......... 37100................ Oxnard-Thousand Oaks-

1.1583 1.1059 Ventura, CA. Ventura County, CA........ 37340................ Palm Bay-Melbourne-

0.9440 0.9613 Titusville, FL. Brevard County, FL........ 37460................ \2\ Panama City-Lynn Haven, 0.8609 0.9025 FL. Bay County, FL............ 37620................ Parkersburg-Marietta-

0.7964 0.8556 Vienna, WV-OH (WV Hospitals). Washington County, OH..... Pleasants County, WV...... Wirt County, WV........... Wood County, WV........... 37620................ \2\ Parkersburg-Marietta- 0.8673 0.9071 Vienna, WV-OH (OH Hospitals). Washington County, OH..... Pleasants County, WV...... Wirt County, WV........... Wood County, WV........... 37700................ Pascagoula, MS............. 0.8229 0.8750 George County, MS......... Jackson County, MS........ 37860................ \2\ Pensacola-Ferry Pass- 0.8609 0.9025 Brent, FL. Escambia County, FL....... Santa Rosa County, FL..... 37900................ Peoria, IL................. 0.8973 0.9285 Marshall County, IL....... Peoria County, IL......... Stark County, IL.......... Tazewell County, IL....... Woodford County, IL....... 37964................ \1\ Philadelphia, PA....... 1.1009 1.0680 Bucks County, PA.......... Chester County, PA........ Delaware County, PA....... Montgomery County, PA..... Philadelphia County, PA... 38060................ \1\ Phoenix-Mesa-

1.0307 1.0209 Scottsdale, AZ. Maricopa County, AZ....... Pinal County, AZ.......... 38220................ Pine Bluff, AR............. 0.8423 0.8891

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Cleveland County, AR...... Jefferson County, AR...... Lincoln County, AR........ 38300................ \1\ Pittsburgh, PA......... 0.8671 0.9070 Allegheny County, PA...... Armstrong County, PA...... Beaver County, PA......... Butler County, PA......... Fayette County, PA........ Washington County, PA..... Westmoreland County, PA... 38340................ \2\ Pittsfield, MA......... 1.0664 1.0450 Berkshire County, MA...... 38540................ Pocatello, ID.............. 0.9400 0.9585 Bannock County, ID........ Power County, ID.......... 38660................ Ponce, PR.................. 0.4852 0.6094 Juana D[iacute]az Municipio, PR. Ponce Municipio, PR....... Villalba Municipio, PR.... 38860................ Portland-South Portland-

0.9916 0.9942 Biddeford, ME. Cumberland County, ME..... Sagadahoc County, ME...... York County, ME........... 38900................ \1\ Portland-Vancouver-

1.1405 1.0942 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, 0.9857 0.9902 FL. Martin County, FL......... St. Lucie County, FL...... 39100................ Poughkeepsie-Newburgh-

1.0913 1.0617 Middletown, NY. Dutchess County, NY....... Orange County, NY......... 39140................ Prescott, AZ............... 0.9858 0.9903 Yavapai County, AZ........ 39300................ \1\ Providence-New Bedford- 1.0791 1.0535 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............. 0.9537 0.9681 Juab County, UT........... Utah County, UT........... 39380................ \2\ Pueblo, CO............. 0.9331 0.9537 Pueblo County, CO......... 39460................ Punta Gorda, FL............ 0.9432 0.9607 Charlotte County, FL...... 39540................ \2\ Racine, WI............. 0.9466 0.9631 Racine County, WI......... 39580................ Raleigh-Cary, NC........... 0.9855 0.9900 Franklin County, NC....... Johnston County, NC....... Wake County, NC........... 39660................ Rapid City, SD............. 1.0359 1.0244 Meade County, SD.......... Pennington County, SD..... 39740................ Reading, PA................ 0.9642 0.9753 Berks County, PA.......... 39820................ Redding, CA................ 1.3205 1.2097 Shasta County, CA......... 39900................ Reno-Sparks, NV............ 1.1975 1.1314 Storey County, NV......... Washoe County, NV.........

[[Page 24252]]

40060................ \1\ Richmond, VA........... 0.9174 0.9427 Amelia County, VA......... Caroline County, VA....... Charles City County, VA... Chesterfield County, VA... Cumberland County, VA..... Dinwiddie County, VA...... Goochland County, VA...... Hanover County, VA........ Henrico County, VA........ King and Queen County, VA. King William County, VA... Louisa County, VA......... New Kent County, VA....... Powhatan County, VA....... Prince George County, VA.. Sussex County, VA......... Colonial Heights City, VA. Hopewell City, VA......... Petersburg City, VA....... Richmond City, VA......... 40140................ \1\ \2\ Riverside-San

1.1291 1.0867 Bernardino-Ontario, CA. Riverside County, CA...... San Bernardino County, CA. 40220................ Roanoke, VA................ 0.8677 0.9074 Botetourt County, VA...... Craig County, VA.......... Franklin County, VA....... Roanoke County, VA........ Roanoke City, VA.......... Salem City, VA............ 40340................ Rochester, MN.............. 1.1246 1.0837 Dodge County, MN.......... Olmsted County, MN........ Wabasha County, MN........ 40380................ \1\ Rochester, NY.......... 0.9007 0.9309 Livingston County, NY..... Monroe County, NY......... Ontario County, NY........ Orleans County, NY........ Wayne County, NY.......... 40420................ Rockford, IL............... 0.9987 0.9991 Boone County, IL.......... Winnebago County, IL...... 40484................ \2\ Rockingham County-

1.1665 1.1112 Strafford County, NH. Rockingham County, NH..... Strafford County, NH...... 40580................ Rocky Mount, NC............ 0.8869 0.9211 Edgecombe County, NC...... Nash County, NC........... 40660................ Rome, GA................... 0.9307 0.9520 Floyd County, GA.......... 40900................ \1\ Sacramento--Arden-

1.3350 1.2188 Arcade--Roseville, CA. El Dorado County, CA...... Placer County, CA......... Sacramento County, CA..... Yolo County, CA........... 40980................ \2\ Saginaw-Saginaw

0.9055 0.9343 Township North, MI. Saginaw County, MI........ 41060................ St. Cloud, MN.............. 1.0438 1.0298 Benton County, MN......... Stearns County, MN........ 41100................ St. George, UT............. 0.9295 0.9512 Washington County, UT..... 41140................ St. Joseph, MO-KS.......... 1.0174 1.0119 Doniphan County, KS....... Andrew County, MO......... Buchanan County, MO....... DeKalb County, MO......... 41180................ \1\ St. Louis, MO-IL....... 0.9017 0.9316

[[Page 24253]]

Bond County, IL........... Calhoun County, IL........ Clinton County, IL........ Jersey County, IL......... Macoupin County, IL....... Madison County, IL........ Monroe County, IL......... St. Clair County, IL...... Crawford County, MO....... Franklin County, MO....... Jefferson County, MO...... Lincoln County, MO........ St. Charles County, MO.... St. Louis County, MO...... Warren County, MO......... Washington County, MO..... St. Louis City, MO........ 41420................ Salem, OR.................. 1.0452 1.0307 Marion County, OR......... Polk County, OR........... 41500................ Salinas, CA................ 1.4457 1.2871 Monterey County, CA....... 41540................ Salisbury, MD.............. 0.8958 0.9274 Somerset County, MD....... Wicomico County, MD....... 41620................ Salt Lake City, UT......... 0.9421 0.9600 Salt Lake County, UT...... Summit County, UT......... Tooele County, UT......... 41660................ San Angelo, TX............. 0.8385 0.8864 Irion County, TX.......... Tom Green County, TX...... 41700................ \1\ San Antonio, TX........ 0.8859 0.9204 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 1.1371 1.0920 Marcos, CA. San Diego County, CA...... 41780................ Sandusky, OH............... 0.9328 0.9535 Erie County, OH........... 41884................ \1\ San Francisco-San Mateo- 1.5049 1.3230 Redwood City, CA. Marin County, CA.......... San Francisco County, CA.. San Mateo County, CA...... 41900................ San Germ[aacute]n-Cabo

0.4884 0.6122 Rojo, PR. Cabo Rojo Municipio, PR... Lajas Municipio, PR....... Sabana Grande Municipio, PR. San Germ[aacute]n Municipio, PR. 41940................ \1\ San Jose-Sunnyvale-

1.5281 1.3369 Santa Clara, CA. San Benito County, CA..... Santa Clara County, CA.... 41980................ \1\ San Juan-Caguas-

0.4396 0.5696 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.......

[[Page 24254]]

Ciales Municipio, PR...... Cidra Municipio, PR....... Comer[iacute]o Municipio, PR. Corozal Municipio, PR..... Dorado Municipio, PR...... Florida Municipio, PR..... Guaynabo Municipio, PR.... Gurabo Municipio, PR...... Hatillo Municipio, PR..... Humacao Municipio, PR..... Juncos Municipio, PR...... Las Piedras Municipio, PR. Lo[iacute]za Municipio, PR Manat[iacute] Municipio, PR. Maunabo Municipio, PR..... Morovis Municipio, PR..... Naguabo Municipio, PR..... Naranjito Municipio, PR... Orocovis Municipio, PR.... Quebradillas Municipio, PR R[iacute]o Grande Municipio, PR. San Juan Municipio, PR.... San Lorenzo Municipio, PR. Toa Alta Municipio, PR.... Toa Baja Municipio, PR.... Trujillo Alto Municipio, PR. Vega Alta Municipio, PR... Vega Baja Municipio, PR... Yabucoa Municipio, PR..... 42020................ San Luis Obispo-Paso

1.1616 1.1080 Robles, CA. San Luis Obispo County, CA 42044................ \1\ \2\ Santa Ana-Anaheim- 1.1291 1.0867 Irvine, CA. Orange County, CA......... 42060................ \2\ Santa Barbara-Santa

1.1291 1.0867 Maria, CA. Santa Barbara County, CA.. 42100................ Santa Cruz-Watsonville, CA. 1.5509 1.3506 Santa Cruz County, CA..... 42140................ Santa Fe, NM............... 1.0821 1.0555 Santa Fe County, NM....... 42220................ Santa Rosa-Petaluma, CA.... 1.4459 1.2872 Sonoma County, CA......... 42260................ Sarasota-Bradenton-Venice, 0.9866 0.9908 FL. Manatee County, FL........ Sarasota County, FL....... 42340................ Savannah, GA............... 0.9089 0.9367 Bryan County, GA.......... Chatham County, GA........ Effingham County, GA...... 42540................ Scranton--Wilkes-Barre, PA. 0.8503 0.8949 Lackawanna County, PA..... Luzerne County, PA........ Wyoming County, PA........ 42644................ \1\ Seattle-Bellevue-

1.1438 1.0964 Everett, WA. King County, WA........... Snohomish County, WA...... 42680................ Sebastian-Vero Beach, FL... 0.9604 0.9727 Indian River County, FL... 43100................ \2\ Sheboygan, WI.......... 0.9466 0.9631 Sheboygan County, WI...... 43300................ Sherman-Denison, TX........ 0.8521 0.8962 Grayson County, TX........ 43340................ Shreveport-Bossier City, LA 0.8879 0.9218 Bossier Parish, LA........ Caddo Parish, LA.......... De Soto Parish, LA........ 43580................ Sioux City, IA-NE-SD....... 0.9201 0.9446 Woodbury County, IA....... Dakota County, NE......... Dixon County, NE.......... Union County, SD..........

[[Page 24255]]

43620................ Sioux Falls, SD............ 0.9559 0.9696 Lincoln County, SD........ McCook County, SD......... Minnehaha County, SD...... Turner County, SD......... 43780................ South Bend-Mishawaka, IN-MI 0.9677 0.9778 St. Joseph County, IN..... Cass County, MI........... 43900................ Spartanburg, SC............ 0.9192 0.9439 Spartanburg County, SC.... 44060................ Spokane, WA................ 1.0448 1.0305 Spokane County, WA........ 44100................ Springfield, IL............ 0.8900 0.9233 Menard County, IL......... Sangamon County, IL....... 44140................ \2\ Springfield, MA........ 1.0664 1.0450 Franklin County, MA....... Hampden County, MA........ Hampshire County, MA...... 44180................ Springfield, MO............ 0.8490 0.8940 Christian County, MO...... Dallas County, MO......... Greene County, MO......... Polk County, MO........... Webster County, MO........ 44220................ \2\ Springfield, OH........ 0.8673 0.9071 Clark County, OH.......... 44300................ State College, PA.......... 0.8804 0.9165 Centre County, PA......... 44700................ Stockton, CA............... 1.1483 1.0993 San Joaquin County, CA.... 44940................ \2\ Sumter, SC............. 0.8604 0.9022 Sumter County, SC......... 45060................ Syracuse, NY............... 0.9723 0.9809 Madison County, NY........ Onondaga County, NY....... Oswego County, NY......... 45104................ Tacoma, WA................. 1.0907 1.0613 Pierce County, WA......... 45220................ Tallahassee, FL............ 0.9316 0.9526 Gadsden County, FL........ Jefferson County, FL...... Leon County, FL........... Wakulla County, FL........ 45300................ \1\ Tampa-St. Petersburg- 0.9249 0.9479 Clearwater, FL. Hernando County, FL....... Hillsborough County, FL... Pasco County, FL.......... Pinellas County, FL....... 45460................ Terre Haute, IN............ 0.8663 0.9064 Clay County, IN........... Sullivan County, IN....... Vermillion County, IN..... Vigo County, IN........... 45500................ Texarkana, TX-Texarkana, AR 0.8133 0.8680 Miller County, AR......... Bowie County, TX.......... 45780................ Toledo, OH................. 0.9588 0.9716 Fulton County, OH......... Lucas County, OH.......... Ottawa County, OH......... Wood County, OH........... 45820................ Topeka, KS................. 0.8738 0.9118 Jackson County, KS........ Jefferson County, KS...... Osage County, KS.......... Shawnee County, KS........ Wabaunsee County, KS...... 45940................ \2\ Trenton-Ewing, NJ...... 1.1226 1.0824 Mercer County, NJ.........

[[Page 24256]]

46060................ Tucson, AZ................. 0.9239 0.9472 Pima County, AZ........... 46140................ Tulsa, OK.................. 0.8146 0.8690 Creek County, OK.......... Okmulgee County, OK....... Osage County, OK.......... Pawnee County, OK......... Rogers County, OK......... Tulsa County, OK.......... Wagoner County, OK........ 46220................ Tuscaloosa, AL............. 0.8644 0.9050 Greene County, AL......... Hale County, AL........... Tuscaloosa County, AL..... 46340................ Tyler, TX.................. 0.8854 0.9200 Smith County, TX.......... 46540................ Utica-Rome, NY............. 0.8422 0.8890 Herkimer County, NY....... Oneida County, NY......... 46660................ Valdosta, GA............... 0.8340 0.8831 Brooks County, GA......... Echols County, GA......... Lanier County, GA......... Lowndes County, GA........ 46700................ Vallejo-Fairfield, CA...... 1.5154 1.3293 Solano County, CA......... 47020................ Victoria, TX............... 0.8554 0.8986 Calhoun County, TX........ Goliad County, TX......... Victoria County, TX....... 47220................ \2\ Vineland-Millville-

1.1226 1.0824 Bridgeton, NJ. Cumberland County, NJ..... 47260................ \1\ Virginia Beach-Norfolk- 0.8840 0.9190 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................ \1\ Visalia-Porterville, CA 1.1291 1.0867 Tulare County, CA......... 47380................ Waco, TX................... 0.8653 0.9057 McLennan County, TX....... 47580................ Warner Robins, GA.......... 0.8402 0.8876 Houston County, GA........ 47644................ \1\ Warren-Troy-Farmington 1.0123 1.0084 Hills, MI. Lapeer County, MI......... Livingston County, MI..... Macomb County, MI......... Oakland County, MI........ St. Clair County, MI...... 47894................ \1\ Washington-Arlington- 1.1076 1.0725 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.......

[[Page 24257]]

Loudoun County, VA........ Prince William County, VA. Spotsylvania County, VA... Stafford County, VA....... Warren County, VA......... Alexandria City, VA....... Fairfax City, VA.......... Falls Church City, VA..... Fredericksburg City, VA... Manassas City, VA......... Manassas Park City, VA.... Jefferson County, WV...... 47940................ \2\ Waterloo-Cedar Falls, 0.8696 0.9088 IA. Black Hawk County, IA..... Bremer County, IA......... Grundy County, IA......... 48140................ Wausau, WI................. 0.9799 0.9862 Marathon County, WI....... 48260................ Weirton-Steubenville, WV-OH 0.8072 0.8636 (WV Hospitals). Jefferson County, OH...... Brooke County, WV......... Hancock County, WV........ 48260................ \2\ Weirton-Steubenville, 0.8673 0.9071 WV-OH (OH Hospitals). Jefferson County, OH...... Brooke County, WV......... Hancock County, WV........ 48300................ \2\ Wenatchee, WA.......... 1.0440 1.0299 Chelan County, WA......... Douglas County, WA........ 48424................ \1\ West Palm Beach-Boca

0.9642 0.9753 Raton-Boynton Beach, FL. Palm Beach County, FL..... 48540................ \2\ Wheeling, WV-OH (WV

0.7637 0.8314 Hospitals). Belmont County, OH........ Marshall County, WV....... Ohio County, WV........... 48540................ \2\ Wheeling, WV-OH (OH

0.8673 0.9071 Hospitals). Belmont County, OH........ Marshall County, WV....... Ohio County, WV........... 48620................ Wichita, KS................ 0.9093 0.9370 Butler County, KS......... Harvey County, KS......... Sedgwick County, KS....... Sumner County, KS......... 48660................ Wichita Falls, TX.......... 0.8360 0.8846 Archer County, TX......... Clay County, TX........... Wichita County, TX........ 48700................ \2\ Williamsport, PA....... 0.8330 0.8824 Lycoming County, PA....... 48864................ Wilmington, DE-MD-NJ (DE, 1.0878 1.0593 MD Hospitals). New Castle County, DE..... Cecil County, MD.......... Salem County, NJ.......... 48864................ \2\ Wilmington, DE-MD-NJ

1.1226 1.0824 (NJ Hospitals). New Castle County, DE..... Cecil County, MD.......... Salem County, NJ.......... 48900................ Wilmington, NC............. 0.9840 0.9890 Brunswick County, NC...... New Hanover County, NC.... Pender County, NC......... 49020................ Winchester, VA-WV.......... 1.0099 1.0068 Frederick County, VA...... Winchester City, VA....... Hampshire County, WV...... 49180................ Winston-Salem, NC.......... 0.9300 0.9515 Davie County, NC.......... Forsyth County, NC........ Stokes County, NC.........

[[Page 24258]]

Yadkin County, NC......... 49340................ Worcester, MA.............. 1.0747 1.0506 Worcester County, MA...... 49420................ \2\ Yakima, WA............. 1.0440 1.0299 Yakima County, WA......... 49500................ Yauco, PR.................. 0.3861 0.5212 Gu[aacute]nica Municipio, PR. Guayanilla Municipio, PR.. Pe[ntilde]uelas Municipio, PR. Yauco Municipio, PR....... 49620................ York-Hanover, PA........... 0.9416 0.9596 York County, PA........... 49660................ Youngstown-Warren-Boardman, 0.8815 0.9173 OH-PA. Mahoning County, OH....... Trumbull County, OH....... Mercer County, PA......... 49700................ \2\ Yuba City, CA.......... 1.1291 1.0867 Sutter County, CA......... Yuba County, CA........... 49740................ Yuma, AZ................... 0.9179 0.9430 Yuma County, AZ ..........

\1\ Large urban area. \2\ Hospitals geographically located in the area are assigned the statewide rural wage index for FY 2007. \3\ For this area, the wage index and GAF on this table are only effective from October 1, 2006 through March 31, 2007. See Table 4A-2 for the values that are effective from April 1 through September 30, 2007.

Table 4A-2.--Wage Index and Capital Geographic Adjustment Factor (GAF) for Certain Urban Areas by CBSA for the Period April 1 Through September 30, 2007*

Urban area (constituent Wage CBSA code

counties)

index GAF

11460................ Ann Arbor, MI.............. 1.0853 1.0577 Washtenaw County, MI 31084................ Los Angeles-Long Beach-

1.1762 1.1175 Glendale, CA. Los Angeles County, CA.... 34740................ Muskegon-Norton Shores, MI. 0.9961 0.9973 Muskegon County, MI....... 35004................ \1\ Nassau-Suffolk, NY..... 1.2701 1.1779 Nassau County, NY......... Suffolk County, NY........ 35644................ \1\ New York-White Plains- 1.3215 1.2103 Wayne, NY-NJ. Bergen County, NJ......... Hudson County, NJ......... Passaic County, NJ........ Bronx County, NY.......... Kings County, NY.......... New York County, NY....... Putnam County, NY......... Queens County, NY......... Richmond County, NY....... Rockland County, NY....... Westchester County, NY ...

\1\ Large urban area. * See Table 4A-1 for the wage index and GAF that are effective from October 1, 2006 through March 31, 2007. (For areas that are not listed on this table, the wage index and GAF on Table 4A-1 are effective for the entire FY 2007.)

Table 4B.--Wage Index and Capital Georgraphic Adjustment (GAF) for Rural Areas by CBSA-FY 2007

Wage CBSA code

Nonurban area

index GAF

01................... Alabama.................... 0.7670 0.8339 02................... Alaska..................... 1.0669 1.0453 03................... Arizona.................... 0.9158 0.9415 04................... Arkansas................... 0.7366 0.8111 05................... California................. 1.1291 1.0867 06................... Colorado................... 0.9331 0.9537 07................... Connecticut................ 1.1750 1.1168

[[Page 24259]]

08................... Delaware................... 0.9843 0.9892 10................... Florida.................... 0.8609 0.9025 11................... Georgia.................... 0.7577 0.8270 12................... Hawaii..................... 1.0502 1.0341 13................... Idaho...................... 0.8674 0.9072 14................... Illinois................... 0.8334 0.8827 15................... Indiana.................... 0.8479 0.8932 16................... Iowa....................... 0.8696 0.9088 17................... Kansas..................... 0.8017 0.8595 18................... Kentucky................... 0.7793 0.8430 19................... Louisiana.................. 0.7487 0.8202 20................... Maine...................... 0.8399 0.8874 21................... Maryland................... 0.8946 0.9266 22................... Massachusetts \1\.......... 1.0664 1.0450 23................... Michigan................... 0.9055 0.9343 24................... Minnesota.................. 0.9256 0.9484 25................... Mississippi................ 0.7579 0.8271 26................... Missouri................... 0.8206 0.8734 27................... Montana.................... 0.8591 0.9012 28................... Nebraska................... 0.8691 0.9084 29................... Nevada..................... 0.8967 0.9281 30................... New Hampshire.............. 1.1665 1.1112 31................... New Jersey \1\............. 1.1226 1.0824 32................... New Mexico................. 0.8353 0.8841 33................... New York................... 0.8267 0.8778 34................... North Carolina............. 0.8607 0.9024 35................... North Dakota............... 0.7237 0.8014 36................... Ohio....................... 0.8673 0.9071 37................... Oklahoma................... 0.7663 0.8334 38................... Oregon..................... 0.9826 0.9881 39................... Pennsylvania............... 0.8330 0.8824 40................... Puerto Rico \1\............ ......... ......... 41................... Rhode Island \1\........... 1.0791 1.0535 42................... South Carolina............. 0.8604 0.9022 43................... South Dakota............... 0.8485 0.8936 44................... Tennessee.................. 0.7957 0.8551 45................... Texas...................... 0.8003 0.8585 46................... Utah....................... 0.8163 0.8702 47................... Vermont.................... 1.0986 1.0665 49................... Virginia................... 0.7966 0.8558 50................... Washington................. 1.0440 1.0299 51................... West Virginia.............. 0.7637 0.8314 52................... Wisconsin.................. 0.9466 0.9631 53................... Wyoming.................... 0.9303 0.9517

\1\ All counties in the State or Territory are classified as urban, with the exception of Massachusetts. Massachusetts has area(s) designated as rural. However, no short-term, acute care hospitals were located in Rural Massachusetts during FY 2003, the base year for the FY 2007 wage index. Massachusetts, New Jersey, and Rhode Island rural floors are imputed as discussed in the FY 2005 IPPS final rule (69 FR 49109).

Table 4C-1.--Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That Are Reclassified by CBSA--FY 2007

Wage CBSA code

Area

index GAF

10180................ Abilene, TX................ 0.8051 0.8620 10420................ Akron, OH.................. 0.8737 0.9117 10580................ Albany-Schenectady-Troy, NY 0.8753 0.9128 10740................ Albuquerque, NM............ 0.9477 0.9639 10780................ Alexandria, LA............. 0.8028 0.8603 10900................ Allentown-Bethlehem-Easton, 0.9927 0.9950 PA-NJ. 11100................ Amarillo, TX............... 0.9177 0.9429 11260................ Anchorage, AK.............. 1.2062 1.1370 11460................ \1\Ann Arbor, MI........... 1.0630 1.0427 11500................ Anniston-Oxford, AL........ 0.7978 0.8567 11700................ Asheville, NC.............. 0.9110 0.9382 12020................ Athens-Clarke County, GA... 0.9707 0.9798 12060................ Atlanta-Sandy Springs-

0.9644 0.9755 Marietta, GA. 12260................ Augusta-Richmond County, GA- 0.9554 0.9692 SC.

[[Page 24260]]

12420................ Austin-Round Rock, TX...... 0.9360 0.9557 12620................ Bangor, ME................. 0.9702 0.9795 12700................ Barnstable Town, MA........ 1.2181 1.1447 12940................ Baton Rouge, LA............ 0.8102 0.8658 13020................ Bay City, MI............... 1.0040 1.0027 13644................ Bethesda-Gaithersburg-

1.1028 1.0693 Frederick, MD. 13780................ Binghamton, NY............. 0.8499 0.8946 13820................ Birmingham-Hoover, AL...... 0.8919 0.9246 13900................ Bismarck, ND............... 0.7255 0.8027 14484................ Boston-Quincy, MA.......... 1.1318 1.0885 14540................ Bowling Green, KY.......... 0.8164 0.8703 15380................ Buffalo-Niagara Falls, NY.. 0.9475 0.9637 15540................ Burlington-South

0.9355 0.9554 Burlington, VT. 15764................ Cambridge-Newton-

1.0986 1.0665 Framingham, MA (VT Hospitals). 15764................ Cambridge-Newton-

1.1665 1.1112 Framingham, MA (NH Hospitals). 16180................ Carson City, NV............ 0.9569 0.9703 16580................ Champaign-Urbana, IL....... 0.9155 0.9413 16620................ Charleston, WV............. 0.8294 0.8798 16700................ Charleston-North

0.9168 0.9422 Charleston, SC. 16740................ Charlotte-Gastonia-Concord, 0.9520 0.9669 NC-SC. 16820................ Charlottesville, VA........ 0.9732 0.9816 16860................ Chattanooga, TN-GA......... 0.8841 0.9191 16974................ Chicago-Naperville-Joliet, 1.0596 1.0404 IL. 17140................ Cincinnati-Middletown, OH- 0.9599 0.9724 KY-IN. 17300................ Clarksville, TN-KY......... 0.8094 0.8652 17460................ Cleveland-Elyria-Mentor, OH 0.9212 0.9453 17780................ College Station-Bryan, TX.. 0.9064 0.9349 17860................ Columbia, MO............... 0.8550 0.8983 17900................ Columbia, SC............... 0.8604 0.9022 17980................ Columbus, GA-AL............ 0.8256 0.8770 18140................ Columbus, OH............... 0.9919 0.9944 18700................ Corvallis, OR.............. 1.1175 1.0790 19124................ Dallas-Plano-Irving, TX.... 0.9870 0.9911 19340................ Davenport-Moline-Rock

0.8696 0.9088 Island, IA-IL. 19380................ Dayton, OH................. 0.9049 0.9339 19460................ Decatur, AL................ 0.8220 0.8744 19740................ Denver-Aurora, CO.......... 1.0805 1.0545 19780................ Des Moines-West Des Moines, 0.8976 0.9287 IA. 19804................ Detroit-Livonia-Dearborn, 1.0235 1.0160 MI. 20100................ Dover, DE.................. 0.9843 0.9892 20260................ Duluth, MN-WI.............. 1.0157 1.0107 20500................ Durham, NC................. 0.9805 0.9866 20764................ Edison, NJ................. 1.1242 1.0835 21060................ Elizabethtown, KY.......... 0.8207 0.8734 21500................ Erie, PA................... 0.8360 0.8846 21604................ Essex County, MA........... 1.1665 1.1112 21660................ Eugene-Springfield, OR..... 1.0525 1.0357 21780................ Evansville, IN-KY.......... 0.8545 0.8979 22020

Fargo, ND-MN............... 0.8485 0.8936 22180................ Fayetteville, NC........... 0.8962 0.9277 22220................ Fayetteville-Springdale-

0.8599 0.9018 Rogers, AR-MO. 22380................ Flagstaff, AZ.............. 1.1121 1.0755 22420................ Flint, MI.................. 1.0685 1.0464 22520................ Florence-Muscle Shoals, AL. 0.8008 0.8589 22540................ Fond du Lac, WI............ 0.9489 0.9647 22660................ Fort Collins-Loveland, CO.. 0.9594 0.9720 22744................ Fort Lauderdale-Pompano

1.0470 1.0320 Beach-Deerfield Beach, FL. 22900................ Fort Smith, AR-OK.......... 0.7663 0.8334 23020................ Fort Walton Beach-Crestview- 0.8609 0.9025 Destin, FL. 23060................ Fort Wayne, IN............. 0.9498 0.9653 23104................ Fort Worth-Arlington, TX... 0.9591 0.9718 23540................ Gainesville, FL............ 0.9299 0.9514 23844................ Gary, IN................... 0.9278 0.9500 24300................ Grand Junction, CO......... 1.0037 1.0025 24340................ Grand Rapids-Wyoming, MI... 0.9469 0.9633 24500................ Great Falls, MT............ 0.8781 0.9148 24540................ Greeley, CO................ 0.9636 0.9749 24580................ Green Bay, WI.............. 0.9620 0.9738 24660................ Greensboro-High Point, NC.. 0.8992 0.9298 24780................ Greenville, NC............. 0.9300 0.9515

[[Page 24261]]

24860................ Greenville, SC............. 0.9286 0.9505 25060................ Gulfport-Biloxi, MS........ 0.8607 0.9024 25420................ Harrisburg-Carlisle, PA.... 0.9263 0.9489 25540................ Hartford-West Hartford-East 1.1750 1.1168 Hartford, CT (CT Hospitals). 25540................ Hartford-West Hartford-East 1.0918 1.0620 Hartford, CT (MA Hospitals). 25860................ Hickory-Lenoir-Morganton, 0.8901 0.9234 NC. 26100................ Holland-Grand Haven, MI.... 0.9241 0.9474 26180................ Honolulu, HI............... 1.1066 1.0718 26420................ Houston-Sugar Land-Baytown, 1.0030 1.0021 TX. 26580................ Huntington-Ashland, WV-KY- 0.8759 0.9133 OH. 26620................ Huntsville, AL............. 0.8829 0.9182 26820................ Idaho Falls, ID (ID

0.9300 0.9515 Hospitals). 26820................ Idaho Falls, ID (WY

0.9303 0.9517 Hospitals). 26900................ Indianapolis-Carmel, IN.... 0.9582 0.9712 26980................ Iowa City, IA.............. 0.9568 0.9702 27060................ Ithaca, NY................. 0.9439 0.9612 27140................ Jackson, MS................ 0.8278 0.8786 27180................ Jackson, TN................ 0.8640 0.9047 27260................ Jacksonville, FL........... 0.9046 0.9336 27860................ Jonesboro, AR (AR

0.7952 0.8548 Hospitals). 27860................ Jonesboro, AR (MO

0.8206 0.8734 Hospitals). 27900................ Joplin, MO................. 0.8620 0.9033 28020................ Kalamazoo-Portage, MI...... 1.0737 1.0499 28100................ Kankakee-Bradley, IL....... 0.9728 0.9813 28140................ Kansas City, MO-KS......... 0.9501 0.9656 28420................ Kennewick-Richland-Pasco, 1.0440 1.0299 WA (WA Hospitals). 28420................ Kennewick-Richland-Pasco, 1.0033 1.0023 WA (ID Hospitals). 28700................ Kingsport-Bristol-Bristol, 0.8062 0.8628 TN-VA. 28740................ Kingston, NY............... 0.9058 0.9345 28940................ Knoxville, TN.............. 0.8278 0.8786 29180................ Lafayette, LA.............. 0.8300 0.8802 29404................ Lake County-Kenosha County, 1.0408 1.0278 IL-WI. 29460................ Lakeland, FL............... 0.8908 0.9239 29540................ Lancaster, PA.............. 0.9768 0.9841 29620................ Lansing-East Lansing, MI... 0.9823 0.9878 29740................ Las Cruces, NM............. 0.9270 0.9494 29820................ Las Vegas-Paradise, NV..... 1.1240 1.0833 30020................ Lawton, OK................. 0.8116 0.8668 30460................ Lexington-Fayette, KY...... 0.8928 0.9253 30620................ Lima, OH................... 0.9060 0.9346 30700................ Lincoln, NE................ 0.9746 0.9825 30780................ Little Rock-North Little

0.8667 0.9067 Rock, AR. 30980................ Longview, TX............... 0.8905 0.9237 31084................ \1\ Los Angeles-Long Beach- 1.1600 1.1070 Santa Ana, CA. 31140................ Louisville-Jefferson

0.9137 0.9401 County, KY-IN. 31180................ Lubbock, TX................ 0.8626 0.9037 31340................ Lynchburg, VA.............. 0.8716 0.9102 31420................ Macon, GA.................. 0.9176 0.9428 31540................ Madison, WI................ 1.0502 1.0341 31700................ Manchester-Nashua, NH...... 1.1665 1.1112 32780................ Medford, OR................ 1.0450 1.0306 32820................ Memphis, TN-MS-AR.......... 0.9032 0.9327 33124................ Miami-Miami Beach-Kendall, 0.9825 0.9880 FL. 33260................ Midland, TX................ 0.9602 0.9726 33340................ Milwaukee-Waukesha-West

1.0098 1.0067 Allis, WI. 33460................ Minneapolis-St. Paul-

1.0842 1.0569 Bloomington, MN-WI. 33540................ Missoula, MT............... 0.8909 0.9239 33700................ Modesto, CA................ 1.1731 1.1155 33740................ Monroe, LA................. 0.8015 0.8594 33860................ Montgomery, AL............. 0.8035 0.8609 34060................ Morgantown, WV............. 0.8449 0.8910 34980................ Nashville-Davidson--

0.9571 0.9704 Murfreesboro, TN. 35084................ Newark-Union, NJ-PA........ 1.1886 1.1256 35300................ New Haven-Milford, CT...... 1.2093 1.1390 35380................ New Orleans-Metairie-

0.8855 0.9201 Kenner, LA. 35644................ \1\ New York-White Plains- 1.3038 1.1992 Wayne, NY-NJ. 35980................ Norwich-New London, CT..... 1.2020 1.1343 36084................ Oakland-Fremont-Hayward, CA 1.5669 1.3601 36140................ Ocean City, NJ............. 1.0254 1.0173 36220................ Odessa, TX................. 0.9737 0.9819

[[Page 24262]]

36260................ Ogden-Clearfield, UT....... 0.9021 0.9319 36420................ Oklahoma City, OK.......... 0.8857 0.9202 36540................ Omaha-Council Bluffs, NE-IA 0.9453 0.9622 36740................ Orlando-Kissimmee, FL...... 0.9409 0.9591 37860................ Pensacola-Ferry Pass-Brent, 0.7999 0.8582 FL. 37900................ Peoria, IL................. 0.8827 0.9181 37964................ Philadelphia, PA (PA

1.1009 1.0680 Hospitals). 37964................ Philadelphia, PA (NJ

1.1226 1.0824 Hospitals). 38220................ Pine Bluff, AR............. 0.8224 0.8747 38300................ Pittsburgh, PA (PA and WV 0.8671 0.9070 Hospitals). 38300................ Pittsburgh, PA (OH

0.8673 0.9071 Hospitals). 38340................ Pittsfield, MA............. 1.0986 1.0665 38540................ Pocatello, ID.............. 0.9400 0.9585 38860................ Portland-South Portland-

0.9487 0.9646 Biddeford, ME. 38900................ Portland-Vancouver-

1.1405 1.0942 Beaverton, OR-WA. 38940................ Port St. Lucie-Fort Pierce, 0.9857 0.9902 FL. 39100................ Poughkeepsie-Newburgh-

1.0583 1.0396 Middletown, NY. 39340................ Provo-Orem, UT............. 0.9537 0.9681 39580................ Raleigh-Cary, NC........... 0.9570 0.9704 39740................ Reading, PA................ 0.9534 0.9678 39820................ Redding, CA................ 1.2884 1.1895 39900................ Reno-Sparks, NV............ 1.1524 1.1020 40060................ Richmond, VA............... 0.9174 0.9427 40220................ Roanoke, VA................ 0.8677 0.9074 40340................ Rochester, MN.............. 1.1246 1.0837 40380................ Rochester, NY.............. 0.9007 0.9309 40420................ Rockford, IL............... 0.9773 0.9844 40484................ Rockingham County, NH...... 1.0309 1.0211 40660................ Rome, GA................... 0.9307 0.9520 40900................ Sacramento--Arden-Arcade-- 1.3350 1.2188 Roseville, CA. 40980................ Saginaw-Saginaw Township

0.9055 0.9343 North, MI. 41060................ St. Cloud, MN.............. 0.9971 0.9980 41100................ St. George, UT............. 0.9295 0.9512 41140................ St. Joseph, MO-KS.......... 0.9993 0.9995 41180................ St. Louis, MO-IL........... 0.8902 0.9234 41620................ Salt Lake City, UT......... 0.9421 0.9600 41700................ San Antonio, TX............ 0.8859 0.9204 41884................ San Francisco-San Mateo-

1.5049 1.3230 Redwood City, CA. 41980................ San Juan-Caguas-Guaynabo, 0.4396 0.5696 PR. 42044................ Santa Ana-Anaheim-Irvine, 1.1291 1.0867 CA. 42140................ Santa Fe, NM............... 0.9814 0.9872 42220................ Santa Rosa-Petaluma, CA.... 1.4294 1.2772 42260................ Sarasota-Bradenton-Venice, 0.9866 0.9908 FL. 42340................ Savannah, GA............... 0.8958 0.9274 42644................ Seattle-Bellevue-Everett, 1.1255 1.0843 WA. 43300................ Sherman-Denison, TX........ 0.8376 0.8857 43340................ Shreveport-Bossier City, LA 0.8715 0.9101 43580................ Sioux City, IA-NE-SD....... 0.8816 0.9173 43620................ Sioux Falls, SD............ 0.9456 0.9624 43780................ South Bend-Mishawaka, IN-MI 0.9543 0.9685 43900................ Spartanburg, SC............ 0.9192 0.9439 44060................ Spokane, WA................ 1.0284 1.0194 44180................ Springfield, MO............ 0.8345 0.8835 44300................ State College, PA.......... 0.8361 0.8846 44940................ Sumter, SC................. 0.8604 0.9022 45060................ Syracuse, NY............... 0.9428 0.9605 45104................ Tacoma, WA................. 1.0907 1.0613 45220................ Tallahassee, FL............ 0.8982 0.9291 45300................ Tampa-St. Petersburg-

0.9249 0.9479 Clearwater, FL. 45500................ Texarkana, TX-Texarkana, AR 0.8133 0.8680 45780................ Toledo, OH................. 0.9588 0.9716 45820................ Topeka, KS................. 0.8591 0.9012 46140................ Tulsa, OK.................. 0.8146 0.8690 46220................ Tuscaloosa, AL............. 0.7785 0.8424 46340................ Tyler, TX.................. 0.8854 0.9200 46660................ Valdosta, GA............... 0.8101 0.8657 46700................ Vallejo-Fairfield, CA...... 1.4527 1.2914 47260................ Virginia Beach-Norfolk-

0.8840 0.9190 Newport News, VA. 47380................ Waco, TX................... 0.8653 0.9057 47894................ Washington-Arlington-

1.1076 1.0725 Alexandria DC-VA.

[[Page 24263]]

48140................ Wausau, WI................. 0.9625 0.9742 48620................ Wichita, KS................ 0.8832 0.9185 48700................ Williamsport, PA........... 0.8330 0.8824 48864................ Wilmington, DE-MD-NJ....... 1.0878 1.0593 48900................ Wilmington, NC............. 0.9516 0.9666 49180................ Winston-Salem, NC.......... 0.9129 0.9395 49340................ Worcester, MA.............. 1.1665 1.1112 49660................ Youngstown-Warren-Boardman, 0.8815 0.9173 OH-PA. 04................... Arkansas................... 0.7487 0.8202 05................... California................. 1.1291 1.0867 07................... Connecticut................ 1.1750 1.1168 10................... Florida.................... 0.8609 0.9025 14................... Illinois................... 0.8210 0.8737 16................... Iowa....................... 0.8696 0.9088 17................... Kansas..................... 0.8017 0.8595 19................... Louisiana.................. 0.7487 0.8202 23................... Michigan................... 0.9055 0.9343 24................... Minnesota.................. 0.9256 0.9484 26................... Missouri................... 0.8206 0.8734 29................... Nevada..................... 0.8674 0.9072 30................... New Hampshire.............. 1.1381 1.0926 33................... New York................... 0.8267 0.8778 34................... North Carolina............. 0.8607 0.9024 36................... Ohio....................... 0.8673 0.9071 37................... Oklahoma................... 0.7663 0.8334 38................... Oregon..................... 0.9826 0.9881 39................... Pennsylvania............... 0.8330 0.8824 44................... Tennessee.................. 0.7957 0.8551 45................... Texas...................... 0.8003 0.8585 47................... Vermont.................... 0.9974 0.9982 50................... Washington................. 1.0440 1.0299 53................... Wyoming.................... 0.9154 0.9413

\1\ For this area, the wage index and GAF on this table are only effective from October 1, 2006 through March 31, 2007. See Table 4C-2 for the values that are effective from April 1 through September 30, 2007.

Table 4C-2.--Wage Index and Capital Geographic Adjustment Factor (GAF) for Certain Hospitals That Are Reclassified by CBSA for the Period April 1 Through September 30, 2007*

Wage CBSA code

Area

index GAF

11460................ Ann Arbor, MI.............. 1.0391 1.0266 31084................ Los Angeles-Long Beach-

1.1603 1.1072 Santa Ana, CA. 34740................ Muskegon-Norton Shores, MI. 0.9683 0.9782 35004................ Nassau-Suffolk, NY......... 1.2511 1.1658 35644................ New York-White Plains-

1.3008 1.1973 Wayne, NY-NJ.

* See Table 4C-1 for the wage index and GAF that are effective from October 1, 2006 through March 31, 2007. (For areas that are not listed on this table, the wage index and GAF on Table 4C-1 are effective for the entire FY 2007.)

Table 4F.--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF) by CBSA--FY 2007

Wage index-- CBSA code

Area

Wage GAF

reclassified GAS--reclassified index

hospitals

hospitals

10380................ Aguadilla-Isabela-San

0.8950 0.9268 ................... ................. Sebastian, PR. 21940................ Fajardo, PR................ 0.9247 0.9478 ................... ................. 25020................ Guayama, PR................ 0.7409 0.8144 ................... ................. 32420................ Mayaguez, PR............... 0.8812 0.9170 ................... ................. 38660................ Ponce, PR.................. 1.1086 1.0732 ................... ................. 41900................ San German-Cabo Rojo, PR... 1.1160 1.0781 ................... ................. 41980................ San Juan-Caguas-Guaynabo, 1.0045 1.0031

1.0045

1.0031 PR. 49500................ Yauco, PR.................. 0.8822 0.9177 ................... .................

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

[[Page 24264]]

Act, reclassified under section 508 of Pub. L. 108-173, or redesignated under section 1886(d)(8) of the Act. If a hospital has a half fiscal year reclassification, the hospital will be eligible for the out-migration adjustment for the portion of the fiscal year that it is not reclassified. Hospitals that have already been reclassified under section 1886(d)(10) of the Act, reclassified under section 508 of Pub. L. 108-173, or redesignated under section 1886(d)(8) of the Act for any portion of the fiscal year are designated with an asterisk Hospitals have 45 days from the publication of this proposed rule to review their individual situations to determine whether to submit a request to withdraw their reclassification/redesignation and receive the out-migration adjustment instead. We will automatically assume that hospitals that have already been reclassified under section 1886(d)(10) of the Act, reclassified under section 508 of Pub. L. 108-173, or redesignated under section 1886(d)(8) of the Act 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 2007

Reclassified Reclassified Provider No.

between 10/1/06 between 4/1/07 Out-migration Qualifying county and 3/31/07 and 9/30/2007 adjustment

name

010005.............................

*

*

0.0259 MARSHALL. 010008.............................

*

*

0.0212 CRENSHAW. 010009.............................

*

*

0.0092 MORGAN. 010010............................. ................ ................

0.0259 MARSHALL. 010012.............................

*

*

0.0205 DE KALB. 010022.............................

*

*

0.0714 CHEROKEE. 010025.............................

*

*

0.0235 CHAMBERS. 010029.............................

*

*

0.0107 LEE. 010035.............................

*

*

0.0375 CULLMAN. 010038............................. ................ ................

0.0062 CALHOUN. 010045.............................

*

*

0.0160 FAYETTE. 010047............................. ................ ................

0.0155 BUTLER. 010052............................. ................ ................

0.0121 TALLAPOOSA. 010054.............................

*

*

0.0092 MORGAN. 010061............................. ................ ................

0.0506 JACKSON. 010065.............................

*

*

0.0121 TALLAPOOSA. 010072.............................

*

*

0.0310 TALLADEGA. 010078............................. ................ ................

0.0062 CALHOUN. 010083.............................

*

*

0.0121 BALDWIN. 010085.............................

*

*

0.0092 MORGAN. 010100.............................

*

*

0.0121 BALDWIN. 010101.............................

*

*

0.0310 TALLADEGA. 010109............................. ................ ................

0.0451 PICKENS. 010129............................. ................ ................

0.0121 BALDWIN. 010143.............................

*

*

0.0375 CULLMAN 010146............................. ................ ................

0.0062 CALHOUN. 010150.............................

*

*

0.0155 BUTLER. 010158.............................

*

*

0.0093 FRANKLIN. 010164.............................

*

*

0.0310 TALLADEGA. 040014.............................

*

*

0.0159 WHITE. 040019.............................

*

*

0.0697 ST. FRANCIS. 040047.............................

*

*

0.0090 RANDOLPH. 040069.............................

*

*

0.0140 MISSISSIPPI. 040071.............................

*

*

0.0026 JEFFERSON. 040076.............................

*

*

0.1075 HOT SPRING. 040100.............................

*

*

0.0159 WHITE. 050008............................. ................ ................

0.0026 SAN FRANCISCO. 050009.............................

*

*

0.0478 NAPA. 050013.............................

*

*

0.0478 NAPA. 050014.............................

*

*

0.0131 AMADOR. 050016............................. ................ ................

0.0103 SAN LUIS OBISPO. 050042.............................

*

*

0.0219 TEHAMA. 050046............................. ................

*

0.0156 VENTURA. 050047............................. ................ ................

0.0026 SAN FRANCISCO. 050055............................. ................ ................

0.0026 SAN FRANCISCO. 050065.............................

*

*

0.0029 ORANGE. 050069.............................

*

*

0.0029 ORANGE. 050073.............................

*

*

0.0269 SOLANO. 050076.............................

*

*

0.0026 SAN FRANCISCO. 050082............................. ................

*

0.0156 VENTURA. 050084............................. ................ ................

0.0555 SAN JOAQUIN. 050089.............................

*

*

0.0152 SAN BERNARDINO. 050090.............................

*

*

0.0308 SONOMA. 050099.............................

*

*

0.0152 SAN BERNARDINO. 050101.............................

*

*

0.0269 SOLANO. 050117............................. ................ ................

0.0463 MERCED. 050118.............................

*

*

0.0555 SAN JOAQUIN. 050122............................. ................ ................

0.0555 SAN JOAQUIN. 050129.............................

*

*

0.0152 SAN BERNARDINO. 050131............................. ................ ................

0.0033 MARIN.

[[Page 24265]]

050133............................. ................ ................

0.0170 YUBA. 050136.............................

*

*

0.0308 SONOMA. 050140.............................

*

*

0.0152 SAN BERNARDINO. 050150.............................

*

*

0.0316 NEVADA. 050152............................. ................ ................

0.0026 SAN FRANCISCO. 050159............................. ................

*

0.0156 VENTURA. 050167............................. ................ ................

0.0555 SAN JOAQUIN. 050168.............................

*

*

0.0029 ORANGE. 050173.............................

*

*

0.0029 ORANGE. 050174.............................

*

*

0.0308 SONOMA. 050177............................. ................ ................

0.0156 VENTURA. 050193.............................

*

*

0.0029 ORANGE. 050224.............................

*

*

0.0029 ORANGE. 050226.............................

*

*

0.0029 ORANGE. 050228.............................

*

*

0.0026 SAN FRANCISCO. 050230.............................

*

*

0.0029 ORANGE. 050232............................. ................ ................

0.0103 SAN LUIS OBISPO. 050236............................. ................

*

0.0156 VENTURA. 050245.............................

*

*

0.0152 SAN BERNARDINO. 050272.............................

*

*

0.0152 SAN BERNARDINO. 050279.............................

*

*

0.0152 SAN BERNARDINO. 050291.............................

*

*

0.0308 SONOMA. 050298.............................

*

*

0.0152 SAN BERNARDINO. 050300.............................

*

*

0.0152 SAN BERNARDINO. 050313............................. ................ ................

0.0555 SAN JOAQUIN. 050325............................. ................ ................

0.0176 TUOLUMNE. 050327.............................

*

*

0.0152 SAN BERNARDINO. 050335............................. ................ ................

0.0176 TUOLUMNE. 050336............................. ................ ................

0.0555 SAN JOAQUIN. 050348.............................

*

*

0.0029 ORANGE. 050360............................. ................ ................

0.0033 MARIN. 050367.............................

*

*

0.0269 SOLANO. 050385.............................

*

*

0.0308 SONOMA. 050394............................. ................

*

0.0156 VENTURA. 050407............................. ................ ................

0.0026 SAN FRANCISCO. 050426.............................

*

*

0.0029 ORANGE. 050444............................. ................ ................

0.0463 MERCED. 050454............................. ................ ................

0.0026 SAN FRANCISCO. 050457............................. ................ ................

0.0026 SAN FRANCISCO. 050469.............................

*

*

0.0152 SAN BERNARDINO. 050476............................. ................ ................

0.0257 LAKE. 050494.............................

* ................

0.0316 NEVADA. 050506............................. ................ ................

0.0103 SAN LUIS OBISPO. 050510.............................

*

*

0.0033 MARIN. 050517.............................

*

*

0.0152 SAN BERNARDINO. 050526.............................

*

*

0.0029 ORANGE. 050528.............................

*

*

0.0463 MERCED. 050535.............................

*

*

0.0029 ORANGE. 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............................. ................ ................

0.0103 SAN LUIS OBISPO. 050667.............................

*

*

0.0478 NAPA.

[[Page 24266]]

050668............................. ................ ................

0.0026 SAN FRANCISCO. 050678.............................

*

*

0.0029 ORANGE. 050680.............................

*

*

0.0269 SOLANO. 050690.............................

*

*

0.0308 SONOMA. 050693.............................

*

*

0.0029 ORANGE. 050695............................. ................ ................

0.0555 SAN JOAQUIN. 050720.............................

*

*

0.0029 ORANGE. 050728.............................

*

*

0.0308 SONOMA. 050731............................. ................ ................

0.0152 SAN BERNARDINO. 060001............................. ................ ................

0.0294 WELD. 060003.............................

*

*

0.0203 BOULDER. 060010............................. ................ ................

0.0095 LARIMER. 060027.............................

*

*

0.0203 BOULDER. 060030............................. ................ ................

0.0095 LARIMER. 060103.............................

*

*

0.0203 BOULDER. 070003.............................

*

*

0.0009 WINDHAM. 070006.............................

*

*

0.0047 FAIRFIELD. 070010.............................

*

*

0.0047 FAIRFIELD. 070018.............................

*

*

0.0047 FAIRFIELD. 070020............................. ................ ................

0.0073 MIDDLESEX. 070021.............................

*

*

0.0009 WINDHAM. 070028.............................

*

*

0.0047 FAIRFIELD. 070033.............................

*

*

0.0047 FAIRFIELD. 070034.............................

*

*

0.0047 FAIRFIELD. 080001............................. ................ ................

0.0063 NEW CASTLE. 080003............................. ................ ................

0.0063 NEW CASTLE. 100014............................. ................ ................

0.0118 VOLUSIA. 100017............................. ................ ................

0.0118 VOLUSIA. 100045.............................

*

*

0.0118 VOLUSIA. 100047............................. ................ ................

0.0021 CHARLOTTE. 100062............................. ................ ................

0.0060 MARION. 100068............................. ................ ................

0.0118 VOLUSIA. 100072............................. ................ ................

0.0118 VOLUSIA. 100077............................. ................ ................

0.0021 CHARLOTTE. 100102............................. ................ ................

0.0125 COLUMBIA. 100118.............................

*

*

0.0398 FLAGLER. 100156............................. ................ ................

0.0125 COLUMBIA. 100175............................. ................ ................

0.0231 DE SOTO. 100212............................. ................ ................

0.0060 MARION. 100232.............................

*

*

0.0347 PUTNAM. 100236............................. ................ ................

0.0021 CHARLOTTE. 100252.............................

*

*

0.0233 OKEECHOBEE. 100290............................. ................ ................

0.0582 SUMTER. 110023.............................

*

*

0.0500 GORDON. 110027............................. ................ ................

0.0387 FRANKLIN. 110029.............................

*

*

0.0063 HALL. 110041.............................

*

*

0.0777 HABERSHAM. 110069.............................

*

*

0.0474 HOUSTON. 110124............................. ................ ................

0.0428 WAYNE. 110136............................. ................ ................

0.0261 BALDWIN 110146............................. ................ ................

0.0786 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. 130024............................. ................ ................

0.0275 BONNER. 130049.............................

*

*

0.0349 KOOTENAI. 130066............................. ................ ................

0.0349 KOOTENAI. 140012.............................

*

*

0.0220 LEE. 140026............................. ................ ................

0.0346 LA SALLE. 140033.............................

*

*

0.0147 LAKE. 140043.............................

*

*

0.0046 WHITESIDE. 140058.............................

*

*

0.0081 MORGAN. 140084.............................

*

*

0.0147 LAKE. 140100.............................

*

*

0.0147 LAKE. 140110.............................

*

*

0.0346 LA SALLE. 140130.............................

*

*

0.0147 LAKE.

[[Page 24267]]

140155............................. ................ ................

0.0027 KANKAKEE. 140160.............................

*

*

0.0286 STEPHENSON. 140161.............................

*

*

0.0138 LIVINGSTON. 140186............................. ................ ................

0.0027 KANKAKEE. 140202.............................

*

*

0.0147 LAKE. 140205............................. ................ ................

0.0163 BOONE. 140234.............................

*

*

0.0346 LA SALLE. 140291.............................

*

*

0.0147 LAKE. 150006.............................

*

*

0.0084 LA PORTE. 150015.............................

*

*

0.0084 LA PORTE. 150022............................. ................ ................

0.0249 MONTGOMERY. 150030.............................

*

*

0.0201 HENRY. 150035............................. ................ ................

0.0083 PORTER. 150045............................. ................ ................

0.0416 DE KALB. 150065.............................

*

*

0.0139 JACKSON. 150076.............................

*

*

0.0189 MARSHALL. 150088.............................

*

*

0.0196 MADISON. 150091............................. ................ ................

0.0573 HUNTINGTON. 150102.............................

*

*

0.0160 STARKE. 150113.............................

*

*

0.0196 MADISON. 150122.............................

*

*

0.0199 RIPLEY. 150146.............................

*

*

0.0440 NOBLE. 160013............................. ................ ................

0.0218 MUSCATINE. 160030............................. ................ ................

0.0040 STORY. 160032............................. ................ ................

0.0272 JASPER. 160080.............................

*

*

0.0049 CLINTON. 170137.............................

*

*

0.0336 DOUGLAS. 180012.............................

*

*

0.0083 HARDIN. 180049............................. ................ ................

0.0576 MADISON. 180066.............................

*

*

0.0567 LOGAN. 180127.............................

*

*

0.0352 FRANKLIN. 180128............................. ................ ................

0.0282 LAWRENCE. 190001.............................

*

*

0.0645 WASHINGTON. 190003.............................

*

*

0.0107 IBERIA. 190015.............................

*

*

0.0401 TANGIPAHOA. 190017............................. ................ ................

0.0235 ST. LANDRY. 190054............................. ................ ................

0.0107 IBERIA. 190078............................. ................ ................

0.0235 ST. LANDRY. 190088............................. ................ ................

0.0705 WEBSTER. 190099.............................

*

*

0.0390 AVOYELLES. 190106.............................

*

*

0.0238 ALLEN. 190133............................. ................ ................

0.0238 ALLEN. 190144............................. ................ ................

0.0705 WEBSTER. 190184............................. ................ ................

0.0161 CALDWELL. 190190............................. ................ ................

0.0161 CALDWELL. 190191.............................

*

*

0.0235 ST. LANDRY. 190246............................. ................ ................

0.0161 CALDWELL. 200002............................. ................ ................

0.0129 LINCOLN. 200024.............................

*

*

0.0071 ANDROSCOGGIN. 200032............................. ................ ................

0.0466 OXFORD. 200034.............................

*

*

0.0071 ANDROSCOGGIN. 200050.............................

*

*

0.0140 HANCOCK. 210001............................. ................ ................

0.0129 WASHINGTON. 210004............................. ................ ................

0.0040 MONTGOMERY. 210016............................. ................ ................

0.0040 MONTGOMERY. 210018............................. ................ ................

0.0040 MONTGOMERY. 210022............................. ................ ................

0.0040 MONTGOMERY. 210023............................. ................ ................

0.0209 ANNE ARUNDEL. 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. 220006............................. ................ ................

0.0306 ESSEX. 220010.............................

*

*

0.0306 ESSEX. 220011.............................

*

*

0.0249 MIDDLESEX. 220019.............................

*

*

0.0056 WORCESTER. 220025.............................

*

*

0.0056 WORCESTER. 220028.............................

*

*

0.0056 WORCESTER.

[[Page 24268]]

220029.............................

*

*

0.0306 ESSEX. 220033.............................

*

*

0.0306 ESSEX. 220035.............................

*

*

0.0306 ESSEX. 220049.............................

*

*

0.0249 MIDDLESEX. 220058.............................

*

*

0.0056 WORCESTER. 220062.............................

*

*

0.0056 WORCESTER. 220063.............................

*

*

0.0249 MIDDLESEX. 220070.............................

*

*

0.0249 MIDDLESEX. 220080.............................

*

*

0.0306 ESSEX. 220082.............................

*

*

0.0249 MIDDLESEX. 220084.............................

*

*

0.0249 MIDDLESEX. 220089............................. ................ ................

0.0249 MIDDLESEX. 220090.............................

*

*

0.0056 WORCESTER. 220095.............................

*

*

0.0056 WORCESTER. 220098.............................

*

*

0.0249 MIDDLESEX. 220101.............................

*

*

0.0249 MIDDLESEX. 220105.............................

*

*

0.0249 MIDDLESEX. 220163.............................

*

*

0.0056 WORCESTER. 220171.............................

*

*

0.0249 MIDDLESEX. 220174.............................

*

*

0.0306 ESSEX. 230003.............................

*

*

0.0035 OTTAWA. 230013.............................

*

*

0.0091 OAKLAND. 230015............................. ................ ................

0.0359 ST. JOSEPH. 230019.............................

*

*

0.0091 OAKLAND. 230021............................. ................ ................

0.0136 BERRIEN. 230022.............................

*

*

0.0113 BRANCH. 230029.............................

*

*

0.0091 OAKLAND. 230037.............................

*

*

0.0178 HILLSADLE. 230041............................. ................ ................

0.0099 BAY. 230047.............................

*

*

0.0082 MACOMB. 230069.............................

*

*

0.0487 LIVINGSTON. 230071.............................

*

*

0.0091 OAKLAND. 230072.............................

*

*

0.0035 OTTAWA. 230075............................. ................ ................

0.0145 CALHOUN. 230078.............................

*

*

0.0136 BERRIEN. 230092.............................

*

*

0.0389 JACKSON. 230093.............................

*

*

0.0079 MECOSTA. 230096.............................

*

*

0.0359 ST. JOSEPH. 230099.............................

*

*

0.0339 MONROE. 230106............................. ................

*

0.0030 NEWAYGO. 230121.............................

*

*

0.0691 SHIAWASSEE. 230130.............................

*

*

0.0091 OAKLAND. 230151.............................

*

*

0.0091 OAKLAND. 230174.............................

*

*

0.0035 OTTAWA. 230184............................. ................ ................

0.0389 JACKSON. 230195.............................

*

*

0.0082 MACOMB. 230204.............................

*

*

0.0082 MACOMB. 230207.............................

*

*

0.0091 OAKLAND. 230217.............................

*

*

0.0145 CALHOUN. 230222............................. ................ ................

0.0228 MIDLAND. 230223.............................

*

*

0.0091 OAKLAND. 230227.............................

*

*

0.0082 MACOMB. 230254.............................

*

*

0.0091 OAKLAND. 230257.............................

*

*

0.0082 MACOMB. 230264.............................

*

*

0.0082 MACOMB. 230269.............................

*

*

0.0091 OAKLAND. 230277.............................

*

*

0.0091 OAKLAND. 230279.............................

*

*

0.0487 LIVINGSTON. 240018.............................

*

*

0.1196 GOODHUE. 240044............................. ................ ................

0.0868 WINONA. 240064.............................

*

*

0.0138 ITASCA. 240069.............................

*

*

0.0419 STEELE. 240071.............................

*

*

0.0454 RICE. 240187.............................

*

*

0.0506 MC LEOD. 240211.............................

*

*

0.0705 PINE. 250040.............................

*

*

0.0294 JACKSON. 260011.............................

*

*

0.0007 COLE. 260047.............................

*

*

0.0007 COLE. 260074.............................

*

*

0.0158 RANDOLPH. 260097............................. ................ ................

0.0425 JOHNSON.

[[Page 24269]]

280077.............................

*

*

0.0089 DODGE. 280123............................. ................ ................

0.0137 GAGE. 290019.............................

*

*

0.0026 CARSON CITY. 290049............................. ................ ................

0.0026 CARSON CITY. 300011.............................

*

*

0.0069 HILLSBOURGH. 300012.............................

*

*

0.0069 HILLSBOURGH. 300017.............................

*

*

0.0361 ROCKINGHAM. 300020.............................

*

*

0.0069 HILLSBOURGH. 300023.............................

*

*

0.0361 ROCKINGHAM. 300029.............................

*

*

0.0361 ROCKINGHAM. 300034.............................

*

*

0.0069 HILLSBOURGH. 310002.............................

*

*

0.0351 ESSEX. 310009.............................

*

*

0.0351 ESSEX. 310010............................. ................ ................

0.0092 MERCER. 310011............................. ................ ................

0.0115 CAPE MAY. 310013.............................

*

*

0.0351 ESSEX. 310018.............................

*

*

0.0351 ESSEX. 310021.............................

*

*

0.0092 MERCER. 310038.............................

*

*

0.0350 MIDDLESEX. 310039.............................

*

*

0.0350 MIDDLESEX. 310044............................. ................ ................

0.0092 MERCER. 310054.............................

*

*

0.0351 ESSEX. 310070.............................

*

*

0.0350 MIDDLESEX. 310076.............................

*

*

0.0351 ESSEX. 310078.............................

*

*

0.0351 ESSEX. 310083.............................

*

*

0.0351 ESSEX. 310092............................. ................ ................

0.0092 MERCER. 310093.............................

*

*

0.0351 ESSEX. 310096.............................

*

*

0.0351 ESSEX. 310108.............................

*

*

0.0350 MIDDLESEX. 310110............................. ................ ................

0.0092 MERCER. 310119.............................

*

*

0.0351 ESSEX. 310123............................. ................ ................

0.0351 ESSEX. 310124............................. ................ ................

0.0350 MIDDLESEX. 320003............................. ................ ................

0.0629 SAN MIGUEL 320011............................. ................ ................

0.0442 RIO ARRIBA. 320018............................. ................ ................

0.0063 DONA ANA. 320085............................. ................ ................

0.0063 DONA ANA. 330004.............................

*

*

0.0959 ULSTER. 330008.............................

*

*

0.0470 WYOMING. 330027.............................

*

*

0.0137 NASSAU. 330094.............................

*

*

0.0778 COLUMBIA. 330106.............................

*

*

0.0137 NASSAU. 330126.............................

* ................

0.0560 ORANGE. 330135.............................

* ................

0.0560 ORANGE. 330167............................. ................

*

0.0137 NASSAU. 330181............................. ................

*

0.0137 NASSAU. 330182.............................

*

*

0.0137 NASSAU. 330191.............................

*

*

0.0026 WARREN. 330198............................. ................

*

0.0137 NASSAU. 330205.............................

* ................

0.0560 ORANGE. 330209.............................

* ................

0.0560 ORANGE. 330224.............................

*

*

0.0959 ULSTER. 330225............................. ................

*

0.0137 NASSAU. 330235.............................

*

*

0.0270 CAYUGA. 330259............................. ................

*

0.0137 NASSAU. 330264.............................

* ................

0.0560 ORANGE. 330276............................. ................ ................

0.0063 FULTON. 330331............................. ................

*

0.0137 NASSAU. 330332............................. ................

*

0.0137 NASSAU. 330372............................. ................

*

0.0137 NASSAU. 330386.............................

*

*

0.1139 SULLIVAN. 340015............................. ................ ................

0.0267 ROWAN. 340020............................. ................ ................

0.0207 LEE. 340021.............................

*

*

0.0216 CLEVELAND. 340037............................. ................ ................

0.0216 CLEVELAND. 340039.............................

*

*

0.0144 IREDELL. 340069.............................

*

*

0.0053 WAKE. 340070.............................

*

*

0.0448 ALAMANCE. 340073.............................

*

*

0.0053 WAKE.

[[Page 24270]]

340085............................. ................ ................

0.0377 DAVIDSON. 340096............................. ................ ................

0.0377 DAVIDSON. 340104............................. ................ ................

0.0216 CLEVELAND. 340114.............................

*

*

0.0053 WAKE. 340126.............................

*

*

0.0161 WILSON. 340127.............................

*

*

0.0961 GRANVILLE. 340129.............................

*

*

0.0144 IREDELL. 340133............................. ................ ................

0.0308 MARTIN. 340138.............................

*

*

0.0053 WAKE. 340144.............................

*

*

0.0144 IREDELL. 340145.............................

*

*

0.0563 LINCOLN. 340173.............................

*

*

0.0053 WAKE. 360013.............................

*

*

0.0166 SHELBY. 360025.............................

*

*

0.0087 ERIE. 360036.............................

*

*

0.0263 WAYNE. 360065.............................

*

*

0.0141 HURON. 360070............................. ................ ................

0.0028 STARK. 360078.............................

*

*

0.0159 PORTAGE. 360084.............................

*

*

0.0028 STARK. 360086.............................

*

*

0.0168 CLARK. 360095.............................

*

*

0.0087 HANCOCK. 360100............................. ................ ................

0.0028 STARK. 360107.............................

*

*

0.0213 SANDUSKY 360131............................. ................ ................

0.0028 STARK. 360151............................. ................ ................

0.0028 STARK. 360156............................. ................ ................

0.0213 SANDUSKY 360175.............................

*

*

0.0159 CLINTON. 360187.............................

*

*

0.0168 CLARK. 360197.............................

*

*

0.0092 LOGAN. 360267............................. ................ ................

0.0028 STARK. 370004.............................

*

*

0.0193 OTTAWA. 370014.............................

*

*

0.0831 BRYAN. 370015.............................

*

*

0.0463 MAYES. 370023............................. ................ ................

0.0084 STEPHENS. 370065............................. ................ ................

0.0121 CRAIG. 370113.............................

*

*

0.0205 DELAWRE. 370149............................. ................ ................

0.0356 POTTAWATOMIE. 380002............................. ................ ................

0.0130 JOSEPHINE. 380022.............................

*

*

0.0201 LINN. 380029............................. ................ ................

0.0075 MARION. 380051............................. ................ ................

0.0075 MARION. 380056............................. ................ ................

0.0075 MARION. 390011............................. ................ ................

0.0012 CAMBRIA. 390030.............................

*

*

0.0276 SCHUYLKILL. 390031.............................

*

*

0.0276 SCHUYLKILL. 390044............................. ................ ................

0.0200 BERKS. 390046.............................

*

*

0.0098 YORK. 390056............................. ................ ................

0.0042 HUNTINGDON. 390065.............................

*

*

0.0501 ADAMS. 390066.............................

*

*

0.0259 LEBANON. 390096............................. ................ ................

0.0200 BERKS. 390101............................. ................ ................

0.0098 YORK. 390110.............................

*

*

0.0012 CAMBRIA. 390130............................. ................ ................

0.0012 CAMBRIA. 390138.............................

*

*

0.0325 FRANKLIN. 390146.............................

*

*

0.0053 WARREN. 390150.............................

*

*

0.0206 GREENE. 390151.............................

*

*

0.0325 FRANKLIN. 390162............................. ................ ................

0.0200 NORTHAMPTON. 390181.............................

*

*

0.0276 SCHUYLKILL. 390183.............................

*

*

0.0276 SCHUYLKILL. 390201.............................

*

*

0.1127 MONROE. 390233............................. ................ ................

0.0098 YORK. 420007.............................

*

*

0.0001 SPARTANBURG. 420009.............................

*

*

0.0153 OCONEE. 420020.............................

*

*

0.0035 GEORGETOWN. 420027.............................

*

*

0.0210 ANDERSON. 420030.............................

*

*

0.0103 COLLETON. 420039.............................

*

*

0.0153 UNION. 420043............................. ................ ................

0.0177 CHEROKEE.

[[Page 24271]]

420062............................. ................ ................

0.0135 CHESTERFIELD. 420068.............................

*

*

0.0097 ORANGE.BURG 420070.............................

*

*

0.0101 SUMTER. 420083.............................

*

*

0.0001 SPARTANBURG. 420093............................. ................ ................

0.0001 SPARTANBURG. 420098............................. ................ ................

0.0035 GEORGETOWN. 440008.............................

*

*

0.0663 HENDERSON. 440012............................. ................ ................

0.0016 SULLIVAN. 440017............................. ................ ................

0.0016 SULLIVAN. 440024.............................

*

*

0.0387 BRADLEY. 440030............................. ................ ................

0.0056 HAMBLEN. 440035.............................

*

*

0.0441 MONTGOMERY. 440047............................. ................ ................

0.0499 GIBSON. 440051............................. ................ ................

0.0104 MC NAIRY. 440056............................. ................ ................

0.0321 JEFFERSON. 440060.............................

*

*

0.0499 GIBSON. 440063............................. ................ ................

0.0011 WASHINGTON. 440067.............................

*

*

0.0056 HAMBLEN. 440073.............................

*

*

0.0513 MAURY. 440105............................. ................ ................

0.0011 WASHINGTON. 440115............................. ................ ................

0.0499 GIBSON. 440148.............................

*

*

0.0568 DE KALB. 440153............................. ................ ................

0.0007 COCKE. 440174............................. ................ ................

0.0372 HAYWOOD. 440176............................. ................ ................

0.0016 SULLIVAN. 440181............................. ................ ................

0.0407 HARDEMAN. 440184............................. ................ ................

0.0011 WASHINGTON. 440185.............................

*

*

0.0387 BRADLEY. 450032.............................

*

*

0.0416 HARRISON. 450039.............................

*

*

0.0097 TARRANT. 450059.............................

*

*

0.0073 COMAL. 450064.............................

*

*

0.0097 TARRANT. 450087.............................

*

*

0.0097 TARRANT. 450099.............................

*

*

0.0180 GRAY. 450121.............................

*

*

0.0097 TARRANT. 450135.............................

*

*

0.0097 TARRANT. 450137.............................

*

*

0.0097 TARRANT. 450144.............................

*

*

0.0573 ANDREWS. 450163............................. ................ ................

0.0134 KELBERG. 450187.............................

*

*

0.0264 WASHINGTON. 450194.............................

*

*

0.0328 CHEROKEE. 450214.............................

*

*

0.0368 WHARTON. 450224.............................

*

*

0.0411 WOOD. 450324............................. ................ ................

0.0156 GRAYSON. 450347.............................

*

*

0.0427 WALKER. 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. 450469............................. ................ ................

0.0156 GRAYSON. 450547.............................

*

*

0.0411 WOOD. 450563.............................

*

*

0.0097 TARRANT. 450565............................. ................ ................

0.0486 PALO PINTO. 450596............................. ................ ................

0.0808 HOOD. 450597............................. ................ ................

0.0077 DE WIT. 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. 450779.............................

*

*

0.0097 TARRANT. 450813.............................

*

*

0.0195 ANDERSON. 450858.............................

*

*

0.0097 TARRANT. 450872.............................

*

*

0.0097 TARRANT.

[[Page 24272]]

450880.............................

*

*

0.0097 TARRANT. 460017............................. ................ ................

0.0392 BOX ELDER. 460039.............................

*

*

0.0392 BOX ELDER. 490019............................. ................ ................

0.1240 CULPEPER. 490038............................. ................ ................

0.0022 SMYTH. 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. 500129.............................

*

*

0.0055 PIERCE. 500139.............................

*

*

0.0023 THURSTON. 500143............................. ................ ................

0.0023 THURSTON. 510018.............................

*

*

0.0209 JACKSON. 510039............................. ................ ................

0.0112 OHIO. 510047.............................

*

*

0.0275 MARION. 510050............................. ................ ................

0.0112 OHIO. 510077.............................

*

*

0.0021 MINGO. 520028.............................

*

*

0.0157 GREEN. 520035............................. ................ ................

0.0077 SHEBOYGAN. 520044............................. ................ ................

0.0077 SHEBOYGAN. 520057............................. ................ ................

0.0118 SAUK. 520059.............................

*

*

0.0200 RACINE. 520071.............................

*

*

0.0239 JEFFERSON. 520095.............................

*

*

0.0118 SAUK. 520096.............................

*

*

0.0200 RACINE. 520102.............................

*

*

0.0298 WALWORTH 520116.............................

*

*

0.0239 JEFFERSON. 520132............................. ................ ................

0.0077 SHEBOYGAN.

Table 5.--List of Diagnosis-Related Groups, Relative Weighting Factors, and Geometric and Arithmetic Mean Length of Stay (LOS)

FY 07 proposed rule FY 07 proposed rule

Geometric Arithmetic DRG

post-acute care DRG special pay DRG MDC

Type

DRG title

Weights mean LOS mean LOS

1................. Yes................. No.................. 01 SURG................ CRANIOTOMY AGE >17 W

3.5289

7.3

9.8 CC. 2................. Yes................. No.................. 01 SURG................ CRANIOTOMY AGE >17 W/O 1.9870

3.4

4.4 CC. 3................. No.................. No.................. 01 SURG*............... CRANIOTOMY AGE 0-17... 1.9870

9.2

12.5 4................. No.................. No.................. 01 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 5................. No.................. No.................. 01 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 6................. No.................. No.................. 01 SURG................ CARPAL TUNNEL RELEASE. 0.7965

2.1

3.1 7................. Yes................. Yes................. 01 SURG................ PERIPH & CRANIAL NERVE 2.5775

6.6

9.5 & DOTHER NERV SYST PROC W CC. 8................. Yes................. Yes................. 01 SURG................ PERIPH & CRANIAL NERVE 1.4057

2.0

2.8 & DOTHER NERV SYST PROC W/O CC. 9................. No.................. No.................. 01 MED................. SPINAL DISORDERS &

1.4543

4.4

6.2 INJURIES. 10................ Yes................. No.................. 01 MED................. NERVOUS SYSTEM

1.2513

4.6

6.0 NEOPLASMS W CC. 11................ Yes................. No.................. 01 MED................. NERVOUS SYSTEM

0.8359

2.7

3.6 DNEOPLASMS W/O CC. 12................ Yes................. No.................. 01 MED................. DEGENERATIVE NERVOUS

1.0105

4.4

5.6 SYSTEM DISORDERS. 13................ Yes................. No.................. 01 MED................. MULTIPLE SCLEROSIS &

0.9266

4.0

4.9 DCEREBELLAR ATAXIA. 14................ Yes................. No.................. 01 MED................. INTRACRANIAL

1.2480

4.3

5.5 HEMORRHAGE OR DCEREBRAL INFARCTION. 15................ Yes................. No.................. 01 MED................. NONSPECIFIC CVA &

0.9170

3.1

4.0 PRECEREBRAL OCCLUSION W/O INFARCT. 16................ Yes................. No.................. 01 MED................. NONSPECIFIC

1.3632

5.0

6.4 CEREBROVASCULAR DISORDERS W CC.

[[Page 24273]]

17................ Yes................. No.................. 01 MED................. NONSPECIFIC

0.6692

2.4

3.0 CEREBROVASCULAR ISORDERS W/O CC. 18................ Yes................. No.................. 01 MED................. CRANIAL & PERIPHERAL

1.0501

4.1

5.2 NERVE DISORDERS W CC. 19................ Yes................. No.................. 01 MED................. CRANIAL & PERIPHERAL

0.7128

2.7

3.4 NERVE DISORDERS W/O CC. 20................ Yes................. No.................. 01 MED................. NERVOUS SYSTEM

2.7596

8.0

10.3 INFECTION EXCEPT VIRAL DMENINGITIS. 21................ No.................. No.................. 01 MED................. VIRAL MENINGITIS...... 1.4536

4.7

6.2 22................ No.................. No.................. 01 MED................. HYPERTENSIVE

1.2386

3.9

5.0 ENCEPHALOPATHY. 23................ No.................. No.................. 01 MED................. NONTRAUMATIC STUPOR & 0.8423

3.0

3.9 COMA. 24................ Yes................. No.................. 01 MED................. SEIZURE & HEADACHE AGE 1.0388

3.5

4.7 >17 W CC. 25................ Yes................. No.................. 01 MED................. SEIZURE & HEADACHE AGE 0.6436

2.5

3.1 >17 W/O CC. 26................ No.................. No.................. 01 MED................. SEIZURE & HEADACHE AGE 1.1844

2.6

3.8 0-17. 27................ No.................. No.................. 01 MED................. TRAUMATIC STUPOR &

1.4281

3.1

4.8 COMA, COMA >1 HR. 28................ Yes................. No.................. 01 MED................. TRAUMATIC STUPOR &

1.4037

4.2

5.7 COMA, COMA 17 W CC. 29................ Yes................. No.................. 01 MED................. TRAUMATIC STUPOR &

0.7658

2.6

3.2 COMA, COMA 17 W/O CC. 30................ No.................. No.................. 01 MED*................ TRAUMATIC STUPOR &

0.7658

*

* COMA, COMA 17 W

0.9511

3.0

3.9 CC. 32................ No.................. No.................. 01 MED................. CONCUSSION AGE >17 W/O 0.5859

1.8

2.3 CC. 33................ No.................. No.................. 01 MED*................ CONCUSSION AGE 0-17... 0.5859

*

* 34................ Yes................. No.................. 01 MED................. OTHER DISORDERS OF

1.0347

3.6

4.8 NERVOUS SYSTEM W CC. 35................ Yes................. No.................. 01 MED................. OTHER DISORDERS OF

0.6453

2.5

3.1 NERVOUS SYSTEM W/O CC. 36................ No.................. No.................. 02 SURG................ RETINAL PROCEDURES.... 0.7936

1.3

1.7 37................ No.................. No.................. 02 SURG................ ORBITAL PROCEDURES.... 1.2193

2.7

4.1 38................ No.................. No.................. 02 SURG................ PRIMARY IRIS

0.5783

2.2

2.8 PROCEDURES. 39................ No.................. No.................. 02 SURG................ LENS PROCEDURES WITH

0.7098

1.5

2.0 OR WITHOUT VITRECTOMY. 40................ No.................. No.................. 02 SURG................ EXTRAOCULAR PROCEDURES 1.1061

3.0

4.1 EXCEPT ORBIT AGE >17. 41................ No.................. No.................. 02 SURG*............... EXTRAOCULAR PROCEDURES 1.1061

*

* EXCEPT ORBIT AGE 0-17. 42................ No.................. No.................. 02 SURG................ INTRAOCULAR PROCEDURES 0.9264

2.1

3.0 EXCEPT RETINA, IRIS & LENS. 43................ No.................. No.................. 02 MED................. HYPHEMA............... 0.5799

2.4

3.0 44................ No.................. No.................. 02 MED................. ACUTE MAJOR EYE

0.8191

3.8

4.8 INFECTIONS. 45................ No.................. No.................. 02 MED................. NEUROLOGICAL EYE

0.6809

2.5

3.0 DISORDERS. 46................ No.................. No.................. 02 MED................. OTHER DISORDERS OF THE 0.8135

3.2

4.2 EYE AGE >17 W CC. 47................ No.................. No.................. 02 MED................. OTHER DISORDERS OF THE 0.5728

2.4

3.0 EYE AGE >17 W/O CC. 48................ No.................. No.................. 02 MED*................ OTHER DISORDERS OF THE 0.5728

*

* EYE AGE 0-17. 49................ No.................. No.................. 03 SURG................ MAJOR HEAD & NECK

1.7653

3.2

4.5 PROCEDURES. 50................ No.................. No.................. 03 SURG................ SIALOADENECTOMY....... 0.8292

1.5

1.9 51................ No.................. No.................. 03 SURG................ SALIVARY GLAND

0.8841

1.9

2.7 PROCEDURES EXCEPT SIALOADENECTOMY. 52................ No.................. No.................. 03 SURG................ CLEFT LIP & PALATE

0.7608

1.4

1.7 REPAIR. 53................ No.................. No.................. 03 SURG................ SINUS & MASTOID

1.2984

2.5

4.0 PROCEDURES AGE >17. 54................ No.................. No.................. 03 SURG*............... SINUS & MASTOID

1.2984

*

* PROCEDURES AGE 0-17. 55................ No.................. No.................. 03 SURG................ MISCELLANEOUS EAR,

0.9555

1.9

2.9 NOSE, MOUTH & THROAT PROCEDURES. 56................ No.................. No.................. 03 SURG................ RHINOPLASTY........... 0.9535

1.9

2.7 57................ No.................. No.................. 03 SURG................ T&A PROC, EXCEPT

1.0220

2.1

3.2 TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE >17. 58................ No.................. No.................. 03 SURG*............... T&A PROC, EXCEPT

1.0220

*

* TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE 0-17.

[[Page 24274]]

59................ No.................. No.................. 03 SURG................ TONSILLECTOMY &/OR

0.7380

1.8

2.4 ADENOIDECTOMY ONLY, AGE >17. 60................ No.................. No.................. 03 SURG*............... TONSILLECTOMY &/OR

0.7380

1.4

1.7 ADENOIDECTOMY ONLY, AGE 0-17. 61................ No.................. No.................. 03 SURG................ MYRINGOTOMY W TUBE

1.5534

3.7

6.1 INSERTION AGE >17. 62................ No.................. No.................. 03 SURG*............... MYRINGOTOMY W TUBE

1.5534

1.3

1.5 INSERTION AGE 0-17. 63................ No.................. No.................. 03 SURG................ OTHER EAR, NOSE, MOUTH 1.4153

3.0

4.5 & THROAT O.R. PROCEDURES. 64................ No.................. No.................. 03 MED................. EAR, NOSE, MOUTH &

1.2875

4.2

6.3 THROAT MALIGNANCY. 65................ No.................. No.................. 03 MED................. DYSEQUILIBRIUM........ 0.5799

2.3

2.8 66................ No.................. No.................. 03 MED................. EPISTAXIS............. 0.6790

2.4

3.1 67................ No.................. No.................. 03 MED................. EPIGLOTTITIS.......... 0.9830

2.8

3.7 68................ No.................. No.................. 03 MED................. OTITIS MEDIA & URI AGE 0.7572

3.1

3.8 >17 W CC. 69................ No.................. No.................. 03 MED................. OTITIS MEDIA & URI AGE 0.5706

2.5

2.9 >17 W/O CC. 70................ No.................. No.................. 03 MED................. OTITIS MEDIA & URI AGE 0.4794

2.0

2.3 0-17. 71................ No.................. No.................. 03 MED................. LARYNGOTRACHEITIS..... 0.9064

3.4

4.4 72................ No.................. No.................. 03 MED................. NASAL TRAUMA &

0.7502

2.6

3.3 DEFORMITY. 73................ Yes................. No.................. 03 MED................. OTHER EAR, NOSE, MOUTH 0.9140

3.3

4.3 & THROAT DIAGNOSES AGE >17. 74................ No.................. No.................. 03 MED*................ OTHER EAR, NOSE, MOUTH 0.9140

3.3

3.3 & THROAT DIAGNOSES AGE 0-17. 75................ Yes................. No.................. 04 SURG................ MAJOR CHEST PROCEDURES 3.0790

7.4

9.7 76................ Yes................. No.................. 04 SURG................ OTHER RESP SYSTEM O.R. 2.7410

8.2

10.7 PROCEDURES W CC. 77................ Yes................. No.................. 04 SURG................ OTHER RESP SYSTEM O.R. 1.1515

3.3

4.5 PROCEDURES W/O CC. 78................ Yes................. No.................. 04 MED................. PULMONARY EMBOLISM.... 1.3229

5.3

6.2 79................ Yes................. No.................. 04 MED................. RESPIRATORY INFECTIONS 1.7331

6.7

8.3 & INFLAMMATIONS AGE >17 W CC. 80................ Yes................. No.................. 04 MED................. RESPIRATORY INFECTIONS 1.0190

4.3

5.3 & INFLAMMATIONS AGE >17 W/O CC. 81................ No.................. No.................. 04 MED*................ RESPIRATORY INFECTIONS 1.7331

5.2

6.2 & INFLAMMATIONS AGE 0- 7. 82................ Yes................. No.................. 04 MED................. RESPIRATORY NEOPLASMS. 1.4335

5.1

6.8 83................ Yes................. No.................. 04 MED................. MAJOR CHEST TRAUMA W

1.1185

4.2

5.3 CC. 84................ Yes................. No.................. 04 MED................. MAJOR CHEST TRAUMA W/O 0.6523

2.6

3.2 CC. 85................ Yes................. No.................. 04 MED................. PLEURAL EFFUSION W CC. 1.2935

4.7

6.2 86................ Yes................. No.................. 04 MED................. PLEURAL EFFUSION W/O

0.7154

2.7

3.5 CC. 87................ No.................. No.................. 04 MED................. PULMONARY EDEMA &

1.5310

4.9

6.4 ESPIRATORY FAILURE. 88................ No.................. No.................. 04 MED................. CHRONIC OBSTRUCTIVE

0.9557

4.0

4.9 PULMONARY DISEASE. 89................ Yes................. No.................. 04 MED................. SIMPLE PNEUMONIA &

1.1291

4.6

5.6 PLEURISY AGE >17 W CC. 90................ Yes................. No.................. 04 MED................. SIMPLE PNEUMONIA &

0.7043

3.2

3.7 PLEURISY AGE >17 W/O CC. 91................ No.................. No.................. 04 MED................. SIMPLE PNEUMONIA &

0.7054

2.5

3.4 PLEURISY AGE 0-17. 92................ Yes................. No.................. 04 MED................. INTERSTITIAL LUNG

1.2410

4.8

6.0 DISEASE W CC. 93................ Yes................. No.................. 04 MED................. INTERSTITIAL LUNG

0.7539

3.0

3.8 DISEASE W/O CC. 94................ No.................. No.................. 04 MED................. PNEUMOTHORAX W CC..... 1.2852

4.5

5.9 95................ No.................. No.................. 04 MED................. PNEUMOTHORAX W/O CC... 0.7018

2.7

3.4 96................ No.................. No.................. 04 MED................. BRONCHITIS & ASTHMA

0.8093

3.5

4.3 AGE >17 W CC. 97................ No.................. No.................. 04 MED................. BRONCHITIS & ASTHMA

0.6199

2.8

3.4 AGE >17 W/O CC. 98................ No.................. No.................. 04 MED................. BRONCHITIS & ASTHMA

0.6892

2.8

3.1 AGE 0-17. 99................ No.................. No.................. 04 MED................. RESPIRATORY SIGNS &

0.7101

2.4

3.1 SYMPTOMS W CC. 100............... No.................. No.................. 04 MED................. RESPIRATORY SIGNS &

0.5098

1.7

2.1 SYMPTOMS W/O CC. 101............... Yes................. No.................. 04 MED................. OTHER RESPIRATORY

0.9106

3.2

4.2 DSYSTEM DIAGNOSES W CC. 102............... Yes................. No.................. 04 MED................. OTHER RESPIRATORY

0.5625

2.0

2.5 SYSTEM DIAGNOSES W/O CC.

[[Page 24275]]

103............... No.................. No.................. PRE SURG................ HEART TRANSPLANT OR

19.5988

22.2

35.1 IMPLANT OF HEART ASSIST SYSTEM. 104............... Yes................. No.................. 05 SURG................ CARDIAC VALVE & OTH

7.4447

12.8

15.1 MAJOR CARDIOTHORACIC PROC W CARD CATH. 105............... Yes................. No.................. 05 SURG................ CARDIAC VALVE & OTH

5.6619

8.4

10.2 MAJOR CARDIOTHORACIC PROC W/O CARD CATH. 106............... No.................. No.................. 05 SURG................ CORONARY BYPASS W PTCA 5.9701

9.3

10.9 107............... Yes................. No.................. 05 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 108............... Yes................. No.................. 05 SURG................ OTHER CARDIOTHORACIC

5.4207

8.8

10.9 PROCEDURES. 109............... Yes................. No.................. 05 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 110............... No.................. No.................. 05 SURG................ MAJOR CARDIOVASCULAR

3.6419

5.4

8.1 PROCEDURES W CC. 111............... No.................. No.................. 05 SURG................ MAJOR CARDIOVASCULAR

2.2318

2.3

3.1 PROCEDURES W/O CC. 112............... No.................. No.................. 05 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 113............... Yes................. No.................. 05 SURG................ AMPUTATION FOR CIRC

3.3828

10.8

13.7 SYSTEM DISORDERS EXCEPT UPPER LIMB & TOE. 114............... Yes................. No.................. 05 SURG................ UPPER LIMB & TOE

1.8874

6.6

8.7 AMPUTATION FOR CIRC SYSTEM DISORDERS. 115............... No.................. No.................. 05 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 116............... No.................. No.................. 05 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 117............... No.................. No.................. 05 SURG................ CARDIAC PACEMAKER

1.2528

2.6

4.3 REVISION EXCEPT DEVICE REPLACEMENT. 118............... No.................. No.................. 05 SURG................ CARDIAC PACEMAKER

1.3882

2.0

3.0 DEVICE REPLACEMENT. 119............... No.................. No.................. 05 SURG................ VEIN LIGATION &

1.4787

3.3

5.4 STRIPPING. 120............... Yes................. No.................. 05 SURG................ OTHER CIRCULATORY

2.3109

6.0

9.2 SYSTEM O.R. PROCEDURES. 121............... Yes................. No.................. 05 MED................. CIRCULATORY DISORDERS 1.6883

5.2

6.5 W AMI & MAJOR COMP, DISCHARGED ALIVE. 122............... No.................. No.................. 05 MED................. CIRCULATORY DISORDERS 0.9802

2.7

3.4 W AMI W/O MAJOR COMP, DISCHARGED ALIVE. 123............... No.................. No.................. 05 MED................. CIRCULATORY DISORDERS 1.6053

2.9

4.7 W AMI, EXPIRED. 124............... No.................. No.................. 05 MED................. CIRCULATORY DISORDERS 1.1670

3.3

4.4 EXCEPT AMI, W CARD CATH & COMPLEX DIAG. 125............... No.................. No.................. 05 MED................. CIRCULATORY DISORDERS 0.7862

2.1

2.7 EXCEPT AMI, W CARD CATH W/O COMPLEX DIAG. 126............... Yes................. No.................. 05 MED................. ACUTE & SUBACUTE

2.5526

9.0

11.3 ENDOCARDITIS. 127............... Yes................. No.................. 05 MED................. HEART FAILURE & SHOCK. 1.0635

4.1

5.1 128............... No.................. No.................. 05 MED................. DEEP VEIN

0.8850

4.4

5.2 THROMBOPHLEBITIS. 129............... No.................. No.................. 05 MED................. CARDIAC ARREST,

1.1301

1.6

2.5 UNEXPLAINED. 130............... Yes................. No.................. 05 MED................. PERIPHERAL VASCULAR

1.0637

4.3

5.5 DISORDERS W CC. 131............... Yes................. No.................. 05 MED................. PERIPHERAL VASCULAR

0.6813

3.1

3.7 DISORDERS W/O CC. 132............... No.................. No.................. 05 MED................. ATHEROSCLEROSIS W CC.. 0.6482

2.2

2.8 133............... No.................. No.................. 05 MED................. ATHEROSCLEROSIS W/O CC 0.5237

1.8

2.1 134............... No.................. No.................. 05 MED................. HYPERTENSION.......... 0.6464

2.5

3.1 135............... No.................. No.................. 05 MED................. CARDIAC CONGENITAL &

0.9122

3.3

4.3 VALVULAR DISORDERS AGE >17 W CC. 136............... No.................. No.................. 05 MED................. CARDIAC CONGENITAL &

0.5684

2.1

2.7 VALVULAR DISORDERS AGE >17 W/O CC. 137............... No.................. No.................. 05 MED*................ CARDIAC CONGENITAL &

0.9122

*

* VALVULAR DISORDERS AGE 0-17. 138............... No.................. No.................. 05 MED................. CARDIAC ARRHYTHMIA &

0.8504

3.0

3.9 CONDUCTION DISORDERS W CC. 139............... No.................. No.................. 05 MED................. CARDIAC ARRHYTHMIA &

0.5221

2.0

2.4 CONDUCTION DISORDERS W/O CC. 140............... No.................. No.................. 05 MED................. ANGINA PECTORIS....... 0.5846

1.9

2.4 141............... No.................. No.................. 05 MED................. SYNCOPE & COLLAPSE W

0.7009

2.7

3.4 CC. 142............... No.................. No.................. 05 MED................. SYNCOPE & COLLAPSE W/O 0.5312

2.1

2.5 CC. 143............... No.................. No.................. 05 MED................. CHEST PAIN............ 0.5137

1.7

2.1

[[Page 24276]]

144............... Yes................. No.................. 05 MED................. OTHER CIRCULATORY

1.3781

4.2

5.9 SYSTEM DIAGNOSES W CC. 145............... Yes................. No.................. 05 MED................. OTHER CIRCULATORY

0.5993

2.0

2.5 SYSTEM DIAGNOSES W/O CC. 146............... Yes................. No.................. 06 SURG................ RECTAL RESECTION W CC. 2.8001

8.4

9.9 147............... Yes................. No.................. 06 SURG................ RECTAL RESECTION W/O

1.5698

4.9

5.6 CC. 148............... Yes................. No.................. 06 SURG................ MAJOR SMALL & LARGE

3.5831

9.9

12.1 BOWEL PROCEDURES W CC. 149............... Yes................. No.................. 06 SURG................ MAJOR SMALL & LARGE

1.5441

5.1

5.7 BOWEL PROCEDURES W/O CC. 150............... Yes................. No.................. 06 SURG................ PERITONEAL

2.9172

8.7

10.8 ADHESIOLYSIS W CC. 151............... Yes................. No.................. 06 SURG................ PERITONEAL

1.3530

4.0

5.0 ADHESIOLYSIS W/O CC. 152............... No.................. No.................. 06 SURG................ MINOR SMALL & LARGE

2.0074

6.5

7.9 BOWEL PROCEDURES W CC. 153............... No.................. No.................. 06 SURG................ MINOR SMALL & LARGE

1.1984

4.4

4.9 BOWEL PROCEDURES W/O CC. 154............... Yes................. No.................. 06 SURG................ STOMACH, ESOPHAGEAL & 4.2032

9.7

13.2 DUODENAL PROCEDURES AGE >17 W CC. 155............... Yes................. No.................. 06 SURG................ STOMACH, ESOPHAGEAL & 1.3089

3.0

4.0 DUODENAL PROCEDURES AGE >17 W/O CC. 156............... No.................. No.................. 06 SURG................ STOMACH, ESOPHAGEAL & 1.3089

8.9

9.3 DUODENAL PROCEDURES AGE 0-17. 157............... Yes................. No.................. 06 SURG................ ANAL & STOMAL

1.4076

4.2

5.8 PROCEDURES W CC. 158............... Yes................. No.................. 06 SURG................ ANAL & STOMAL

0.7114

2.1

2.6 PROCEDURES W/O CC. 159............... No.................. No.................. 06 SURG................ HERNIA PROCEDURES

1.4745

3.7

5.1 EXCEPT INGUINAL & FEMORAL AGE >17 W CC. 160............... No.................. No.................. 06 SURG................ HERNIA PROCEDURES

0.8749

2.2

2.7 EXCEPT INGUINAL & FEMORAL AGE >17 W/O CC. 161............... No.................. No.................. 06 SURG................ INGUINAL & FEMORAL

1.2461

3.2

4.5 HERNIA PROCEDURES AGE >17 W CC. 162............... No.................. No.................. 06 SURG................ INGUINAL & FEMORAL

0.6982

1.7

2.1 HERNIA PROCEDURES AGE >17 W/O CC. 163............... No.................. No.................. 06 SURG*............... HERNIA PROCEDURES AGE 0.6982

2.3

2.8 0-17. 164............... No.................. No.................. 06 SURG................ APPENDECTOMY W

2.2048

6.4

7.7 COMPLICATED PRINCIPAL DIAG W CC. 165............... No.................. No.................. 06 SURG................ APPENDECTOMY W

1.1907

3.4

4.0 COMPLICATED PRINCIPAL DIAG W/O CC. 166............... No.................. No.................. 06 SURG................ APPENDECTOMY W/O

1.3900

3.2

4.3 COMPLICATED PRINCIPAL DIAG W CC. 167............... No.................. No.................. 06 SURG................ APPENDECTOMY W/O

0.8536

1.8

2.1 COMPLICATED PRINCIPAL DIAG W/O CC. 168............... No.................. No.................. 03 SURG................ MOUTH PROCEDURES W CC. 1.3278

3.4

4.9 169............... No.................. No.................. 03 SURG................ MOUTH PROCEDURES W/O

0.7643

1.9

2.4 CC. 170............... Yes................. No.................. 06 SURG................ OTHER DIGESTIVE SYSTEM 2.9351

7.8

10.9 O.R. PROCEDURES W CC. 171............... Yes................. No.................. 06 SURG................ OTHER DIGESTIVE SYSTEM 1.2434

3.1

4.2 O.R. PROCEDURES W/O CC. 172............... Yes................. No.................. 06 MED................. DIGESTIVE MALIGNANCY W 1.4585

5.1

6.9 CC. 173............... Yes................. No.................. 06 MED................. DIGESTIVE MALIGNANCY W/ 0.7562

2.7

3.5 O CC. 174............... No.................. No.................. 06 MED................. G.I. HEMORRHAGE W CC.. 1.1360

3.8

4.7 175............... No.................. No.................. 06 MED................. G.I. HEMORRHAGE W/O CC 0.6295

2.4

2.9 176............... Yes................. No.................. 06 MED................. COMPLICATED PEPTIC

1.1757

4.0

5.1 ULCER. 177............... No.................. No.................. 06 MED................. UNCOMPLICATED PEPTIC

0.9595

3.6

4.4 ULCER W CC. 178............... No.................. No.................. 06 MED................. UNCOMPLICATED PEPTIC

0.6833

2.6

3.1 ULCER W/O CC. 179............... No.................. No.................. 06 MED................. INFLAMMATORY BOWEL

1.1460

4.5

5.8 DISEASE. 180............... Yes................. No.................. 06 MED................. G.I. OBSTRUCTION W CC. 1.0702

4.1

5.3 181............... Yes................. No.................. 06 MED................. G.I. OBSTRUCTION W/O

0.6400

2.8

3.3 CC. 182............... No.................. No.................. 06 MED................. ESOPHAGITIS, GASTROENT 0.9046

3.4

4.5 & MISC DIGEST DISORDERS AGE >17 W CC. 183............... No.................. No.................. 06 MED................. ESOPHAGITIS, GASTROENT 0.6078

2.4

2.9 & MISC DIGEST DISORDERS AGE >17 W/O CC. 184............... No.................. No.................. 06 MED................. ESOPHAGITIS, GASTROENT 0.8504

2.8

4.3 & MISC DIGEST DISORDERS AGE 0-17. 185............... No.................. No.................. 03 MED................. DENTAL & ORAL DIS

0.9381

3.3

4.5 EXCEPT EXTRACTIONS & RESTORATIONS, AGE >17. 186............... No.................. No.................. 03 MED*................ DENTAL & ORAL DIS

0.9381

2.6

3.1 EXCEPT EXTRACTIONS & RESTORATIONS, AGE 0- 17.

[[Page 24277]]

187............... No.................. No.................. 03 MED................. DENTAL EXTRACTIONS &

0.8880

3.1

4.2 RESTORATIONS. 188............... Yes................. No.................. 06 MED................. OTHER DIGESTIVE SYSTEM 1.1808

4.1

5.5 DIAGNOSES AGE >17 W CC. 189............... Yes................. No.................. 06 MED................. OTHER DIGESTIVE SYSTEM 0.6314

2.4

3.1 DIAGNOSES AGE >17 W/O CC. 190............... No.................. No.................. 06 MED................. OTHER DIGESTIVE SYSTEM 1.0119

3.5

4.9 DIAGNOSES AGE 0-17. 191............... Yes................. No.................. 07 SURG................ PANCREAS, LIVER &

3.9647

8.8

12.5 SHUNT PROCEDURES W CC. 192............... Yes................. No.................. 07 SURG................ PANCREAS, LIVER &

1.7088

4.2

5.5 SHUNT PROCEDURES W/O CC. 193............... No.................. No.................. 07 SURG................ BILIARY TRACT PROC

3.4693

10.1

12.6 EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W CC. 194............... No.................. No.................. 07 SURG................ BILIARY TRACT PROC

1.6583

5.4

6.4 EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC. 195............... No.................. No.................. 07 SURG................ CHOLECYSTECTOMY W

3.0330

8.8

10.6 C.D.E. W CC. 196............... No.................. No.................. 07 SURG................ CHOLECYSTECTOMY W

1.5984

4.5

5.3 C.D.E. W/O CC. 197............... Yes................. No.................. 07 SURG................ CHOLECYSTECTOMY EXCEPT 2.6196

7.4

9.1 BY LAPAROSCOPE W/O C.D.E. W CC. 198............... Yes................. No.................. 07 SURG................ CHOLECYSTECTOMY EXCEPT 1.2463

3.7

4.3 BY LAPAROSCOPE W/O C.D.E. W/O CC. 199............... No.................. No.................. 07 SURG................ HEPATOBILIARY

2.3139

6.4

9.0 DIAGNOSTIC PROCEDURE FOR MALIGNANCY. 200............... No.................. No.................. 07 SURG................ HEPATOBILIARY

3.0580

6.5

10.4 DIAGNOSTIC PROCEDURE FOR NON-MALIGNANCY. 201............... No.................. No.................. 07 SURG................ OTHER HEPATOBILIARY OR 3.6519

10.0

13.6 PANCREAS O.R. PROCEDURES. 202............... No.................. No.................. 07 MED................. CIRRHOSIS & ALCOHOLIC 1.4205

4.6

6.2 HEPATITIS. 203............... No.................. No.................. 07 MED................. MALIGNANCY OF

1.3745

4.8

6.5 HEPATOBILIARY SYSTEM OR PANCREAS. 204............... No.................. No.................. 07 MED................. DISORDERS OF PANCREAS 1.1749

4.1

5.4 EXCEPT MALIGNANCY. 205............... Yes................. No.................. 07 MED................. DISORDERS OF LIVER

1.2942

4.4

5.9 EXCEPT MALIG,CIRR,ALC HEPA W CC. 206............... Yes................. No.................. 07 MED................. DISORDERS OF LIVER

0.7720

3.0

3.8 EXCEPT MALIG,CIRR,ALC HEPA W/O CC. 207............... No.................. No.................. 07 MED................. DISORDERS OF THE

1.2145

4.1

5.3 BILIARY TRACT W CC. 208............... No.................. No.................. 07 MED................. DISORDERS OF THE

0.6986

2.4

3.0 BILIARY TRACT W/O CC. 209............... No.................. No.................. 08 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 210............... Yes................. Yes................. 08 SURG................ HIP & FEMUR PROCEDURES 2.0150

6.0

6.8 EXCEPT MAJOR JOINT AGE >17 W CC. 211............... Yes................. Yes................. 08 SURG................ HIP & FEMUR PROCEDURES 1.3653

4.3

4.6 EXCEPT MAJOR JOINT AGE >17 W/O CC. 212............... No.................. No.................. 08 SURG................ HIP & FEMUR PROCEDURES 0.9730

2.2

2.5 EXCEPT MAJOR JOINT AGE 0-17. 213............... Yes................. No.................. 08 SURG................ AMPUTATION FOR

2.2463

7.1

9.5 MUSCULOSKELETAL SYSTEM & CONN TISSUE DISORDERS. 214............... No.................. No.................. 08 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 215............... No.................. No.................. 08 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 216............... Yes................. No.................. 08 SURG................ BIOPSIES OF

1.7169

3.1

5.4 MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE. 217............... Yes................. No.................. 08 SURG................ WND DEBRID & SKN GRFT 3.1361

9.0

12.8 EXCEPT HAND,FOR MUSCSKELET & CONN TISS DIS. 218............... Yes................. No.................. 08 SURG................ LOWER EXTREM & HUMER

1.7105

4.4

5.5 PROC EXCEPT HIP,FOOT,FEMUR AGE >17 W CC. 219............... Yes................. No.................. 08 SURG................ LOWER EXTREM & HUMER

1.1071

2.7

3.2 PROC EXCEPT HIP,FOOT,FEMUR AGE >17 W/O CC. 220............... No.................. No.................. 08 SURG*............... LOWER EXTREM & HUMER

1.1071

2.6

4.0 PROC EXCEPT HIP,FOOT,FEMUR AGE 0- 17. 221............... No.................. No.................. 08 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 222............... No.................. No.................. 08 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0

[[Page 24278]]

223............... No.................. No.................. 08 SURG................ MAJOR SHOULDER/ELBOW

1.1303

2.4

3.3 PROC, OR OTHER UPPER EXTREMITY PROC W CC. 224............... No.................. No.................. 08 SURG................ SHOULDER,ELBOW OR

0.8067

1.6

1.9 FOREARM PROC,EXC MAJOR JOINT PROC, W/O CC. 225............... Yes................. No.................. 08 SURG................ FOOT PROCEDURES....... 1.3235

3.8

5.4 226............... Yes................. No.................. 08 SURG................ SOFT TISSUE PROCEDURES 1.6783

4.6

6.5 W CC. 227............... Yes................. No.................. 08 SURG................ SOFT TISSUE PROCEDURES 0.8719

2.1

2.6 W/O CC. 228............... No.................. No.................. 08 SURG................ MAJOR THUMB OR JOINT

1.1877

2.9

4.2 PROC,OR OTH HAND OR WRIST PROC W CC. 229............... No.................. No.................. 08 SURG................ HAND OR WRIST PROC,

0.7617

2.0

2.5 EXCEPT MAJOR JOINT PROC, W/O CC. 230............... No.................. No.................. 08 SURG................ LOCAL EXCISION &

1.4347

3.6

5.4 REMOVAL OF INT FIX DEVICES OF HIP & FEMUR. 231............... No.................. No.................. 08 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 232............... No.................. No.................. 08 SURG................ ARTHROSCOPY........... 0.9804

1.9

2.7 233............... Yes................. Yes................. 08 SURG................ OTHER MUSCULOSKELET

1.8831

4.4

6.4 SYS & CONN TISS O.R. PROC W CC. 234............... Yes................. Yes................. 08 SURG................ OTHER MUSCULOSKELET

1.1441

1.9

2.7 SYS & CONN TISS O.R. PROC W/O CC. 235............... Yes................. No.................. 08 MED................. FRACTURES OF FEMUR.... 0.9366

3.8

4.9 236............... Yes................. No.................. 08 MED................. FRACTURES OF HIP &

0.8791

3.8

4.5 PELVIS. 237............... No.................. No.................. 08 MED................. SPRAINS, STRAINS, &

0.7345

3.0

3.8 DISLOCATIONS OF HIP, PELVIS & THIGH. 238............... Yes................. No.................. 08 MED................. OSTEOMYELITIS......... 1.5466

6.5

8.4 239............... Yes................. No.................. 08 MED................. PATHOLOGICAL FRACTURES 1.2001

4.9

6.2 & MUSCULOSKELETAL & CONN TISS MALIGNANCY. 240............... Yes................. No.................. 08 MED................. CONNECTIVE TISSUE

1.4523

4.9

6.5 DISORDERS W CC. 241............... Yes................. No.................. 08 MED................. CONNECTIVE TISSUE

0.7172

3.0

3.6 DISORDERS W/O CC. 242............... No.................. No.................. 08 MED................. SEPTIC ARTHRITIS...... 1.2350

5.1

6.5 243............... No.................. No.................. 08 MED................. MEDICAL BACK PROBLEMS. 0.8680

3.6

4.5 244............... Yes................. No.................. 08 MED................. BONE DISEASES &

0.8186

3.6

4.5 SPECIFIC ARTHROPATHIES W CC. 245............... Yes................. No.................. 08 MED................. BONE DISEASES &

0.5581

2.5

3.1 SPECIFIC ARTHROPATHIES W/O CC. 246............... No.................. No.................. 08 MED................. NON-SPECIFIC

0.6742

2.8

3.6 ARTHROPATHIES. 247............... No.................. No.................. 08 MED................. SIGNS & SYMPTOMS OF

0.6852

2.6

3.3 MUSCULOSKELETAL SYSTEM & CONN TISSUE. 248............... No.................. No.................. 08 MED................. TENDONITIS, MYOSITIS & 0.9368

3.8

4.8 BURSITIS. 249............... No.................. No.................. 08 MED................. AFTERCARE,

0.8157

2.8

4.0 MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE. 250............... Yes................. No.................. 08 MED................. FX, SPRN, STRN & DISL 0.7774

3.2

3.9 OF FOREARM, HAND, FOOT AGE >17 W CC. 251............... Yes................. No.................. 08 MED................. FX, SPRN, STRN & DISL 0.5561

2.3

2.8 OF FOREARM, HAND, FOOT AGE >17 W/O CC. 252............... No.................. No.................. 08 MED*................ FX, SPRN, STRN & DISL 0.5561

*

* OF FOREARM, HAND, FOOT AGE 0-17. 253............... Yes................. No.................. 08 MED................. FX, SPRN, STRN & DISL 0.9049

3.8

4.6 OF DUPARM, LOWLEG EX FOOT AGE >17 W CC. 254............... Yes................. No.................. 08 MED................. FX, SPRN, STRN & DISL 0.5741

2.6

3.1 OF UPARM, LOWLEG EX FOOT AGE >17 W/O CC. 255............... No.................. No.................. 08 MED*................ FX, SPRN, STRN & DISL 0.5741

*

* OF UPARM, LOWLEG EX FOOT AGE 0-17. 256............... Yes................. No.................. 08 MED................. OTHER MUSCULOSKELETAL 0.9598

3.9

5.1 SYSTEM & CONNECTIVE TISSUE DIAGNOSES. 257............... No.................. No.................. 09 SURG................ TOTAL MASTECTOMY FOR

0.9016

2.0

2.6 MALIGNANCY W CC. 258............... No.................. No.................. 09 SURG................ TOTAL MASTECTOMY FOR

0.7045

1.5

1.7 MALIGNANCY W/O CC. 259............... No.................. No.................. 09 SURG................ SUBTOTAL MASTECTOMY

0.9445

1.8

2.8 FOR MALIGNANCY W CC. 260............... No.................. No.................. 09 SURG................ SUBTOTAL MASTECTOMY

0.6437

1.2

1.4 FOR MALIGNANCY W/O CC.

[[Page 24279]]

261............... No.................. No.................. 09 SURG................ BREAST PROC FOR NON-

0.8875

1.6

2.2 MALIGNANCY EXCEPT BIOPSY & LOCAL EXCISION. 262............... No.................. No.................. 09 SURG................ BREAST BIOPSY & LOCAL 1.0346

3.2

4.6 EXCISION FOR NON- MALIGNANCY. 263............... Yes................. No.................. 09 SURG................ SKIN GRAFT &/OR DEBRID 2.2702

8.3

11.1 FOR SKN ULCER OR CELLULITIS W CC. 264............... Yes................. No.................. 09 SURG................ SKIN GRAFT &/OR DEBRID 1.2644

4.9

6.4 FOR SKN ULCER OR CELLULITIS W/O CC. 265............... Yes................. No.................. 09 SURG................ SKIN GRAFT &/OR DEBRID 1.6907

4.2

6.7 EXCEPT FOR SKIN ULCER OR CELLULITIS W CC. 266............... Yes................. No.................. 09 SURG................ SKIN GRAFT &/OR DEBRID 0.9200

2.2

3.0 EXCEPT FOR SKIN ULCER OR CELLULITIS W/O CC. 267............... No.................. No.................. 09 SURG................ PERIANAL & PILONIDAL

0.9870

2.8

4.2 PROCEDURES. 268............... No.................. No.................. 09 SURG................ SKIN, SUBCUTANEOUS

1.2352

2.4

3.7 TISSUE & BREAST PLASTIC PROCEDURES. 269............... Yes................. No.................. 09 SURG................ OTHER SKIN, SUBCUT

1.8802

6.0

8.2 TISS & BREAST PROC W CC. 270............... Yes................. No.................. 09 SURG................ OTHER SKIN, SUBCUT

0.8949

2.7

3.6 TISS & BREAST PROC W/ O CC. 271............... Yes................. No.................. 09 MED................. SKIN ULCERS........... 1.2353

5.6

7.1 272............... Yes................. No.................. 09 MED................. MAJOR SKIN DISORDERS W 1.1364

4.5

5.9 CC. 273............... Yes................. No.................. 09 MED................. MAJOR SKIN DISORDERS W/ 0.6838

2.9

3.7 O CC. 274............... No.................. No.................. 09 MED................. MALIGNANT BREAST

1.2180

4.5

6.2 DISORDERS W CC. 275............... No.................. No.................. 09 MED................. MALIGNANT BREAST

0.6697

2.3

3.3 DISORDERS W/O CC. 276............... No.................. No.................. 09 MED................. NON-MALIGANT BREAST

0.8441

3.6

4.6 DISORDERS. 277............... Yes................. No.................. 09 MED................. CELLULITIS AGE >17 W

1.0015

4.5

5.5 CC. 278............... Yes................. No.................. 09 MED................. CELLULITIS AGE >17 W/O 0.6817

3.4

4.0 CC. 279............... No.................. No.................. 09 MED*................ CELLULITIS AGE 0-17... 0.6817

3.9

4.2 280............... Yes................. No.................. 09 MED................. TRAUMA TO THE SKIN,

0.8212

3.2

4.1 SUBCUT TISS & BREAST AGE >17 W CC. 281............... Yes................. No.................. 09 MED................. TRAUMA TO THE SKIN,

0.5678

2.3

2.8 SUBCUT TISS & BREAST AGE >17 W/O CC. 282............... No.................. No.................. 09 MED*................ TRAUMA TO THE SKIN,

0.5678

*

* SUBCUT TISS & BREAST AGE 0-17. 283............... Yes................. No.................. 09 MED................. MINOR SKIN DISORDERS W 0.8525

3.5

4.6 CC. 284............... Yes................. No.................. 09 MED................. MINOR SKIN DISORDERS W/ 0.5295

2.3

2.9 O CC. 285............... Yes................. No.................. 10 SURG................ AMPUTAT OF LOWER LIMB 2.3169

8.1

10.3 FOR ENDOCRINE, NUTRIT, & METABOL DISORDERS. 286............... No.................. No.................. 10 SURG................ ADRENAL & PITUITARY

1.9369

3.8

5.2 PROCEDURES. 287............... Yes................. No.................. 10 SURG................ SKIN GRAFTS & WOUND

2.0354

7.6

10.0 DEBRID FOR ENDOC, NUTRIT & METAB DISORDERS. 288............... No.................. No.................. 10 SURG................ O.R. PROCEDURES FOR

1.7332

2.9

3.7 OBESITY. 289............... No.................. No.................. 10 SURG................ PARATHYROID PROCEDURES 0.8548

1.6

2.4 290............... No.................. No.................. 10 SURG................ THYROID PROCEDURES.... 0.8454

1.5

2.0 291............... No.................. No.................. 10 SURG................ THYROGLOSSAL

0.5867

1.3

1.5 PROCEDURES. 292............... Yes................. No.................. 10 SURG................ OTHER ENDOCRINE,

2.6043

7.3

10.2 NUTRIT & METAB O.R. PROC W CC. 293............... Yes................. No.................. 10 SURG................ OTHER ENDOCRINE,

1.3605

3.4

4.7 NUTRIT & METAB O.R. PROC W/O CC. 294............... Yes................. No.................. 10 MED................. DIABETES AGE >35...... 0.8642

3.3

4.3 295............... No.................. No.................. 10 MED................. DIABETES AGE 0-35..... 0.9301

2.8

3.7 296............... Yes................. No.................. 10 MED................. NUTRITIONAL & MISC

0.9041

3.6

4.7 METABOLIC DISORDERS AGE >17 W CC. 297............... Yes................. No.................. 10 MED................. NUTRITIONAL & MISC

0.5589

2.5

3.0 METABOLIC DISORDERS AGE >17 W/O CC. 298............... No.................. No.................. 10 MED................. NUTRITIONAL & MISC

0.7622

2.5

3.6 METABOLIC DISORDERS AGE 0-17. 299............... No.................. No.................. 10 MED................. INBORN ERRORS OF

1.1353

3.8

5.1 METABOLISM. 300............... Yes................. No.................. 10 MED................. ENDOCRINE DISORDERS W 1.1666

4.6

5.9 CC. 301............... Yes................. No.................. 10 MED................. ENDOCRINE DISORDERS W/ 0.6427

2.7

3.4 O CC. 302............... No.................. No.................. 11 SURG................ KIDNEY TRANSPLANT..... 5.5466

6.8

8.0 303............... No.................. No.................. 11 SURG................ KIDNEY, URETER & MAJOR 2.3084

5.7

7.3 BLADDER PROCEDURES FOR NEOPLASM. 304............... Yes................. No.................. 11 SURG................ KIDNEY, URETER & MAJOR 2.3631

6.0

8.5 BLADDER PROC FOR NON- NEOPL W CC.

[[Page 24280]]

305............... Yes................. No.................. 11 SURG................ KIDNEY, URETER & MAJOR 1.1498

2.5

3.1 BLADDER PROC FOR NON- NEOPL W/O CC. 306............... No.................. No.................. 11 SURG................ PROSTATECTOMY W CC.... 1.3307

3.6

5.6 307............... No.................. No.................. 11 SURG................ PROSTATECTOMY W/O CC.. 0.6569

1.7

2.0 308............... No.................. No.................. 11 SURG................ MINOR BLADDER

1.7066

3.9

6.2 PROCEDURES W CC. 309............... No.................. No.................. 11 SURG................ MINOR BLADDER

0.9014

1.6

2.0 PROCEDURES W/O CC. 310............... No.................. No.................. 11 SURG................ TRANSURETHRAL

1.1913

3.1

4.5 PROCEDURES W CC. 311............... No.................. No.................. 11 SURG................ TRANSURETHRAL

0.6397

1.5

1.9 PROCEDURES W/O CC. 312............... No.................. No.................. 11 SURG................ URETHRAL PROCEDURES,

1.1947

3.3

4.9 AGE >17 W CC. 313............... No.................. No.................. 11 SURG................ URETHRAL PROCEDURES,

0.7523

1.8

2.4 AGE >17 W/O CC. 314............... No.................. No.................. 11 SURG*............... URETHRAL PROCEDURES,

0.7523

29.4

89.0 AGE 0-17. 315............... No.................. No.................. 11 SURG................ OTHER KIDNEY & URINARY 1.9482

3.7

6.7 TRACT O.R. PROCEDURES. 316............... Yes................. No.................. 11 MED................. RENAL FAILURE......... 1.3481

4.8

6.3 317............... No.................. No.................. 11 MED................. ADMIT FOR RENAL

0.8454

2.4

3.5 DIALYSIS. 318............... No.................. No.................. 11 MED................. KIDNEY & URINARY TRACT 1.2571

4.4

6.0 NEOPLASMS W CC. 319............... No.................. No.................. 11 MED................. KIDNEY & URINARY TRACT 0.6169

1.9

2.6 NEOPLASMS W/O CC. 320............... Yes................. No.................. 11 MED................. KIDNEY & URINARY TRACT 0.9538

4.1

5.1 INFECTIONS AGE >17 W CC. 321............... Yes................. No.................. 11 MED................. KIDNEY & URINARY TRACT 0.6512

3.0

3.6 INFECTIONS AGE >17 W/ O CC. 322............... No.................. No.................. 11 MED................. KIDNEY & URINARY TRACT 0.7212

3.1

3.6 INFECTIONS AGE 0-17. 323............... No.................. No.................. 11 MED................. URINARY STONES W CC,

0.8239

2.3

3.1 D&/OR ESW LITHOTRIPSY. 324............... No.................. No.................. 11 MED................. URINARY STONES W/O CC. 0.5233

1.6

1.8 325............... No.................. No.................. 11 MED................. KIDNEY & URINARY TRACT 0.7334

2.9

3.7 SIGNS & SYMPTOMS AGE >17 W CC. 326............... No.................. No.................. 11 MED................. KIDNEY & URINARY TRACT 0.4932

2.1

2.6 SIGNS & SYMPTOMS AGE >17 W/O CC. 327............... No.................. No.................. 11 MED................. KIDNEY & URINARY TRACT 0.3724

1.8

2.0 SIGNS & SYMPTOMS AGE 0-17. 328............... No.................. No.................. 11 MED................. URETHRAL STRICTURE AGE 0.7346

2.5

3.4 >17 W CC. 329............... No.................. No.................. 11 MED................. URETHRAL STRICTURE AGE 0.4671

1.4

1.7 >17 W/O CC. 330............... No.................. No.................. 11 MED*................ URETHRAL STRICTURE AGE 0.4671

*

* 0-17. 331............... Yes................. No.................. 11 MED................. OTHER KIDNEY & URINARY 1.1580

4.2

5.5 TRACT DIAGNOSES AGE >17 W CC. 332............... Yes................. No.................. 11 MED................. OTHER KIDNEY & URINARY 0.6602

2.4

3.1 TRACT DIAGNOSES AGE >17 W/O CC. 333............... No.................. No.................. 11 MED................. OTHER KIDNEY & URINARY 1.1833

3.7

5.4 TRACT DIAGNOSES AGE 0- 17. 334............... No.................. No.................. 12 SURG................ MAJOR MALE PELVIC

1.4154

3.3

4.0 PROCEDURES W CC. 335............... No.................. No.................. 12 SURG................ MAJOR MALE PELVIC

1.0701

2.2

2.5 PROCEDURES W/O CC. 336............... No.................. No.................. 12 SURG................ TRANSURETHRAL

0.8824

2.4

3.2 PROSTATECTOMY W CC. 337............... No.................. No.................. 12 SURG................ TRANSURETHRAL

0.5989

1.6

1.8 PROSTATECTOMY W/O CC. 338............... No.................. No.................. 12 SURG................ TESTES PROCEDURES, FOR 1.4072

3.7

5.8 MALIGNANCY. 339............... No.................. No.................. 12 SURG................ TESTES PROCEDURES, NON- 1.3418

3.3

5.2 MALIGNANCY AGE >17. 340............... No.................. No.................. 12 SURG*............... TESTES PROCEDURES, NON- 1.3418

*

* MALIGNANCY AGE 0-17. 341............... No.................. No.................. 12 SURG................ PENIS PROCEDURES...... 1.2527

1.9

3.2 342............... No.................. No.................. 12 SURG................ CIRCUMCISION AGE >17.. 0.8546

2.3

3.0 343............... No.................. No.................. 12 SURG*............... CIRCUMCISION AGE 0-17. 0.8546

*

* 344............... No.................. No.................. 12 SURG................ OTHER MALE

1.1078

1.8

2.7 REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY.

[[Page 24281]]

345............... No.................. No.................. 12 SURG................ OTHER MALE

1.3524

3.4

5.4 REPRODUCTIVE SYSTEM O.R. PROC EXCEPT FOR MALIGNANCY. 346............... No.................. No.................. 12 MED................. MALIGNANCY, MALE

1.1351

4.5

5.9 REPRODUCTIVE SYSTEM, W CC. 347............... No.................. No.................. 12 MED................. MALIGNANCY, MALE

0.5734

2.0

2.7 REPRODUCTIVE SYSTEM, W/O CC. 348............... No.................. No.................. 12 MED................. BENIGN PROSTATIC

0.7721

3.1

4.0 HYPERTROPHY W CC. 349............... No.................. No.................. 12 MED................. BENIGN PROSTATIC

0.4942

2.1

2.6 HYPERTROPHY W/O CC. 350............... No.................. No.................. 12 MED................. INFLAMMATION OF THE

0.8552

3.6

4.5 MALE REPRODUCTIVE SYSTEM. 351............... No.................. No.................. 12 MED*................ STERILIZATION, MALE... 0.8690

*

* 352............... No.................. No.................. 12 MED................. OTHER MALE

0.8690

3.0

4.2 REPRODUCTIVE SYSTEM DIAGNOSES. 353............... No.................. No.................. 13 SURG................ PELVIC EVISCERATION,

1.7446

4.5

6.0 DRADICAL HYSTERECTOMY & RADICAL VULVECTOMY. 354............... No.................. No.................. 13 SURG................ UTERINE, ADNEXA PROC

1.5594

4.5

5.6 FOR NON-OVARIAN/ ADNEXAL MALIG W CC. 355............... No.................. No.................. 13 SURG................ UTERINE, ADNEXA PROC

0.9349

2.8

3.0 FOR NON-OVARIAN/ ADNEXAL MALIG W/O CC. 356............... No.................. No.................. 13 SURG................ FEMALE REPRODUCTIVE

0.7426

1.6

1.9 SYSTEM RECONSTRUCTIVE PROCEDURES. 357............... No.................. No.................. 13 SURG................ UTERINE & ADNEXA PROC 2.2785

6.4

8.0 FOR OVARIAN OR ADNEXAL MALIGNANCY. 358............... No.................. No.................. 13 SURG................ UTERINE & ADNEXA PROC 1.1816

3.1

3.9 FOR NON-MALIGNANCY W CC. 359............... No.................. No.................. 13 SURG................ UTERINE & ADNEXA PROC 0.8258

2.1

2.3 FOR NON-MALIGNANCY W/ O CC. 360............... No.................. No.................. 13 SURG................ VAGINA, CERVIX & VULVA 0.8803

2.0

2.5 PROCEDURES. 361............... No.................. No.................. 13 SURG................ LAPAROSCOPY &

1.1046

2.1

3.0 INCISIONAL TUBAL INTERRUPTION. 362............... No.................. No.................. 13 SURG*............... ENDOSCOPIC TUBAL

1.1046

1.0

1.0 INTERRUPTION. 363............... No.................. No.................. 13 SURG................ D&C, CONIZATION &

1.0198

2.8

4.1 RADIO-IMPLANT, FOR MALIGNANCY. 364............... No.................. No.................. 13 SURG................ D&C, CONIZATION EXCEPT 0.9331

3.0

4.2 FOR MALIGNANCY. 365............... No.................. No.................. 13 SURG................ OTHER FEMALE

2.0803

5.3

7.9 REPRODUCTIVE SYSTEM O.R. PROCEDURES. 366............... No.................. No.................. 13 MED................. MALIGNANCY, FEMALE

1.2888

4.6

6.3 REPRODUCTIVE SYSTEM W CC. 367............... No.................. No.................. 13 MED................. MALIGNANCY, FEMALE

0.5895

2.3

3.0 REPRODUCTIVE SYSTEM W/ O CC. 368............... No.................. No.................. 13 MED................. INFECTIONS, FEMALE

1.2262

5.0

6.4 REPRODUCTIVE SYSTEM. 369............... No.................. No.................. 13 MED................. MENSTRUAL & OTHER

0.6696

2.5

3.3 FEMALE REPRODUCTIVE SYSTEM DISORDERS. 370............... No.................. No.................. 14 SURG................ CESAREAN SECTION W CC. 1.1080

4.0

5.0 371............... No.................. No.................. 14 SURG................ CESAREAN SECTION W/O

0.7664

3.1

3.4 CC. 372............... No.................. No.................. 14 MED................. VAGINAL DELIVERY W

0.7390

2.7

3.5 COMPLICATING DIAGNOSES. 373............... No.................. No.................. 14 MED................. VAGINAL DELIVERY W/O

0.5276

2.1

2.2 COMPLICATING DIAGNOSES. 374............... No.................. No.................. 14 SURG................ VAGINAL DELIVERY W

0.7708

2.4

3.0 STERILIZATION &/OR D&C. 375............... No.................. No.................. 14 SURG................ VAGINAL DELIVERY W

1.2156

4.0

6.2 O.R. PROC EXCEPT STERIL &/OR D&C. 376............... No.................. No.................. 14 MED................. POSTPARTUM & POST

0.7273

2.5

3.3 ABORTION DIAGNOSES W/ O O.R. PROCEDURE. 377............... No.................. No.................. 14 SURG................ POSTPARTUM & POST

1.5307

3.1

4.4 ABORTION DIAGNOSES W O.R. PROCEDURE. 378............... No.................. No.................. 14 MED................. ECTOPIC PREGNANCY..... 0.7782

1.8

2.2 379............... No.................. No.................. 14 MED................. THREATENED ABORTION... 0.5628

2.2

3.2 380............... No.................. No.................. 14 MED................. ABORTION W/O D&C...... 0.4872

1.5

2.0

[[Page 24282]]

381............... No.................. No.................. 14 SURG................ ABORTION W D&C,

0.7239

1.7

2.4 ASPIRATION CURETTAGE OR HYSTEROTOMY. 382............... No.................. No.................. 14 MED................. FALSE LABOR........... 0.2783

1.3

1.5 383............... No.................. No.................. 14 MED................. OTHER ANTEPARTUM

0.6683

2.6

3.7 DIAGNOSES W MEDICAL COMPLICATIONS. 384............... No.................. No.................. 14 MED................. OTHER ANTEPARTUM

0.4601

1.7

2.5 DIAGNOSES W/O MEDICAL COMPLICATIONS. 385............... No.................. No.................. 15 MED*................ NEONATES, DIED OR

1.4095

*

* TRANSFERRED TO ANOTHER ACUTE CARE FACILITY. 386............... No.................. No.................. 15 MED*................ EXTREME IMMATURITY OR

4.648

*

* RESPIRATORY DISTRESS SYNDROME, NEONATE. 387............... No.................. No.................. 15 MED*................ PREMATURITY W MAJOR

3.1744

*

* PROBLEMS. 388............... No.................. No.................. 15 MED*................ PREMATURITY W/O MAJOR 1.9153

*

* PROBLEMS. 389............... No.................. No.................. 15 MED*................ FULL TERM NEONATE W

3.2608

1.8

2.0 MAJOR PROBLEMS. 390............... No.................. No.................. 15 MED*................ NEONATE W OTHER

1.1541

*

* SIGNIFICANT PROBLEMS. 391............... No.................. No.................. 15 MED*................ NORMAL NEWBORN........ 0.1562

*

* 392............... No.................. No.................. 16 SURG................ SPLENECTOMY AGE >17... 3.1188

6.3

8.8 393............... No.................. No.................. 16 SURG*............... SPLENECTOMY AGE 0--7.. 3.1188

*

* 394............... No.................. No.................. 16 SURG................ OTHER O.R. PROCEDURES 1.8725

4.4

7.3 OF THE BLOOD AND BLOOD FORMING ORGANS. 395............... Yes................. No.................. 16 MED................. RED BLOOD CELL

0.9413

3.2

4.3 DISORDERS AGE >17. 396............... No.................. No.................. 16 MED................. RED BLOOD CELL

0.6888

2.5

3.0 DISORDERS AGE 0-17. 397............... No.................. No.................. 16 MED................. COAGULATION DISORDERS. 1.3611

3.7

5.1 398............... No.................. No.................. 16 MED................. RETICULOENDOTHELIAL & 1.2912

4.4

5.7 IMMUNITY DISORDERS W CC. 399............... No.................. No.................. 16 MED................. RETICULOENDOTHELIAL & 0.7064

2.7

3.4 IMMUNITY DISORDERS W/ O CC. 400............... No.................. No.................. 17 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 401............... Yes................. No.................. 17 SURG................ LYMPHOMA & NON-ACUTE

2.8703

8.1

11.2 LEUKEMIA W OTHER O.R. PROC W CC. 402............... Yes................. No.................. 17 SURG................ LYMPHOMA & NON-ACUTE

1.1380

2.8

3.9 LEUKEMIA W OTHER O.R. PROC W/O CC. 403............... Yes................. No.................. 17 MED................. LYMPHOMA & NON-ACUTE

1.8986

5.7

8.0 LEUKEMIA W CC. 404............... Yes................. No.................. 17 MED................. LYMPHOMA & NON-ACUTE

0.9137

3.0

4.0 LEUKEMIA W/O CC. 405............... No.................. No.................. 17 MED*................ ACUTE LEUKEMIA W/O

3.4703

*

* MAJOR O.R. PROCEDURE AGE 0-17. 406............... No.................. No.................. 17 SURG................ MYELOPROLIF DISORD OR 2.7839

6.7

9.4 POORLY DIFF NEOPL W MAJ O.R.PROC W CC. 407............... No.................. No.................. 17 SURG................ MYELOPROLIF DISORD OR 1.1617

2.9

3.5 POORLY DIFF NEOPL W MAJ O.R.PROC W/O CC. 408............... No.................. No.................. 17 SURG................ MYELOPROLIF DISORD OR 2.1388

5.1

8.2 POORLY DIFF NEOPL W OTHER O.R.PROC. 409............... No.................. No.................. 17 MED................. RADIOTHERAPY.......... 1.2059

4.5

6.0 410............... No.................. No.................. 17 MED................. CHEMOTHERAPY W/O ACUTE 1.0178

2.9

3.8 LEUKEMIA AS SECONDARY DIAGNOSIS. 411............... No.................. No.................. 17 MED*................ HISTORY OF MALIGNANCY 0.6205

1.6

2.0 W/O ENDOSCOPY. 412............... No.................. No.................. 17 MED*................ HISTORY OF MALIGNANCY 0.6205

1.4

1.5 W ENDOSCOPY. 413............... No.................. No.................. 17 MED................. OTHER MYELOPROLIF DIS 1.4097

5.1

6.8 OR POORLY DIFF NEOPL DIAG W CC. 414............... No.................. No.................. 17 MED................. OTHER MYELOPROLIF DIS 0.8055

3.0

4.0 OR POORLY DIFF NEOPL DIAG W/O CC. 415............... Yes................. No.................. 18 SURG................ O.R. PROCEDURE FOR

4.1393

11.0

14.8 INFECTIOUS & PARASITIC DISEASES. 416............... Yes................. No.................. 18 MED................. SEPTICEMIA AGE >17.... 1.8340

5.7

7.6 417............... No.................. No.................. 18 MED................. SEPTICEMIA AGE 0-17... 1.9140

5.2

6.5 418............... Yes................. No.................. 18 MED................. POSTOPERATIVE & POST- 1.1938

4.7

6.1 TRAUMATIC INFECTIONS.

[[Page 24283]]

419............... No.................. No.................. 18 MED................. FEVER OF UNKNOWN

0.8951

3.4

4.4 ORIGIN AGE >17 W CC. 420............... No.................. No.................. 18 MED................. FEVER OF UNKNOWN

0.6263

2.6

3.2 ORIGIN AGE >17 W/O CC. 421............... No.................. No.................. 18 MED................. VIRAL ILLNESS AGE >17. 0.8210

3.1

4.0 422............... No.................. No.................. 18 MED................. VIRAL ILLNESS & FEVER 0.8240

2.6

3.7 OF UNKNOWN ORIGIN AGE 0-17. 423............... Yes................. No.................. 18 MED................. OTHER INFECTIOUS &

1.9053

5.9

8.2 PARASITIC DISEASES DIAGNOSES. 424............... No.................. No.................. 19 SURG................ O.R. PROCEDURE W

2.3978

7.4

11.4 PRINCIPAL DIAGNOSES OF MENTAL ILLNESS. 425............... No.................. No.................. 19 MED................. ACUTE ADJUSTMENT

0.7075

2.6

3.5 REACTION & PSYCHOSOCIAL DYSFUNCTION. 426............... No.................. No.................. 19 MED................. DEPRESSIVE NEUROSES... 0.7464

3.2

4.5 427............... No.................. No.................. 19 MED................. NEUROSES EXCEPT

0.8104

3.2

4.7 DEPRESSIVE. 428............... No.................. No.................. 19 MED................. DISORDERS OF

1.1577

4.5

7.3 PERSONALITY & IMPULSE CONTROL. 429............... Yes................. No.................. 19 MED................. ORGANIC DISTURBANCES & 0.9614

4.4

5.8 MENTAL RETARDATION. 430............... Yes................. No.................. 19 MED................. PSYCHOSES............. 1.2316

5.9

8.0 431............... No.................. No.................. 19 MED................. CHILDHOOD MENTAL

1.0504

4.3

6.8 DISORDERS. 432............... No.................. No.................. 19 MED................. OTHER MENTAL DISORDER 0.7280

2.7

4.0 DIAGNOSES. 433............... No.................. No.................. 20 MED................. ALCOHOL/DRUG ABUSE OR 0.4017

2.1

2.8 DEPENDENCE, LEFT AMA. 434............... No.................. No.................. 20 MED................. NO LONGER VALID....... 0.0000

0.0

0.0 435............... No.................. No.................. 20 MED................. NO LONGER VALID....... 0.0000

0.0

0.0 436............... No.................. No.................. 20 MED................. NO LONGER VALID....... 0.0000

0.0

0.0 437............... No.................. No.................. 20 MED................. NO LONGER VALID....... 0.0000

0.0

0.0 438............... No.................. No.................. 20 MED................. NO LONGER VALID....... 0.0000

0.0

0.0 439............... No.................. No.................. 21 SURG................ SKIN GRAFTS FOR

2.0857

5.4

8.4 INJURIES. 440............... Yes................. No.................. 21 SURG................ WOUND DEBRIDEMENTS FOR 2.0128

5.6

8.5 INJURIES. 441............... No.................. No.................. 21 SURG................ HAND PROCEDURES FOR

1.0682

2.3

3.5 INJURIES. 442............... Yes................. No.................. 21 SURG................ OTHER O.R. PROCEDURES 2.6213

5.9

8.9 FOR INJURIES W CC. 443............... Yes................. No.................. 21 SURG................ OTHER O.R. PROCEDURES 1.0919

2.7

3.5 FOR INJURIES W/O CC. 444............... Yes................. No.................. 21 MED................. TRAUMATIC INJURY AGE

0.8329

3.2

4.1 >17 W CC. 445............... Yes................. No.................. 21 MED................. TRAUMATIC INJURY AGE

0.5792

2.3

2.8 >17 W/O CC. 446............... No.................. No.................. 21 MED*................ TRAUMATIC INJURY AGE 0- 0.5792

*

* 17. 447............... No.................. No.................. 21 MED................. ALLERGIC REACTIONS AGE 0.6470

1.9

2.6 >17. 448............... No.................. No.................. 21 MED*................ ALLERGIC REACTIONS AGE 0.6470

*

* 0-17. 449............... No.................. No.................. 21 MED................. POISONING & TOXIC

0.9882

2.7

3.7 EFFECTS OF DRUGS AGE >17 W CC. 450............... No.................. No.................. 21 MED................. POISONING & TOXIC

0.5741

1.6

2.0 EFFECTS OF DRUGS AGE >17 W/O CC. 451............... No.................. No.................. 21 MED*................ POISONING & TOXIC

0.5741

10.2

10.5 EFFECTS OF DRUGS AGE 0-17. 452............... No.................. No.................. 21 MED................. COMPLICATIONS OF

1.1377

3.5

4.9 TREATMENT W CC. 453............... No.................. No.................. 21 MED................. COMPLICATIONS OF

0.5867

2.2

2.8 TREATMENT W/O CC. 454............... No.................. No.................. 21 MED................. OTHER INJURY,

0.9136

3.0

4.1 POISONING & TOXIC EFFECT DIAG W CC. 455............... No.................. No.................. 21 MED................. OTHER INJURY,

0.5053

1.8

2.3 POISONING & TOXIC EFFECT DIAG W/O CC. 456............... No.................. No.................. 22 MED................. NO LONGER VALID....... 0.0000

0.0

0.0 457............... No.................. No.................. 22 MED................. NO LONGER VALID....... 0.0000

0.0

0.0 458............... No.................. No.................. 22 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 459............... No.................. No.................. 22 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 460............... No.................. No.................. 22 MED................. NO LONGER VALID....... 0.0000

0.0

0.0 461............... No.................. No.................. 23 SURG................ O.R. PROC W DIAGNOSES 1.5386

3.3

5.6 OF OTHER CONTACT W HEALTH SERVICES. 462............... Yes................. No.................. 23 MED................. REHABILITATION........ 1.5753

8.4

9.9 463............... Yes................. No.................. 23 MED................. SIGNS & SYMPTOMS W CC. 0.7661

3.1

3.9 464............... Yes................. No.................. 23 MED................. SIGNS & SYMPTOMS W/O

0.5663

2.4

2.9 CC. 465............... No.................. No.................. 23 MED................. AFTERCARE W HISTORY OF 0.6205

2.5

3.6 MALIGNANCY AS SECONDARY DIAGNOSIS. 466............... No.................. No.................. 23 MED................. AFTERCARE W/O HISTORY 0.7848

2.7

5.0 OF MALIGNANCY AS SECONDARY DIAGNOSIS.

[[Page 24284]]

467............... No.................. No.................. 23 MED................. OTHER FACTORS

0.5408

1.9

2.7 INFLUENCING HEALTH STATUS. 468............... Yes................. No.................. ...... SURG................ EXTENSIVE O.R.

3.8122

9.6

12.9 PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS. 469............... No.................. No.................. ...... **.................. PRINCIPAL DIAGNOSIS

0.0000

0.0

0.0 INVALID AS DISCHARGE DIAGNOSIS. 470............... No.................. No.................. ...... **.................. UNGROUPABLE........... 0.0000

0.0

0.0 471............... Yes................. Yes................. 08 SURG................ BILATERAL OR MULTIPLE 2.7365

4.2

4.6 MAJOR JOINT PROCS OF LOWER EXTREMITY. 472............... No.................. No.................. 22 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 473............... No.................. No.................. 17 MED................. ACUTE LEUKEMIA W/O

3.4703

7.3

12.7 MAJOR O.R. PROCEDURE AGE >17. 474............... No.................. No.................. 04 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 475............... Yes................. No.................. 04 MED................. RESPIRATORY SYSTEM

3.8279

7.9

10.9 DIAGNOSIS WITH VENTILATOR SUPPORT. 476............... No.................. No.................. ...... SURG................ PROSTATIC O.R.

2.1079

6.9

10.0 PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS. 477............... Yes................. No.................. ...... SURG................ NON-EXTENSIVE O.R.

2.0694

5.9

8.6 PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS. 478............... Yes................. No.................. 05 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 479............... No.................. No.................. 05 SURG................ OTHER VASCULAR

1.2715

1.9

2.6 PROCEDURES W/O CC. 480............... No.................. No.................. PRE SURG................ LIVER TRANSPLANT AND/ 11.7482

14.0

19.2 OR INTESTINAL TRANSPLANT. 481............... No.................. No.................. PRE SURG................ BONE MARROW TRANSPLANT 7.1983

18.7

22.0 482............... Yes................. No.................. PRE SURG................ TRACHEOSTOMY FOR

3.5956

9.4

11.8 FACE,MOUTH & NECK DIAGNOSES. 483............... No.................. No.................. PRE SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 484............... No.................. No.................. 24 SURG................ CRANIOTOMY FOR

5.3652

8.6

12.8 MULTIPLE SIGNIFICANT TRAUMA. 485............... Yes................. No.................. 24 SURG................ LIMB REATTACHMENT, HIP 3.5846

8.1

9.9 AND FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA. 486............... No.................. No.................. 24 SURG................ OTHER O.R. PROCEDURES 5.1310

8.5

12.3 FOR MULTIPLE SIGNIFICANT TRAUMA. 487............... Yes................. No.................. 24 MED................. OTHER MULTIPLE

2.1184

5.2

7.1 SIGNIFICANT TRAUMA. 488............... No.................. No.................. 25 SURG................ HIV W EXTENSIVE O.R.

4.8181

12.2

17.5 PROCEDURE. 489............... No.................. No.................. 25 MED................. HIV W MAJOR RELATED

1.7760

5.8

8.2 CONDITION. 490............... No.................. No.................. 25 MED................. HIV W OR W/O OTHER

1.0808

3.8

5.3 RELATED CONDITION. 491............... No.................. No.................. 08 SURG................ MAJOR JOINT & LIMB

1.5997

2.5

3.0 REATTACHMENT PROCEDURES OF UPPER EXTREMITY. 492............... No.................. No.................. 17 MED................. CHEMOTHERAPY W ACUTE

3.6663

8.9

13.8 LEUKEMIA OR W USE OF HI DOSE CHEMOAGENT. 493............... No.................. No.................. 07 SURG................ LAPAROSCOPIC

1.7812

4.6

6.0 CHOLECYSTECTOMY W/O C.D.E. W CC. 494............... No.................. No.................. 07 SURG................ LAPAROSCOPIC

0.9795

2.1

2.7 CHOLECYSTECTOMY W/O C.D.E. W/O CC. 495............... No.................. No.................. PRE SURG................ LUNG TRANSPLANT....... 10.0630

14.2

17.0 496............... No.................. No.................. 08 SURG................ COMBINED ANTERIOR/

5.3926

6.4

8.8 POSTERIOR SPINAL FUSION. 497............... Yes................. Yes................. 08 SURG................ SPINAL FUSION EXCEPT

3.3300

4.8

5.7 CERVICAL W CC. 498............... Yes................. Yes................. 08 SURG................ SPINAL FUSION EXCEPT

2.5267

3.3

3.7 CERVICAL W/O CC. 499............... No.................. No.................. 08 SURG................ BACK & NECK PROCEDURES 1.3408

3.0

4.2 EXCEPT SPINAL FUSION W CC. 500............... No.................. No.................. 08 SURG................ BACK & NECK PROCEDURES 0.8707

1.8

2.2 DEXCEPT SPINAL FUSION W/O CC. 501............... Yes................. No.................. 08 SURG................ KNEE PROCEDURES W PDX 2.7150

8.4

10.4 OF INFECTION W CC. 502............... Yes................. No.................. 08 SURG................ KNEE PROCEDURES W PDX 1.5598

5.0

5.8 OF INFECTION W/O CC. 503............... No.................. No.................. 08 SURG................ KNEE PROCEDURES W/O

1.2375

3.0

3.9 PDX OF INFECTION.

[[Page 24285]]

504............... No.................. No.................. 22 SURG................ EXTEN. BURNS OR FULL 13.2723

21.0

28.3 THICKNESS BURN W/MV 96+HRS W/SKIN GFT. 505............... No.................. No.................. 22 MED................. EXTEN. BURNS OR FULL

3.0532

2.8

6.4 THICKNESS BURN W/MV 96+HRS W/O SKIN GFT. 506............... No.................. No.................. 22 SURG................ FULL THICKNESS BURN W 4.7246

10.9

15.2 DSKIN GRAFT OR INHAL INJ W CC OR SIG TRAUMA. 507............... No.................. No.................. 22 SURG................ FULL THICKNESS BURN W 2.2603

5.5

7.8 SKIN GRFT OR INHAL INJ W/O CC OR SIG TRAUMA. 508............... No.................. No.................. 22 MED................. FULL THICKNESS BURN W/ 1.6171

5.3

7.5 O SKIN GRFT OR INHAL INJ W CC OR SIG TRAUMA. 509............... No.................. No.................. 22 MED................. FULL THICKNESS BURN W/ 1.1338

3.7

5.3 O SKIN GRFT OR INH INJ W/O CC OR SIG TRAUMA. 510............... No.................. No.................. 22 MED................. NON-EXTENSIVE BURNS W 1.4467

4.1

6.1 CC OR SIGNIFICANT TRAUMA. 511............... No.................. No.................. 22 MED................. NON-EXTENSIVE BURNS W/ 0.8610

2.6

3.7 O CC OR SIGNIFICANT DTRAUMA. 512............... No.................. No.................. PRE SURG................ SIMULTANEOUS PANCREAS/ 9.9384

11.1

13.5 KIDNEY TRANSPLANT. 513............... No.................. No.................. PRE SURG................ PANCREAS TRANSPLANT... 6.5546

8.8

10.0 514............... No.................. No.................. 05 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 515............... No.................. No.................. 05 SURG................ CARDIAC DEFIBRILLATOR 4.1471

2.2

3.8 IMPLANT W/O CARDIAC CATH. 516............... No.................. No.................. 05 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 517............... No.................. No.................. 05 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 518............... No.................. No.................. 05 SURG................ PERC CARDIO PROC W/O

1.1424

1.8

2.5 CORONARY ARTERY STENT OR AMI. 519............... No.................. No.................. 08 SURG................ CERVICAL SPINAL FUSION 2.2859

2.9

4.7 W CC. 520............... No.................. No.................. 08 SURG................ CERVICAL SPINAL FUSION 1.4721

1.6

1.9 W/O CC. 521............... Yes................. No.................. 20 MED................. ALCOHOL/DRUG ABUSE OR 0.9157

4.0

5.4 DEPENDENCE W CC. 522............... Yes................. No.................. 20 MED................. ALC/DRUG ABUSE OR

1.0575

8.1

10.5 DEPEND W REHABILITATION THERAPY W/O CC. 523............... No.................. No.................. 20 MED................. ALC/DRUG ABUSE OR

0.5474

3.2

3.8 DEPEND W/O REHABILITATION THERAPY W/O CC. 524............... No.................. No.................. 01 MED................. TRANSIENT ISCHEMIA.... 0.6913

2.6

3.1 525............... No.................. No.................. 05 SURG................ OTHER HEART ASSIST

12.0673

7.7

14.5 SYSTEM IMPLANT. 526............... No.................. No.................. 05 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 527............... No.................. No.................. 05 SURG................ NO LONGER VALID....... 0.0000

0.0

0.0 528............... No.................. No.................. 01 SURG................ INTRACRANIAL VASCULAR 7.3829

13.3

16.4 PROC W PDX HEMORRHAGE. 529............... Yes................. No.................. 01 SURG................ VENTRICULAR SHUNT

2.2423

4.7

7.5 PROCEDURES W CC. 530............... Yes................. No.................. 01 SURG................ VENTRICULAR SHUNT

1.1697

2.3

3.0 PROCEDURES W/O CC. 531............... Yes................. No.................. 01 SURG................ SPINAL PROCEDURES W CC 3.0552

6.3

9.1 532............... Yes................. No.................. 01 SURG................ SPINAL PROCEDURES W/O 1.3777

2.8

3.6 CC. 533............... No.................. No.................. 01 SURG................ EXTRACRANIAL

1.4911

2.3

3.7 PROCEDURES W CC. 534............... No.................. No.................. 01 SURG................ EXTRACRANIAL

0.9668

1.4

1.7 PROCEDURES W/O CC. 535............... No.................. No.................. 05 SURG................ CARDIAC DEFIB IMPLANT 5.8951

6.9

9.2 W CARDIAC CATH W AMI/ HF/SHOCK. 536............... No.................. No.................. 05 SURG................ CARDIAC DEFIB IMPLANT 5.2199

5.5

7.3 W CARDIAC CATH W/O AMI/HF/SHOCK. 537............... Yes................. No.................. 08 SURG................ LOCAL EXCIS & REMOV OF 1.8568

4.7

6.6 INT FIX DEV EXCEPT HIP & FEMUR W CC. 538............... Yes................. No.................. 08 SURG................ LOCAL EXCIS & REMOV OF 1.0223

2.2

2.9 INT FIX DEV EXCEPT HIP & FEMUR W/O CC. 539............... No.................. No.................. 17 SURG................ LYMPHOMA & LEUKEMIA W 3.1235

6.8

10.5 MAJOR OR PROCEDURE W CC. 540............... No.................. No.................. 17 SURG................ LYMPHOMA & LEUKEMIA W 1.1837

2.6

3.5 MAJOR OR PROCEDURE W/ O CC. 541............... Yes................. No.................. PRE SURG................ ECMO OR TRACH W MV

19.9990

36.9

44.1 96+HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.. 542............... Yes................. No.................. PRE SURG................ TRACH W MV 96+HRS OR 12.5966

27.2

32.6 PDX EXC FACE, MOUTH & NECK W/O MAJ O.R..

[[Page 24286]]

543............... Yes................. No.................. 01 SURG................ CRANIOTOMY W/IMPLANT

4.6474

8.4

12.0 OF CHEMO AGENT OR ACUTE COMPLX CNS PDX. 544............... Yes................. No.................. 08 SURG................ MAJOR JOINT

1.8941

4.0

4.4 REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY. 545............... Yes................. Yes................. 08 SURG................ REVISION OF HIP OR

2.4127

4.5

5.2 KNEE REPLACEMENT. 546............... No.................. No.................. 08 SURG................ SPINAL FUSION EXC CERV 4.8421

6.9

8.7 WITH CURVATURE OF THE SPINE OR MALIG. 547............... Yes................. No.................. 05 SURG................ CORONARY BYPASS W

5.6862

10.9

12.4 CARDIAC CATH W MAJOR CV DX. 548............... Yes................. No.................. 05 SURG................ CORONARY BYPASS W

4.1762

8.1

8.9 CARDIAC CATH W/O MAJOR CV DX. 549............... Yes................. Yes................. 05 SURG................ CORONARY BYPASS W/O

4.8829

8.7

10.3 CARDIAC CATH W MAJOR CV DX. 550............... Yes................. Yes................. 05 SURG................ CORONARY BYPASS W/O

3.4598

6.2

6.8 CARDIAC CATH W/O MAJOR CV DX. 551............... No.................. No.................. 05 SURG................ PERMANENT CARDIAC

2.6339

4.2

6.1 PACEMAKER IMPL W MAJ CV DX OR AICD LEAD OR GNRTR. 552............... No.................. No.................. 05 SURG................ OTHER PERMANENT

1.7670

2.5

3.5 CARDIAC PACEMAKER IMPLANT W/O MAJOR CV DX. 553............... Yes................. No.................. 05 SURG................ OTHER VASCULAR

2.8371

6.3

9.3 PROCEDURES W CC W MAJOR CV DX. 554............... Yes................. No.................. 05 SURG................ OTHER VASCULAR

1.9483

3.7

5.6 PROCEDURES W CC W/O MAJOR CV DX. 555............... No.................. No.................. 05 SURG................ PERCUTANEOUS

1.8654

3.4

4.8 CARDIOVASCULAR PROC W MAJOR CV DX. 556............... No.................. No.................. 05 SURG................ PERCUTANEOUS

1.2241

1.6

2.0 CARDIOVASC PROC W NON- DRUG-ELUTING STENT W/ O MAJ CV DX. 557............... No.................. No.................. 05 SURG................ PERCUTANEOUS

2.1323

3.0

4.1 CARDIOVASCULAR PROC W DRUG-ELUTING STENT W MAJOR CV DX. 558............... No.................. No.................. 05 SURG................ PERCUTANEOUS

1.4299

1.5

1.8 CARDIOVASCULAR PROC W DRUG-ELUTING STENT W/ O MAJ CV DX. 559............... No.................. No.................. 08 MED................. ACUTE ISCHEMIC STROKE 2.2370

5.4

6.9 WITH USE OF THROMBOLYTIC AGENT.

DRGS 469 and 470 contain cases which could not be assigned to valid drgs. Note: An asterisk in the gmlos or amlos column indicates there is no data to compute. Note: Arithmetic mean is presented for informational purposes only. Note: Geometric mean is used only to determine payment for transfer cases. 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

052.2......... Postvaricella Y

1 20, 543 myelitis. 053.14........ Herpes zoster Y

1 20, 543 myelitis. 054.74........ Herpes simplex Y

1 20, 543 myelitis. 238.71........ Essential

N

16 398, 399 thrombocythemi a. 238.72........ Low grade

N

16 395, 396 myelodysplasti c syndrome lesions. 238.73........ High grade N

16 395, 396 myelodysplasti c syndrome lesions. 238.74........ Myelodysplastic N

16 395, 396 syndrome with 5q deletion. 238.75........ Myelodysplastic N

16 395, 396 syndrome, unspecified. 238.76........ Myelofibrosis N

17 401, 402, 403, 404, with myeloid

539, 540 Metaplasia. 238.79........ Other lymphatic N

17 401, 402, 403, 404, and

539, 540 Hematopoietic tissues. 277.30........ Amyloidosis, N

8 240, 241 unspecified. 277.31........ Familial

N

8 240, 241 Mediterranean fever. 277.39........ Other

N

8 240, 241 amyloidosis. 284.01........ Constitutional N

16 395, 396 red blood cell aplasia. 284.09........ Other

N

16 395, 396 constitutional aplastic anemia. 284.1......... Pancytopenia... N

16 395, 396

[[Page 24287]]

284.2......... Myelophthisis.. N

17 401, 402, 403, 404, 539, 540 288.00........ Neutropenia, N

16 398, 399 unspecified.

25 490 288.01........ Congenital N

16 398, 399 neutropenia.

25 490 288.02........ Cyclic

N

16 398, 399 neutropenia.

25 490 288.03........ Drug induced N

16 398, 399 neutropenia.

25 490 288.04........ Neutropenia due N

16 398, 399 to infection.

25 490 288.09........ Other

N

16 398, 399 neutropenia.

25 490 288.4......... Hemophagocytic N

16 398, 399 syndromes. 288.50........ Leukocytopenia, N

16 398, 399 unspecified. 288.51........ Lymphocytopenia N

16 398, 399 288.59........ Other decreased N

16 398, 399 white blood cell count. 288.60........ Leukocytosis, N

16 398, 399 unspecified. 288.61........ Lymphocytosis N

16 398, 399 (symptomatic). 288.62........ Leukemoid

N

16 398, 399 reaction. 288.63........ Monocytosis N

16 398, 399 (symptomatic). 288.64........ Plasmacytosis.. N

16 398, 399 288.65........ Basophilia..... N

16 398, 399 288.69........ Other elevated N

16 398, 399 white blood cell count. 289.53........ Neutropenic N

16 398, 399 splenomegaly. 289.83........ Myelofibrosis.. N

17 401, 402, 403, 404, 539, 540 323.01........ Encephalitis N

1 20, 543 and encephalomyeli tis in viral diseases classified elsewhere. 323.02........ Myelitis in N

1 20, 543 viral diseases classified elsewhere. 323.41........ Other

N

1 20, 543 encephalitis and encephalomyeli tis due to infection classified elsewhere. 323.42........ Other myelitis N

1 20, 543 due to infection classified elsewhere. 323.51........ Encephalitis N

1 20, 543 and encephalomyeli tis following immunization procedures. 323.52........ Myelitis

N

1 20, 543 following immunization procedures. 323.61........ Infectious N

1 20, 543 acute disseminated encephalomyeli tis (ADEM). 323.62........ Other

N

1 20, 543 postinfectious encephalitis and encephalomyeli tis. 323.63........ Postinfectious N

1 20, 543 myelitis. 323.71........ Toxic

N

1 34, 35, 543 encephalitis and encephalomyeli tis. 323.72........ Toxic myelitis. N

1 34, 35, 543 323.81........ Other causes of N

1 20, 543 encephalitis

25 489 and encephalomyeli tis. 323.82........ Other causes of N

1 20, 543 myelitis.

25 489 331.83........ Mild cognitive N

1 12 impairment, so stated. 333.71........ Athetoid

N

1 12 cerebral palsy. 333.72........ Acute dystonia N

1 34, 35 due to drugs. 333.79........ Other acquired N

1 34, 35 torsion dystonia. 333.85........ Subacute

N

1 34, 35 dyskinesia due to drugs. 338.0......... Central pain N

23 463, 464 syndrome. 338.11........ Acute pain due N

23 463, 464 to trauma. 338.12........ Acute post- N

23 463, 464 thoracotomy pain. 338.18........ Other acute N

23 463, 464 postoperative pain. 338.19........ Other acute N

23 463, 464 pain. 338.21........ Chronic pain N

23 463, 464 due to trauma. 338.22........ Chronic post- N

23 463, 464 thoracotomy pain. 338.28........ Other chronic N

23 463, 464 postoperative pain. 338.29........ Other chronic N

23 463, 464 pain. 338.3......... Neoplasm

N

23 463, 464 related pain (acute) (chronic). 338.4......... Chronic pain N

23 463, 464 syndrome. 341.20........ Acute

N

1 20, 543 (transverse) myelitis NOS. 341.21........ Acute

N

1 20, 543 (transverse) myelitis in conditions classified elsewhere. 341.22........ Idiopathic N

1 20, 543 transverse myelitis. 377.43........ Optic nerve N

2 45 hypoplasia. 379.60........ Inflammation N

2 46, 47, 48 (infection) of postprocedural bleb, unspecified. 379.61........ Inflammation N

2 46, 47, 48 (infection) of postprocedural bleb, stage 1. 379.62........ Inflammation N

2 46, 47, 48 (infection) of postprocedural bleb, stage 2. 379.63........ Inflammation N

2 46, 47, 48 (infection) of postprocedural bleb, stage 3. 389.15........ Sensorineural N

3 73, 74 hearing loss, unilateral. 389.16........ Sensorineural N

3 73, 74 hearing loss, asymmetrical. 429.83........ Takotsubo

N

5 144, 145 syndrome.

[[Page 24288]]

478.11........ Nasal mucositis N

3 15, 73, 74 (ulcerative).

391 \1\ 478.19........ Other disease N

3 73, 74 of nasal

15 391 \1\ cavity and sinuses. 518.7......... Transfusion Y

4 101, 102 related acute lung injury (TRALI). 519.11........ Acute

N

PRE 482 bronchospasm.

4 96, 97, 98 519.19........ Other diseases N

PRE 482 of trachea and

4 96, 97, 98 bronchus. 521.81........ Cracked tooth.. N

PRE 482 3 185, 186, 187 521.89........ Other specific N

PRE 482 diseases of

3 185, 186, 187 hard tissues of teeth. 523.00........ Acute

N

PRE 482 gingivitis,

3 185, 186, 187 plaque induced. 523.01........ Acute

N

PRE 482 gingivitis,

3 185, 186, 187 non-plaque induced. 523.10........ Chronic

N

PRE 482 gingivitis,

3 185, 186, 187 plaque induced. 523.11........ Chronic

N

PRE 482 gingivitis,

3 185, 186, 187 non-plaque induced. 523.30........ Aggressive N

PRE 482 periodontitis,

3 185, 186, 187 unspecified. 523.31........ Aggressive N

PRE 482 periodontitis,

3 185, 186, 187 localized. 523.32........ Aggressive N

PRE 482 periodontitis,

3 185, 186, 187 generalized. 523.33........ Acute

N

PRE 482 periodontitis.

3 185, 186, 187 523.40........ Chronic

N

PRE 482 periodontitis,

3 185, 186, 187 unspecified. 523.41........ Chronic

N

PRE 482 periodontitis,

3 185, 186, 187 localized. 523.42........ Chronic

N

PRE 482 periodontitis,

3 185, 186, 187 generalized. 525.60........ Unspecified N

PRE 482 unsatisfactory

3 185, 186, 187 restoration of tooth. 525.61........ Open

N

PRE 482 restoration

3 185, 186, 187 margins. 525.62........ Unrepairable N

PRE 482 overhanging of

3 185, 186, 187 dental restorative materials. 525.63........ Fractured

N

PRE 482 dental

3 185, 186, 187 restorative material without loss of material. 525.64........ Fractured

N

PRE 482 dental

3 185, 186, 187 restorative material with loss of material. 525.65........ Contour of N

PRE 482 existing

3 185, 186, 187 restoration of tooth biologically incompatible with oral health. 525.66........ Allergy to N

PRE 482 existing

3 185, 186, 187 dental restorative material. 525.67........ Poor aesthetics N

PRE 482 of existing

3 185, 186, 187 restoration. 525.69........ Other

N

PRE 482 unsatisfactory

3 185, 186, 187 restoration of existing tooth. 526.61........ Perforation of N

PRE 482 root canal

3 185, 186, 187 space. 526.62........ Endodontic N

PRE 482 overfill.

3 185, 186, 187 526.63........ Endodontic N

PRE 482 underfill.

3 185, 186, 187 526.69........ Other

N

PRE 482 periradicular

3 185, 186, 187 pathology associated with previous endodontic treatment. 528.00........ Stomatitis and N

PRE 482 mucositis,

3 185, 186, 187 unspecified. 528.01........ Mucositis

N

PRE 482 (ulcerative)

3 185, 186, 187 due to antineoplastic therapy. 528.02........ Mucositis

N

PRE 482 (ulcerative)

3 185, 186, 187 due to other drugs. 528.09........ Other

N

PRE 482 stomatitis and

3 185, 186, 187 mucositis (ulcerative). 538........... Gastrointestina N

6 182, 183, 184 l mucositis (ulcerative). 608.20........ Torsion of N

12 352 testis, unspecified.

[[Page 24289]]

608.21........ Extravaginal N

12 352 torsion of spermatic cord. 608.22........ Intravaginal N

12 352 torsion of spermatic cord. 608.23........ Torsion of N

12 352 appendix testis. 608.24........ Torsion of N

12 352 appendix epididymis. 616.81........ Mucositis

N

13 358, 359, 368 (ulcerative) of cervix, vagina, and vulva. 616.89........ Other

N

13 358, 359, 368 inflammatory disease of cervix, vagina and vulva. 618.84........ Cervical stump N

13 358, 359, 369 prolapse. 629.29........ Other female N

13 358, 359, 369 genital mutilation status. 629.81........ Habitual

N

13 358, 359, 368 aborter without current pregnancy. 629.89........ Other specified N

13 358, 359, 368 disorders of female genital organs. 649.00........ Tobacco use N

14 469 disorder complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not applicable. 649.01........ Tobacco use N

14 370, 371, 372, 373, disorder

374, 375 complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepartum condition. 649.02........ Tobacco use N

14 370, 371, 372, 373, disorder

374, 375 complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complication. 649.03........ Tobacco use N

14 383, 384 disorder complicating pregnancy, childbirth, or the puerperium, antepartum condition or complication. 649.04........ Tobacco use N

14 376, 377 disorder complicating pregnancy, childbirth, or the puerperium, postpartum condition or complication. 649.10........ Obesity

N

14 469 complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not applicable. 649.11........ Obesity

N

14 370, 371, 372, 373, complicating

374, 375 pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepartum condition. 649.12........ Obesity

N

14 370, 371, 372, 373, complicating

374, 375 pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complication. 649.13........ Obesity

N

14 383, 384 complicating pregnancy, childbirth, or the puerperium, antepartum condition or complication. 649.14........ Obesity

N

14 376, 377 complicating pregnancy, childbirth, or the puerperium, postpartum condition or complication. 649.20........ Bariatric

N

14 469 surgery status complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not applicable. 649.21........ Bariatric

N

14 370, 371, 372, 373, surgery status

374, 375 complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepartum condition. 649.22........ Bariatric

N

14 370, 371, 372, 373, surgery status

374, 375 complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complication. 649.23........ Bariatric

N

14 383, 384 surgery status complicating pregnancy, childbirth, or the puerperium, antepartum condition or complication. 649.24........ Bariatric

N

14 376, 377 surgery status complicating pregnancy, childbirth, or the puerperium, postpartum condition or complication. 649.30........ Coagulation N

14 469 defects complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not applicable. 649.31........ Coagulation N

14 370, 371, 372, 373, defects

374, 375 complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepartum condition. 649.32........ Coagulation N

14 370, 371, 372, 373, defects

374, 375 complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complication. 649.33........ Coagulation N

14 383, 384 defects complicating pregnancy, childbirth, or the puerperium, antepartum condition or complication. 649.34........ Coagulation N

14 376, 377 defects complicating pregnancy, childbirth, or the puerperium, postpartum condition or complication. 649.40........ Epilepsy

N

14 469 complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not applicable. 649.41........ Epilepsy

N

14 370, 371, 372, 373, complicating

374, 375 pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepartum condition. 649.42........ Epilepsy

N

14 370, 371, 372, 373, complicating

374, 375 pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complication. 649.43........ Epilepsy

N

14 383, 384 complicating pregnancy, childbirth, or the puerperium, antepartum condition or complication. 649.44........ Epilepsy

N

14 376, 377 complicating pregnancy, childbirth, or the puerperium, postpartum condition or complication. 649.50........ Spotting

N

14 469 complicating pregnancy, unspecified as to episode of care or not applicable. 649.51........ Spotting

N

14 370, 371, 372, 373, complicating

374, 375 pregnancy, delivered, with or without mention of antepartum condition. 649.53........ Spotting

N

14 383, 384 complicating pregnancy, antepartum condition or complication. 649.60........ Uterine size N

14 469 date discrepancy, unspecified as to episode of care or not applicable. 649.61........ Uterine size N

14 370, 371, 372, 373, date

374, 375 discrepancy, delivered, with or without mention of antepartum condition. 649.62........ Uterine size N

14 370, 371, 372, 373, date

374, 375 discrepancy, delivered, with mention of postpartum complication. 649.63........ Uterine size N

14 383, 384 date discrepancy, antepartum condition or complication. 649.64........ Uterine size N

14 376, 377 date discrepancy, postpartum condition or complication.

[[Page 24290]]

729.71........ Nontraumatic N

8 248 compartment syndrome of upper extremity. 729.72........ Nontraumatic N

8 248 compartment syndrome of lower extremity. 729.73........ Nontraumatic N

8 248 compartment syndrome of abdomen. 729.79........ Nontraumatic N

8 248 compartment syndrome of other sites. 731.3......... Major osseous N

8 244, 245 defects. 780.32........ Complex febrile Y

1 24, 25, 26 convulsions. 780.96........ Generalized N

23 463, 464 pain. 780.97........ Altered mental N

23 463, 464 status. 784.91........ Postnasal drip. N

3 73, 74 784.99........ Other symptoms N

3 73, 74 involving head and neck. 788.64........ Urinary

N

11 325, 326, 327 hesitancy. 788.65........ Straining on N

11 325, 326, 327 urination. 793.91........ Image test N

23 463, 464 inconclusive due to excess body fat. 793.99........ Other

N

23 463, 464 nonspecific abnormal findings on radiological and other examinations of body structure. 795.06........ Papanicolaou N

13 358, 359, 369 smear of cervix with cytologic evidence of malignancy. 795.81........ Elevated

N

23 463, 464 carcinoembryon ic antigen [CEA]. 795.82........ Elevated cancer N

23 463, 464 antigen 125 [CA 125]. 795.89........ Other abnormal N

23 463, 464 tumor markers. 958.90........ Compartment N

21 454, 455 syndrome, unspecified. 958.91........ Traumatic

N

21 454, 455 compartment syndrome of upper extremity. 958.92........ Traumatic

N

21 454, 455 compartment syndrome of lower extremity. 958.93........ Traumatic

N

21 454, 455 compartment syndrome of abdomen. 958.99........ Traumatic

N

21 454, 455 compartment syndrome of other sites. 995.20........ Unspecified N

15 387 \2\, 389 \2\ adverse effect

21 449, 450, 451 of unspecified drug, medicinal and biological substance. 995.21........ Arthus

N

15 387 \2\, 389 \2\ phenomenon.

21 449, 450, 451 995.22........ Unspecified N

15 387 \2\, 389 \2\ adverse effect

21 449, 450, 451 of anesthesia. 995.23........ Unspecified N

15 387 \2\, 389 \2\ adverse effect

21 449, 450, 451 of insulin. 995.27........ Other drug N

15 387 \2\, 389 \2\ allergy.

21 449, 450, 451 995.29........ Unspecified N

15 387 \2\, 389 \2\ adverse effect

21 449, 450, 451 of other drug, medicinal and biological substance. V18.51........ Family history, N

23 467 Colonic polyps. V18.59........ Family history, N

23 467 Other digestive disorders. V26.34........ Testing of male N

23 467 for genetic disease carrier status. V26.35........ Encounter for N

23 467 testing of male partner of habitual aborter. V26.39........ Other genetic N

23 467 testing of male. V45.86........ Bariatric

N

23 467 surgery status. V58.30........ Encounter for N

23 467 change or removal of nonsurgical wound dressing. V58.31........ Encounter for N

23 467 change or removal of surgical wound dressing. V58.32........ Encounter for N

23 467 removal of sutures. V72.11........ Encounter for N

23 467 hearing

15 391 \1\ examinationfol lowing failed hearing screening. V72.19........ Other

N

23 467 examination of

15 391 \1\ ears and hearing. V82.71........ Screening for N

23 467 genetic disease carrier status. V82.79........ Other genetic N

23 467 screening. V85.51........ Body Mass

N

23 467 Index, pediatric, less than 5th percentile for age. V85.52........ Body Mass

N

23 467 Index, pediatric, 5th percentile to less than 85th percentile for age. V85.53........ Body Mass

N

23 467 Index, pediatric, 85th percentile to less than 95th percentile for age. V85.54........ Body Mass

N

23 467 Index, pediatric, greater than or equal to 95th percentile for age. V86.0......... Estrogen

N

23 467 receptor positive status [ER+]. V86.1......... Estrogen

N

23 467 receptor negative status [ER-].

\1\ On ``Only secondary diagnosis'' list. \2\ Principal or secondary diagnosis of major problem.

Table 6B.--New Procedure Codes

Procedure code Description O.R. MDC

DRG

00.44......... Procedure on N vessel bifurcation. 00.56......... Insertion or Y

5 117,120 \1\ replacement of implantable pressure sensor (lead) for intracardiac hemodynamic monitoring. 00.57......... Implantation or Y

5 118,120 \1\ replacement of subcutaneous device for intracardiac hemodynamic monitoring. 37.20......... Noninvasive N programmed electrical stimulation [NIPS].

[[Page 24291]]

39.74......... Endovascular Y

1 1, 2, 3, 543 removal of

21 442, 443 obstruction

24 486 from head and neck vessel(s). 68.41......... Laparoscopic Y

13 354, 355, 357, total

14 358, 359 abdominal

375 hysterectomy. 68.49......... Other and

Y

13 354, 355, 357,358, unspecified

14 359 total

375 abdominal hysterectomy. 68.61......... Laparoscopic Y

13 353 radical

14 375 abdominal hysterectomy. 68.69......... Other and

Y

13 353 unspecified

14 375 radical abdominal hysterectomy. 68.71......... Laparoscopic Y

13 353 radical

14 375 vaginal hysterectomy [LRVH]. 68.79......... Other and

Y

13 353 unspecified

14 375 radical vaginal hysterectomy.

\1\ Assigned to DRG 120 when both Code 00.56 and Code 00.57 are reported.

Table 6C.--Invalid Diagnosis Codes

Diagnosis code Description CC MDC

DRG

238.7......... Other lymphatic N

17 401, 402, 403, 404, and

539, 540 hematopoietic tissues. 277.3......... Amyloidosis.... N

8 240, 241 284.0......... Constitutional Y

16 395, 396 aplastic anemia. 288.0......... Agranulocytosis Y

16 398, 399 490 25 323.0......... Encephalitis in N

1 20, 543 viral diseases classified elsewhere. 323.4......... Other

N

1 20, 543 encephalitis due to infection classified elsewhere. 323.5......... Encephalitis N

1 20, 543 following immunization procedures. 323.6......... Postinfectious N

1 20, 543 encephalitis. 323.7......... Toxic

N

1 34, 35, 543 encephalitis. 323.8......... Other causes of N

1 20, 543 489 encephalitis.

25 333.7......... Symptomatic N

1 12 torsion dystonia. 478.1......... Other diseases N

3 73, 74 391 \1\ of nasal

15 cavity and sinuses. 519.1......... Other diseases N

PRE 482 of trachea and

4 96, 97, 98 bronchus, not elsewhere classified. 521.8......... Other specific N

PRE 482 diseases of

3 185, 186, 187 hard tissues of teeth. 523.0......... Acute

N

PRE 482 gingivitis.

3 185, 186, 187 523.1......... Chronic

N

PRE 482 gingivitis.

3 185, 186, 187 523.3......... Acute

N

PRE 482 periodontitis.

3 185, 186, 187 523.4......... Chronic

N

PRE 482 periodontitis.

3 185, 186, 187 528.0......... Stomatitis..... N

PRE 482 3 185, 186, 187 608.2......... Torsion of N

12 352 testis. 616.8......... Other specified N

13 358, 359, 368 inflammatory diseases of cervix, vagina, and vulva. 629.8......... Other specified N

13 358, 359, 369 disorders of female genital organs. 784.9......... Other symptoms N

3 73, 74 involving head and neck. 793.9......... Other

N

23 463, 464 nonspecific abnormal findings on radiological and other examinations of body structure. 995.2......... Unspecified N

15 387 \2\, 389 \2\ adverse effect

21 449, 450, 451 of drug, medicinal and biological substance. V18.5......... Family history, N

23 467 Digestive disorders. V58.3......... Attention to N

23 467 surgical dressings and sutures. V72.1......... Examination of N

15 391 \1\ ears and

23 467 hearing.

\1\ On ``Only secondary diagnosis'' list. \2\ Principal or secondary diagnosis of major problem.

[[Page 24292]]

Table 6D.--Invalid Procedure Codes

Procedure code Description O.R. MDC

DRG

68.4.......... Total abdominal Y

13 354, 355, 357, 358, hysterectomy.

14 359 375 68.6.......... Radical

Y

13 353 abdominal

14 375 hysterectomy. 68.7.......... Radical vaginal Y

13 353 hysterectomy.

14 375

Table 6E.--Revised Diagnosis Codes

Diagnosis code

Description

CC

MDC

DRG

255.10................. Hyperaldosteronism,

N

10 300, 301 unspecified. 285.29................. Anemia of other chronic N

16 395, 396 disease. 323.1.................. Encephalitis, myelitis, N

1 20, 543 and encephalomyelitis in rickettsial diseases classified elsewhere. 323.2.................. Encephalitis, myelitis, N

1 20, 543 and encephalomyelitis in protozoal diseases classified elsewhere. 323.9.................. Unspecified causes of N

1 20, 543 encephalitis, myelitis,

25 489 and encephalomyelitis. 333.6.................. Genetic torsion dystonia. N

1 12 345.40................. Localization-related N

1 24, 25, 26 (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, without mention of intractable epilepsy. 345.41................. Localization-related Y

1 24, 25, 26 (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, with intractable epilepsy. 345.50................. Localization-related N

1 24, 25, 26 (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy. 345.51................. Localization-related Y

1 24, 25, 26 (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, with intractable epilepsy. 345.80................. Other forms of epilepsy N

1 24, 25, 26 and recurrent seizures, without mention of intractable epilepsy. 345.81................. Other forms of epilepsy Y

1 24, 25, 26 and recurrent seizures, with intractable epilepsy. 389.11................. Sensory hearing loss, N

3 73, 74 bilateral. 389.12................. Neural hearing loss, N

3 73, 74 bilateral. 389.14................. Central hearing loss, N

3 73, 74 bilateral. 389.18................. Sensorineural hearing N

3 73, 74 loss of combined types, bilateral. 403.00................. Hypertensive chronic Y

11 331, 332, 333 kidney disease, malignant, with chronic kidney disease stage I through stage IV, or unspecified. 403.01................. Hypertensive chronic Y

PRE 11 512 \1\, 513 \1\ kidney disease,

315, 316 malignant, with chronic kidney disease stage V or end stage renal disease. 403.10................. Hypertensive chronic N

11 331, 332, 333 kidney disease, benign, with chronic kidney disease stage I through stage IV, or unspecified. 403.11................. Hypertensive chronic Y

PRE 11 512 \1\, 513 \1\ kidney disease, benign,

315, 316 with chronic kidney disease stage V or end stage renal disease. 403.90................. Hypertensive chronic N

11 331, 332, 333 kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified. 403.91................. Hypertensive chronic Y

PRE 11 512 \1\, 513 \1\ kidney disease,

315, 316 unspecified, with chronic kidney disease stage V or end stage renal disease. 404.00................. Hypertensive heart and Y

5 134 chronic kidney disease, malignant, without heart failure and with chronic kidney disease stage I through stage IV, or unspecified. 404.01................. Hypertensive heart and Y

5 121 \2\, 124 \3\, chronic kidney disease,

....... 127, 535, malignant, with heart

....... 547 \4\, 549 \4\, failure and with chronic

....... 551 \4\, 553 \4\, kidney disease stage I

....... 555 \4\, 557 \4\ through stage IV, or

15 387 \5\, 389 \5\ unspecified. 404.02................. Hypertensive heart and Y

PRE 11 512 \1\, 513 \1\ chronic kidney disease,

315, 316 malignant, without heart failure and with chronic kidney disease stage V or end stage renal disease. 404.03................. Hypertensive heart and Y

PRE 512 \1\, 513 \1\ chronic kidney disease,

5 121 \2\, 124 \3\, malignant, with heart

....... 127, 535, failure and with chronic

....... 547 \4\, 549 \4\, kidney disease stage V

....... 551 \4\, 553 \4\, or end stage renal

....... 555 \4\, 557 \4\ disease.

15 387 \5\, 389 \5\ 404.10................. Hypertensive heart and N

5 134 chronic kidney disease, benign, without heart failure and with chronic kidney disease stage I through stage IV, or unspecified.

[[Page 24293]]

404.11................. Hypertensive heart and Y

5 121 \2\, 124 \3\, chronic kidney disease,

....... 127, 535, benign, with heart

....... 547 \4\, 549 \4\, failure and with chronic

....... 551 \4\, 553 \4\, kidney disease stage I

....... 555 \4\, 557 \4\ through stage IV, or

15 387 \5\, 389 \5\ unspecified. 404.12................. Hypertensive heart and Y

PRE 11 512 \1\, 513 \1\ chronic kidney disease,

315, 316 benign, without heart failure and with chronic kidney disease stage V or end stage renal disease. 404.13................. Hypertensive heart and Y

PRE 512 \1\, 513 \1\ chronic kidney disease,

5 121 \2\, 124 \3\, benign, with heart

....... 127, 535, failure and chronic

....... 547 \4\, 549 \4\, kidney disease stage V

....... 551 \4\, 553 \4\, or end stage renal

....... 5554, 557 \4\ disease.

15 387 \5\, 389 \5\ 404.90................. Hypertensive heart and N

5 134 chronic kidney disease, unspecified, without heart failure and with chronic kidney disease stage I through stage IV, or unspecified. 404.91................. Hypertensive heart and Y

5 121 \2\, 124 \3\, chronic kidney disease,

....... 127, 535, unspecified, with heart

....... 547 \4\, 549 \4\, failure and with chronic

....... 551 \4\, 553 \4\, kidney disease stage I

....... 555 \4\, 557 \4\ through stage IV, or

15 387 \5\, 389 \5\ unspecified. 404.92................. Hypertensive heart and Y

PRE 11 512 \1\, 513 \1\ chronic kidney disease,

315, 316 unspecified, without heart failure and with chronic kidney disease stage V or end stage renal disease. 404.93................. Hypertensive heart and Y

PRE 512 \1\, 513 \1\ chronic kidney disease,

5 121 \2\, 124 \3\, unspecified, with heart

....... 127, 535, failure and chronic

....... 547 \4\, 549 \4\, kidney disease stage V

....... 551 \4\, 553 \4\, or end stage renal

....... 555 \4\, 557 \4\ disease.

15 387 \5\, 389 \5\ 524.21................. Malocclusion, Angle's N

PRE 482 class I.

3 185, 186, 187 524.22................. Malocclusion, Angle's N

PRE 482 class II.

3 185, 186, 187 524.23................. Malocclusion, Angle's N

PRE 482 class III.

3 185, 186, 187 524.35................. Rotation of tooth/teeth.. N

PRE 482 3 185, 186, 187 600.00................. Hypertrophy (benign) of N

12 348, 349 prostate without-urinary obstruction and other lower urinary tract (LUTS) symptoms (LUTS). 600.01................. Hypertrophy (benign) of N

12 348, 349 prostate with urinary obstruction and other lower urinary tract symptoms (LUTS). 600.20................. Benign localized

N

12 348, 349 hyperplasia of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS). 600.21................. Benign localized

N

12 348, 349 hyperplasia of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS). 600.90................. Hyperplasia of prostate, N

12 348, 349 unspecified, without urinary obstruction and other lower urinary symptoms (LUTS). 600.91................. Hyperplasia of prostate, N

12 348, 349 unspecified, with urinary obstruction and other lower urinary symptoms (LUTS). 780.31................. Febrile convulsions

Y

1 15 24, 25, 26 387 \5\, 389 (simple), unspecified.

\5\ 780.95................. Excessive crying of

N

23 463, 464 child, adolescent, or adult. 790.93................. Elevated prostate

N

23 463, 464 specific antigen [PSA]. 873.63................. Tooth (broken)

N

3 185, 186, (fractured) (due to

24 187 487 trauma), without mention of complication. 873.73................. Tooth (broken)

N

3 185, 186, 187 (fractured) (due to

24 487 trauma), complicated. 995.91................. Sepsis................... Y

18 416, 417 995.92................. Severe sepsis............ Y

18 416, 417 995.93................. Systemic inflammatory Y

18 416, 417 response syndrome due to noninfectious process without acute organ dysfunction. 995.94................. Systemic inflammatory Y

18 416, 417 response syndrome due to noninfectious process with acute organ dysfunction. V26.31................. Testing of female for N

23 467 genetic disease carrier status. V26.32................. Other genetic testing of N

23 467 female.

\1\ Principal or secondary diagnosis. \2\ Principal or secondary diagnosis of major complication.

[[Page 24294]]

\3\ Principal or secondary diagnosis of complex diagnosis. \4\ Principal or secondary diagnosis of major cardiovascular. \5\ Principal or secondary diagnosis of major problem.

Table 6F.--Revised Procedure Code Titles

Procedure code Description O.R. MDC

DRG

37.26......... Catheter based N*

5 104, 518, 555, 556, invasive

557, 558 electrophysiol ogic testing.

*Non-O.R. code that affects DRG assignment.

Table 6G.--Additions To The CC Exclusions List

[CCs that are added to the list, effective October 1, 2006, are included in this table. Each of the principal diagnoses is shown with an asterisk, and the revisions to the CC Exclusions List are provided in an indented column immediately following the affected principal diagnosis.]

*0519 0522 *0522 0520 0521 0522 0527 0528 0529 05314 05474 *0527 0522 *0528 0522 *0529 0522 *0530 05314 *05310 05314 *05311 05314 *05312 05314 *05313 05314 *05314 0522 0530 05310 05311 05312 05313 05314 05319 05379 0538 05474 *05319 05314 *05379 05314 *0538 05314 *0539 05314 *05472 05314 *05474 0522 0530 05310 05311 05312 05313 05314 05319 05379 0538 0543 0545 05471 05472 05474 05479 0548 *05479 05314 05474 *0548 05314 05474 *0549 05314 05474 *07888 0522 05314 05474 *07889 0522 05314 05474 *07981 0522 05314 05474 *07988 0522 05314 05474 *07989 0522 05314 05474 *07998 0522 05314 05474 *07999 0522 05314 05474 *1398 0522 05314 05474 *28401 2800 2814 2818 28241 28242 28249 28260 28261 28262 28263 28264 28268 28269 2830 28310 28311 28319 2832 2839 2848 2849 2850 2851 *28409 2800 2814 2818 28241 28242 28249 28260 28261 28262 28263 28264 28268 28269 2830 28310 28311 28319 2832 2839 2848 2849 2850 2851 *2841 2800 2814

[[Continued on page 24295]]

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

[[pp. 24295-24344]] Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2007 Rates

[[Continued from page 24294]]

[[Page 24295]]

2818 28241 28242 28249 28260 28261 28262 28263 28264 28268 28269 2830 28310 28311 28319 2832 2839 2848 2849 2850 2851 *2842 2800 2814 2818 28241 28242 28249 28260 28261 28262 28263 28264 28268 28269 2830 28310 28311 28319 2832 2839 2848 2849 2850 2851 *28800 2881 28981 28982 *28801 2881 28981 28982 *28802 2881 28981 28982 *28803 2881 28981 28982 *28804 2881 28981 28982 *28809 2881 28981 28982 *2884 2881 28981 28982 *28850 2881 28981 28982 *28851 2881 28981 28982 *28859 2881 28981 28982 *28860 2881 28981 28982 *28861 2881 28981 28982 *28862 2881 28981 28982 *28863 2881 28981 28982 *28864 2881 28981 28982 *28865 2881 28981 28982 *28869 2881 28981 28982 *28953 2881 28981 28982 *28983 2800 2814 2818 28241 28242 28249 28260 28261 28262 28263 28264 28268 28269 2830 28310 28311 28319 2832 2839 2848 2849 2850 2851 2860 2861 2862 2863 2864 2865 2866 2867 2869 2870 2871 2872 28730 28731 28732 28733 28739 2874 2875 2878 2879 2881 28981 28982 *32301 0522 05314 05474 34982 *32302 0522 05314 05474 34982 *32341 0522 05314 05474 34982 *32342 0522 05314 05474 34982 *32351 0522 05314 05474 34982 *32352 0522 05314 05474 34982 *32361 0522 05314

[[Page 24296]]

05474 34982 *32362 0522 05314 05474 34982 *32363 0522 05314 05474 34982 *32371 0522 05314 05474 34982 *32372 0522 05314 05474 34982 *32381 0522 05314 05474 34982 *32382 0522 05314 05474 34982 *33183 3314 *33371 7817 *33372 7817 *33379 7817 *33385 7817 *3380 04082 44024 78001 78003 7801 78031 78032 78039 7817 7854 78550 78551 78552 78559 7863 78820 78829 7895 7907 7911 7913 79901 79902 7991 7994 *33811 04082 44024 78001 78003 7801 78031 78032 78039 7817 7854 78550 78551 78552 78559 7863 78820 78829 7895 7907 7911 7913 79901 79902 7991 7994 *33812 04082 44024 78001 78003 7801 78031 78032 78039 7817 7854 78550 78551 78552 78559 7863 78820 78829 7895 7907 7911 7913 79901 79902 7991 7994 *33818 04082 44024 78001 78003 7801 78031 78032 78039 7817 7854 78550 78551 78552 78559 7863 78820 78829 7895 7907 7911 7913 79901 79902 7991 7994 *33819 04082 44024 78001 78003 7801 78031 78032 78039 7817 7854 78550 78551 78552 78559 7863 78820 78829 7895 7907 7911 7913 79901 79902 7991 7994 *33821 04082 44024 78001 78003 7801 78031 78032 78039 7817 7854 78550 78551 78552 78559 7863 78820 78829 7895 7907 7911 7913 79901 79902 7991 7994

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[[Continued on page 24345]]

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

[[pp. 24345-24394]] Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2007 Rates

[[Continued from page 24344]]

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85229 85230 85231 85232 85233 85234 85235 85236 85239 85240 85241 85242 85243 85244 85245 85246 85249 85250 85251 85252 85253 85254 85255 85256 85259 85300 85301 85302 85303 85304 85305 85306 85309 85310 85311 85312 85313 85314 85315 85316 85319 85400 85401 85402 85403 85404 85405 85406 85409 85410 85411 85412 85413 85414 85415 85416 85419 8600 8601 8602 8603 8604 8605 86101 86102 86103 86110 86111 86112 86113 86122 86130 86131 86132 8621 86221 86222 86229 86231 86232 86239 8629 8631 86330 86331 86339 86350 86351 86352 86353 86354 86355 86356 86359 86390 86391 86392 86393 86394 86395 86399 86400 86401 86402 86403 86404 86405 86409 86410 86411 86412 86413 86414 86415 86419 86500 86501 86502 86503 86504 86509 86510 86511 86512 86513 86514 86519 86600 86601 86602 86603 86610 86611 86612 86613 8670 8671 8672 8673 8674 8675 8676 8677 8678 8679 86800 86801 86802 86803 86804 86809 86810 86811 86812 86813 86814 86819 8690 8691 8703 8704 8708 8709 8710 8711 8712 8713 8714 8719 87272 87273 87274 87333 8739 87400 87401 87402 87410 87411 87412 8743 8745 8750 8751 8870 8871 8872 8873 8874 8875 8876 8877 8960 8961 8962 8963 8970 8971

[[Page 24360]]

8972 8973 8974 8975 8976 8977 90000 90001 90002 90003 9001 90081 90082 90089 9009 9010 9011 9012 9013 90141 90142 90183 9020 90210 90211 90219 90220 90222 90223 90224 90225 90226 90227 90229 90231 90232 90233 90234 90239 90240 90241 90242 90249 90250 90251 90252 90253 90254 90259 90287 9251 9252 9290 95200 95201 95202 95203 95204 95205 95206 95207 95208 95209 95210 95211 95212 95213 95214 95215 95216 95217 95218 95219 9522 9523 9524 9528 9529 9530 9531 9532 9533 9534 9535 9538 9539 9580 9581 9582 9583 9584 9585 9587 *9973 5187 *99791 5187 *99799 5187 *99881 5187 *99883 5187 *99889 5187 *9989 5187

Table 6H.--Deletions From the CC Exclusions List [CCs that are deleted from the list, effective October 1, 2006, are included in this table. Each of the principal diagnoses is shown with an asterisk, and the revisions to the CC Exclusions List are provided in an indented column immediately following the affected principal diagnosis.]

*2800 2840 *2801 2840 *2808 2840 *2809 2840 *2810 2840 *2811 2840 *2812 2840 *2813 2840 *2814 2840 *2818 2840 *2819 2840 *2820 2840 *2821 2840 *2822 2840 *2823 2840 *28241 2840 *28242 2840 *28249 2840 *2825 2840 *28260 2840 *28261 2840 *28262 2840 *28263 2840 *28264 2840 *28268 2840 *28269 2840 *2827 2840 *2828 2840 *2829 2840 *2830 2840 *28310 2840 *28311 2840 *28319 2840 *2832 2840 *2839 2840 *2840 2800 2814 2818 28241 28242 28249 28260 28261

[[Page 24361]]

28262 28263 28264 28268 28269 2830 28310 28311 28319 2832 2839 2840 2848 2849 2850 2851 *2848 2840 *2849 2840 *2850 2840 *2851 2840 *28521 2840 *28522 2840 *28529 2840 *2858 2840 *2859 2840 *2880 2880 2881 28981 28982 *2881 2880 *2882 2880 *2883 2880 *2888 2880 *2889 2880 *28981 2840 2880 *28982 2840 2880 *28989 2840 2880 *2899 2840 2880 *3230 34982 *3234 34982 *3235 34982 *3236 34982 *3237 34982 *3238 34982 *3337 7817 *5173 2840 *5191 51900 51901 51902 51909 *5280 5283 *6168 6140 6143 6145 6150 6163 6164 *6298 6140 6143 6145 6150 6163 6164 6207

Table 7A.--Medicare Prospective Payment System Selected Percentile Lengths of Stay FY 2005 MedPAR Update December 2005 Grouper V23.0

Arithmetic DRG

Number of mean length- 10th

25th

50th

75th

90th discharges

of-stay percentile percentile percentile percentile percentile

1.......................................

24,336

9.6056

2

4

7

12

19 2.......................................

10,279

4.3955

1

2

4

6

8 3.......................................

2

12.5000

4

4

21

21

21 6.......................................

291

3.0619

1

1

2

4

7 7.......................................

14,913

9.2679

2

4

7

12

19 8.......................................

3,415

2.7628

1

1

2

3

6 9.......................................

1,761

6.0023

1

3

4

7

11 10......................................

19,577

5.9190

2

3

4

7

12 11......................................

3,075

3.5463

1

2

3

5

7 12......................................

56,255

5.3867

2

3

4

6

10 13......................................

7,499

4.8481

2

3

4

6

8 14......................................

278,220

5.3760

2

3

4

7

10 15......................................

20,045

4.0130

1

2

3

5

8 16......................................

17,338

6.2840

2

3

5

8

12 17......................................

2,968

3.0387

1

1

2

4

6 18......................................

33,376

5.1560

2

3

4

6

10 19......................................

8,423

3.3765

1

2

3

4

6 20......................................

6,408

9.8262

3

5

8

13

19 21......................................

2,205

6.2036

2

3

5

8

12 22......................................

3,151

5.0232

2

2

4

6

10 23......................................

10,668

3.8978

1

2

3

5

7 24......................................

63,283

4.6436

1

2

3

6

9 25......................................

27,276

3.1226

1

2

3

4

6 26......................................

24

3.7917

1

1

2

5

9 27......................................

5,925

4.7406

1

1

3

6

10

[[Page 24362]]

28......................................

19,839

5.5783

1

2

4

7

11 29......................................

6,500

3.2209

1

1

3

4

6 31......................................

4,967

3.9088

1

2

3

5

7 32......................................

1,857

2.2752

1

1

2

3

4 34......................................

27,466

4.7076

1

2

4

6

9 35......................................

7,830

3.0425

1

1

3

4

6 36......................................

1,207

1.6694

1

1

1

1

3 37......................................

1,233

4.0706

1

1

3

5

9 38......................................

49

2.8367

1

1

2

3

6 39......................................

362

2.0193

1

1

1

2

4 40......................................

1,252

4.1262

1

1

4

5

7 42......................................

941

3.0595

1

1

2

4

7 43......................................

123

2.9431

1

1

2

4

5 44......................................

1,311

4.7414

2

3

4

6

9 45......................................

2,766

3.0387

1

2

2

4

6 46......................................

3,942

4.1870

1

2

3

5

8 47......................................

1,322

3.0242

1

1

2

4

6 49......................................

2,415

4.5172

1

2

3

5

9 50......................................

2,025

1.8652

1

1

1

2

3 51......................................

192

2.6979

1

1

1

3

6 52......................................

317

1.7003

1

1

1

2

3 53......................................

2,138

3.9995

1

1

2

5

9 55......................................

1,367

2.8983

1

1

2

3

6 56......................................

450

2.6800

1

1

2

3

5 57......................................

881

3.1510

1

1

2

3

7 59......................................

127

2.3780

1

1

2

3

5 60......................................

3

1.6667

1

1

1

3

3 61......................................

222

6.0541

1

1

4

8

13 62......................................

4

1.5000

1

1

1

1

3 63......................................

2,826

4.5467

1

1

3

6

10 64......................................

3,252

6.2232

1

2

4

8

13 65......................................

40,702

2.7629

1

1

2

3

5 66......................................

8,210

3.1097

1

1

2

4

6 67......................................

379

3.6992

1

2

3

5

8 68......................................

19,066

3.8447

1

2

3

5

7 69......................................

5,201

2.9435

1

2

3

4

5 70......................................

23

2.3478

1

1

2

3

4 71......................................

71

4.3380

1

2

3

5

8 72......................................

1,341

3.3057

1

2

3

4

6 73......................................

9,967

4.2892

1

2

3

5

8 74......................................

3

3.3333

3

3

3

4

4 75......................................

46,673

9.5853

3

5

7

12

19 76......................................

47,942

10.4748

3

5

8

13

19 77......................................

2,086

4.5005

1

2

4

6

9 78......................................

49,512

6.0951

2

4

5

7

10 79......................................

160,409

8.0438

3

4

7

10

15 80......................................

7,190

5.2405

2

3

4

7

10 81......................................

6

6.1667

2

3

5

8

8 82......................................

63,099

6.6687

2

3

5

9

13 83......................................

7,053

5.1999

2

3

4

6

10 84......................................

1,379

3.1407

1

2

3

4

6 85......................................

22,193

6.1053

2

3

5

8

12 86......................................

1,726

3.4936

1

2

3

5

7 87......................................

96,631

6.3599

2

3

5

8

12 88......................................

427,997

4.8483

2

3

4

6

9 89......................................

555,221

5.5216

2

3

5

7

10 90......................................

43,748

3.7105

2

2

3

5

6 91......................................

53

3.4151

1

1

2

4

6 92......................................

16,534

5.9330

2

3

5

7

11 93......................................

1,446

3.7420

1

2

3

5

7 94......................................

13,561

5.8975

2

3

5

8

12 95......................................

1,568

3.3846

1

2

3

4

6 96......................................

60,151

4.2912

2

2

4

5

8 97......................................

27,006

3.3549

1

2

3

4

6 98......................................

13

3.0769

2

2

2

4

6 99......................................

21,448

3.1000

1

1

2

4

6 100.....................................

6,432

2.1206

1

1

2

3

4 101.....................................

23,374

4.1844

1

2

3

5

8 102.....................................

4,920

2.5317

1

1

2

3

5

[[Page 24363]]

103.....................................

859

34.9488

8

11

22

45

76 104.....................................

20,084

14.6532

6

8

12

18

26 105.....................................

32,527

9.9333

4

6

8

11

18 106.....................................

3,427

10.9311

5

7

9

13

18 108.....................................

8,740

10.7237

4

6

9

13

20 110.....................................

57,543

8.0134

1

3

6

10

16 111.....................................

10,746

3.1084

1

1

2

5

6 113.....................................

34,591

12.5649

4

6

10

15

24 114.....................................

7,940

8.3304

2

4

7

11

16 117.....................................

5,332

4.2815

1

1

2

5

9 118.....................................

7,631

3.0250

1

1

2

4

7 119.....................................

965

5.3751

1

1

3

7

13 120.....................................

33,340

8.9613

1

3

6

12

19 121.....................................

150,106

6.2060

2

3

5

8

12 122.....................................

54,557

3.3059

1

1

3

4

6 123.....................................

29,530

4.7386

1

1

3

6

11 124.....................................

120,235

4.3915

1

2

3

6

9 125.....................................

92,072

2.7033

1

1

2

3

5 126.....................................

5,417

10.6799

3

6

9

13

20 127.....................................

668,008

5.0818

2

3

4

6

9 128.....................................

4,229

5.1726

2

3

5

6

9 129.....................................

3,511

2.5483

1

1

1

2

5 130.....................................

87,632

5.3553

1

3

4

7

10 131.....................................

22,947

3.6999

1

2

3

5

6 132.....................................

101,483

2.7988

1

1

2

3

5 133.....................................

5,883

2.1321

1

1

2

3

4 134.....................................

40,294

3.0936

1

2

2

4

6 135.....................................

7,172

4.2876

1

2

3

5

8 136.....................................

936

2.6880

1

1

2

3

5 138.....................................

206,196

3.8775

1

2

3

5

7 139.....................................

74,082

2.4272

1

1

2

3

4 140.....................................

31,544

2.4063

1

1

2

3

4 141.....................................

123,475

3.4314

1

2

3

4

6 142.....................................

49,367

2.4888

1

1

2

3

5 143.....................................

238,376

2.0951

1

1

2

3

4 144.....................................

104,952

5.8085

1

2

4

7

12 145.....................................

5,728

2.5513

1

1

2

3

5 146.....................................

10,226

9.7570

4

6

8

11

17 147.....................................

2,608

5.5498

2

4

5

7

9 148.....................................

132,689

11.9313

5

6

9

15

22 149.....................................

19,473

5.6473

3

4

5

7

8 150.....................................

22,894

10.7215

4

6

9

13

19 151.....................................

5,368

5.0183

1

2

4

7

9 152.....................................

5,000

7.9332

3

5

7

9

14 153.....................................

1,947

4.8639

2

3

5

6

7 154.....................................

26,973

12.9702

3

6

10

16

25 155.....................................

5,995

3.9585

1

2

3

6

8 156.....................................

4

9.2500

7

7

8

8

14 157.....................................

8,294

5.6907

1

2

4

7

11 158.....................................

3,710

2.6447

1

1

2

3

5 159.....................................

19,181

5.0884

1

2

4

6

10 160.....................................

11,929

2.6554

1

1

2

3

5 161.....................................

10,141

4.5089

1

2

3

6

9 162.....................................

4,954

2.0838

1

1

2

3

4 163.....................................

4

2.7500

1

1

2

3

5 164.....................................

5,972

7.6911

3

4

7

9

13 165.....................................

2,447

4.0016

2

2

4

5

7 166.....................................

5,128

4.3235

1

2

3

5

8 167.....................................

4,877

2.1300

1

1

2

3

4 168.....................................

1,532

4.8570

1

2

3

6

10 169.....................................

772

2.3964

1

1

2

3

5 170.....................................

17,895

10.7070

2

5

8

13

21 171.....................................

1,404

4.1695

1

2

3

5

8 172.....................................

33,137

6.7936

2

3

5

8

13 173.....................................

2,230

3.5309

1

1

3

4

7 174.....................................

261,063

4.6851

2

3

4

6

8 175.....................................

29,906

2.8557

1

2

2

4

5 176.....................................

14,599

5.0884

2

3

4

6

9 177.....................................

7,657

4.4324

2

2

4

5

8

[[Page 24364]]

178.....................................

2,550

3.0761

1

2

3

4

5 179.....................................

14,661

5.7827

2

3

4

7

11 180.....................................

91,338

5.2551

2

3

4

6

10 181.....................................

25,241

3.3112

1

2

3

4

6 182.....................................

297,097

4.4814

1

2

3

6

8 183.....................................

81,861

2.8942

1

1

2

4

5 184.....................................

76

4.3421

1

2

3

4

8 185.....................................

6,243

4.4810

1

2

3

6

9 186.....................................

7

3.1429

1

2

2

3

5 187.....................................

645

4.2016

1

2

3

6

8 188.....................................

93,582

5.4542

1

2

4

7

11 189.....................................

13,160

3.0575

1

1

2

4

6 190.....................................

63

4.8730

1

2

3

6

8 191.....................................

10,550

12.3736

3

6

9

15

25 192.....................................

1,376

5.5094

1

3

5

7

9 193.....................................

4,039

12.5519

5

7

10

15

23 194.....................................

463

6.3672

2

4

6

8

11 195.....................................

2,835

10.5661

4

6

9

13

18 196.....................................

595

5.3647

2

3

5

7

10 197.....................................

16,352

9.0237

3

5

7

11

16 198.....................................

4,110

4.3275

2

3

4

5

7 199.....................................

1,478

9.0068

2

4

7

12

19 200.....................................

1,014

10.3156

1

3

7

13

21 201.....................................

2,707

13.5670

3

6

10

17

27 202.....................................

27,516

6.1369

2

3

5

8

12 203.....................................

32,333

6.4419

2

3

5

8

13 204.....................................

69,207

5.3851

2

3

4

6

10 205.....................................

32,741

5.8448

2

3

4

7

12 206.....................................

2,042

3.7958

1

2

3

5

7 207.....................................

38,339

5.2460

1

2

4

7

10 208.....................................

9,538

2.9494

1

1

2

4

6 210.....................................

126,376

6.6274

3

4

5

8

11 211.....................................

25,712

4.5900

3

3

4

5

7 212.....................................

10

2.5000

1

2

2

4

4 213.....................................

9,459

8.9875

2

4

7

11

18 216.....................................

19,928

5.3145

1

1

3

7

13 217.....................................

15,593

12.1150

3

5

8

15

24 218.....................................

29,975

5.3809

2

3

4

7

10 219.....................................

21,059

3.1663

1

2

3

4

5 220.....................................

2

4.0000

1

1

7

7

7 223.....................................

12,649

3.2641

1

1

2

4

7 224.....................................

9,937

1.9359

1

1

1

2

3 225.....................................

6,246

5.2730

1

2

4

7

11 226.....................................

6,736

6.3550

1

3

4

8

13 227.....................................

4,868

2.6313

1

1

2

3

5 228.....................................

2,680

4.1981

1

1

3

5

9 229.....................................

1,123

2.4880

1

1

2

3

5 230.....................................

2,459

5.4254

1

2

4

7

11 232.....................................

568

2.7394

1

1

2

3

6 233.....................................

18,412

6.3241

1

2

5

8

13 234.....................................

9,074

2.6676

1

1

1

3

6 235.....................................

4,753

4.6749

1

2

4

6

8 236.....................................

41,727

4.4100

1

3

4

5

8 237.....................................

1,918

3.7873

1

2

3

5

7 238.....................................

9,766

8.0468

2

4

6

10

15 239.....................................

40,272

6.0349

2

3

5

7

11 240.....................................

12,903

6.4095

2

3

5

8

12 241.....................................

2,833

3.6287

1

2

3

4

6 242.....................................

2,729

6.4723

2

3

5

8

12 243.....................................

100,743

4.4942

1

2

4

6

8 244.....................................

17,027

4.4384

1

2

4

6

8 245.....................................

5,905

3.1160

1

1

3

4

6 246.....................................

1,407

3.5586

1

2

3

4

7 247.....................................

21,432

3.2912

1

2

3

4

6 248.....................................

16,495

4.8125

2

3

4

6

9 249.....................................

13,445

3.9212

1

1

3

5

8 250.....................................

4,144

3.8446

1

2

3

5

7 251.....................................

2,068

2.7964

1

1

3

3

5 252.....................................

1

1.0000

1

1

1

1

1

[[Page 24365]]

253.....................................

24,751

4.5342

2

3

4

5

8 254.....................................

9,993

3.0679

1

2

3

4

5 255.....................................

1

1.0000

1

1

1

1

1 256.....................................

7,608

4.9628

1

2

4

6

9 257.....................................

13,094

2.5466

1

1

2

3

5 258.....................................

11,391

1.6969

1

1

1

2

3 259.....................................

2,658

2.8503

1

1

1

3

7 260.....................................

2,432

1.4030

1

1

1

1

2 261.....................................

1,570

2.1949

1

1

1

2

4 262.....................................

599

4.6194

1

2

3

6

9 263.....................................

22,466

10.4537

3

5

7

13

20 264.....................................

3,905

6.2453

2

3

5

7

11 265.....................................

4,011

6.5410

1

2

4

8

14 266.....................................

2,221

3.0360

1

1

2

4

6 267.....................................

273

4.2125

1

1

3

5

9 268.....................................

994

3.6579

1

1

2

4

7 269.....................................

11,015

7.9966

2

3

6

10

15 270.....................................

2,568

3.5927

1

1

3

5

7 271.....................................

21,705

6.7812

2

3

5

8

12 272.....................................

6,079

5.8138

2

3

4

7

11 273.....................................

1,267

3.7119

1

2

3

5

7 274.....................................

2,242

6.1704

1

3

5

8

12 275.....................................

180

3.2056

1

1

2

4

7 276.....................................

1,623

4.6161

1

2

4

6

8 277.....................................

119,318

5.4224

2

3

4

7

10 278.....................................

33,958

3.9963

2

2

3

5

7 279.....................................

6

4.1667

2

3

5

5

5 280.....................................

19,321

3.9877

1

2

3

5

7 281.....................................

6,560

2.8002

1

1

2

4

5 283.....................................

6,782

4.5823

1

2

3

6

9 284.....................................

1,870

2.9128

1

1

2

4

5 285.....................................

8,034

9.8114

3

5

8

12

18 286.....................................

2,859

5.1784

2

2

4

6

10 287.....................................

5,418

9.5314

3

5

7

11

17 288.....................................

11,270

3.7031

1

2

3

4

6 289.....................................

6,334

2.3892

1

1

1

2

5 290.....................................

11,872

2.0299

1

1

1

2

3 291.....................................

59

1.4915

1

1

1

1

2 292.....................................

7,563

10.0186

2

4

8

12

19 293.....................................

319

4.6865

1

2

3

6

9 294.....................................

97,793

4.2386

1

2

3

5

8 295.....................................

4,360

3.6961

1

2

3

4

7 296.....................................

247,607

4.6431

1

2

4

6

9 297.....................................

42,717

3.0296

1

2

3

4

5 298.....................................

110

3.5545

1

1

2

4

6 299.....................................

1,544

5.1101

1

2

4

6

10 300.....................................

21,677

5.8069

2

3

5

7

11 301.....................................

3,920

3.3571

1

2

3

4

6 302.....................................

10,267

7.9781

4

5

6

9

14 303.....................................

24,561

7.2806

3

4

6

8

14 304.....................................

14,043

8.3545

2

3

6

10

17 305.....................................

3,003

3.1052

1

2

3

4

6 306.....................................

5,792

5.5830

1

2

3

8

13 307.....................................

1,943

2.0314

1

1

2

2

3 308.....................................

6,673

6.1560

1

2

4

8

14 309.....................................

3,268

1.9819

1

1

1

2

4 310.....................................

25,310

4.4992

1

2

3

6

10 311.....................................

5,873

1.8502

1

1

1

2

3 312.....................................

1,322

4.9448

1

2

3

6

11 313.....................................

502

2.3845

1

1

2

3

5 314.....................................

2

89.0000

5

5

173

173

173 315.....................................

34,708

6.7296

1

1

4

9

16 316.....................................

204,595

6.1566

2

3

5

8

12 317.....................................

2,698

3.4959

1

1

2

4

7 318.....................................

5,901

5.9548

1

3

4

8

12 319.....................................

386

2.5466

1

1

2

3

5 320.....................................

225,362

4.9903

2

3

4

6

9 321.....................................

32,132

3.5412

1

2

3

4

6 322.....................................

67

3.5821

2

2

3

4

6

[[Page 24366]]

323.....................................

20,435

3.1085

1

1

2

4

6 324.....................................

4,625

1.8461

1

1

1

2

3 325.....................................

9,915

3.7382

1

2

3

5

7 326.....................................

2,596

2.5559

1

1

2

3

5 327.....................................

11

2.0000

1

1

2

2

3 328.....................................

574

3.3885

1

1

3

4

7 329.....................................

55

1.6727

1

1

1

2

3 331.....................................

56,928

5.4050

1

2

4

7

10 332.....................................

4,148

3.0668

1

1

2

4

6 333.....................................

242

5.3719

1

2

4

6

10 334.....................................

9,483

4.0363

1

2

3

5

7 335.....................................

12,125

2.4941

1

2

2

3

4 336.....................................

28,106

3.2238

1

1

2

4

7 337.....................................

21,429

1.8439

1

1

2

2

3 338.....................................

670

5.7910

1

2

4

8

13 339.....................................

1,226

5.1835

1

2

3

7

11 340.....................................

1

2.0000

2

2

2

2

2 341.....................................

3,118

3.2049

1

1

1

3

7 342.....................................

455

3.0440

1

1

2

3

6 344.....................................

2,346

2.7289

1

1

1

3

7 345.....................................

1,393

5.4113

1

2

3

7

12 346.....................................

4,007

5.8982

2

3

4

7

11 347.....................................

247

2.7126

1

1

2

4

6 348.....................................

4,275

4.0044

1

2

3

5

8 349.....................................

556

2.6529

1

1

2

3

5 350.....................................

7,277

4.5139

2

2

4

6

8 352.....................................

1,176

4.1896

1

2

3

5

9 353.....................................

3,076

6.0039

2

3

4

7

11 354.....................................

7,559

5.5536

2

3

4

6

10 355.....................................

4,995

3.0162

2

2

3

3

4 356.....................................

22,243

1.8699

1

1

2

2

3 357.....................................

5,525

8.0443

3

4

6

10

15 358.....................................

20,877

3.8586

2

2

3

4

7 359.....................................

28,606

2.3498

1

2

2

3

3 360.....................................

14,265

2.5481

1

1

2

3

4 361.....................................

288

2.9688

1

1

2

3

7 362.....................................

2

1.0000

1

1

1

1

1 363.....................................

1,979

4.0889

1

2

2

4

9 364.....................................

1,367

4.1895

1

2

3

5

8 365.....................................

1,607

7.8363

2

3

5

10

16 366.....................................

4,664

6.2281

2

3

5

8

12 367.....................................

449

3.0356

1

1

2

4

6 368.....................................

4,156

6.3780

2

3

5

8

12 369.....................................

3,783

3.2495

1

1

2

4

6 370.....................................

2,212

5.0190

2

3

4

5

7 371.....................................

2,662

3.3933

2

3

3

4

4 372.....................................

1,355

3.4635

2

2

2

3

5 373.....................................

5,213

2.2486

1

2

2

3

3 374.....................................

153

2.9739

2

2

2

3

4 375.....................................

13

6.2308

1

2

3

7

15 376.....................................

474

3.2911

1

2

2

4

7 377.....................................

111

4.4414

1

2

3

6

9 378.....................................

204

2.1716

1

1

2

3

4 379.....................................

486

3.1914

1

1

2

3

6 380.....................................

111

1.9910

1

1

1

2

4 381.....................................

172

2.4186

1

1

1

2

5 382.....................................

51

1.4510

1

1

1

1

3 383.....................................

2,816

3.6364

1

1

2

4

7 384.....................................

147

2.4966

1

1

1

3

4 387.....................................

1

9.0000

9

9

9

9

9 389.....................................

3

2.0000

1

1

2

3

3 392.....................................

2,121

8.8237

2

4

6

11

19 394.....................................

2,760

7.2779

1

2

5

9

16 395.....................................

115,737

4.2702

1

2

3

5

8 396.....................................

20

2.9500

1

2

3

3

4 397.....................................

16,460

5.1170

1

2

4

6

10 398.....................................

18,608

5.7065

2

3

4

7

11 399.....................................

1,644

3.3802

1

2

3

4

6 401.....................................

6,443

11.0118

2

5

8

14

22

[[Page 24367]]

402.....................................

1,341

3.8926

1

1

3

5

9 403.....................................

31,520

7.8447

2

3

6

10

16 404.....................................

3,629

3.9862

1

2

3

5

8 406.....................................

2,301

9.4198

2

4

7

12

20 407.....................................

608

3.5049

1

2

3

5

6 408.....................................

1,941

8.1891

1

2

5

11

19 409.....................................

1,735

5.9873

2

3

4

6

12 410.....................................

29,030

3.7625

1

2

3

5

6 411.....................................

5

2.0000

1

1

1

3

4 412.....................................

8

1.5000

1

1

1

2

2 413.....................................

5,728

6.7263

2

3

5

9

13 414.....................................

481

4.0520

1

2

3

5

7 415.....................................

55,707

14.0947

4

6

11

17

27 416.....................................

287,777

7.4539

2

3

6

9

14 417.....................................

33

6.5455

2

3

5

8

12 418.....................................

29,900

6.0648

2

3

5

7

11 419.....................................

17,739

4.3418

1

2

3

5

8 420.....................................

3,054

3.1673

1

2

3

4

6 421.....................................

13,253

4.0073

1

2

3

5

7 422.....................................

77

3.6753

1

2

2

4

7 423.....................................

9,078

8.0063

2

3

6

10

16 424.....................................

1,034

11.3598

2

4

8

14

23 425.....................................

13,110

3.4657

1

1

3

4

7 426.....................................

4,246

4.3243

1

2

3

5

8 427.....................................

1,575

4.6387

1

2

3

5

8 428.....................................

831

7.2972

1

2

4

7

13 429.....................................

24,106

5.5073

2

3

4

6

10 430.....................................

75,207

7.7972

2

3

6

9

14 431.....................................

338

6.8402

1

2

4

7

12 432.....................................

401

4.0449

1

1

3

4

8 433.....................................

5,146

2.9195

1

1

2

3

6 439.....................................

1,750

8.5280

1

3

5

10

17 440.....................................

5,181

8.1670

2

3

5

9

16 441.....................................

687

3.4731

1

1

2

4

7 442.....................................

18,533

8.6498

2

3

6

10

18 443.....................................

3,572

3.5269

1

1

3

5

7 444.....................................

6,005

4.0206

1

2

3

5

7 445.....................................

2,261

2.8178

1

1

2

4

5 447.....................................

6,342

2.5732

1

1

2

3

5 449.....................................

40,821

3.6926

1

1

3

4

7 450.....................................

7,412

1.9899

1

1

1

2

4 451.....................................

2

10.5000

8

8

13

13

13 452.....................................

28,666

4.9275

1

2

3

6

10 453.....................................

5,381

2.7640

1

1

2

3

5 454.....................................

4,755

4.1085

1

2

3

5

8 455.....................................

885

2.3017

1

1

2

3

4 461.....................................

2,271

5.5685

1

1

3

7

12 462.....................................

7,873

9.5382

4

5

7

10

12 463.....................................

32,987

3.8751

1

2

3

5

7 464.....................................

7,681

2.9046

1

1

2

4

5 465.....................................

171

3.6023

1

1

2

5

8 466.....................................

1,250

4.7560

1

1

2

5

8 467.....................................

1,037

2.6914

1

1

2

3

6 468.....................................

51,814

12.5399

3

6

10

16

24 471.....................................

16,680

4.8562

3

3

4

5

8 473.....................................

8,558

12.4167

2

3

7

17

32 475.....................................

119,967

10.6391

2

5

9

14

20 476.....................................

2,841

9.9335

1

4

8

14

19 477.....................................

28,081

8.5088

1

3

7

11

17 479.....................................

27,608

2.5529

1

1

2

3

5 480.....................................

884

19.1618

6

8

13

23

39 481.....................................

1,183

22.0211

12

16

20

24

33 482.....................................

5,078

11.2115

4

6

9

13

20 484.....................................

456

12.7741

2

5

10

17

26 485.....................................

3,658

9.4672

4

5

7

11

17 486.....................................

2,607

12.1952

2

5

10

16

25 487.....................................

4,878

6.8569

1

3

5

9

14 488.....................................

823

17.4836

4

7

13

21

35 489.....................................

13,668

8.1512

2

3

6

10

16

[[Page 24368]]

490.....................................

5,341

5.3026

1

2

4

7

10 491.....................................

22,698

3.0177

1

2

2

3

5 492.....................................

3,897

13.8111

3

5

6

23

32 493.....................................

60,917

6.0332

2

3

5

8

11 494.....................................

24,482

2.6885

1

1

2

4

5 495.....................................

336

17.0417

8

10

13

20

33 496.....................................

3,710

8.7685

3

4

6

10

18 497.....................................

31,247

5.6724

3

3

5

6

9 498.....................................

21,409

3.6627

2

3

3

4

6 499.....................................

35,214

4.1547

1

2

3

5

8 500.....................................

46,705

2.1886

1

1

2

3

4 501.....................................

3,172

9.8373

4

5

8

12

18 502.....................................

756

5.7315

2

3

5

7

10 503.....................................

5,863

3.9168

1

2

3

5

7 504.....................................

191

28.1885

8

13

24

36

51 505.....................................

180

6.3611

1

1

2

7

15 506.....................................

964

15.2656

3

7

12

20

30 507.....................................

323

7.7895

1

3

6

10

15 508.....................................

663

7.4087

1

3

5

9

15 509.....................................

157

5.2038

1

2

3

6

11 510.....................................

1,798

6.0801

1

2

4

7

12 511.....................................

636

3.6840

1

1

2

5

8 512.....................................

530

13.5491

6

8

10

14

25 513.....................................

213

10.0235

5

7

8

11

17 515.....................................

58,194

3.8449

1

1

2

5

9 518.....................................

23,656

2.4643

1

1

1

3

5 519.....................................

12,546

4.6720

1

1

3

6

11 520.....................................

16,538

1.9346

1

1

1

2

4 521.....................................

32,469

5.4433

2

3

4

7

11 522.....................................

5,805

9.2951

4

4

7

12

17 523.....................................

15,604

3.8646

1

2

3

5

6 524.....................................

109,168

3.1419

1

2

3

4

6 525.....................................

203

13.8719

1

3

7

17

35 528.....................................

1,841

16.2960

6

9

14

21

29 529.....................................

5,110

7.2626

1

2

4

9

16 530.....................................

3,374

2.9452

1

1

2

3

6 531.....................................

4,874

8.9241

2

4

7

11

18 532.....................................

2,832

3.6335

1

1

3

5

7 533.....................................

46,528

3.6527

1

1

2

4

8 534.....................................

42,555

1.7237

1

1

1

2

3 535.....................................

8,766

9.2450

2

4

8

12

17 536.....................................

8,191

7.2792

2

3

6

9

14 537.....................................

8,953

6.4996

1

3

5

8

13 538.....................................

5,456

2.9041

1

1

2

4

6 539.....................................

4,954

10.5365

2

4

7

14

23 540.....................................

1,493

3.5050

1

1

3

4

7 541.....................................

25,010

41.5518

16

23

34

50

73 542.....................................

23,224

30.4308

11

17

25

37

53 543.....................................

5,478

11.7158

2

5

9

16

24 544.....................................

445,170

4.3989

3

3

4

5

7 545.....................................

43,505

5.0296

3

3

4

6

8 546.....................................

2,348

8.7709

3

4

7

10

16 547.....................................

32,613

12.1280

6

8

10

14

20 548.....................................

32,131

8.7786

5

6

8

10

13 549.....................................

13,102

10.1125

5

6

8

12

18 550.....................................

34,474

6.7767

4

5

6

8

10 551.....................................

53,809

6.0733

1

2

5

8

12 552.....................................

81,920

3.4753

1

1

2

5

7 553.....................................

39,195

9.0732

1

3

7

12

19 554.....................................

77,181

5.5751

1

2

4

7

12 555.....................................

37,296

4.8187

1

2

3

6

10 556.....................................

18,962

2.0159

1

1

1

2

4 557.....................................

123,883

4.1057

1

2

3

5

8 558.....................................

192,407

1.8118

1

1

1

2

4 559.....................................

2,889

6.8463

2

3

5

8

13 12,149,409

[[Page 24369]]

Table 7B.--Medicare Prospective Payment System Selected Percentile Lengths of Stay FY 2005 MedPAR Update December 2005 Grouper V24.0

Arithmetic DRG

Number of mean length- 10th

25th

50th

75th

90th discharges

of-stay percentile percentile percentile percentile percentile

1.......................................

24,342

9.6035

2

4

7

12

19 2.......................................

10,268

4.3919

1

2

4

6

8 3.......................................

2

12.5000

4

4

21

21

21 6.......................................

291

3.0619

1

1

2

4

7 7.......................................

14,937

9.2561

2

4

7

12

19 8.......................................

3,419

2.7640

1

1

2

3

6 9.......................................

1,762

6.0335

1

3

4

7

11 10......................................

19,573

5.9187

2

3

4

7

12 11......................................

3,070

3.5476

1

2

3

5

7 12......................................

57,060

5.4770

2

3

4

6

10 13......................................

7,489

4.8484

2

3

4

6

8 14......................................

278,444

5.3747

2

3

4

7

10 15......................................

19,998

4.0114

1

2

3

5

7 16......................................

17,374

6.2850

2

3

5

8

12 17......................................

2,960

3.0372

1

1

2

4

6 18......................................

33,407

5.1537

2

3

4

6

10 19......................................

8,413

3.3808

1

2

3

4

6 20......................................

6,389

9.8455

3

5

8

12

18 21......................................

2,204

6.1892

2

3

5

8

12 22......................................

3,158

5.0130

2

2

4

6

10 23......................................

10,736

3.9275

1

2

3

5

7 24......................................

63,274

4.6447

1

2

3

6

9 25......................................

27,221

3.1235

1

2

3

4

6 26......................................

24

3.7917

1

1

2

5

9 27......................................

5,910

4.7389

1

1

3

6

10 28......................................

19,811

5.5762

1

2

4

7

11 29......................................

6,491

3.2169

1

1

3

4

6 31......................................

4,963

3.9079

1

2

3

5

7 32......................................

1,854

2.2681

1

1

2

3

4 34......................................

27,481

4.7113

1

2

4

6

9 35......................................

7,817

3.0380

1

1

3

4

6 36......................................

1,207

1.6827

1

1

1

1

3 37......................................

1,228

4.0847

1

1

3

5

9 38......................................

49

2.8367

1

1

2

3

6 39......................................

361

2.0305

1

1

1

2

4 40......................................

1,251

4.1431

1

1

4

5

7 42......................................

943

3.0403

1

1

2

4

7 43......................................

123

2.9512

1

1

2

4

5 44......................................

1,298

4.7473

2

3

4

6

8 45......................................

2,761

3.0315

1

2

2

4

6 46......................................

3,930

4.1880

1

2

3

5

8 47......................................

1,310

3.0069

1

1

2

4

6 49......................................

2,417

4.5122

1

2

3

5

9 50......................................

2,024

1.8656

1

1

1

2

3 51......................................

191

2.6859

1

1

1

3

6 52......................................

316

1.7025

1

1

1

2

3 53......................................

2,144

4.0005

1

1

2

5

9 55......................................

1,365

2.8864

1

1

2

3

6 56......................................

451

2.6674

1

1

2

3

5 57......................................

882

3.1610

1

1

2

3

7 59......................................

127

2.3780

1

1

2

3

5 60......................................

3

1.6667

1

1

1

3

3 61......................................

222

6.0541

1

1

4

8

13 62......................................

4

1.5000

1

1

1

1

3 63......................................

2,819

4.5413

1

1

3

6

10 64......................................

3,237

6.2252

1

2

4

8

13 65......................................

40,692

2.7630

1

1

2

3

5 66......................................

8,202

3.1099

1

1

2

4

6 67......................................

378

3.6958

1

2

3

5

8 68......................................

19,016

3.8478

1

2

3

5

7 69......................................

5,160

2.9453

1

2

3

4

5 70......................................

23

2.3478

1

1

2

3

4 71......................................

70

4.3429

1

2

3

5

7 72......................................

1,338

3.3169

1

2

3

4

6 73......................................

9,943

4.2956

1

2

3

5

8 74......................................

3

3.3333

3

3

3

4

4 75......................................

46,669

9.5793

3

5

7

12

19 76......................................

48,046

10.4814

3

5

8

13

20 77......................................

2,086

4.4971

1

2

4

6

9

[[Page 24370]]

78......................................

49,542

6.0974

2

4

5

7

10 79......................................

160,422

8.0472

3

4

7

10

15 80......................................

7,151

5.2225

2

3

4

6

9 81......................................

6

6.1667

2

3

5

8

8 82......................................

63,105

6.6705

2

3

5

9

13 83......................................

7,054

5.2007

2

3

4

6

10 84......................................

1,379

3.1378

1

2

3

4

6 85......................................

22,190

6.1035

2

3

5

8

12 86......................................

1,719

3.4607

1

2

3

5

7 87......................................

96,722

6.3636

2

3

5

8

12 88......................................

428,131

4.8522

2

3

4

6

9 89......................................

554,927

5.5242

2

3

5

7

10 90......................................

143,397

3.7046

2

2

3

5

6 91......................................

53

3.4151

1

1

2

4

6 92......................................

16,515

5.9398

2

3

5

7

11 93......................................

1,431

3.7519

1

2

3

5

7 94......................................

13,559

5.9001

2

3

5

8

12 95......................................

1,567

3.3854

1

2

3

4

6 96......................................

60,067

4.2943

2

2

4

5

8 97......................................

26,938

3.3583

1

2

3

4

6 98......................................

13

3.0769

2

2

2

4

6 99......................................

21,398

3.0985

1

1

2

4

6 100.....................................

6,411

2.1093

1

1

2

3

4 101.....................................

23,326

4.1821

1

2

3

5

8 102.....................................

4,896

2.5353

1

1

2

3

5 103.....................................

859

34.9488

8

11

22

45

76 104.....................................

20,062

14.6431

6

8

12

18

26 105.....................................

32,513

9.9310

4

6

8

11

18 106.....................................

3,425

10.9323

5

7

9

13

18 108.....................................

8,715

10.7177

4

6

9

13

19 110.....................................

57,507

8.0074

1

3

6

10

16 111.....................................

10,723

3.1038

1

1

2

4

6 113.....................................

34,611

12.5574

4

6

10

15

24 114.....................................

7,947

8.3434

2

4

7

11

16 117.....................................

5,333

4.2738

1

1

2

5

9 118.....................................

7,615

3.0223

1

1

2

4

7 119.....................................

964

5.3932

1

1

3

7

13 120.....................................

33,418

8.9638

1

3

6

12

19 121.....................................

150,021

6.2025

2

3

5

8

12 122.....................................

54,501

3.3056

1

1

3

4

6 123.....................................

29,532

4.7330

1

1

3

6

11 124.....................................

120,245

4.3891

1

2

3

6

9 125.....................................

92,047

2.7024

1

1

2

3

5 126.....................................

5,419

10.7123

3

6

9

13

20 127.....................................

668,127

5.0831

2

3

4

6

9 128.....................................

4,228

5.1824

2

3

5

6

9 129.....................................

3,516

2.5444

1

1

1

2

5 130.....................................

87,532

5.3515

1

3

4

7

10 131.....................................

22,847

3.7023

1

2

3

5

6 132.....................................

101,519

2.8000

1

1

2

3

5 133.....................................

5,861

2.1435

1

1

2

3

4 134.....................................

40,204

3.0925

1

2

2

4

6 135.....................................

7,152

4.2875

1

2

3

5

8 136.....................................

934

2.6938

1

1

2

3

5 138.....................................

206,178

3.8766

1

2

3

5

7 139.....................................

73,962

2.4279

1

1

2

3

4 140.....................................

31,440

2.4072

1

1

2

3

4 141.....................................

123,506

3.4313

1

2

3

4

6 142.....................................

49,357

2.4907

1

1

2

3

4 143.....................................

238,140

2.0969

1

1

2

3

4 144.....................................

105,005

5.8109

1

2

4

7

12 145.....................................

5,713

2.5452

1

1

2

3

5 146.....................................

10,240

9.7635

4

6

8

11

17 147.....................................

2,600

5.5485

2

4

5

7

8 148.....................................

132,760

11.9306

5

6

9

15

22 149.....................................

19,451

5.6456

3

4

5

7

8 150.....................................

22,923

10.7178

4

6

9

13

19 151.....................................

5,379

5.0134

1

2

4

7

9 152.....................................

5,000

7.9154

3

5

7

9

14

[[Page 24371]]

153.....................................

1,943

4.8636

2

3

5

6

7 154.....................................

26,986

12.9751

3

6

10

16

25 155.....................................

5,993

3.9580

1

2

3

6

8 156.....................................

4

9.2500

7

7

8

8

14 157.....................................

8,303

5.6904

1

2

4

7

11 158.....................................

3,703

2.6425

1

1

2

3

5 159.....................................

19,177

5.0870

1

2

4

6

10 160.....................................

11,919

2.6539

1

1

2

3

5 161.....................................

10,150

4.5100

1

2

3

6

9 162.....................................

4,955

2.0852

1

1

2

3

4 163.....................................

4

2.7500

1

1

2

3

5 164.....................................

5,979

7.6887

3

4

7

9

14 165.....................................

2,445

4.0045

2

2

4

5

7 166.....................................

5,128

4.3249

1

2

3

5

8 167.....................................

4,888

2.1291

1

1

2

3

4 168.....................................

1,531

4.8537

1

2

3

6

10 169.....................................

771

2.3904

1

1

2

3

5 170.....................................

17,892

10.6930

2

5

8

13

21 171.....................................

1,402

4.1676

1

2

3

5

8 172.....................................

33,088

6.7832

2

3

5

8

13 173.....................................

2,201

3.4993

1

1

3

4

7 174.....................................

261,230

4.6845

2

3

4

6

8 175.....................................

29,881

2.8559

1

2

2

4

5 176.....................................

14,624

5.0844

2

3

4

6

9 177.....................................

7,655

4.4286

2

2

4

5

8 178.....................................

2,554

3.0779

1

2

3

4

5 179.....................................

14,667

5.7799

2

3

4

7

11 180.....................................

91,385

5.2542

2

3

4

6

10 181.....................................

25,208

3.3076

1

2

3

4

6 182.....................................

297,098

4.4827

1

2

3

6

8 183.....................................

81,695

2.8952

1

1

2

4

5 184.....................................

76

4.3421

1

2

3

4

8 185.....................................

6,238

4.4833

1

2

3

6

9 186.....................................

7

3.1429

1

2

2

3

5 187.....................................

640

4.1984

1

2

3

6

8 188.....................................

93,553

5.4513

1

2

4

7

11 189.....................................

13,057

3.0531

1

1

2

4

6 190.....................................

63

4.8730

1

2

3

6

8 191.....................................

10,552

12.3500

3

6

9

15

25 192.....................................

1,376

5.4964

1

3

5

7

9 193.....................................

4,034

12.5473

5

7

10

15

23 194.....................................

463

6.3672

2

4

6

8

11 195.....................................

2,835

10.5686

4

6

9

13

18 196.....................................

594

5.3468

2

3

5

7

10 197.....................................

16,367

9.0180

3

5

7

11

16 198.....................................

4,102

4.3206

2

3

4

5

7 199.....................................

1,473

8.9885

2

4

7

12

19 200.....................................

1,013

10.3416

1

3

7

13

21 201.....................................

2,713

13.5584

3

6

10

17

27 202.....................................

27,472

6.1313

2

3

5

8

12 203.....................................

32,349

6.4399

2

3

5

8

13 204.....................................

69,238

5.3850

2

3

4

6

10 205.....................................

32,709

5.8510

2

3

4

7

11 206.....................................

2,040

3.8103

1

2

3

5

7 207.....................................

38,281

5.2408

1

2

4

7

10 208.....................................

9,447

2.9451

1

1

2

4

5 210.....................................

126,388

6.6248

3

4

6

8

11 211.....................................

25,730

4.5898

3

3

4

5

7 212.....................................

10

2.5000

1

2

2

4

4 213.....................................

9,465

8.9718

2

4

7

11

18 216.....................................

19,942

5.3156

1

1

3

7

13 217.....................................

15,610

12.0976

3

5

8

15

24 218.....................................

30,001

5.3765

2

3

4

7

10 219.....................................

21,067

3.1625

1

2

3

4

5 220.....................................

2

4.0000

1

1

7

7

7 223.....................................

12,657

3.2634

1

1

2

4

7 224.....................................

9,940

1.9360

1

1

1

2

3 225.....................................

6,246

5.2789

1

2

4

7

11 226.....................................

6,748

6.3594

1

3

4

8

13

[[Page 24372]]

227.....................................

4,864

2.6301

1

1

2

3

5 228.....................................

2,673

4.1968

1

1

3

5

9 229.....................................

1,118

2.4875

1

1

2

3

5 230.....................................

2,464

5.4180

1

2

4

7

11 232.....................................

569

2.7346

1

1

2

3

6 233.....................................

18,441

6.3221

1

2

5

8

13 234.....................................

9,076

2.6644

1

1

1

3

6 235.....................................

4,745

4.6565

1

2

4

6

8 236.....................................

41,690

4.4064

1

3

4

5

8 237.....................................

1,918

3.7904

1

2

3

5

7 238.....................................

9,728

8.0118

2

4

6

10

15 239.....................................

40,288

6.0331

2

3

5

7

11 240.....................................

12,888

6.4250

2

3

5

8

12 241.....................................

2,812

3.6348

1

2

3

4

6 242.....................................

2,724

6.4589

2

3

5

8

12 243.....................................

100,724

4.4958

1

2

4

6

8 244.....................................

16,990

4.4383

1

2

4

5

8 245.....................................

5,860

3.1056

1

1

3

4

6 246.....................................

1,400

3.5536

1

2

3

4

7 247.....................................

21,406

3.2872

1

2

3

4

6 248.....................................

16,433

4.8139

2

3

4

6

9 249.....................................

13,453

3.9550

1

1

3

5

8 250.....................................

4,139

3.8425

1

2

3

5

7 251.....................................

2,049

2.8019

1

1

3

3

5 252.....................................

1

1.0000

1

1

1

1

1 253.....................................

24,733

4.5276

2

3

4

5

8 254.....................................

9,965

3.0711

1

2

3

4

5 255.....................................

1

1.0000

1

1

1

1

1 256.....................................

7,577

4.9555

1

2

4

6

9 257.....................................

13,101

2.5513

1

1

2

3

5 258.....................................

11,379

1.6977

1

1

1

2

3 259.....................................

2,656

2.8407

1

1

1

3

7 260.....................................

2,435

1.4049

1

1

1

1

2 261.....................................

1,573

2.1933

1

1

1

2

4 262.....................................

596

4.6393

1

2

3

6

9 263.....................................

22,506

10.4499

3

5

7

13

20 264.....................................

3,901

6.2153

2

3

5

7

11 265.....................................

4,014

6.5399

1

2

4

8

14 266.....................................

2,220

3.0171

1

1

2

4

6 267.....................................

272

4.2132

1

1

3

5

8 268.....................................

992

3.6563

1

1

2

4

7 269.....................................

11,031

7.9837

2

3

6

10

15 270.....................................

2,565

3.5977

1

1

3

5

7 271.....................................

21,624

6.7865

2

3

5

8

12 272.....................................

6,071

5.8122

2

3

4

7

11 273.....................................

1,263

3.7126

1

2

3

5

7 274.....................................

2,223

6.1858

1

3

5

8

12 275.....................................

173

3.3064

1

1

2

4

6 276.....................................

1,615

4.6136

1

2

4

6

8 277.....................................

119,112

5.4229

2

3

4

7

10 278.....................................

33,788

3.9930

2

2

3

5

7 279.....................................

6

4.1667

2

3

5

5

5 280.....................................

19,291

3.9889

1

2

3

5

7 281.....................................

6,530

2.8018

1

1

2

4

5 283.....................................

6,765

4.5808

1

2

3

6

9 284.....................................

1,856

2.9230

1

1

2

4

5 285.....................................

8,029

9.8162

3

5

8

12

18 286.....................................

2,853

5.1854

2

2

4

6

10 287.....................................

5,440

9.5362

3

5

7

11

18 288.....................................

11,290

3.7006

1

2

3

4

6 289.....................................

6,337

2.3926

1

1

1

2

5 290.....................................

11,858

2.0279

1

1

1

2

3 291.....................................

59

1.4915

1

1

1

1

2 292.....................................

7,564

10.0071

2

4

8

12

19 293.....................................

316

4.7089

1

2

3

6

8 294.....................................

97,541

4.2412

1

2

3

5

8 295.....................................

4,362

3.6997

1

2

3

4

7 296.....................................

247,608

4.6432

1

2

4

6

9 297.....................................

42,673

3.0303

1

2

3

4

5

[[Page 24373]]

298.....................................

110

3.5545

1

1

2

4

6 299.....................................

1,541

5.1304

1

2

4

6

10 300.....................................

21,697

5.8067

2

3

5

7

11 301.....................................

3,912

3.3566

1

2

3

4

6 302.....................................

10,255

7.9757

4

5

6

9

13 303.....................................

24,546

7.2813

3

4

6

8

14 304.....................................

14,020

8.3536

2

3

6

10

17 305.....................................

2,996

3.1031

1

2

3

4

6 306.....................................

5,804

5.5829

1

2

3

8

13 307.....................................

1,942

2.0391

1

1

2

2

3 308.....................................

6,675

6.1486

1

2

4

8

14 309.....................................

3,267

1.9773

1

1

1

2

4 310.....................................

25,304

4.4981

1

2

3

6

10 311.....................................

5,872

1.8551

1

1

1

2

3 312.....................................

1,320

4.9356

1

2

3

6

10 313.....................................

501

2.3852

1

1

2

3

5 314.....................................

12

89.0000

5

5

173

173

173 315.....................................

34,750

6.7385

1

1

4

9

16 316.....................................

204,504

6.1586

2

3

5

8

12 317.....................................

2,696

3.4970

1

1

2

4

7 318.....................................

5,891

5.9701

1

3

4

8

12 319.....................................

382

2.5733

1

1

2

3

5 320.....................................

225,245

4.9895

2

3

4

6

9 321.....................................

31,997

3.5392

1

2

3

4

6 322.....................................

67

3.5821

2

2

3

4

6 323.....................................

20,408

3.1059

1

1

2

4

6 324.....................................

4,621

1.8455

1

1

1

2

3 325.....................................

9,909

3.7375

1

2

3

5

7 326.....................................

2,596

2.5632

1

1

2

3

5 327.....................................

11

2.0000

1

1

2

2

3 328.....................................

573

3.3805

1

1

3

4

6 329.....................................

54

1.6852

1

1

1

2

3 331.....................................

56,851

5.4046

1

2

4

7

10 332.....................................

4,131

3.0690

1

1

2

4

6 333.....................................

242

5.3719

1

2

4

6

10 334.....................................

9,503

4.0414

1

2

3

5

7 335.....................................

12,142

2.4975

1

2

2

3

4 336.....................................

28,146

3.2243

1

1

2

4

7 337.....................................

21,461

1.8444

1

1

2

2

3 338.....................................

674

5.7908

1

2

4

8

13 339.....................................

1,230

5.1976

1

2

3

7

12 340.....................................

1

2.0000

2

2

2

2

2 341.....................................

3,120

3.2032

1

1

1

3

7 342.....................................

456

3.0395

1

1

2

3

6 344.....................................

2,342

2.7331

1

1

1

3

7 345.....................................

1,387

5.4232

1

2

3

7

12 346.....................................

3,983

5.8943

2

3

4

7

11 347.....................................

240

2.6917

1

1

2

3

5 348.....................................

4,273

4.0059

1

2

3

5

8 349.....................................

555

2.6396

1

1

2

3

5 350.....................................

7,266

4.5140

2

2

4

6

8 352.....................................

1,176

4.1820

1

2

3

5

9 353.....................................

3,082

6.0039

2

3

4

7

11 354.....................................

7,554

5.5586

2

3

4

6

10 355.....................................

4,988

3.0158

2

2

3

3

4 356.....................................

22,223

1.8694

1

1

2

2

3 357.....................................

5,519

8.0364

3

4

6

10

15 358.....................................

20,865

3.8574

2

2

3

4

7 359.....................................

28,581

2.3500

1

2

2

3

3 360.....................................

14,256

2.5446

1

1

2

3

4 361.....................................

287

2.9756

1

1

2

3

6 362.....................................

2

1.0000

1

1

1

1

1 363.....................................

1,979

4.0859

1

2

2

4

9 364.....................................

1,377

4.1888

1

2

3

5

9 365.....................................

1,605

7.8517

2

3

5

10

16 366.....................................

4,644

6.2351

2

3

5

8

12 367.....................................

437

3.0092

1

1

2

4

5 368.....................................

4,150

6.4051

2

3

5

8

12 369.....................................

3,727

3.2667

1

1

2

4

6

[[Page 24374]]

370.....................................

2,209

5.0023

2

3

4

5

7 371.....................................

2,663

3.3924

2

3

3

4

4 372.....................................

1,349

3.4633

2

2

2

3

5 373.....................................

5,186

2.2443

1

2

2

3

3 374.....................................

153

2.9739

2

2

2

3

4 375.....................................

13

6.2308

1

2

3

7

15 376.....................................

473

3.2939

1

2

2

4

7 377.....................................

109

4.4495

1

2

3

6

8 378.....................................

203

2.1773

1

1

2

3

4 379.....................................

484

3.2004

1

1

2

3

6 380.....................................

110

2.0273

1

1

1

2

4 381.....................................

170

2.4294

1

1

1

2

4 382.....................................

49

1.4694

1

1

1

1

2 383.....................................

2,780

3.6439

1

1

2

4

7 384.....................................

147

2.4966

1

1

1

3

4 387.....................................

1

9.0000

9

9

9

9

9 389.....................................

3

2.0000

1

1

2

3

3 392.....................................

2,120

8.8330

2

4

6

11

19 394.....................................

2,758

7.2708

1

2

5

9

16 395.....................................

115,655

4.2739

1

2

3

5

8 396.....................................

20

2.9500

1

2

3

3

4 397.....................................

16,459

5.1109

1

2

4

6

10 398.....................................

18,615

5.7086

2

3

4

7

11 399.....................................

1,633

3.3791

1

2

3

4

6 401.....................................

6,439

11.0110

2

5

8

14

22 402.....................................

1,340

3.8955

1

1

3

5

8 403.....................................

31,515

7.8539

2

3

6

10

16 404.....................................

3,614

3.9801

1

2

3

5

8 406.....................................

2,300

9.4235

2

4

7

12

20 407.....................................

610

3.5049

1

2

3

5

7 408.....................................

1,943

8.2203

1

2

5

11

19 409.....................................

1,740

5.9891

2

3

4

6

12 410.....................................

29,094

3.7690

1

2

3

5

6 411.....................................

5

2.0000

1

1

1

3

4 412.....................................

8

1.5000

1

1

1

2

2 413.....................................

5,728

6.7243

2

3

5

9

13 414.....................................

478

4.0146

1

2

3

5

7 415.....................................

55,770

14.0714

4

6

11

17

28 416.....................................

288,297

7.4530

2

4

6

9

14 417.....................................

33

6.5455

2

3

5

8

12 418.....................................

29,873

6.0664

2

3

5

7

11 419.....................................

17,681

4.3426

1

2

3

5

8 420.....................................

3,029

3.1700

1

2

3

4

6 421.....................................

13,246

4.0091

1

2

3

5

7 422.....................................

77

3.6753

1

2

2

4

7 423.....................................

9,067

8.0275

2

3

6

10

16 424.....................................

1,033

11.3679

2

4

8

14

23 425.....................................

13,142

3.4810

1

1

3

4

7 426.....................................

4,389

4.5129

1

2

3

5

9 427.....................................

1,603

4.7324

1

2

3

6

9 428.....................................

855

7.3111

1

2

4

8

14 429.....................................

24,588

5.6295

2

3

4

7

10 430.....................................

76,498

7.8309

2

3

6

9

15 431.....................................

339

6.8171

1

2

4

7

12 432.....................................

400

4.0400

1

1

3

4

8 433.....................................

4,640

2.8390

1

1

2

3

4 439.....................................

1,751

8.3501

1

3

5

10

17 440.....................................

5,187

8.1656

2

3

5

9

17 441.....................................

685

3.4730

1

1

2

4

7 442.....................................

18,537

8.6463

2

3

6

10

18 443.....................................

3,580

3.5260

1

1

3

5

7 444.....................................

5,993

4.0310

1

2

3

5

7 445.....................................

2,240

2.8210

1

1

2

4

5 447.....................................

6,355

2.5769

1

1

2

3

5 449.....................................

40,805

3.6894

1

1

3

4

7 450.....................................

7,411

1.9873

1

1

1

2

4 451.....................................

2

10.5000

8

8

13

13

13 452.....................................

28,672

4.9315

1

2

3

6

10 453.....................................

5,363

2.7583

1

1

2

3

5

[[Page 24375]]

454.....................................

4,747

4.1062

1

2

3

5

8 455.....................................

885

2.2814

1

1

2

3

4 461.....................................

2,273

5.5794

1

1

3

7

13 462.....................................

8,971

9.5207

4

6

8

11

16 463.....................................

32,939

3.8728

1

2

3

5

7 464.....................................

7,650

2.8997

1

1

2

4

5 465.....................................

165

3.6182

1

1

2

4

6 466.....................................

1,205

4.9842

1

1

2

5

7 467.....................................

1,028

2.6625

1

1

2

3

5 468.....................................

51,844

12.5282

3

6

10

16

24 471.....................................

15,609

4.5466

3

3

4

5

7 473.....................................

8,557

12.4122

2

3

7

17

32 475.....................................

120,026

10.6390

2

5

9

14

21 476.....................................

2,847

9.9424

1

4

8

14

20 477.....................................

28,111

8.5004

1

3

7

11

17 479.....................................

27,545

2.5522

1

1

2

3

5 480.....................................

884

19.1618

6

8

13

23

39 481.....................................

1,183

22.0211

12

16

20

24

33 482.....................................

5,072

11.1808

4

6

9

13

20 484.....................................

455

12.7560

2

5

10

17

26 485.....................................

3,660

9.4104

4

5

7

11

17 486.....................................

2,600

12.1862

2

5

10

16

25 487.....................................

4,866

6.8531

1

3

5

9

14 488.....................................

820

17.4744

4

7

13

21

34 489.....................................

13,634

8.1556

2

3

6

10

16 490.....................................

5,299

5.3025

1

2

4

6

10 491.....................................

22,716

3.0154

1

2

2

3

5 492.....................................

3,906

13.7983

3

5

6

23

32 493.....................................

60,947

6.0341

2

3

5

8

11 494.....................................

24,474

2.6904

1

1

2

4

5 495.....................................

336

17.0417

8

10

13

20

33 496.....................................

3,715

8.7505

3

4

6

10

18 497.....................................

31,285

5.6682

3

3

5

6

9 498.....................................

21,475

3.6630

2

3

3

4

6 499.....................................

35,262

4.1552

1

2

3

5

8 500.....................................

46,802

2.1900

1

1

2

3

4 501.....................................

3,178

9.8420

4

5

8

12

18 502.....................................

756

5.7116

2

3

5

7

10 503.....................................

5,879

3.9160

1

2

3

5

7 504.....................................

190

28.2789

8

13

24

36

51 505.....................................

177

6.3503

1

1

2

6

13 506.....................................

960

15.2063

3

7

12

20

30 507.....................................

322

7.7702

1

3

6

10

15 508.....................................

658

7.3708

1

3

5

9

14 509.....................................

156

5.2179

1

2

3

6

11 510.....................................

1,779

6.0438

1

2

4

7

12 511.....................................

626

3.6773

1

1

2

4

7 512.....................................

530

13.5491

6

8

10

14

25 513.....................................

213

10.0235

5

7

8

11

17 515.....................................

58,196

3.8438

1

1

2

5

9 518.....................................

23,688

2.4604

1

1

1

3

5 519.....................................

12,559

4.6661

1

1

3

6

11 520.....................................

16,572

1.9340

1

1

1

2

4 521.....................................

29,820

5.2943

1

2

4

6

8 522.....................................

3,580

10.3455

3

4

5

7

8 523.....................................

14,736

3.8210

1

2

3

4

6 524.....................................

109,259

3.1436

1

2

3

4

6 525.....................................

203

13.9458

1

3

7

17

35 528.....................................

1,838

16.2927

6

9

14

21

29 529.....................................

5,103

7.2536

1

2

4

9

16 530.....................................

3,371

2.9436

1

1

2

3

6 531.....................................

4,884

8.9378

2

4

7

11

18 532.....................................

2,838

3.6350

1

1

3

5

7 533.....................................

46,516

3.6549

1

1

2

4

8 534.....................................

42,526

1.7237

1

1

1

2

3 535.....................................

8,772

9.2410

2

4

8

12

18 536.....................................

8,193

7.2754

2

3

6

9

14 537.....................................

8,952

6.4947

1

3

5

8

13 538.....................................

5,452

2.9057

1

1

2

4

6

[[Page 24376]]

539.....................................

4,962

10.5316

2

4

7

14

23 540.....................................

1,495

3.5010

1

1

3

4

7 541.....................................

24,941

41.4444

16

23

34

50

72 542.....................................

23,183

30.3714

11

17

25

37

53 543.....................................

5,475

11.7145

2

5

9

16

24 544.....................................

445,895

4.3971

3

3

4

5

7 545.....................................

44,700

5.1342

3

3

4

6

9 546.....................................

2,349

8.7292

3

4

7

10

16 547.....................................

32,600

12.1272

6

8

10

14

20 548.....................................

32,135

8.7775

5

6

8

10

13 549.....................................

13,107

10.1157

5

6

8

12

18 550.....................................

34,471

6.7739

4

5

6

8

10 551.....................................

53,828

6.0746

1

2

5

8

12 552.....................................

81,945

3.4779

1

1

2

5

7 553.....................................

39,190

9.0613

1

3

7

12

19 554.....................................

77,166

5.5699

1

2

4

7

12 555.....................................

37,283

4.8161

1

2

3

6

10 556.....................................

18,925

2.0092

1

1

1

2

4 557.....................................

123,799

4.1037

1

2

3

5

8 558.....................................

192,346

1.8113

1

1

1

2

4 559.....................................

2,886

6.8257

2

3

5

8

13 12,144,751

Table 8A.--Statewide Average Operating Cost-to-Charge Ratios--March 2006

State

Urban Rural

Alabama........................................... 0.265 0.334 Alaska............................................ 0.423 0.719 Arizona........................................... 0.285 0.37 Arkansas.......................................... 0.34 0.357 California........................................ 0.24 0.347 Colorado.......................................... 0.314 0.486 Connecticut....................................... 0.428

0.5 Delaware.......................................... 0.528 0.508 District of Columbia.............................. 0.397 ......... Florida........................................... 0.252

0.3 Georgia........................................... 0.355 0.404 Hawaii............................................ 0.384 0.432 Idaho............................................. 0.48 0.528 Illinois.......................................... 0.326 0.418 Indiana........................................... 0.424 0.454 Iowa.............................................. 0.39 0.467 Kansas............................................ 0.299 0.454 Kentucky.......................................... 0.386 0.394 Louisiana......................................... 0.308 0.374 Maine............................................. 0.496 0.475 Maryland.......................................... 0.763 0.882 Massachusetts..................................... 0.472 ......... Michigan.......................................... 0.376 0.474 Minnesota......................................... 0.391 0.52 Mississippi....................................... 0.331 0.38 Missouri.......................................... 0.333 0.387 Montana........................................... 0.431 0.478 Nebraska.......................................... 0.361 0.475 Nevada............................................ 0.24 0.477 New Hampshire..................................... 0.463 0.463 New Jersey........................................ 0.18 ......... New Mexico........................................ 0.385 0.39 New York.......................................... 0.365 0.526 North Carolina.................................... 0.439 0.433 North Dakota...................................... 0.43 0.455 Ohio.............................................. 0.376 0.549 Oklahoma.......................................... 0.321 0.405 Oregon............................................ 0.474 0.475 Pennsylvania...................................... 0.282 0.444 Puerto Rico....................................... 0.461 ......... Rhode Island...................................... 0.409 ......... South Carolina.................................... 0.294 0.297 South Dakota...................................... 0.375 0.461 Tennessee......................................... 0.324 0.386 Texas............................................. 0.282 0.369 Utah.............................................. 0.423 0.589 Vermont........................................... 0.555 0.627 Virginia.......................................... 0.366 0.378 Washington........................................ 0.427 0.469 West Virginia..................................... 0.488 0.454 Wisconsin......................................... 0.442 0.481 Wyoming...........................................

0.4 0.561

Table 8B.--Statewide Average Capital Cost-to-Charge Ratios--March 2006

State

Ratio

Alabama...................................................... 0.026 Alaska....................................................... 0.042 Arizona...................................................... 0.026 Arkansas..................................................... 0.027 California................................................... 0.016 Colorado..................................................... 0.03 Connecticut.................................................. 0.03 Delaware..................................................... 0.042 District of Columbia......................................... 0.027 Florida...................................................... 0.024 Georgia...................................................... 0.032 Hawaii....................................................... 0.033 Idaho........................................................ 0.037 Illinois..................................................... 0.027 Indiana...................................................... 0.038 Iowa......................................................... 0.03 Kansas....................................................... 0.032 Kentucky..................................................... 0.031 Louisiana.................................................... 0.031 Maine........................................................ 0.035 Maryland..................................................... 0.013 Massachusetts................................................ 0.034 Michigan..................................................... 0.032 Minnesota.................................................... 0.029 Mississippi.................................................. 0.03 Missouri..................................................... 0.027 Montana...................................................... 0.039 Nebraska..................................................... 0.038 Nevada....................................................... 0.021 New Hampshire................................................ 0.037 New Jersey................................................... 0.013 New Mexico................................................... 0.034 New York..................................................... 0.03 North Carolina............................................... 0.037 North Dakota................................................. 0.04 Ohio......................................................... 0.031 Oklahoma..................................................... 0.031 Oregon....................................................... 0.032 Pennsylvania................................................. 0.023 Puerto Rico.................................................. 0.035 Rhode Island................................................. 0.023 South Carolina............................................... 0.027 South Dakota................................................. 0.037 Tennessee.................................................... 0.033 Texas........................................................ 0.028 Utah......................................................... 0.039 Vermont...................................................... 0.043 Virginia..................................................... 0.037 Washington................................................... 0.035 West Virginia................................................ 0.034 Wisconsin.................................................... 0.038 Wyoming...................................................... 0.047

[[Page 24377]]

Table 8C.--Statewide Average Total Cost-to-Charge Ratios for LTCHS-- March 2006

State

Urban Rural

Alabama........................................... 0.291 0.365 Alaska............................................ 0.458 0.788 Arizona........................................... 0.307 0.407 Arkansas.......................................... 0.368 0.390 California........................................ 0.254 0.368 Colorado.......................................... 0.350 0.531 Connecticut....................................... 0.454 0.538 Delaware.......................................... 0.567 0.558 District of Columbia*............................. 0.436 ......... Florida........................................... 0.276 0.343 Georgia........................................... 0.384 0.439 Hawaii............................................ 0.417 0.465 Idaho............................................. 0.516 0.573 Illinois.......................................... 0.351 0.457 Indiana........................................... 0.462 0.499 Iowa.............................................. 0.412 0.506 Kansas............................................ 0.326 0.495 Kentucky.......................................... 0.418 0.423 Louisiana......................................... 0.340 0.402 Maine............................................. 0.533 0.507 Maryland**........................................ 0.361 0.458 Massachusetts*.................................... 0.501 ......... Michigan.......................................... 0.410 0.510 Minnesota......................................... 0.419 0.550 Mississippi....................................... 0.360 0.407 Missouri.......................................... 0.357 0.430 Montana........................................... 0.467 0.522 Nebraska.......................................... 0.395 0.523 Nevada............................................ 0.259 0.550 New Hampshire..................................... 0.501 0.498 New Jersey*....................................... 0.194 ......... New Mexico........................................ 0.418 0.415 New York.......................................... 0.393 0.561 North Carolina.................................... 0.478 0.476 North Dakota...................................... 0.467 0.504 Ohio.............................................. 0.404 0.595 Oklahoma.......................................... 0.351 0.441 Oregon............................................ 0.507 0.513 Pennsylvania...................................... 0.299 0.479 Puerto Rico*...................................... 0.493 ......... Rhode Island*..................................... 0.432 ......... South Carolina.................................... 0.320 0.326 South Dakota...................................... 0.410 0.506 Tennessee......................................... 0.360 0.421 Texas............................................. 0.307 0.404 Utah.............................................. 0.460 0.649 Vermont........................................... 0.601 0.667 Virginia.......................................... 0.399 0.419 Washington........................................ 0.462 0.516 West Virginia..................................... 0.515 0.487 Wisconsin......................................... 0.483 0.519 Wyoming........................................... 0.440 0.614

* All counties in the State or Territory are classified as urban, with the exception of Massachusetts, which has areas designated as rural. However, no short-term acute care IPPS hospitals or LTCHs are located in those areas as of March 2005. ** National average IPPS total cost-to-charge ratios, as discussed in section II.F.5. of this proposed rule.

Table 9A.--Hospital Reclassifications and Redesignations by Individual Hospital and CBSA--FY2007

Reclassified Reclassified Provider No.

Geographic CBSA CBSA 10/1/2006- CBSA 4/1/2007-9/

LUGAR 3/31/2007

30/2007

010005...........................

01

13820

13820 010008...........................

01

33860

33860 010009...........................

19460

26620

26620 010012...........................

01

16860

16860 010022...........................

01

40660

40660 LUGAR 010025...........................

01

17980

17980 010029...........................

12220

17980

17980 010035...........................

01

13820

13820 010044...........................

01

13820

13820 010045...........................

01

13820

13820 010054...........................

19460

26620

26620 010059...........................

19460

26620

26620 010065...........................

01

33860

33860 010072...........................

01

11500

11500 LUGAR 010083...........................

01

37860

37860 010085...........................

19460

26620

26620 010100...........................

01

37860

37860 010101...........................

01

11500

11500 LUGAR 010118...........................

01

46220

46220 010126...........................

01

33860

33860 010143...........................

01

13820

13820 010150...........................

01

33860

33860 010158...........................

01

19460

19460 010164...........................

01

11500

11500 LUGAR 020008...........................

02

11260

11260 030007...........................

03

22380

22380 030033...........................

03

22380

22380 040014...........................

04

30780

30780 040017...........................

04

22220

22220 040019...........................

04

32820

32820 040020...........................

27860

32820

32820 040027...........................

04

44180

44180 040039...........................

04

26

26 040041...........................

04

30780

30780 040047...........................

04

26

26 040069...........................

04

32820

32820 040071...........................

38220

30780

30780 040076...........................

04

30780

30780 040080...........................

04

27860

27860 040088...........................

04

43340

43340 040091...........................

04

45500

45500

[[Page 24378]]

040100...........................

04

30780

30780 040119...........................

04

30780

30780 050006...........................

05

39820

39820 050009...........................

34900

46700

46700 050013...........................

34900

46700

46700 050014...........................

05

40900

40900 050022...........................

40140

42044

42044 050042...........................

05

39820

39820 050046...........................

37100 ................

31084 ....................... 050054...........................

40

42044

42044 ....................... 050065...........................

42044

31084

31084 050069...........................

42044

31084

31084 050071...........................

41940

36084

36084 050073...........................

46700

36084

36084 050076...........................

41884

36084

36084 050082...........................

37100 ................

31084 050089...........................

40

31084

31084 050090...........................

42220

41884

41884 050099...........................

40

31084

31084 050101...........................

46700

36084

36084 050102...........................

40

42044

42044 050118...........................

44700

33700

33700 050129...........................

40

31084

31084 050136...........................

42220

41884

41884 050140...........................

40

31084

31084 050150...........................

05

40900

40900 050159...........................

37100 ................

31084 050168...........................

42044

31084

31084 050173...........................

42044

31084

31084 050174...........................

42220

41884

41884 050193...........................

42044

31084

31084 050197...........................

41884

36084

36084 050224...........................

42044

31084

31084 050226...........................

42044

31084

31084 050228...........................

41884

36084

36084 050230...........................

42044

31084

31084 050236...........................

37100 ................

31084 050243...........................

40

42044

42044 050245...........................

40

31084

31084 050251...........................

05

39900

39900 050272...........................

40

31084

31084 050279...........................

40

31084

31084 050291...........................

42220

41884

41884 050292...........................

40

42044

42044 050298...........................

40

31084

31084 050300...........................

40

31084

31084 050327...........................

40

31084

31084 050329...........................

40

42044

42044 050348...........................

42044

31084

31084 050367...........................

46700

36084

36084 050385...........................

42220

41884

41884 050390...........................

40

42044

42044 050394...........................

37100 ................

31084 050423...........................

40

42044

42044 050426...........................

42044

31084

31084 050430...........................

05

39900

39900 050510...........................

41884

36084

36084 050517...........................

40

31084

31084 050526...........................

42044

31084

31084 050534...........................

40

42044

42044 050535...........................

42044

31084

31084 050541...........................

41884

36084

36084 050543...........................

42044

31084

31084 050547...........................

42220

41884

41884 050548...........................

42044

31084

31084 050549...........................

37100 ................

31084 050550...........................

42044

31084

31084 050551...........................

42044

31084

31084

[[Page 24379]]

050567...........................

42044

31084

31084 050569...........................

05

42220

42220 050570...........................

42044

31084

31084 050573...........................

40

42044

42044 050580...........................

42044

31084

31084 050584...........................

40

31084

31084 050585...........................

42044

31084

31084 050586...........................

40

31084

31084 050589...........................

42044

31084

31084 050592...........................

42044

31084

31084 050594...........................

42044

31084

31084 050603...........................

42044

31084

31084 050609...........................

42044

31084

31084 050616...........................

37100 ................

31084 050667...........................

34900

46700

46700 050678...........................

42044

31084

31084 050680...........................

46700

36084

36084 050684...........................

40

42044

42044 050686...........................

40

42044

42044 050690...........................

42220

41884

41884 050693...........................

42044

31084

31084 050694...........................

40

42044

42044 050701...........................

40

42044

42044 050709...........................

40

31084

31084 050718...........................

40

42044

42044 050720...........................

42044

31084

31084 050728...........................

42220

41884

41884 050749...........................

37100 ................

31084 060003...........................

14500

19740

19740 060023...........................

24300

19740

19740 060027...........................

14500

19740

19740 060044...........................

06

19740

19740 060049...........................

06

22660

22660 060075...........................

06

24300

24300 060096...........................

06

19740

19740 060103...........................

14500

19740

19740 070001...........................

35300 ................

35004 070003...........................

07

25540

25540 LUGAR 070005...........................

35300 ................

35004 070006...........................

14860 ................

35644 070010...........................

14860 ................

35644 070016...........................

35300 ................

35004 070017...........................

35300 ................

35004 070018...........................

14860 ................

35644 070019...........................

35300 ................

35004 070021...........................

07

25540

25540 LUGAR 070022...........................

35300 ................

35004 070028...........................

14860 ................

35644 070031...........................

35300 ................

35004 070033...........................

14860

35644

35644 070034...........................

14860 ................

35644 070036...........................

25540

35300

35300 070038...........................

35300 ................

35004 070039...........................

35300 ................

35004 080004...........................

20100

48864

48864 080004...........................

08

20100

20100 080006...........................

08

36140

36140 090001...........................

47894

13644

13644 100022...........................

33124

22744

22744 100023...........................

10

36740

36740 100024...........................

10

33124

33124 100045...........................

19660

36740

36740 100049...........................

10

29460

29460 100081...........................

10

23020

23020 LUGAR 100109...........................

10

36740

36740 100118...........................

10

27260

27260 100139...........................

10

23540

23540 LUGAR 100150...........................

10

33124

33124

[[Page 24380]]

100157...........................

29460

45300

45300 100176...........................

48424

38940

38940 100217...........................

42680

38940

38940 100232...........................

10

27260

27260 100239...........................

45300

42260

42260 100249...........................

10

45300

45300 100252...........................

10

38940

38940 100258...........................

48424

22744

22744 100292...........................

10

23020

23020 LUGAR 110001...........................

19140

12060

12060 110002...........................

11

12060

12060 110003...........................

11

27260

27260 110023...........................

11

12060

12060 110025...........................

15260

27260

27260 110029...........................

23580

12060

12060 110038...........................

11

46660

46660 110040...........................

11

12060

12060 LUGAR 110041...........................

11

12020

12020 110052...........................

11

16860

16860 LUGAR 110054...........................

40660

12060

12060 110069...........................

47580

31420

31420 110075...........................

11

42340

42340 110088...........................

11

12060

12060 LUGAR 110095...........................

11

46660

46660 110117...........................

11

12060

12060 LUGAR 110122...........................

46660

45220

45220 110125...........................

11

31420

31420 110128...........................

11

42340

42340 110150...........................

11

12060

12060 110153...........................

47580

31420

31420 110168...........................

40660

12060

12060 110187...........................

11

12060

12060 LUGAR 110189...........................

11

12060

12060 110205...........................

11

12060

12060 120028...........................

12

26180

26180 130002...........................

13

29

29 130003...........................

30300

28420

28420 130018...........................

13

38540

38540 130049...........................

17660

44060

44060 130067...........................

13

26820

26820 LUGAR 140012...........................

14

16974

16974 140015...........................

14

41180

41180 140032...........................

14

41180

41180 140033...........................

29404

16974

16974 140034...........................

14

41180

41180 140040...........................

14

37900

37900 140043...........................

14

40420

40420 140046...........................

14

41180

41180 140058...........................

14

41180

41180 140064...........................

14

37900

37900 140084...........................

29404

16974

16974 140093...........................

19180

16580

16580 140100...........................

29404

16974

16974 140110...........................

14

16974

16974 140130...........................

29404

16974

16974 140143...........................

14

37900

37900 140160...........................

14

40420

40420 140161...........................

14

16974

16974 140164...........................

14

41180

41180 140167...........................

14

28100

28100 LUGAR 140189...........................

14

16580

16580 140202...........................

29404

16974

16974 140233...........................

40420

16974

16974 140234...........................

14

37900

37900 140236...........................

14

28100

28100 LUGAR 140291...........................

29404

16974

16974 150002...........................

23844

16974

16974 150004...........................

23844

16974

16974

[[Page 24381]]

150006...........................

33140

43780

43780 150008...........................

23844

16974

16974 150011...........................

15

26900

26900 150015...........................

33140

16974

16974 150030...........................

15

26900

26900 LUGAR 150034...........................

23844

16974

16974 150048...........................

15

17140

17140 150051...........................

14

020

26900 26900 150065...........................

15

26900

26900 150069...........................

15

17140

17140 150076...........................

15

43780

43780 150088...........................

11300

26900

26900 150090...........................

23844

16974

16974 150102...........................

15

23844

23844 LUGAR 150112...........................

18020

26900

26900 150113...........................

11300

26900

26900 150122...........................

15

26900

26900 150125...........................

23844

16974

16974 150126...........................

23844

16974

16974 150133...........................

15

23060

23060 150146...........................

15

23060

23060 150147...........................

23844

16974

16974 160001...........................

16

19780

19780 160016...........................

16

19780

19780 160057...........................

16

26980

26980 160064...........................

16

24

24 160080...........................

16

19340

19340 160089...........................

16

19780

19780 160147...........................

16

19780

19780 170006...........................

17

27900

27900 170010...........................

17

46140

46140 170012...........................

17

48620

48620 170013...........................

17

48620

48620 170020...........................

17

48620

48620 170023...........................

17

48620

48620 170033...........................

17

48620

48620 170058...........................

17

28140

28140 170068...........................

17

11100

11100 170120...........................

17

27900

27900 170142...........................

17

45820

45820 170175...........................

17

48620

48620 170190...........................

17

45820

45820 170193...........................

17

48620

48620 180005...........................

18

26580

26580 180011...........................

18

30460

30460 180012...........................

21060

31140

31140 180013...........................

14540

34980

34980 180017...........................

18

21060

21060 180018...........................

18

30460

30460 180019...........................

18

17140

17140 180024...........................

18

31140

31140 180027...........................

18

17300

17300 180028...........................

18

26580

26580 180029...........................

18

28700

28700 180044...........................

18

26580

26580 180048...........................

18

31140

31140 180066...........................

18

34980

34980 180069...........................

18

26580

26580 180075...........................

18

14540

14540 LUGAR 180078...........................

18

26580

26580 180080...........................

18

28940

28940 180093...........................

18

21780

21780 180102...........................

18

17300

17300 180104...........................

18

17300

17300 180116...........................

18

14

14 180124...........................

14540

34980

34980 180127...........................

18

31140

31140 180132...........................

18

30460

30460

[[Page 24382]]

180139...........................

18

30460

30460 190001...........................

19

35380

35380 190003...........................

19

29180

29180 190015...........................

19

35380

35380 190086...........................

19

33740

33740 190099...........................

19

12940

12940 190106...........................

19

10780

10780 190131...........................

12940

35380

35380 190155...........................

19

12940

12940 LUGAR 190164...........................

19

10780

10780 190191...........................

19

12940

12940 190208...........................

19

04

04 190218...........................

19

43340

43340 190223...........................

19

12940

12940 LUGAR 200020...........................

38860

40484

40484 200024...........................

30340

38860

38860 200034...........................

30340

38860

38860 200039...........................

20

38860

38860 200050...........................

20

12620

12620 200063...........................

20

38860

38860 220001...........................

49340

14484

14484 220002...........................

15764

14484

14484 220010...........................

21604

14484

14484 220011...........................

15764

14484

14484 220019...........................

49340

14484

14484 220025...........................

49340

14484

14484 220028...........................

49340

14484

14484 220029...........................

21604

14484

14484 220033...........................

21604

14484

14484 220035...........................

21604

14484

14484 220049...........................

15764

14484

14484 220058...........................

49340

14484

14484 220060...........................

14484

12700

12700 220062...........................

49340

14484

14484 220063...........................

15764

14484

14484 220070...........................

15764

14484

14484 220077...........................

44140

25540

25540 220080...........................

21604

14484

14484 220082...........................

15764

14484

14484 220084...........................

15764

14484

14484 220090...........................

49340

14484

14484 220095...........................

49340

14484

14484 220098...........................

15764

14484

14484 220101...........................

15764

14484

14484 220105...........................

15764

14484

14484 220133...........................

15764

14484

14484 220163...........................

49340

14484

14484 220171...........................

15764

14484

14484 220174...........................

21604

14484

14484 230002...........................

19804 ................

11460 230003...........................

26100 ................

34740 230013...........................

47644 ................

19804 230019...........................

47644 ................

19804 230020...........................

19804 ................

11460 230022...........................

23

29620

29620 230024...........................

19804 ................

11460 230029...........................

47644 ................

19804 230030...........................

23

40980

40980 230035...........................

23

24340

24340 LUGAR 230036...........................

23

13020

13020 230037...........................

23

11460

11460 230047...........................

47644

19804

19804 230053...........................

19804 ................

11460 230054...........................

23

24580

24580 230065........................... ................

19804

11460 230069...........................

47644

11460

11460 230071...........................

47644 ................

19804 230072...........................

26100 ................

34740

[[Page 24383]]

230077...........................

40980

22420

22420 230080...........................

23

40980

40980 230089...........................

19804 ................

11460 230092...........................

27100

29620

29620 230093...........................

23

24340

24340 230096...........................

23

28020

28020 230097...........................

23

24340

24340 230099...........................

33780

11460

11460 230104...........................

19804 ................

11460 230105...........................

23

13020

13020 230119...........................

19804 ................

11460 230121...........................

23

29620

29620 LUGAR 230130...........................

47644 ................

19804 230134...........................

23

26100

26100 LUGAR 230135...........................

19804 ................

11460 230142...........................

19804 ................

11460 230146...........................

19804 ................

11460 230151...........................

47644 ................

19804 230165........................... ................

19804

11460 230174...........................

26100 ................

34740 230176...........................

19804 ................

11460 230195...........................

47644

19804

19804 230204...........................

47644

19804

19804 230207...........................

47644 ................

19804 230208...........................

23

24340

24340 LUGAR 230217...........................

12980

29620

29620 230223...........................

47644 ................

19804 230227...........................

47644

19804

19804 230244...........................

19804

11460

11460 230254...........................

47644 ................

19804 230257...........................

47644

19804

19804 230264...........................

47644

19804

19804 230269...........................

47644 ................

19804 230270...........................

19804 ................

11460 230273...........................

19804 ................

11460 230277...........................

47644 ................

19804 230279...........................

47644

11460

11460 230293...........................

19804 ................

11460 230295...........................

23

26100

26100 LUGAR 240018...........................

24

33460

33460 240030...........................

24

41060

41060 240036...........................

41060

33460

33460 240064...........................

24

20260

20260 240069...........................

24

40340

40340 240071...........................

24

40340

40340 240075...........................

24

410060

410060 240088...........................

24

410060

410060 240093...........................

24

33460

33460 241050...........................

24

40340

40340 LUGAR 240150...........................

24

40340

40340 LUGAR 240187...........................

24

33460

33460 240211...........................

24

33460

33460 250002...........................

25

22520

22520 250004...........................

25

32820

32820 250006...........................

25

32820

32820 250009...........................

25

27180

27180 250023...........................

25

250060

250060 LUGAR 250031...........................

25

27140

27140 250034...........................

25

32820

32820 250040...........................

37700

250060

250060 250042...........................

25

32820

32820 250044...........................

25

22520

22520 250069...........................

25

46220

46220 250079...........................

25

27140

27140 250081...........................

25

46220

46220 250082...........................

25

38220

38220 250094...........................

25620

250060

250060 250097...........................

25

12940

12940

[[Page 24384]]

250099...........................

25

27140

27140 250100...........................

25

46220

46220 250104...........................

25

27140

27140 250117...........................

25

250060

250060 LUGAR 260009...........................

26

28140

28140 260011...........................

27620

17860

17860 260015...........................

26

27860

27860 260017...........................

26

41180

41180 260022...........................

26

16

16 260025...........................

26

41180

41180 260049...........................

26

44180

44180 LUGAR 260050...........................

26

41140

41140 260064...........................

26

17860

17860 260074...........................

26

17860

17860 260094...........................

26

44180

44180 260110...........................

26

41180

41180 260113...........................

26

14

14 260116...........................

26

14

14 260119...........................

26

27860

27860 260175...........................

26

28140

28140 260183...........................

26

41180

41180 260186...........................

26

17860

17860 270003...........................

27

24500

24500 270011...........................

27

24500

24500 270017...........................

27

33540

33540 270051...........................

27

33540

33540 280009...........................

28

300700

300700 280023...........................

28

300700

300700 280032...........................

28

300700

300700 280061...........................

28

53

53 280065...........................

28

24540

24540 280077...........................

28

36540

36540 280125...........................

28

43580

43580 290002...........................

29

16180

16180 LUGAR 290006...........................

29

39900

39900 290008...........................

29

41620

41620 290019...........................

16180

39900

39900 300005...........................

30

31700

31700 300011...........................

31700

15764

15764 300012...........................

31700

15764

15764 300014...........................

40484

31700

31700 300017...........................

40484

21604

21604 300018...........................

40484

31700

31700 300019...........................

30

49340

49340 300020...........................

31700

15764

15764 300023...........................

40484

21604

21604 300029...........................

40484

21604

21604 300034...........................

31700

15764

15764 310002...........................

35084

35644

35644 310009...........................

35084

35644

35644 310013...........................

35084

35644

35644 310014...........................

15804

37964

37964 310015...........................

35084

35644

35644 310017...........................

35084

35644

35644 310018...........................

35084

35644

35644 310021...........................

45940

35084

35084 310031...........................

15804

20764

20764 310038...........................

20764

35644

35644 310039...........................

20764

35644

35644 310048...........................

20764

35084

35084 310050...........................

35084

35644

35644 310054...........................

35084

35644

35644 310070...........................

20764

35644

35644 310076...........................

35084

35644

35644 310078...........................

35084

35644

35644 310081...........................

15804

37964

37964 310083...........................

35084

35644

35644 310093...........................

35084

35644

35644

[[Page 24385]]

310096...........................

35084

35644

35644 310108...........................

20764

35644

35644 310119...........................

35084

35644

35644 320005...........................

22140

10740

10740 320006...........................

32

42140

42140 320013...........................

32

42140

42140 320014...........................

32

29740

29740 320033...........................

32

42140

42140 LUGAR 320063...........................

32

36220

36220 320065...........................

32

36220

36220 330004...........................

28740

39100

39100 330008...........................

33

15380

15380 LUGAR 330027...........................

35004

35644

35644 330038...........................

33

40380

40380 LUGAR 330073...........................

33

40380

40380 LUGAR 330079...........................

33

47

47 330085...........................

33

450060

450060 330094...........................

33

28740

28740 330103...........................

33

39

39 330106...........................

35004 ................

35644 330136...........................

33

450060

450060 330157...........................

33

450060

450060 330167...........................

35004 ................

35644 330181...........................

35004 ................

35644 330182...........................

35004

35644

35644 330191...........................

24020

10580

10580 330198...........................

35004 ................

35644 330224...........................

28740

39100

39100 330225...........................

35004 ................

35644 330229...........................

27460

21500

21500 330235...........................

33

450060

450060 LUGAR 330239...........................

27460

21500

21500 330250...........................

33

15540

15540 330259...........................

35004 ................

35644 330277...........................

33

270060

270060 330331...........................

35004 ................

35644 330332...........................

35004 ................

35644 330359...........................

33

39100

39100 LUGAR 330372...........................

35004 ................

35644 330386...........................

33

39100

39100 340004...........................

24660

49180

49180 340008...........................

34

16740

16740 340010...........................

24140

39580

39580 340013...........................

34

24860

24860 340014...........................

49180

24660

24660 340021...........................

34

16740

16740 340023...........................

11700

24860

24860 340027...........................

34

24780

24780 340039...........................

34

16740

16740 340047...........................

49180

24660

24660 340050...........................

34

22180

22180 340051...........................

34

25860

25860 340068...........................

34

48900

48900 340069...........................

39580

200500

200500 340070...........................

15500

24660

24660 340071...........................

34

39580

39580 LUGAR 340073...........................

39580

200500

200500 340091...........................

24660

49180

49180 340109...........................

34

47260

47260 340114...........................

39580

200500

200500 340115...........................

34

200500

200500 340124...........................

34

39580

39580 LUGAR 340126...........................

34

39580

39580 340127...........................

34

200500

200500 340129...........................

34

16740

16740 340131...........................

34

24780

24780 340136...........................

34

200500

200500 LUGAR 340138...........................

39580

200500

200500

[[Page 24386]]

340144...........................

34

16740

16740 401345...........................

34

16740

16740 LUGAR 340147...........................

40580

39580

39580 340148...........................

49180

24660

24660 340173...........................

39580

200500

200500 350003...........................

35

13900

13900 350006...........................

35

13900

13900 350009...........................

35

22020

22020 360008...........................

36

26580

26580 360010...........................

36

10420

10420 360011...........................

36

18140

18140 360013...........................

36

30620

30620 360014...........................

36

18140

18140 360019...........................

10420

17460

17460 360020...........................

10420

17460

17460 360025...........................

41780

17460

17460 360027...........................

10420

17460

17460 360036...........................

36

17460

17460 360039...........................

36

18140

18140 360054...........................

36

26580

26580 360065...........................

36

17460

17460 360078...........................

10420

17460

17460 360079...........................

19380

17140

17140 360084...........................

15940

10420

10420 360086...........................

44220

19380

19380 360095...........................

36

45780

45780 360096...........................

36

49660

49660 LUGAR 360107...........................

36

45780

45780 360121...........................

36

11460

11460 360125...........................

36

17460

17460 LUGAR 360150...........................

10420

17460

17460 360159...........................

36

18140

18140 360175...........................

36

18140

18140 360185...........................

36

49660

49660 LUGAR 360187...........................

44220

19380

19380 360197...........................

36

18140

18140 360211...........................

48260

38300

38300 360238...........................

36

49660

49660 LUGAR 360241...........................

10420

17460

17460 360245...........................

36

17460

17460 LUGAR 360253...........................

19380

17140

17140 370004...........................

37

27900

27900 370006...........................

37

17

17 370014...........................

37

43300

43300 370015...........................

37

46140

46140 370016...........................

37

36420

36420 370018...........................

37

46140

46140 370022...........................

37

30020

30020 370025...........................

37

46140

46140 370026...........................

37

36420

36420 370034...........................

37

22900

22900 370047...........................

37

43300

43300 370049...........................

37

36420

36420 370099...........................

37

46140

46140 370103...........................

37

45

45 370113...........................

37

22220

22220 380001...........................

38

38900

38900 380022...........................

38

18700

18700 LUGAR 380027...........................

38

21660

21660 380050...........................

38

32780

32780 380090...........................

38

21660

21660 390006...........................

39

25420

25420 390013...........................

39

25420

25420 390030...........................

39

10900

10900 390031...........................

39

39740

39740 LUGAR 390046...........................

49620

29540

29540 390048...........................

39

25420

25420 390065...........................

39

47894

47894

[[Page 24387]]

390066...........................

30140

25420

25420 390071...........................

39

48700

48700 LUGAR 390079...........................

39

13780

13780 390081...........................

37964

48864

48864 390086...........................

39

44300

44300 390091...........................

39

38300

38300 390110...........................

27780

38300

38300 390113...........................

39

36

36 390133...........................

10900

37964

37964 390151...........................

39

13644

13644 390156...........................

37964

48864

48864 390180...........................

37964

48864

48864 390222...........................

37964

48864

48864 390246...........................

39

48700

48700 400048...........................

25020

41980

41980 410010...........................

39300

14484

14484 410012...........................

39300

14484

14484 410013...........................

39300

35980

35980 420007...........................

43900

24860

24860 420009...........................

42

24860

24860 LUGAR 420020...........................

42

16700

16700 420027...........................

11340

24860

24860 420028...........................

42

44940

44940 LUGAR 420030...........................

42

16700

16700 420036...........................

42

16740

16740 420039...........................

42

43900

43900 LUGAR 420067...........................

42

42340

42340 420068...........................

42

12260

12260 420069...........................

42

44940

44940 LUGAR 420070...........................

44940

17900

17900 420071...........................

42

24860

24860 420080...........................

42

42340

42340 420083...........................

43900

24860

24860 420085...........................

34820

48900

48900 430012...........................

43

43620

43620 430014...........................

43

22020

22020 430094...........................

43

53

53 440002...........................

27180

32820

32820 440008...........................

44

27180

27180 440020...........................

44

26620

26620 440024...........................

17420

16860

16860 440025...........................

44

34

34 440035...........................

17300

34980

34980 440050...........................

44

11700

11700 440058...........................

44

16860

16860 440059...........................

44

34980

34980 440060...........................

44

27180

27180 440067...........................

34100

28940

28940 440068...........................

44

16860

16860 440072...........................

44

32820

32820 440073...........................

44

34980

34980 440148...........................

44

34980

34980 440151...........................

44

34980

34980 440175...........................

44

34980

34980 440180...........................

44

28940

28940 440185...........................

17420

16860

16860 440192...........................

44

34980

34980 450007...........................

45

41700

41700 450032...........................

45

43340

43340 450039...........................

23104

19124

19124 450059...........................

41700

12420

12420 450064...........................

23104

19124

19124 450073...........................

45

10180

10180 450080...........................

45

30980

30980 450087...........................

23104

19124

19124 450099...........................

45

11100

11100 450121...........................

23104

19124

19124 450135...........................

23104

19124

19124

[[Page 24388]]

450137...........................

23104

19124

19124 450144...........................

45

36220

36220 450148...........................

23104

19124

19124 450187...........................

45

26420

26420 450192...........................

45

19124

19124 450194...........................

45

19124

19124 450196...........................

45

19124

19124 450211...........................

45

26420

26420 450214...........................

45

26420

26420 450224...........................

45

46340

46340 450283...........................

45

19124

19124 LUGAR 450286...........................

45

17780

17780 LUGAR 450347...........................

45

26420

26420 450351...........................

45

23104

23104 450389...........................

45

19124

19124 LUGAR 450395...........................

45

26420

26420 450400...........................

45

47380

47380 450419...........................

23104

19124

19124 450438...........................

45

26420

26420 450447...........................

45

19124

19124 450451...........................

45

23104

23104 450484...........................

45

30980

30980 450508...........................

45

46340

46340 450547...........................

45

19124

19124 450563...........................

23104

19124

19124 450639...........................

23104

19124

19124 450653...........................

45

33260

33260 450656...........................

45

46340

46340 450672...........................

23104

19124

19124 450675...........................

23104

19124

19124 450677...........................

23104

19124

19124 450694...........................

45

26420

26420 450747...........................

45

19124

19124 450755...........................

45

31180

31180 450770...........................

45

12420

12420 LUGAR 450779...........................

23104

19124

19124 450813...........................

45

41700

41700 450830...........................

45

36220

36220 450839...........................

45

43340

43340 450858...........................

23104

19124

19124 450872...........................

23104

19124

19124 450880...........................

23104

19124

19124 460004...........................

36260

41620

41620 460005...........................

36260

41620

41620 460007...........................

46

41100

41100 460011...........................

46

39340

39340 460021...........................

41100

29820

29820 460039...........................

46

36260

36260 460041...........................

36260

41620

41620 460042...........................

36260

41620

41620 470001...........................

47

30

30 470011...........................

47

15764

15764 470012...........................

47

38340

38340 490004...........................

25500

16820

16820 490005...........................

49020

47894

47894 490013...........................

49

31340

31340 490018...........................

49

16820

16820 490042...........................

13980

40220

40220 490048...........................

40220

31340

31340 490079...........................

49

24660

24660 490092...........................

49

400060

400060 490105...........................

49

28700

28700 490106...........................

49

16820

16820 490109...........................

47260

400060

400060 500002...........................

50

28420

28420 500003...........................

34580

42644

42644 500016...........................

48300

42644

42644 500021...........................

45104

42644

42644

[[Page 24389]]

500024...........................

36500

45104

45104 500039...........................

14740

42644

42644 500041...........................

31020

38900

38900 500072...........................

50

42644

42644 500079...........................

45104

42644

42644 500108...........................

45104

42644

42644 500129...........................

45104

42644

42644 500139...........................

36500

45104

45104 510001...........................

340060

38300

38300 510002...........................

51

40220

40220 510006...........................

51

38300

38300 510018...........................

51

16620

16620 LUGAR 510024...........................

340060

38300

38300 510030...........................

51

340060

340060 510046...........................

51

16620

16620 510047...........................

51

38300

38300 510062...........................

51

16620

16620 510070...........................

51

16620

16620 510071...........................

51

16620

16620 510077...........................

51

26580

26580 520002...........................

52

48140

48140 520021...........................

29404

16974

16974 520028...........................

52

31540

31540 520037...........................

52

48140

48140 520059...........................

39540

29404

29404 520060...........................

52

22540

22540 LUGAR 520066...........................

27500

31540

31540 520071...........................

52

33340

33340 LUGAR 520076...........................

52

31540

31540 520088...........................

22540

33340

33340 520094...........................

39540

33340

33340 520095...........................

52

31540

31540 520096...........................

39540

33340

33340 520102...........................

52

33340

33340 LUGAR 520107...........................

52

24580

24580 520113...........................

52

24580

24580 520116...........................

52

33340

33340 LUGAR 520173...........................

52

20260

20260 520189...........................

29404

16974

16974 530015...........................

53

26820

26820 530025...........................

53

22660

22660

Table 9B.--Hospital Reclassifications and Redesignations by Individual Hospital Under Section 508 of Public Law 108-173--FY 2007

Wage index CBSA-- Wage index CBSA-- Provider number

Note Geographic CBSA 10/1/06-3/31/ 4/1/2007-9/30/ Own Wage index-- 07

2007*

10/1/06-3/31/07

050494......................... .......

05

42220 ................ ................ 050549......................... .......

37100

42220 ................ ................ 070001......................... .......

35300

35004 ................ ................ 070005......................... .......

35300

35004 ................ ................ 070006.........................

*

14860

35644 ................ ................ 070010......................... .......

14860

35644 ................ ................ 070016......................... .......

35300

35004 ................ ................ 070017......................... .......

35300

35004 ................ ................ 070018.........................

*

14860

35644 ................ ................ 070019......................... .......

35300

35004 ................ ................ 070022......................... .......

35300

35004 ................ ................ 070028......................... .......

14860

35644 ................ ................ 070031......................... .......

35300

35004 ................ ................ 070034.........................

*

14860

35644 ................ ................ 070039......................... .......

35300

35004 ................ ................ 160040......................... .......

47940

16300 ................ ................ 160067......................... .......

47940

16300 ................ ................

[[Page 24390]]

160110......................... .......

47940

16300 ................ ................ 220046......................... .......

38340

14484 ................ ................ 230003......................... .......

26100

28020 ................ ................ 230004......................... .......

34740

28020 ................ ................ 230013......................... .......

47644

22420 ................ ................ 230019......................... .......

47644

22420 ................ ................ 230020......................... .......

19804

11460 ................ ................ 230024......................... .......

19804

11460 ................ ................ 230029......................... .......

47644

22420 ................ ................ 230038......................... .......

24340

28020 ................ ................ 230053......................... .......

19804

11460 ................ ................ 230059......................... .......

24340

28020 ................ ................ 230066......................... .......

34740

28020 ................ ................ 230071......................... .......

47644

22420 ................ ................ 230072......................... .......

26100

28020 ................ ................ 230089......................... .......

19804

11460 ................ ................ 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 ................ ................ 250078.........................

*

25620

25060

25060 ................ 250122......................... .......

25

25060 ................ ................ 270002.........................

*

27

33540

33540 ................ 270012.........................

*

24500

33540

33540 ................ 270023......................... .......

33540

13740 ................ ................ 270032......................... .......

27

13740 ................ ................ 270057......................... .......

27

13740 ................ ................ 310028......................... .......

35084

35644 ................ ................ 310051......................... .......

35084

35644 ................ ................ 310060......................... .......

10900

35644 ................ ................ 310115......................... .......

10900

35644 ................ ................ 310120......................... .......

35084

35644 ................ ................ 330023.........................

*

39100

35644

35644 ................ 330049......................... .......

39100

35644 ................ ................ 330067.........................

*

39100

35644

35644 ................ 330106......................... .......

35004 ................ ................

1.4485 330126......................... .......

39100

35644 ................ ................ 330135......................... .......

39100

35644 ................ ................ 330205......................... .......

39100

35644 ................ ................ 330209......................... .......

39100

35004 ................ ................ 330264......................... .......

39100

35004 ................ ................ 340002......................... .......

11700

16740 ................ ................ 350002......................... .......

13900

22020 ................ ................ 350010......................... .......

35

22020 ................ ................ 350014......................... .......

35

22020 ................ ................ 350015......................... .......

13900

22020 ................ ................ 350017......................... .......

35

22020 ................ ................ 350019.........................

*

24220

22020

22020 ................ 350030......................... .......

35

22020 ................ ................ 390001......................... .......

42540

10900 ................ ................ 390003......................... .......

39

10900 ................ ................ 390054......................... .......

42540

29540 ................ ................ 390072......................... .......

39

10900 ................ ................ 390095......................... .......

42540

10900 ................ ................

[[Page 24391]]

390119......................... .......

42540

10900 ................ ................ 390137......................... .......

42540

10900 ................ ................ 390169......................... .......

42540

10900 ................ ................ 390185......................... .......

42540

29540 ................ ................ 390192......................... .......

42540

10900 ................ ................ 390237......................... .......

42540

10900 ................ ................ 390270......................... .......

42540

29540 ................ ................ 430005......................... .......

43

39660 ................ ................ 430008.........................

*

43

43620

43620 ................ 430013.........................

*

43

43620

43620 ................ 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 ................ ................ 530008.........................

*

53

16220

16220 ................ 530010.........................

*

53

16220

16220 ................

* These hospitals are assigned a wage index value under a special exceptions policy (see the FY 2005 IPPS final rule, 69 FR 49105).

Table 9C.--Hospitals Redesignated as Rural Under Section 1886(d)(8)(E) of the Act--FY 2007

Geographic Redesignated Provider number

CBSA

rural area

050192..................................

23420

05 050469..................................

40140

05 050528..................................

32900

05 050618..................................

40140

05 070004..................................

25540

07 100048..................................

37860

10 100134..................................

27260

10 170137..................................

29940

17 190048..................................

26380

19 230078..................................

35660

23 260006..................................

41140

26 260047..................................

27620

26 260195..................................

44180

26 330268..................................

10580

33 370054..................................

36420

37 380040..................................

13460

38 390052..................................

39

39 390084..................................

39

39 390093..................................

39

39 390118..................................

39

39 390125..................................

39

39 390138..................................

39

39 390146..................................

39

39 390150..................................

39

39 390181..................................

39

39 390183..................................

39

39 390189..................................

39

39 390199..................................

39

39 390201..................................

39

39 440135..................................

34980

44 450052..................................

45

45 450078..................................

10180

45 450243..................................

10180

45 450348..................................

45

45 500060..................................

42644

50 500148..................................

48300

50

[[Page 24392]]

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 2006 \1\

Number of DRG

cases Threshold

1............................................. 24,328 $53,938 2............................................. 10,275 $37,402 3.............................................

2 $70,158 6.............................................

291 $16,552 7............................................. 14,912 $41,716 8.............................................

3,415 $31,108 9.............................................

1,761 $25,283 10............................................ 19,574 $25,017 11............................................

3,075 $18,962 12............................................ 56,224 $18,919 13............................................

7,495 $17,715 14............................................ 278,100 $24,927 15............................................ 20,038 $20,826 16............................................ 17,333 $26,314 17............................................

2,966 $15,701 18............................................ 33,356 $21,320 19............................................

8,416 $15,732 20............................................

6,407 $40,783 21............................................

2,205 $26,935 22............................................

3,151 $23,912 23............................................ 10,668 $16,962 24............................................ 63,265 $21,159 25............................................ 27,269 $13,798 26............................................

24 $20,300 27............................................

5,923 $25,046 28............................................ 19,837 $25,435 29............................................

6,498 $15,810 31............................................

4,967 $21,053 32............................................

1,856 $14,058 34............................................ 27,462 $21,201 35............................................

7,825 $14,408 36............................................

1,203 $15,522 37............................................

1,233 $24,385 38............................................

48 $11,080 39............................................

362 $14,021 40............................................

1,251 $21,938 42............................................

941 $17,594 43............................................

123 $12,806 44............................................

1,310 $14,842 45............................................

2,765 $16,531 46............................................

3,942 $16,755 47............................................

1,322 $12,080 49............................................

2,414 $31,141 50............................................

2,023 $19,180 51............................................

192 $19,172 52............................................

316 $16,103 53............................................

2,137 $26,620 55............................................

1,366 $20,219 56............................................

450 $19,353 57............................................

881 $20,358 59............................................

127 $15,100 60............................................

3 $18,913 61............................................

222 $28,884 62............................................

4 $7,210 63............................................

2,826 $26,658 64............................................

3,252 $23,164 65............................................ 40,693 $13,497 66............................................

8,208 $12,916 67............................................

379 $17,295 68............................................ 19,063 $14,128 69............................................

5,200 $10,627 70............................................

23 $7,427 71............................................

71 $15,648 72............................................

1,341 $16,527 73............................................

9,963 $18,049 74............................................

3 $8,105 75............................................ 46,661 $48,108 76............................................ 47,934 $43,517 77............................................

2,086 $25,753 78............................................ 49,495 $26,329 79............................................ 160,350 $29,300 80............................................

7,187 $18,853 81............................................

6 $25,887 82............................................ 63,071 $26,543 83............................................

7,053 $21,671 84............................................

1,379 $12,820 85............................................ 22,188 $25,115 86............................................

1,726 $15,503 87............................................ 96,594 $26,870 88............................................ 427,896 $19,083 89............................................ 555,084 $22,017 90............................................ 43,729 $13,109 91............................................

53 $11,679 92............................................ 16,529 $24,748 93............................................

1,446 $16,248 94............................................ 13,561 $23,676 95............................................

1,568 $12,581 96............................................ 60,141 $15,900 97............................................ 26,997 $11,754 98............................................

13 $12,587 99............................................ 21,440 $15,705 100...........................................

6,425 $12,166 101........................................... 23,372 $18,530 102...........................................

4,916 $12,328 103...........................................

859 $234,201 104........................................... 20,077 $124,179 105........................................... 32,514 $93,739 106...........................................

3,427 $111,298 108...........................................

8,740 $89,367 110........................................... 57,543 $59,240 111........................................... 10,744 $45,073 113........................................... 34,572 $45,534 114...........................................

7,940 $30,209 117...........................................

5,331 $25,603 118...........................................

7,618 $33,248 119...........................................

965 $25,877 120........................................... 33,337 $36,476 121........................................... 150,081 $29,689 122........................................... 54,533 $21,009 123........................................... 29,519 $25,707 124........................................... 120,197 $29,665 125........................................... 92,007 $23,825 126...........................................

5,415 $40,840 127........................................... 667,830 $21,961 128...........................................

4,228 $15,640 129...........................................

3,504 $21,695 130........................................... 87,619 $20,101 131........................................... 22,939 $12,055 132........................................... 101,445 $13,662 133...........................................

5,877 $12,148 134........................................... 40,280 $13,518 135...........................................

7,169 $19,603 136...........................................

936 $14,048 138........................................... 206,144 $17,801 139........................................... 74,055 $11,519 140........................................... 31,532 $11,134 141........................................... 123,443 $16,543 142........................................... 49,350 $13,194 143........................................... 238,325 $12,583 144........................................... 104,907 $24,478 145...........................................

5,727 $12,846 146........................................... 10,217 $45,078 147...........................................

2,607 $31,265 148........................................... 132,645 $51,883 149........................................... 19,460 $30,248 150........................................... 22,886 $45,015 151...........................................

5,365 $27,699 152...........................................

4,995 $33,362 153...........................................

1,946 $23,355 154........................................... 26,968 $56,652 155...........................................

5,992 $27,799 156...........................................

4 $43,037 157...........................................

8,291 $25,914 158...........................................

3,707 $14,374 159........................................... 19,172 $28,300 160........................................... 11,919 $18,834 161........................................... 10,136 $25,538 162...........................................

4,950 $15,241 163...........................................

4 $14,007 164...........................................

5,971 $38,851 165...........................................

2,443 $25,609 166...........................................

5,126 $29,243 167...........................................

4,864 $19,695 168...........................................

1,532 $25,261 169...........................................

770 $16,756 170........................................... 17,890 $44,542 171...........................................

1,404 $26,663 172........................................... 33,122 $26,316 173...........................................

2,229 $16,793 174........................................... 260,944 $22,036 175........................................... 29,891 $12,609 176........................................... 14,595 $23,998 177...........................................

7,656 $20,625 178...........................................

2,548 $15,447 179........................................... 14,654 $23,043 180........................................... 91,305 $20,909 181........................................... 25,234 $12,552 182........................................... 297,038 $18,449 183........................................... 81,833 $13,162 184...........................................

76 $14,814 185...........................................

6,240 $18,863 186...........................................

7 $5,726 187...........................................

644 $18,582 188........................................... 93,551 $22,996 189........................................... 13,148 $13,298 190...........................................

63 $16,464 191........................................... 10,546 $54,836 192...........................................

1,376 $32,518 193...........................................

4,038 $51,797 194...........................................

461 $32,202

[[Page 24393]]

195...........................................

2,835 $50,330 196...........................................

594 $32,533 197........................................... 16,347 $42,001 198...........................................

4,105 $26,117 199...........................................

1,477 $37,170 200...........................................

1,014 $39,833 201...........................................

2,707 $52,939 202........................................... 27,497 $25,079 203........................................... 32,322 $26,139 204........................................... 69,183 $22,933 205........................................... 32,722 $23,282 206...........................................

2,041 $16,152 207........................................... 38,324 $24,655 208...........................................

9,535 $15,457 210........................................... 126,270 $36,343 211........................................... 25,668 $26,696 212...........................................

10 $18,770 213...........................................

9,455 $33,757 216........................................... 19,927 $35,368 217........................................... 15,590 $41,834 218........................................... 29,952 $32,692 219........................................... 21,035 $23,451 220...........................................

2 $24,004 223........................................... 12,641 $25,348 224...........................................

9,914 $18,586 225...........................................

6,246 $26,078 226...........................................

6,735 $29,288 227...........................................

4,867 $18,609 228...........................................

2,680 $24,599 229...........................................

1,123 $15,669 230...........................................

2,458 $26,420 232...........................................

566 $20,841 233........................................... 18,408 $34,741 234...........................................

9,070 $27,627 235...........................................

4,753 $16,296 236........................................... 41,708 $15,403 237...........................................

1,917 $13,860 238...........................................

9,766 $26,257 239........................................... 40,264 $23,062 240........................................... 12,897 $24,260 241...........................................

2,829 $14,155 242...........................................

2,726 $22,458 243........................................... 100,715 $17,004 244........................................... 17,015 $15,399 245...........................................

5,904 $10,392 246...........................................

1,407 $13,311 247........................................... 21,424 $12,727 248........................................... 16,489 $18,894 249........................................... 13,442 $15,428 250...........................................

4,144 $15,072 251...........................................

2,068 $10,611 253........................................... 24,748 $16,493 254...........................................

9,990 $10,194 256...........................................

7,606 $18,047 257........................................... 13,084 $19,605 258........................................... 11,372 $15,439 259...........................................

2,657 $21,683 260...........................................

2,421 $15,090 261...........................................

1,568 $20,742 262...........................................

599 $20,894 263........................................... 22,459 $32,488 264...........................................

3,905 $22,421 265...........................................

4,011 $28,291 266...........................................

2,221 $19,694 267...........................................

273 $20,005 268...........................................

994 $25,612 269........................................... 11,014 $30,475 270...........................................

2,567 $17,712 271........................................... 21,702 $21,485 272...........................................

6,074 $20,835 273...........................................

1,267 $12,661 274...........................................

2,242 $22,532 275...........................................

180 $12,564 276...........................................

1,623 $15,496 277........................................... 119,279 $18,413 278........................................... 33,947 $11,744 279...........................................

6 $9,165 280........................................... 19,317 $16,070 281...........................................

6,558 $11,023 283...........................................

6,779 $15,588 284...........................................

1,870 $9,582 285...........................................

8,029 $35,326 286...........................................

2,858 $34,797 287...........................................

5,417 $31,354 288........................................... 11,262 $36,453 289...........................................

6,326 $19,747 290........................................... 11,850 $18,894 291...........................................

59 $13,196 292...........................................

7,563 $41,631 293...........................................

319 $27,017 294........................................... 97,778 $16,203 295...........................................

4,359 $16,127 296........................................... 247,564 $17,305 297........................................... 42,713 $10,753 298...........................................

110 $11,321 299...........................................

1,544 $21,193 300........................................... 21,668 $23,141 301...........................................

3,917 $13,502 302........................................... 10,266 $53,482 303........................................... 24,555 $38,849 304........................................... 14,042 $37,954 305...........................................

3,000 $25,713 306...........................................

5,792 $25,952 307...........................................

1,941 $13,794 308...........................................

6,672 $29,226 309...........................................

3,267 $20,392 310........................................... 25,307 $25,305 311...........................................

5,868 $14,225 312...........................................

1,322 $24,353 313...........................................

502 $16,746 314...........................................

2 $63,207 315........................................... 34,708 $34,675 316........................................... 204,537 $24,329 317...........................................

2,695 $17,236 318...........................................

5,900 $23,909 319...........................................

386 $13,776 320........................................... 225,308 $18,217 321........................................... 32,125 $12,238 322...........................................

67 $13,312 323........................................... 20,424 $18,227 324...........................................

4,622 $11,415 325...........................................

9,912 $14,526 326...........................................

2,596 $9,757 327...........................................

11 $4,343 328...........................................

574 $15,429 329...........................................

55 $11,791 331........................................... 56,911 $22,376 332...........................................

4,148 $13,671 333...........................................

242 $18,937 334...........................................

9,480 $29,861 335........................................... 12,115 $24,029 336........................................... 28,104 $18,105 337........................................... 21,412 $12,512 338...........................................

670 $26,885 339...........................................

1,226 $24,456 341...........................................

3,118 $26,313 342...........................................

455 $16,807 344...........................................

2,344 $26,216 345...........................................

1,393 $24,179 346...........................................

4,006 $22,303 347...........................................

247 $11,878 348...........................................

4,275 $15,630 349...........................................

556 $10,034 350...........................................

7,275 $16,391 352...........................................

1,176 $16,670 353...........................................

3,075 $31,137 354...........................................

7,556 $29,687 355...........................................

4,982 $19,301 356........................................... 22,197 $16,341 357...........................................

5,521 $37,813 358........................................... 20,865 $24,333 359........................................... 28,554 $17,289 360........................................... 14,250 $19,091 361...........................................

288 $23,723 362...........................................

2 $6,842 363...........................................

1,978 $22,611 364...........................................

1,366 $20,070 365...........................................

1,607 $32,785 366...........................................

4,664 $23,778 367...........................................

448 $13,000 368...........................................

4,156 $23,392 369...........................................

3,780 $14,156 370...........................................

2,210 $17,586 371...........................................

2,656 $12,644 372...........................................

1,354 $10,859 373...........................................

5,201 $7,550 374...........................................

153 $12,838 375...........................................

13 $21,703 376...........................................

474 $12,994 377...........................................

111 $24,218 378...........................................

203 $16,225 379...........................................

486 $7,975 380...........................................

111 $9,309 381...........................................

172 $14,935 382...........................................

51 $3,954 383...........................................

2,816 $10,480 384...........................................

147 $7,366 389...........................................

3 $24,011 392...........................................

2,120 $45,705 394...........................................

2,758 $30,927

[[Page 24394]]

395........................................... 115,676 $18,128 396...........................................

20 $13,145 397........................................... 16,409 $23,004 398........................................... 18,602 $24,048 399...........................................

1,639 $14,974 401...........................................

6,443 $43,881 402...........................................

1,341 $25,131 403........................................... 31,499 $29,820 404...........................................

3,625 $19,967 406...........................................

2,300 $42,504 407...........................................

608 $24,913 408...........................................

1,941 $33,805 409...........................................

1,733 $24,885 410........................................... 29,018 $23,855 411...........................................

5 $9,742 412...........................................

8 $9,732 413...........................................

5,727 $25,493 414...........................................

481 $16,066 415........................................... 55,695 $54,398 416........................................... 287,720 $29,284 417...........................................

33 $28,169 418........................................... 29,891 $22,126 419........................................... 17,735 $18,517 420...........................................

3,052 $12,846 421........................................... 13,248 $16,145 422...........................................

77 $11,732 423...........................................

9,071 $28,338 424...........................................

1,034 $36,130 425........................................... 13,105 $13,590 426...........................................

4,244 $10,349 427...........................................

1,575 $11,169 428...........................................

831 $13,862 429........................................... 24,102 $16,887 430........................................... 75,185 $13,563 431...........................................

338 $12,778 432...........................................

401 $14,072 433...........................................

5,145 $6,348 439...........................................

1,750 $29,718 440...........................................

5,181 $29,513 441...........................................

687 $20,575 442........................................... 18,524 $37,538 443...........................................

3,570 $22,683 444...........................................

6,004 $16,185 445...........................................

2,259 $11,272 447...........................................

6,341 $11,444 449........................................... 40,812 $18,232 450...........................................

7,395 $9,416 451...........................................

2 $19,140 452........................................... 28,659 $21,691 453...........................................

5,379 $11,466 454...........................................

4,754 $17,818 455...........................................

885 $10,307 461...........................................

2,271 $27,863 462...........................................

7,854 $16,912 463........................................... 32,979 $15,084 464...........................................

7,677 $11,282 465...........................................

171 $12,777 466...........................................

1,250 $13,996 467...........................................

1,035 $9,965 468........................................... 51,806 $57,172 470...........................................

130 $25,466 471........................................... 15,526 $55,551 473...........................................

8,554 $38,397 475........................................... 119,935 $50,639 476...........................................

2,840 $35,418 477........................................... 28,074 $34,213 479........................................... 27,582 $30,586 480...........................................

884 $128,973 481...........................................

1,183 $91,460 482...........................................

5,076 $49,252 484...........................................

456 $75,162 485...........................................

3,658 $51,585 486...........................................

2,607 $68,837 487...........................................

4,877 $31,891 488...........................................

823 $63,400 489........................................... 13,661 $28,266 490...........................................

5,338 $21,522 491........................................... 22,679 $35,764 492...........................................

3,897 $44,664 493........................................... 60,901 $34,560 494........................................... 24,434 $22,745 495...........................................

336 $120,908 496...........................................

3,709 $96,697 497........................................... 31,216 $62,841 498........................................... 21,383 $51,886 499........................................... 35,204 $28,301 500........................................... 46,619 $19,840 501...........................................

3,171 $42,481 502...........................................

756 $29,355 503...........................................

5,858 $26,581 504...........................................

191 $146,367 505...........................................

180 $27,936 506...........................................

964 $50,384 507...........................................

323 $31,731 508...........................................

662 $23,639 509...........................................

157 $16,201 510...........................................

1,797 $21,194 511...........................................

636 $13,509 512...........................................

530 $90,375 513...........................................

213 $101,858 515........................................... 58,105 $86,680 518........................................... 23,620 $34,456 519........................................... 12,544 $44,211 520........................................... 16,505 $35,796 521........................................... 32,468 $14,497 522...........................................

5,801 $10,106 523........................................... 15,604 $8,206 524........................................... 109,106 $16,158 525...........................................

203 $151,063 528...........................................

1,841 $107,892 529...........................................

5,109 $36,423 530...........................................

3,372 $25,893 531...........................................

4,873 $45,214 532...........................................

2,832 $27,950 533........................................... 46,519 $30,298 534........................................... 42,490 $22,177 535...........................................

8,761 $119,733 536...........................................

8,187 $109,139 537...........................................

8,952 $32,582 538...........................................

5,453 $22,363 539...........................................

4,953 $44,654 540...........................................

1,491 $25,570 541........................................... 25,000 $250,176 542........................................... 23,215 $150,533 543...........................................

5,478 $64,504 544........................................... 444,509 $39,461 545........................................... 44,574 $45,048 546...........................................

2,345 $83,613 547........................................... 32,602 $97,976 548........................................... 32,109 $79,666 549........................................... 13,098 $81,112 550........................................... 34,456 $63,667 551........................................... 53,802 $51,436 552........................................... 81,841 $40,493 553........................................... 39,188 $46,843 554........................................... 77,170 $36,841 555........................................... 37,270 $42,704 556........................................... 18,914 $37,680 557........................................... 123,764 $51,183 558........................................... 191,880 $42,313 559...........................................

2,887 $40,716

\1\ Cases taken from the FY 2005 MedPAR file; DRGs are from GROUPER Version 24.0.

Table 11.--Proposed FY 2007 LTC-DRGs, Relative Weights, Geometric Average Length of Stay, and \5/6\THS of the Geometric Average Length of Stay

Proposed 5/ Proposed 6ths of the Proposed geometric geometric

LTC-DRG

Description relative average average weight length of length of stay

stay

1.............. \5\ CRANIOTOMY

1.6479

35.5

29.6 AGE >17 W CC.

[[Continued on page 24395]]

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

[[pp. 24395-24444]] Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2007 Rates

[[Continued from page 24394]]

[[Page 24395]]

2.............. \7\ CRANIOTOMY

1.6479

35.5

29.6 AGE > 17 W/O CC. 3.............. \7\ CRANIOTOMY

1.6479

35.5

29.6 AGE 0-17. 6.............. \7\ CARPAL

0.4109

17.1

14.3 TUNNEL RELEASE. 7.............. PERIPH & CRANIAL 1.2119

36.2

30.2 NERVE & OTHER NERV SYST PROC W CC. 8.............. \2\ PERIPH &

0.5655

21.2

17.7 CRANIAL NERVE & OTHER NERV SYST PROC W/O CC. 9.............. SPINAL DISORDERS 1.0474

34.0

28.3 & INJURIES. 10............. NERVOUS SYSTEM

0.6992

22.1

18.4 NEOPLASMS W CC. 11............. \2\ NERVOUS

0.5655

21.2

17.7 SYSTEM NEOPLASMS W/O CC. 12............. DEGENERATIVE

0.6811

25.2

21.0 NERVOUS SYSTEM DISORDERS. 13............. MULTIPLE

0.6043

23.1

19.3 SCLEROSIS & CEREBELLAR ATAXIA. 14............. INTERCRANIAL

0.6798

24.8

20.7 HEMORRHAGE OR STROKE WITH INFARCT. 15............. NONSPECIFIC CVA

0.7779

26.1

21.8 & PRECEREBRAL OCCULUSION WITHOUT INFARCT. 16............. NONSPECIFIC

0.6960

23.1

19.3 CEREBROVASCULAR DISORDERS W CC. 17............. \1\ NONSPECIFIC

0.4109

17.1

14.3 CEREBROVASCULAR DISORDERS W/O CC. 18............. CRANIAL &

0.7397

25.2

21.0 PERIPHERAL NERVE DISORDERS W CC. 19............. CRANIAL &

0.4526

19.5

16.3 PERIPHERAL NERVE DISORDERS W/O CC. 20............. NERVOUS SYSTEM

0.9141

24.9

20.8 INFECTION EXCEPT VIRAL MENINGITIS. 21............. \3\ VIRAL

0.7858

25.2

21.0 MENINGITIS. 22............. \3\ HYPERTENSIVE 0.7858

25.2

21.0 ENCEPHALOPATHY. 23............. NONTRAUMATIC

1.0124

29.4

24.5 STUPOR & COMA. 24............. SEIZURE &

0.7194

23.8

19.8 HEADACHE AGE >17 W CC. 25............. \2\ SEIZURE &

0.5655

21.2

17.7 HEADACHE AGE >17 W/O CC. 26............. \7\ SEIZURE &

0.5655

21.1

17.6 HEADACHE AGE 0- 17. 27............. TRAUMATIC STUPOR 1.0016

30.6

25.5 & COMA, COMA >1 HR. 28............. TRAUMATIC STUPOR 0.8052

25.8

21.5 & COMA, COMA >1 HR AGE >17 W CC. 29............. \1\ TRAUMATIC

0.4109

17.1

14.3 STUPOR & COMA, COMA >1 HR AGE >17 W/O CC. 30............. \7\ TRAUMATIC

0.4109

17.1

14.3 STUPOR & COMA, COMA 17 W CC. 32............. \7\ CONCUSSION

0.5655

21.1

17.6 AGE >17 W/O CC. 33............. \7\ CONCUSSION

0.5655

21.1

17.6 AGE 0-17. 34............. OTHER DISORDERS

0.7057

23.4

19.5 OF NERVOUS SYSTEM W CC. 35............. OTHER DISORDERS

0.5093

21.1

17.6 OF NERVOUS SYSTEM W/O CC. 36............. \7\ RETINAL

0.5655

21.1

17.6 PROCEDURES. 37............. \7\ ORBITAL

0.5655

21.1

17.6 PROCEDURES. 38............. \7\ PRIMARY IRIS 0.5655

21.1

17.6 PROCEDURES. 39............. \7\ LENS

0.5655

21.1

17.6 PROCEDURES WITH OR WITHOUT VITRECTOMY. 40............. \7\ EXTRAOCULAR

0.5655

21.1

17.6 PROCEDURES EXCEPT ORBIT AGE >17. 41............. \7\ EXTRAOCULAR

0.5655

21.1

17.6 PROCEDURES EXCEPT ORBIT AGE 0-17. 42............. \7\ INTRAOCULAR

0.5655

21.1

17.6 PROCEDURES EXCEPT RETINA, IRIS & LENS. 43............. \7\ HYPHEMA..... 0.4109

17.1

14.3 44............. \3\ ACUTE MAJOR

0.7858

25.2

21.0 EYE INFECTIONS. 45............. \1\ NEUROLOGICAL 0.4109

17.1

14.3 EYE DISORDERS. 46............. \2\ OTHER

0.5655

21.2

17.7 DISORDERS OF THE EYE AGE >17 W CC. 47............. \7\ OTHER

0.4109

17.1

14.3 DISORDERS OF THE EYE AGE >17 W/O CC. 48............. \7\ OTHER

0.4109

17.1

14.3 DISORDERS OF THE EYE AGE 0- 17. 49............. \7\ MAJOR HEAD & 1.1162

29.5

24.6 NECK PROCEDURES. 50............. \7\

1.1162

29.5

24.6 SIALOADENECTOMY. 51............. \7\ SALIVARY

1.1162

29.5

24.6 GLAND PROCEDURES EXCEPT SIALOADENECTOMY. 52............. \7\ CLEFT LIP &

1.1162

29.5

24.6 PALATE REPAIR. 53............. \7\ SINUS &

1.1162

29.5

24.6 MASTOID PROCEDURES AGE >17. 54............. \7\ SINUS &

1.1162

29.5

24.6 MASTOID PROCEDURES AGE 0-17. 55............. \4\

1.1162

29.5

24.6 MISCELLANEOUS EAR, NOSE, MOUTH & THROAT PROCEDURES. 56............. \7\ RHINOPLASTY. 1.1162

29.5

24.6 57............. \7\ T&A PROC,

0.4109

17.1

14.3 EXCEPT TONSILLECTOMY &/ OR ADENOIDECTOMY ONLY, AGE >17. 58............. \7\ T&A PROC,

0.4109

17.1

14.3 EXCEPT TONSILLECTOMY &/ OR ADENOIDECTOMY ONLY, AGE 0-17. 59............. \7\

0.4109

17.1

14.3 TONSILLECTOMY &/ OR ADENOIDECTOMY ONLY, AGE >17. 60............. \7\

0.4109

17.1

14.3 TONSILLECTOMY &/ OR ADENOIDECTOMY ONLY, AGE 0-17. 61............. \7\ MYRINGOTOMY

0.4109

17.1

14.3 W TUBE INSERTION AGE >17. 62............. \7\ MYRINGOTOMY

0.4109

17.1

14.3 W TUBE INSERTION AGE 0- 17. 63............. \4\ OTHER EAR,

1.1162

29.5

24.6 NOSE, MOUTH & THROAT O.R. PROCEDURES. 64............. EAR, NOSE, MOUTH 1.1890

26.2

21.8 & THROAT MALIGNANCY. 65............. \1\

0.4109

17.1

14.3 DYSEQUILIBRIUM. 66............. \7\ EPISTAXIS... 0.4109

17.1

14.3 67............. \3\ EPIGLOTTITIS 0.7858

25.2

21.0 68............. OTITIS MEDIA &

0.6238

20.3

16.9 URI AGE >17 W CC.

[[Page 24396]]

69............. \1\ OTITIS MEDIA 0.4109

17.1

14.3 & URI AGE >17 W/ O CC. 70............. \7\ OTITIS MEDIA 0.4109

17.1

14.3 & URI AGE 0-17. 71............. \7\

0.5655

21.1

17.6 LARYNGOTRACHEIT IS. 72............. \3\ NASAL TRAUMA 0.7858

25.2

21.0 & DEFORMITY. 73............. \7\ OTHER EAR,

0.7761

22.9

19.1 NOSE, MOUTH & THROAT DIAGNOSES AGE >17. 74............. \7\ OTHER EAR,

0.4109

17.1

14.3 NOSE, MOUTH & THROAT DIAGNOSES AGE 0- 17. 75............. MAJOR CHEST

2.1021

33.8

28.2 PROCEDURES. 76............. OTHER RESP

2.3766

42.2

35.2 SYSTEM O.R. PROCEDURES W CC. 77............. \2\ OTHER RESP

0.5655

21.2

17.7 SYSTEM O.R. PROCEDURES W/O CC. 78............. PULMONARY

0.6774

22.6

18.8 EMBOLISM. 79............. RESPIRATORY

0.8185

22.7

18.9 INFECTIONS & INFLAMMATIONS AGE >17 W CC. 80............. RESPIRATORY

0.6565

20.9

17.4 INFECTIONS & INFLAMMATIONS AGE >17 W/O CC. 81............. \7\ RESPIRATORY

0.4109

17.1

14.3 INFECTIONS & INFLAMMATIONS AGE 0-17. 82............. RESPIRATORY

0.8276

21.4

17.8 NEOPLASMS. 83............. \1\ MAJOR CHEST

0.4109

17.1

14.3 TRAUMA W CC. 84............. \7\ MAJOR CHEST

0.4109

17.1

14.3 TRAUMA W/O CC. 85............. PLEURAL EFFUSION 0.6980

21.4

17.8 W CC. 86............. \7\ PLEURAL

0.4109

17.1

14.3 EFFUSION W/O CC. 87............. PULMONARY EDEMA

1.0305

24.8

20.7 & RESPIRATORY FAILURE. 88............. CHRONIC

0.6417

19.3

16.1 OBSTRUCTIVE PULMONARY DISEASE. 89............. SIMPLE PNEUMONIA 0.6826

20.6

17.2 & PLEURISY AGE >17 W CC. 90............. SIMPLE PNEUMONIA

.4981

17.8

14.8 & PLEURISY AGE >17 W/O CC. 91............. \7\ SIMPLE

0.5655

21.1

17.6 PNEUMONIA & PLEURISY AGE 0- 17. 92............. INTERSTITIAL

0.6673

19.6

16.3 LUNG DISEASE W CC. 93............. \1\ INTERSTITIAL 0.4109

17.1

14.3 LUNG DISEASE W/ O CC. 94............. \8\ PNEUMOTHORAX 0.6826

21.3

17.8 W CC. 95............. \8\ PNEUMOTHORAX 0.6826

21.3

17.8 W/O CC. 96............. \8\ BRONCHITIS & 0.6245

19.1

15.9 ASTHMA AGE >17 W CC. 97............. \8\ BRONCHITIS & 0.6245

19.1

15.9 ASTHMA AGE >17 W/O CC. 98............. \7\ BRONCHITIS & 0.5655

21.1

17.6 ASTHMA AGE 0-17. 99............. RESPIRATORY

0.9396

24.5

20.4 SIGNS & SYMPTOMS W CC. 100............ \3\ RESPIRATORY

0.7858

25.2

21.0 SIGNS & SYMPTOMS W/O CC. 101............ OTHER

0.8165

22.2

18.5 RESPIRATORY SYSTEM DIAGNOSES W CC. 102............ \1\ OTHER

0.4109

17.1

14.3 RESPIRATORY SYSTEM DIAGNOSES W/O CC. 103............ 6HEART

0.0000

0.0

0.0 TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM. 104............ \7\ CARDIAC

1.1162

29.5

24.6 VALVE & OTHER MAJOR CARDIOTHORACIC PROC W CARDIAC CATH. 105............ \7\ CARDIAC

1.1162

29.5

24.6 VALVE & OTHER MAJOR CARDIOTHORACIC PROC W/O CARDIAC CATH. 106............ \7\ CORONARY

1.1162

29.5

24.6 BYPASS W PTCA. 108............ \7\ OTHER

1.1162

29.5

24.6 CARDIOTHORACIC PROCEDURES. 110............ \4\ MAJOR

1.1162

29.5

24.6 CARDIOVASCULAR PROCEDURES W CC. 111............ \7\ MAJOR

1.1162

29.5

24.6 CARDIOVASCULAR PROCEDURES W/O CC. 113............ AMPUTATION FOR

1.3939

35.8

29.8 CIRC SYSTEM DISORDERS EXCEPT UPPER LIMB & TOE. 114............ UPPER LIMB & TOE 1.2598

33.0

27.5 AMPUTATION FOR CIRC SYSTEM DISORDERS. 117............ \3\ CARDIAC

0.7858

25.2

21.0 PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT. 118............ \3\ CARDIAC

0.7858

25.2

21.0 PACEMAKER DEVICE REPLACEMENT. 119............ \3\ VEIN

0.7858

25.2

21.0 LIGATION & STRIPPING. 120............ OTHER

1.0891

31.3

26.1 CIRCULATORY SYSTEM O.R. PROCEDURES. 121............ CIRCULATORY

0.7517

22.6

18.8 DISORDERS W AMI & MAJOR COMP, DISCHARGED ALIVE. 122............ \2\CIRCULATORY

0.5655

21.2

17.7 DISORDERS W AMI W/O MAJOR COMP, DISCHARGED ALIVE. 123............ CIRCULATORY

0.7900

17.0

14.2 DISORDERS W AMI, EXPIRED. 124............ \4\ CIRCULATORY

1.1162

29.5

24.6 DISORDERS EXCEPT AMI, W CARD CATH & COMPLEX DIAG. 125............ \1\ CIRCULATORY

0.4109

17.1

14.3 DISORDERS EXCEPT AMI, W CARD CATH W/O COMPLEX DIAG. 126............ ACUTE & SUBACUTE 0.8925

26.3

21.9 ENDOCARDITIS. 127............ HEART FAILURE &

0.6854

21.2

17.7 SHOCK. 128............ \2\ DEEP VEIN

0.5655

21.2

17.7 THROMBOPHLEBITI S. 129............ \1\ CARDIAC

0.4109

17.1

14.3 ARREST, UNEXPLAINED. 130............ PERIPHERAL

0.6488

22.8

19.0 VASCULAR DISORDERS W CC. 131............ PERIPHERAL

0.5233

21.0

17.5 VASCULAR DISORDERS W/O CC. 132............ ATHEROSCLEROSIS

0.6584

20.5

17.1 W CC. 133............ \2\

0.5655

21.2

17.7 ATHEROSCLEROSIS W/O CC. 134............ HYPERTENSION.... 0.4895

21.3

17.8 135............ CARDIAC

0.8015

23.9

19.9 CONGENITAL & VALVULAR DISORDERS AGE >17 W CC. 136............ \1\ CARDIAC

0.4109

17.1

14.3 CONGENITAL & VALVULAR DISORDERS AGE >17 W/O CC. 137............ \7\ CARDIAC

0.4109

17.1

14.3 CONGENITAL & VALVULAR DISORDERS AGE 0- 17.

[[Page 24397]]

138............ CARDIAC

0.6619

21.9

18.3 ARRHYTHMIA & CONDUCTION DISORDERS W CC. 139............ \2\ CARDIAC

0.5655

21.2

17.7 ARRHYTHMIA & CONDUCTION DISORDERS W/O CC. 140............ \2\ ANGINA

0.5655

21.2

17.7 PECTORIS. 141............ \8\ SYNCOPE &

0.5918

22.1

18.4 COLLAPSE W CC. 142............ \8\ SYNCOPE &

0.5918

22.1

18.4 COLLAPSE W/O CC. 143............ \1\ CHEST PAIN.. 0.4109

17.1

14.3 144............ OTHER

0.7725

22.1

18.4 CIRCULATORY SYSTEM DIAGNOSES W CC. 145............ OTHER

0.4305

17.0

14.2 CIRCULATORY SYSTEM DIAGNOSES W/O CC. 146............ \5\ RECTAL

1.6479

35.5

29.6 RESECTION W CC. 147............ \7\ RECTAL

1.6479

35.5

29.6 RESECTION W/O CC. 148............ MAJOR SMALL &

1.8374

34.2

28.5 LARGE BOWEL PROCEDURES W CC. 149............ \7\ MAJOR SMALL

0.7858

25.2

21.0 & LARGE BOWEL PROCEDURES W/O CC. 150............ \5\ PERITONEAL

1.6479

35.5

29.6 ADHESIOLYSIS W CC. 151............ \7\ PERITONEAL

0.4109

17.1

14.3 ADHESIOLYSIS W/ O CC. 152............ \5\ MINOR SMALL

1.6479

35.5

29.6 & LARGE BOWEL PROCEDURES W CC. 153............ \7\ MINOR SMALL

1.6479

35.5

29.6 & LARGE BOWEL PROCEDURES W/O CC. 154............ \5\ STOMACH,

1.6479

35.5

29.6 ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W CC. 155............ \7\ STOMACH,

1.6479

35.5

29.6 ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W/O CC. 156............ \7\ STOMACH,

1.6479

35.5

29.6 ESOPHAGEAL & DUODENAL PROCEDURES AGE 0-17. 157............ \4\ ANAL &

1.1162

29.5

24.6 STOMAL PROCEDURES W CC. 158............ \7\ ANAL &

1.1162

29.5

24.6 STOMAL PROCEDURES W/O CC. 159............ \5\ HERNIA

1.6479

35.5

29.6 PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W CC. 160............ \1\ HERNIA

0.4109

17.1

14.3 PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W/O CC. 161............ \7\ INGUINAL &

0.4109

17.1

14.3 FEMORAL HERNIA PROCEDURES AGE >17 W CC. 162............ \7\ INGUINAL &

0.4109

17.1

14.3 FEMORAL HERNIA PROCEDURES AGE >17 W/O CC. 163............ \7\ HERNIA

0.4109

17.1

14.3 PROCEDURES AGE 0-17. 164............ \7\ APPENDECTOMY 1.6479

35.5

29.6 W COMPLICATED PRINCIPAL DIAG W CC. 165............ \7\ APPENDECTOMY 1.6479

35.5

29.6 W COMPLICATED PRINCIPAL DIAG W/O CC. 166............ \7\ APPENDECTOMY 1.6479

35.5

29.6 W/O COMPLICATED PRINCIPAL DIAG W CC. 167............ \7\ APPENDECTOMY 1.6479

35.5

29.6 W/O COMPLICATED PRINCIPAL DIAG W/O CC. 168............ \5\ MOUTH

1.6479

35.5

29.6 PROCEDURES W CC. 169............ \7\ MOUTH

0.5655

21.1

17.6 PROCEDURES W/O CC. 170............ OTHER DIGESTIVE

1.6242

35.7

29.8 SYSTEM O.R. PROCEDURES W CC. 171............ \3\ OTHER

0.7858

25.2

21.0 DIGESTIVE SYSTEM O.R. PROCEDURES W/O CC. 172............ DIGESTIVE

0.8564

21.8

18.2 MALIGNANCY W CC. 173............ \2\ DIGESTIVE

0.5655

21.2

17.7 MALIGNANCY W/O CC. 174............ G.I. HEMORRHAGE

0.6886

22.7

18.9 W CC. 175............ \2\ G.I.

0.5655

21.2

17.7 HEMORRHAGE W/O CC. 176............ COMPLICATED

0.9293

25.4

21.2 PEPTIC ULCER. 177............ \2\

0.5655

21.2

17.7 UNCOMPLICATED PEPTIC ULCER W CC. 178............ \7\

0.4109

17.1

14.3 UNCOMPLICATED PEPTIC ULCER W/ O CC. 179............ INFLAMMATORY

0.8190

23.3

19.4 BOWEL DISEASE. 180............ G.I. OBSTRUCTION 0.9222

22.9

19.1 W CC. 181............ \1\ G.I.

0.4109

17.1

14.3 OBSTRUCTION W/O CC. 182............ ESOPHAGITIS,

0.8044

22.5

18.8 GASTROENT & MISC DIGEST DISORDERS AGE >17 W CC. 183............ ESOPHAGITIS,

0.4656

17.6

14.7 GASTROENT & MISC DIGEST DISORDERS AGE >17 W/O CC. 184............ \7\ ESOPHAGITIS, 0.4109

17.1

14.3 GASTROENT & MISC DIGEST DISORDERS AGE 0- 17. 185............ DENTAL & ORAL

0.6611

23.2

19.3 DIS EXCEPT EXTRACTIONS & RESTORATIONS, AGE >17. 186............ \7\ DENTAL &

0.5655

21.1

17.6 ORAL DIS EXCEPT EXTRACTIONS & RESTORATIONS, AGE 0-17. 187............ \7\ DENTAL

0.5655

21.1

17.6 EXTRACTIONS & RESTORATIONS. 188............ OTHER DIGESTIVE

0.9485

24.1

20.1 SYSTEM DIAGNOSES AGE >17 W CC. 189............ OTHER DIGESTIVE

0.5316

18.1

15.1 SYSTEM DIAGNOSES AGE >17 W/O CC. 190............ \7\ OTHER

0.5655

21.1

17.6 DIGESTIVE SYSTEM DIAGNOSES AGE 0- 17. 191............ \5\ PANCREAS,

1.6479

35.5

29.6 LIVER & SHUNT PROCEDURES W CC. 192............ \7\ PANCREAS,

1.6479

35.5

29.6 LIVER & SHUNT PROCEDURES W/O CC. 193............ \5\ BILIARY

1.6479

35.5

29.6 TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W CC. 194............ \7\ BILIARY

1.6479

35.5

29.6 TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC. 195............ \5\

1.6479

35.5

29.6 CHOLECYSTECTOMY W C.D.E. W CC. 196............ \7\

1.1162

29.5

24.6 CHOLECYSTECTOMY W C.D.E. W/O CC. 197............ \4\

1.1162

29.5

24.6 CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC. 198............ \7\

1.1162

29.5

24.6 CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC. 199............ \3\

0.7858

25.2

21.0 HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR MALIGNANCY. 200............ \5\

1.6479

35.5

29.6 HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR NON-MALIGNANCY. 201............ OTHER

1.5988

28.8

24.0 HEPATOBILIARY OR PANCREAS O.R. PROCEDURES. 202............ CIRRHOSIS &

0.6038

20.2

16.8 ALCOHOLIC HEPATITIS. 203............ MALIGNANCY OF

0.7053

19.4

16.2 HEPATOBILIARY SYSTEM OR PANCREAS.

[[Page 24398]]

204............ DISORDERS OF

0.8882

22.1

18.4 PANCREAS EXCEPT MALIGNANCY. 205............ DISORDERS OF

0.6990

23.1

19.3 LIVER EXCEPT MALIG,CIRR,ALC HEPA W CC. 206............ \2\ DISORDERS OF 0.5655

21.2

17.7 LIVER EXCEPT MALIG,CIRR,ALC HEPA W/O CC. 207............ DISORDERS OF THE 0.7310

21.5

17.9 BILIARY TRACT W CC. 208............ \1\ DISORDERS OF 0.4109

17.1

14.3 THE BILIARY TRACT W/O CC. 210............ HIP & FEMUR

1.4809

41.9

34.9 PROCEDURES EXCEPT MAJOR JOINT AGE >17 W CC. 211............ \7\ HIP & FEMUR

1.6479

35.5

29.6 PROCEDURES EXCEPT MAJOR JOINT AGE >17 W/ O CC. 212............ \7\ HIP & FEMUR

1.6479

35.5

29.6 PROCEDURES EXCEPT MAJOR JOINT AGE 0-17. 213............ AMPUTATION FOR

1.1780

33.4

27.8 MUSCULOSKELETAL SYSTEM & CONN TISSUE DISORDERS. 216............ BIOPSIES OF

1.2173

37.5

31.3 MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE. 217............ WND DEBRID & SKN 1.2470

36.5

30.4 GRFT EXCEPT HAND,FOR MUSCSKELET & CONN TISS DIS. 218............ \5\ LOWER EXTREM 1.6479

35.5

29.6 & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE >17 W CC. 219............ \7\ LOWER EXTREM 1.6479

35.5

29.6 & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE >17 W/O CC. 220............ \7\ LOWER EXTREM 1.6479

35.5

29.6 & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE 0-17. 223............ \4\ MAJOR

1.1162

29.5

24.6 SHOULDER/ELBOW PROC, OR OTHER UPPER EXTREMITY PROC W CC. 224............ \1\

0.4109

17.1

14.3 SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC, W/O CC. 225............ FOOT PROCEDURES. 0.9579

30.6

25.5 226............ SOFT TISSUE

1.0653

34.3

28.6 PROCEDURES W CC. 227............ \3\ SOFT TISSUE

0.7858

25.2

21.0 PROCEDURES W/O CC. 228............ \3\ MAJOR THUMB

0.7858

25.2

21.0 OR JOINT PROC,OR OTH HAND OR WRIST PROC W CC. 229............ \7\ HAND OR

0.4109

17.1

14.3 WRIST PROC, EXCEPT MAJOR JOINT PROC, W/O CC. 230............ \5\ LOCAL

1.6479

35.5

29.6 EXCISION & REMOVAL OF INT FIX DEVICES OF HIP & FEMUR. 232............ \5\ ARTHROSCOPY. 1.6479

35.5

29.6 233............ OTHER

1.1794

32.4

27.0 MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC. 234............ \7\ OTHER

0.4109

17.1

14.3 MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC. 235............ \3\ FRACTURES OF 0.7858

25.2

21.0 FEMUR. 236............ FRACTURES OF HIP 0.6874

28.9

24.1 & PELVIS. 237............ \1\ SPRAINS,

0.4109

17.1

14.3 STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH. 238............ OSTEOMYELITIS... 0.8602

28.4

23.7 239............ PATHOLOGICAL

0.6059

20.5

17.1 FRACTURES & MUSCULOSKELETAL & CONN TISS MALIGNANCY. 240............ CONNECTIVE

0.7178

22.4

18.7 TISSUE DISORDERS W CC. 241............ \1\ CONNECTIVE

0.4109

17.1

14.3 TISSUE DISORDERS W/O CC. 242............ SEPTIC ARTHRITIS 0.7699

26.1

21.8 243............ MEDICAL BACK

0.6021

22.2

18.5 PROBLEMS. 244............ BONE DISEASES &

0.5541

22.0

18.3 SPECIFIC ARTHROPATHIES W CC. 245............ BONE DISEASES &

0.4464

19.4

16.2 SPECIFIC ARTHROPATHIES W/ O CC. 246............ \2\ NON-SPECIFIC 0.5655

21.2

17.7 ARTHROPATHIES. 247............ SIGNS & SYMPTOMS 0.4591

17.6

14.7 OF MUSCULOSKELETAL SYSTEM & CONN TISSUE. 248............ TENDONITIS,

0.7341

23.2

19.3 MYOSITIS & BURSITIS. 249............ AFTERCARE,

0.6387

24.0

20.0 MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE. 250............ \1\ FX, SPRN,

0.4109

17.1

14.3 STRN & DISL OF FOREARM, HAND, FOOT AGE >17 W CC. 251............ \7\ FX, SPRN,

0.4109

17.1

14.3 STRN & DISL OF FOREARM, HAND, FOOT AGE >17 W/ O CC. 252............ \7\ FX, SPRN,

0.5655

21.1

17.6 STRN & DISL OF FOREARM, HAND, FOOT AGE 0-17. 253............ FX, SPRN, STRN & 0.5636

24.0

20.0 DISL OF UPARM,LOWLEG EX FOOT AGE >17 W CC. 254............ \1\ FX, SPRN,

0.4109

17.1

14.3 STRN & DISL OF UPARM,LOWLEG EX FOOT AGE >17 W/ O CC. 255............ \7\ FX, SPRN,

0.5655

21.1

17.6 STRN & DISL OF UPARM,LOWLEG EX FOOT AGE 0-17. 256............ OTHER

0.7208

23.7

19.8 MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES. 257............ \4\ TOTAL

1.1162

29.5

24.6 MASTECTOMY FOR MALIGNANCY W CC. 258............ \7\ TOTAL

0.7858

25.2

21.0 MASTECTOMY FOR MALIGNANCY W/O CC. 259............ \3\ SUBTOTAL

0.7858

25.2

21.0 MASTECTOMY FOR MALIGNANCY W CC. 260............ \7\ SUBTOTAL

0.7858

25.2

21.0 MASTECTOMY FOR MALIGNANCY W/O CC. 261............ \2\ BREAST PROC

0.5655

21.2

17.7 FOR NON- MALIGNANCY EXCEPT BIOPSY & LOCAL EXCISION. 262............ \4\ BREAST

1.1162

29.5

24.6 BIOPSY & LOCAL EXCISION FOR NON- MALIGNANCY. 263............ SKIN GRAFT &/OR

1.2749

38.0

31.7 DEBRID FOR SKN ULCER OR CELLULITIS W CC. 264............ SKIN GRAFT &/OR

0.8524

29.9

24.9 DEBRID FOR SKN ULCER OR CELLULITIS W/O CC. 265............ SKIN GRAFT &/OR

1.1068

30.2

25.2 DEBRID EXCEPT FOR SKIN ULCER OR CELLULITIS W CC. 266............ \3\ SKIN GRAFT &/ 0.7858

25.2

21.0 OR DEBRID EXCEPT FOR SKIN ULCER OR CELLULITIS W/O CC. 267............ \7\ PERIANAL &

0.7858

25.2

21.0 PILONIDAL PROCEDURES. 268............ \4\ SKIN,

1.1162

29.5

24.6 SUBCUTANEOUS TISSUE & BREAST PLASTIC PROCEDURES. 269............ OTHER SKIN,

1.2137

34.7

28.9 SUBCUT TISS & BREAST PROC W CC. 270............ \3\ OTHER SKIN,

0.7858

25.2

21.0 SUBCUT TISS & BREAST PROC W/O CC. 271............ SKIN ULCERS..... 0.8290

26.8

22.3 272............ MAJOR SKIN

0.6576

23.1

19.3 DISORDERS W CC. 273............ \1\ MAJOR SKIN

0.4109

17.1

14.3 DISORDERS W/O CC.

[[Page 24399]]

274............ MALIGNANT BREAST 0.7277

21.8

18.2 DISORDERS W CC. 275............ \7\ MALIGNANT

0.7858

25.2

21.0 BREAST DISORDERS W/O CC. 276............ \2\ NON-MALIGANT 0.5655

21.2

17.7 BREAST DISORDERS. 277............ CELLULITIS AGE

0.6087

20.8

17.3 >17 W CC. 278............ CELLULITIS AGE

0.4243

18.0

15.0 >17 W/O CC. 279............ \7\ CELLULITIS

0.4109

17.1

14.3 AGE 0-17. 280............ TRAUMA TO THE

0.6981

23.9

19.9 SKIN, SUBCUT TISS & BREAST AGE >17 W CC. 281............ \2\ TRAUMA TO

0.5655

21.2

17.7 THE SKIN, SUBCUT TISS & BREAST AGE >17 W/O CC. 282............ \7\ TRAUMA TO

0.5655

21.1

17.6 THE SKIN, SUBCUT TISS & BREAST AGE 0-17. 283............ MINOR SKIN

0.6946

23.1

19.3 DISORDERS W CC. 284............ \2\ MINOR SKIN

0.5655

21.2

17.7 DISORDERS W/O CC. 285............ AMPUTAT OF LOWER 1.2354

31.3

26.1 LIMB FOR ENDOCRINE,NUTRI T,& METABOL DISORDERS. 286............ \7\ ADRENAL &

1.1162

29.5

24.6 PITUITARY PROCEDURES. 287............ SKIN GRAFTS &

1.0502

33.0

27.5 WOUND DEBRID FOR ENDOC, NUTRIT & METAB DISORDERS. 288............ 4O.R. PROCEDURES 1.1162

29.5

24.6 FOR OBESITY. 289............ \7\ PARATHYROID

1.1162

29.5

24.6 PROCEDURES. 290............ \7\ THYROID

1.1162

29.5

24.6 PROCEDURES. 291............ \7\ THYROGLOSSAL 1.1162

29.5

24.6 PROCEDURES. 292............ \8\ OTHER

1.1673

31.9

26.6 ENDOCRINE, NUTRIT & METAB O.R. PROC W CC. 293............ \8\ OTHER

1.1673

31.9

26.6 ENDOCRINE, NUTRIT & METAB O.R. PROC W/O CC. 294............ DIABETES AGE >35 0.6986

23.8

19.8 295............ \2\ DIABETES AGE 0.5655

21.2

17.7 0-35. 296............ NUTRITIONAL &

0.7114

22.3

18.6 MISC METABOLIC DISORDERS AGE >17 W CC. 297............ NUTRITIONAL &

0.4609

19.3

16.1 MISC METABOLIC DISORDERS AGE >17 W/O CC. 298............ \7\ NUTRITIONAL

0.4109

17.1

14.3 & MISC METABOLIC DISORDERS AGE 0- 17. 299............ \3\ INBORN

0.7858

25.2

21.0 ERRORS OF METABOLISM. 300............ DENDOCRINE

0.7053

23.7

19.8 DISORDERS W CC. 301............ \2\ ENDOCRINE

0.5655

21.2

17.7 DISORDERS W/O CC. 302............ \6\ KIDNEY

0.0000

0.0

0.0 TRANSPLANT. 303............ \7\

0.7858

25.2

21.0 KIDNEY,URETER & MAJOR BLADDER PROCEDURES FOR NEOPLASM. 304............ \5\

1.6479

35.5

29.6 KIDNEY,URETER & MAJOR BLADDER PROC FOR NON- NEOPL W CC. 305............ \7\

0.7858

25.2

21.0 KIDNEY,URETER & MAJOR BLADDER PROC FOR NON- NEOPL W/O CC. 306............ \4\

1.1162

29.5

24.6 PROSTATECTOMY W CC. 307............ \7\

1.1162

29.5

24.6 PROSTATECTOMY W/ O CC. 308............ \4\ MINOR

1.1162

29.5

24.6 BLADDER PROCEDURES W CC. 309............ \7\ MINOR

1.1162

29.5

24.6 BLADDER PROCEDURES W/O CC. 310............ \4\

1.1162

29.5

24.6 TRANSURETHRAL PROCEDURES W CC. 311............ \7\

1.1162

29.5

24.6 TRANSURETHRAL PROCEDURES W/O CC. 312............ \3\ URETHRAL

0.7858

25.2

21.0 PROCEDURES, AGE >17 W CC. 313............ \7\ URETHRAL

0.7858

25.2

21.0 PROCEDURES, AGE >17 W/O CC. 314............ \7\ URETHRAL

0.7858

25.2

21.0 PROCEDURES, AGE 0-17. 315............ OTHER KIDNEY &

1.3823

33.4

27.8 URINARY TRACT O.R. PROCEDURES. 316............ RENAL FAILURE... 0.8342

22.9

19.1 317............ ADMIT FOR RENAL

0.9186

24.3

20.3 DIALYSIS. 318............ KIDNEY & URINARY 0.7713

21.3

17.8 TRACT NEOPLASMS W CC. 319............ \7\ KIDNEY &

0.7858

25.2

21.0 URINARY TRACT NEOPLASMS W/O CC. 320............ KIDNEY & URINARY 0.6181

21.6

18.0 TRACT INFECTIONS AGE >17 W CC. 321............ KIDNEY & URINARY 0.4478

18.5

15.4 TRACT INFECTIONS AGE >17 W/O CC. 322............ \7\ KIDNEY &

0.4109

17.1

14.3 URINARY TRACT INFECTIONS AGE 0- 17. 323............ \1\ URINARY

0.4109

17.1

14.3 STONES W CC, &/ OR ESW LITHOTRIPSY. 324............ \1\ URINARY

0.4109

17.1

14.3 STONES W/O CC. 325............ \2\ KIDNEY &

0.5655

21.2

17.7 URINARY TRACT SIGNS & SYMPTOMS AGE >17 W CC. 326............ \7\ KIDNEY &

0.4109

17.1

14.3 URINARY TRACT SIGNS & SYMPTOMS AGE >17 W/O CC. 327............ \7\ KIDNEY &

0.4109

17.1

14.3 URINARY TRACT SIGNS & SYMPTOMS AGE 0- 17. 328............ \7\ URETHRAL

0.5655

21.1

17.6 STRICTURE AGE >17 W CC. 329............ \7\ URETHRAL

0.5655

21.1

17.6 STRICTURE AGE >17 W/O CC. 330............ \7\ URETHRAL

0.5655

21.1

17.6 STRICTURE AGE 0- 17. 331............ OTHER KIDNEY &

0.7776

22.5

18.8 URINARY TRACT DIAGNOSES AGE >17 W CC. 332............ \1\ OTHER KIDNEY 0.4109

17.1

14.3 & URINARY TRACT DIAGNOSES AGE >17 W/O CC. 333............ \7\ OTHER KIDNEY 0.4109

17.1

14.3 & URINARY TRACT DIAGNOSES AGE 0- 17. 334............ \7\ MAJOR MALE

0.4109

17.1

14.3 PELVIC PROCEDURES W CC. 335............ \1\ MAJOR MALE

0.4109

17.1

14.3 PELVIC PROCEDURES W/O CC. 336............ \4\

1.1162

29.5

24.6 TRANSURETHRAL PROSTATECTOMY W CC. 337............ \7\

1.1162

29.5

24.6 TRANSURETHRAL PROSTATECTOMY W/ O CC. 338............ \3\ TESTES

0.7858

25.2

21.0 PROCEDURES, FOR MALIGNANCY. 339............ \3\ TESTES

0.7858

25.2

21.0 PROCEDURES, NON- MALIGNANCY AGE >17.

[[Page 24400]]

340............ \7\ TESTES

0.7858

25.2

21.0 PROCEDURES, NON- MALIGNANCY AGE 0-17. 341............ \5\ PENIS

1.6479

35.5

29.6 PROCEDURES. 342............ \7\ CIRCUMCISION 0.7858

25.2

21.0 AGE >17. 343............ \7\ CIRCUMCISION 0.7858

25.2

21.0 AGE 0-17. 344............ \3\ OTHER MALE

0.7858

25.2

21.0 REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY. 345............ \4\ OTHER MALE

1.1162

29.5

24.6 REPRODUCTIVE SYSTEM O.R. PROC EXCEPT FOR MALIGNANCY. 346............ \3\ MALIGNANCY,

0.7858

25.2

21.0 MALE REPRODUCTIVE SYSTEM, W CC. 347............ \1\ MALIGNANCY,

0.4109

17.1

14.3 MALE REPRODUCTIVE SYSTEM, W/O CC. 348............ \2\ BENIGN

0.5655

21.2

17.7 PROSTATIC HYPERTROPHY W CC. 349............ \7\ BENIGN

0.7858

25.2

21.0 PROSTATIC HYPERTROPHY W/O CC. 350............ INFLAMMATION OF

0.5630

21.0

17.5 THE MALE REPRODUCTIVE SYSTEM. 351............ \7\

0.7858

25.2

21.0 STERILIZATION, MALE. 352............ OTHER MALE

0.8138

27.1

22.6 REPRODUCTIVE SYSTEM DIAGNOSES. 353............ \7\ PELVIC

1.1162

29.5

24.6 EVISCERATION, RADICAL HYSTERECTOMY & RADICAL VULVECTOMY. 354............ \7\

1.1162

29.5

24.6 UTERINE,ADNEXA PROC FOR NON- OVARIAN/ADNEXAL MALIG W CC. 355............ \7\

1.1162

29.5

24.6 UTERINE,ADNEXA PROC FOR NON- OVARIAN/ADNEXAL MALIG W/O CC. 356............ \7\ FEMALE

1.1162

29.5

24.6 REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES. 357............ \7\ UTERINE &

1.1162

29.5

24.6 ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY. 358............ \7\ UTERINE &

1.1162

29.5

24.6 ADNEXA PROC FOR NON-MALIGNANCY W CC. 359............ \7\ UTERINE &

1.1162

29.5

24.6 ADNEXA PROC FOR NON-MALIGNANCY W/O CC. 360............ \7\ VAGINA,

1.1162

29.5

24.6 CERVIX & VULVA PROCEDURES. 361............ \7\ LAPAROSCOPY

0.4109

17.1

14.3 & INCISIONAL TUBAL INTERRUPTION. 362............ \7\ ENDOSCOPIC

0.4109

17.1

14.3 TUBAL INTERRUPTION. 363............ \7\ D&C,

0.4109

17.1

14.3 CONIZATION & RADIO-IMPLANT, FOR MALIGNANCY. 364............ \7\ D&C,

0.4109

17.1

14.3 CONIZATION EXCEPT FOR MALIGNANCY. 365............ \4\ OTHER FEMALE 1.1162

29.5

24.6 REPRODUCTIVE SYSTEM O.R. PROCEDURES. 366............ MALIGNANCY,

0.9119

21.6

18.0 FEMALE REPRODUCTIVE SYSTEM W CC. 367............ \1\ MALIGNANCY,

0.4109

17.1

14.3 FEMALE REPRODUCTIVE SYSTEM W/O CC. 368............ INFECTIONS,

0.7859

21.3

17.8 FEMALE REPRODUCTIVE SYSTEM. 369............ \3\ MENSTRUAL &

0.7858

25.2

21.0 OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS. 370............ \7\ CESAREAN

0.4109

17.1

14.3 SECTION W CC. 371............ \7\ CESAREAN

0.4109

17.1

14.3 SECTION W/O CC. 372............ \7\ VAGINAL

0.4109

17.1

14.3 DELIVERY W COMPLICATING DIAGNOSES. 373............ \7\ VAGINAL

0.4109

17.1

14.3 DELIVERY W/O COMPLICATING DIAGNOSES. 374............ \7\ VAGINAL

0.4109

17.1

14.3 DELIVERY W STERILIZATION &/ OR D&C. 375............ \7\ VAGINAL

0.4109

17.1

14.3 DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C. 376............ \4\ POSTPARTUM & 1.1162

29.5

24.6 POST ABORTION DIAGNOSES W/O O.R. PROCEDURE. 377............ \7\ POSTPARTUM & 0.4109

17.1

14.3 POST ABORTION DIAGNOSES W O.R. PROCEDURE. 378............ \7\ ECTOPIC

0.4109

17.1

14.3 PREGNANCY. 379............ \7\ THREATENED

0.4109

17.1

14.3 ABORTION. 380............ \7\ ABORTION W/O 0.4109

17.1

14.3 D&C. 381............ \7\ ABORTION W

0.4109

17.1

14.3 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY. 382............ \7\ FALSE LABOR. 0.4109

17.1

14.3 383............ \1\ OTHER

0.4109

17.1

14.3 ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS. 384............ \7\ OTHER

0.4109

17.1

14.3 ANTEPARTUM DIAGNOSES W/O MEDICAL COMPLICATIONS. 385............ \7\ NEONATES,

0.4109

17.1

14.3 DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY. 386............ \7\ EXTREME

0.4109

17.1

14.3 IMMATURITY. 387............ \7\ PREMATURITY

0.4109

17.1

14.3 W MAJOR PROBLEMS. 388............ \7\ PREMATURITY

0.4109

17.1

14.3 W/O MAJOR PROBLEMS. 389............ \7\ FULL TERM

0.4109

17.1

14.3 NEONATE W MAJOR PROBLEMS. 390............ \7\ NEONATE W

0.4109

17.1

14.3 OTHER SIGNIFICANT PROBLEMS. 391............ \7\ NORMAL

0.4109

17.1

14.3 NEWBORN. 392............ \7\ SPLENECTOMY

1.1162

29.5

24.6 AGE >17. 393............ \7\ SPLENECTOMY

1.1162

29.5

24.6 AGE 0-17. 394............ \4\ OTHER O.R.

1.1162

29.5

24.6 PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS. 395............ RED BLOOD CELL

0.6736

21.4

17.8 DISORDERS AGE >17. 396............ \7\RED BLOOD

0.4109

17.1

14.3 CELL DISORDERS AGE 0-17. 397............ COAGULATION

0.8331

20.4

17.0 DISORDERS. 398............ RETICULOENDOTHEL 0.6890

21.0

17.5 IAL & IMMUNITY DISORDERS W CC. 399............ \1\

0.4109

17.1

14.3 RETICULOENDOTHE LIAL & IMMUNITY DISORDERS W/O CC. 401............ \4\ LYMPHOMA &

1.1162

29.5

24.6 NON-ACUTE LEUKEMIA W OTHER O.R. PROC W CC. 402............ \7\ LYMPHOMA &

0.5655

21.1

17.6 NON-ACUTE LEUKEMIA W OTHER O.R. PROC W/O CC. 403............ LYMPHOMA & NON-

0.8776

23.7

19.8 ACUTE LEUKEMIA W CC. 404............ \3\ LYMPHOMA &

0.7858

25.2

21.0 NON-ACUTE LEUKEMIA W/O CC. 405............ \7\ ACUTE

0.7858

25.2

21.0 LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE 0- 17.

[[Page 24401]]

406............ \5\ MYELOPROLIF

1.6479

35.5

29.6 DISORD OR POORLY DIFF NEOPL W MAJ O.R.PROC W CC. 407............ \7\ MYELOPROLIF

1.1162

29.5

24.6 DISORD OR POORLY DIFF NEOPL W MAJ O.R.PROC W/O CC. 408............ \4\ MYELOPROLIF

1.1162

29.5

24.6 DISORD OR POORLY DIFF NEOPL W OTHER O.R.PROC. 409............ RADIOTHERAPY.... 0.8417

23.2

19.3 410............ CHEMOTHERAPY W/O 1.2412

28.5

23.8 ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS. 411............ \7\ HISTORY OF

0.5655

21.1

17.6 MALIGNANCY W/O ENDOSCOPY. 412............ \7\ HISTORY OF

0.5655

21.1

17.6 MALIGNANCY W ENDOSCOPY. 413............ OTHER

0.8476

21.4

17.8 MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W CC. 414............ \3\ OTHER

0.7858

25.2

21.0 MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W/O CC. 415............ O.R. PROCEDURE

1.3974

35.4

29.5 FOR INFECTIOUS & PARASITIC DISEASES. 416............ SEPTICEMIA AGE

0.8081

23.0

19.2 >17. 417............ \7\ SEPTICEMIA

0.7858

25.2

21.0 AGE 0-17. 418............ POSTOPERATIVE &

0.7961

24.0

20.0 POST-TRAUMATIC INFECTIONS. 419............ \2\ FEVER OF

0.5655

21.2

17.7 UNKNOWN ORIGIN AGE >17 W CC. 420............ \2\ FEVER OF

0.5655

21.2

17.7 UNKNOWN ORIGIN AGE >17 W/O CC. 421............ VIRAL ILLNESS

0.7080

20.4

17.0 AGE >17. 422............ \7\ VIRAL

0.4109

17.1

14.3 ILLNESS & FEVER OF UNKNOWN ORIGIN AGE 0-17. 423............ OTHER INFECTIOUS 1.0463

23.2

19.3 & PARASITIC DISEASES DIAGNOSES. 424............ \3\ O.R.

0.7858

25.2

21.0 PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS. 425............ \1\ ACUTE

0.4109

17.1

14.3 ADJUSTMENT REACTION & PSYCHOLOGICAL DYSFUNCTION. 426............ DEPRESSIVE

0.4007

22.5

18.8 NEUROSES. 427............ \2\ NEUROSES

0.5655

21.2

17.7 EXCEPT DEPRESSIVE. 428............ DISORDERS OF

0.5164

24.5

20.4 PERSONALITY & IMPULSE CONTROL. 429............ ORGANIC

0.5281

23.9

19.9 DISTURBANCES & MENTAL RETARDATION. 430............ PSYCHOSES....... 0.3970

23.0

19.2 431............ \2\ CHILDHOOD

0.5655

21.2

17.7 MENTAL DISORDERS. 432............ \1\ OTHER MENTAL 0.4109

17.1

14.3 DISORDER DIAGNOSES. 433............ \7\ ALCOHOL/DRUG 0.4109

17.1

14.3 ABUSE OR DEPENDENCE, LEFT AMA. 439............ SKIN GRAFTS FOR

1.2390

35.9

29.9 INJURIES. 440............ WOUND

1.2253

34.3

28.6 DEBRIDEMENTS FOR INJURIES. 441............ \2\ HAND

0.5655

21.2

17.7 PROCEDURES FOR INJURIES. 442............ OTHER O.R.

1.3453

34.6

28.8 PROCEDURES FOR INJURIES W CC. 443............ \7\ OTHER O.R.

0.5655

21.1

17.6 PROCEDURES FOR INJURIES W/O CC. 444............ TRAUMATIC INJURY 0.6607

23.2

19.3 AGE >17 W CC. 445............ \2\ TRAUMATIC

0.5655

21.2

17.7 INJURY AGE >17 W/O CC. 446............ \7\ TRAUMATIC

0.5655

21.1

17.6 INJURY AGE 0-17. 447............ \2\ ALLERGIC

0.5655

21.2

17.7 REACTIONS AGE >17. 448............ \7\ ALLERGIC

0.5655

21.1

17.6 REACTIONS AGE 0- 17. 449............ \3\ POISONING &

0.7858

25.2

21.0 TOXIC EFFECTS OF DRUGS AGE >17 W CC. 450............ \7\ POISONING &

0.7858

25.2

21.0 TOXIC EFFECTS OF DRUGS AGE >17 W/O CC. 451............ \7\ POISONING &

0.7858

25.2

21.0 TOXIC EFFECTS OF DRUGS AGE 0- 17. 452............ COMPLICATIONS OF 0.9301

25.7

21.4 TREATMENT W CC. 453............ COMPLICATIONS OF 0.5809

21.6

18.0 TREATMENT W/O CC. 454............ \3\ OTHER

0.7858

25.2

21.0 INJURY, POISONING & TOXIC EFFECT DIAG W CC. 455............ \7\ OTHER

0.7858

25.2

21.0 INJURY, POISONING & TOXIC EFFECT DIAG W/O CC. 461............ O.R. PROC W

1.1512

32.7

27.3 DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES. 462............ REHABILITATION.. 0.5847

22.1

18.4 463............ SIGNS & SYMPTOMS 0.6113

22.9

19.1 W CC. 464............ SIGNS & SYMPTOMS 0.5850

24.3

20.3 W/O CC. 465............ AFTERCARE W

0.6869

21.2

17.7 HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS. 466............ AFTERCARE W/O

0.6666

21.6

18.0 HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS. 467............ \3\ OTHER

0.7858

25.2

21.0 FACTORS INFLUENCING HEALTH STATUS. 468............ EXTENSIVE O.R.

2.1241

40.2

33.5 PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS. 469............ \6\ PRINCIPAL

0.0000

0.0

0.0 DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS. 470............ \6\ UNGROUPABLE. 0.0000

0.0

0.0 471............ \5\ BILATERAL OR 1.6479

35.5

29.6 MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY. 473............ ACUTE LEUKEMIA W/ 0.9992

25.3

21.1 O MAJOR O.R. PROCEDURE AGE >17. 475............ RESPIRATORY

1.9875

33.4

27.8 SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT. 476............ \5\ PROSTATIC

1.6479

35.5

29.6 O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS. 477............ NON-EXTENSIVE

1.5211

35.9

29.9 O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS. 479............ \2\ OTHER

0.5655

21.2

17.7 VASCULAR PROCEDURES W/O CC. 480............ \6\ LIVER

0.0000

0.0

0.0 TRANSPLANT. 481............ \7\ BONE MARROW

1.1162

29.5

24.6 TRANSPLANT. 482............ \5\ TRACHEOSTOMY 1.6479

35.5

29.6 FOR FACE,MOUTH & NECK DIAGNOSES. 484............ \7\ CRANIOTOMY

1.6479

35.5

29.6 FOR MULTIPLE SIGNIFICANT TRAUMA. 485............ \7\ LIMB

1.1162

29.5

24.6 REATTACHMENT, HIP AND FEMUR PROC FOR MULTIPLE SIGNIFICANT TR.

[[Page 24402]]

486............ \3\ OTHER O.R.

0.7858

25.2

21.0 PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA. 487............ \4\ OTHER

1.1162

29.5

24.6 MULTIPLE SIGNIFICANT TRAUMA. 488............ \4\ HIV W

1.1162

29.5

24.6 EXTENSIVE O.R. PROCEDURE. 489............ HIV W MAJOR

0.9391

21.8

18.2 RELATED CONDITION. 490............ HIV W OR W/O

0.6590

20.3

16.9 OTHER RELATED CONDITION. 491............ \5\ MAJOR JOINT

1.6479

35.5

29.6 & LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITY. 492............ \2\ CHEMOTHERAPY 0.5655

21.2

17.7 W ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS. 493............ \4\ LAPAROSCOPIC 1.1162

29.5

24.6 CHOLECYSTECTOMY W/O C.D.E. W CC. 494............ \7\ LAPAROSCOPIC 1.1162

29.5

24.6 CHOLECYSTECTOMY W/O C.D.E. W/O CC. 495............ \6\ LUNG

0.0000

0.0

0.0 TRANSPLANT. 496............ \4\ COMBINED

1.1162

29.5

24.6 ANTERIOR/ POSTERIOR SPINAL FUSION. 497............ \5\ SPINAL

1.6479

35.5

29.6 FUSION W CC. 498............ \7\ SPINAL

1.6479

35.5

29.6 FUSION W/O CC. 499............ \5\ BACK & NECK

1.6479

35.5

29.6 PROCEDURES EXCEPT SPINAL FUSION W CC. 500............ \4\ BACK & NECK

1.1162

29.5

24.6 PROCEDURES EXCEPT SPINAL FUSION W/O CC. 501............ KNEE PROCEDURES

1.2227

33.3

27.8 W PDX OF INFECTION W CC. 502............ \2\ KNEE

0.5655

21.2

17.7 PROCEDURES W PDX OF INFECTION W/O CC. 503............ \4\ KNEE

1.1162

29.5

24.6 PROCEDURES W/O PDX OF INFECTION. 504............ \5\ EXTENSIVE

1.6479

35.5

29.6 BURN OR FULL THICKNESS BURNS WITH MECH VENT 96+ HOURS WITH SKIN GRAFT. 505............ \5\ EXTENSIVE

1.6479

35.5

29.6 BURN OR FULL THICKNESS BURNS WITH MECH VENT 96+ HOURS WITHOUT SKIN GRAFT. 506............ \4\ FULL

1.1162

29.5

24.6 THICKNESS BURN W SKIN GRAFT OR INHAL INJ W CC OR SIG TRAUMA. 507............ \7\ FULL

0.4109

17.1

14.3 THICKNESS BURN W SKIN GRFT OR INHAL INJ W/O CC OR SIG TRAUMA. 508............ FULL THICKNESS

0.7585

25.6

21.3 BURN W/O SKIN GRFT OR INHAL INJ W CC OR SIG TRAUMA. 509............ \1\ FULL

0.4109

17.1

14.3 THICKNESS BURN W/O SKIN GRFT OR INH INJ W/O CC OR SIG TRAUMA. 510............ NON-EXTENSIVE

0.6740

22.6

18.8 BURNS W CC OR SIGNIFICANT TRAUMA. 511............ \1\ NON-

0.4109

17.1

14.3 EXTENSIVE BURNS W/O CC OR SIGNIFICANT TRAUMA. 512............ \6\ SIMULTANEOUS 0.0000

0.0

0.0 PANCREAS/KIDNEY TRANSPLANT. 513............ \6\ PANCREAS

0.0000

0.0

0.0 TRANSPLANT. 515............ \5\ CARDIAC

1.6479

35.5

29.6 DEFIBRILATOR IMPLANT W/O CARDIAC CATH. 518............ \7\ PERCUTANEOUS 0.4109

17.1

14.3 CARDIVASCULAR PROC W/O CORONARY ARTERY STENT OR AMI. 519............ \4\ CERVICAL

1.1162

29.5

24.6 SPINAL FUSION W CC. 520............ \7\ CERVICAL

1.6479

35.5

29.6 SPINAL FUSION W/ O CC. 521............ \2\ ALCOHOL/DRUG 0.5655

21.2

17.7 ABUSE OR DEPENDENCE W CC. 522............ \7\ ALCOHOL/DRUG 0.5655

21.1

17.6 ABUSE OR DEPENDENCE W REHABILITATION THERAPY W/O CC. 523............ \1\ ALCOHOL/DRUG 0.4109

17.1

14.3 ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O CC. 524............ \2\ TRANSIENT

0.5655

21.2

17.7 ISCHEMIA. 525............ \7\ OTHER HEART

1.6479

35.5

29.6 ASSIST SYSTEM IMPLANT. 528............ \7\ INTRACRANIAL 1.6479

35.5

29.6 VASCULAR PROC W PDX HEMORRHAGE. 529............ \5\ VENTRICULAR

1.6479

35.5

29.6 SHUNT PROCEDURES W CC. 530............ \7\ VENTRICULAR

1.6479

35.5

29.6 SHUNT PROCEDURES W/O CC. 531............ \5\ SPINAL

1.6479

35.5

29.6 PROCEDURES WITH CC. 532............ \3\ SPINAL

0.7858

25.2

21.0 PROCEDURES WITHOUT CC. 533............ \5\ EXTRACRANIAL 1.6479

35.5

29.6 VASCULAR PROCEDURES WITH CC. 534............ \7\ EXTRACRANIAL 1.1162

29.5

24.6 VASCULAR PROCEDURES WITHOUT CC. 535............ \5\ CARDIAC

1.6479

35.5

29.6 DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK. 536............ \7\ CARDIAC

1.6479

35.5

29.6 DEFIB IMPLANT W CARDIAC CATH W/ O AMI/HF/SHOCK. 537............ LOCAL EXCISION

1.4500

39.6

33.0 AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC. 538............ \4\ LOCAL

1.1162

29.5

24.6 EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC. 539............ \4\ LYMPHOMA AND 1.1162

29.5

24.6 LEUKEMIA WITH MAJOR O.R. PROCEDURE WITH CC. 540............ \7\ LYMPHOMA AND 0.4109

17.1

14.3 LEUKEMIA WITH MAJOR O.R. PROCEDURE WITHOUT CC. 541............ ECMO OR TRACH W

3.8042

57.7

48.1 MECH VENT 96+ HRS OR PDX EXCEPT FACE,MOUTH & NECK DIAG WITH MAJOR OR. 542............ TRACH W MECH

2.8365

44.7

37.3 VENT 96+ HRS OR PDX EXCEPT FACE,MOUTH & NECK DIAG WITHOUT MAJOR OR. 543............ \5\ CRANIOTOMY W 1.6479

35.5

29.6 IMPLANT OF CHEMO AGENT OR ACUTE COMPLEX CNS PDX. 544............ \5\ MAJOR JOINT

1.6479

35.5

29.6 REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY. 545............ \5\ REVISION OF

1.6479

35.5

29.6 HIP OR KNEE REPLACEMENT. 546............ \7\ SPINAL

1.6479

35.5

29.6 FUSION EXCEPT CERVICAL WITH CURVATURE OF SPINE OR MALIGNANCY.

[[Page 24403]]

547............ \7\ CORONARY

1.6479

35.5

29.6 BYPASS WITH CARDIAC CATH WITH MAJOR CV DIAGNOSIS. 548............ \7\ CORONARY

1.6479

35.5

29.6 BYPASS WITH CARDIAC CATH WITHOUT MAJOR CV DIAGNOSIS. 549............ \7\ CORONARY

1.6479

35.5

29.6 BYPASS WITHOUT CARDIAC CATH WITH MAJOR CV DIAGNOSIS. 550............ \7\ CORONARY

1.6479

35.5

29.6 BYPASS WITHOUT CARDIAC CATH WITHOUT MAJOR CV DIAGNOSIS. 551............ PERMANENT

1.6087

29.5

24.6 CARDIAC PACEMAKER IMPLANT WITH MAJOR CV DIAGNOSIS OR AICD LEAD OR GNRTR. 552............ \4\ OTHER

1.1162

29.5

24.6 PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT MAJOR CV DIAGNOSIS. 553............ OTHER VASCULAR

1.5536

31.8

26.5 PROCEDURES WITH CC WITH MAJOR CV DIAGNOSIS. 554............ OTHER VASCULAR

1.2892

31.6

26.3 PROCEDURES WITH CC WITHOUT MAJOR CV DIAGNOSIS. 555............ \3\ PERCUTANEOUS 0.7858

25.2

21.0 CARDIOVASCULAR PROC WITH MAJOR CV DIAGNOSIS. 556............ \7\ PERCUTANEOUS 0.4109

17.1

14.3 CARDIOVASCULAR PROC WITH NON- DRUG-ELUTING STENT WITHOUT MAJOR CV DIAGNOSIS. 557............ \4\ PERCUTANEOUS 1.1162

29.5

24.6 CARDIOVASCULAR PROC WITH DRUG- ELUTING STENT WITH MAJOR CV DIAGNOSIS. 558............ \7\ PERCUTANEOUS 0.4109

17.1

14.3 CARDIOVASCULAR PROC WITH DRUG- ELUTING STENT WITHOUT MAJOR CV DIAGNOSIS. 559............ \7\ ACUTE

0.7858

25.2

21.0 ISCHEMIC STROKE WITH USE OF THROMBOLYTIC AGENT.

\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 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 5.

\6\ Proposed relative weights for these proposed LTC-DRGs were assigned a value of 0.0000. \7\ Proposed relative weights for these LTC-DRGs were determined by assigning these cases to the appropriate proposed low volume quintile because they had no LTCH cases in the FY 2005 MedPAR file. \8\ Proposed relative weights for these proposed LTC-DRGs were determined after adjusting to account for nonmonotonicity (see step 5 above).

[[Page 24404]]

Appendix A--Regulatory Impact Analysis

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

I. Overall Impact

We have examined the impacts of this proposed rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review) and the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132.

Executive Order 12866 (as amended by Executive Order 13258, which merely reassigns responsibility of duties) directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any 1 year).

We have determined that this proposed rule is a major rule as defined in 5 U.S.C. 804(2). We estimate that the proposed changes for FY 2007 operating and capital payments will redistribute in excess of $100 million among different types of inpatient cases. Further, the market basket update to IPPS rates required by the statute will result in an approximate $3.33 billion increase in FY 2007 operating and capital payments. This amount does not reflect changes in hospital admissions or case-mix intensity, which would also affect overall payment changes.

The RFA requires agencies to analyze options for regulatory relief of small businesses. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and government agencies. Most hospitals and most other providers and suppliers are considered to be small entities, either by nonprofit status or by having revenues of $6 million to $29 million in any 1 year. (For details, see the Small Business Administration's final rule that sets forth size standards for health care industries at 65 FR 69432, November 17, 2000.) For purposes of the RFA, all hospitals and other providers and suppliers are considered to be small entities. Individuals and States are not included in the definition of a small entity. We believe that this proposed rule will have a significant impact on small entities as explained in this Appendix. Because we acknowledge that many of the affected entities are small entities, the analysis discussed throughout the preamble of this proposed rule constitutes our initial regulatory flexibility analysis. Therefore, we are soliciting comments on our estimates and analysis of the impact of this proposed rule on those small entities.

In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis for any proposed rule that may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 603 of the RFA. With the exception of hospitals located in certain New England counties, for purposes of section 1102(b) of the Act, we previously defined a small rural hospital as a hospital with fewer than 100 beds that is located outside of a Metropolitan Statistical Area (MSA) or New England County Metropolitan Area (NECMA). However, under the 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 that is located outside of an MSA and has fewer than 100 beds. Section 601(g) of the Social Security Amendments of 1983 (Pub. L. 98-21) designated hospitals in certain New England counties as belonging to the adjacent NECMA. Thus, for purposes of the IPPS, we continue to classify these hospitals as urban hospitals.

Section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4) also requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any 1 year of $100 million in 1995 dollars, updated annually for inflation. That threshold level is currently approximately $120 million. This proposed rule will not mandate any requirements for State, local, or tribal governments, nor will it affect private sector costs.

Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications. As stated above, this proposed rule will not have a substantial effect on State and local governments.

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 Hospital Insurance Trust Fund.

We believe the 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 2007, 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, generally, we do not attempt to predict behavioral responses to our policy changes (with the exception of the anticipated improvements in documentation and coding that may lead to increases in observed but not real case-mix in response to the adoption of consolidated severity DRGs in FY 2008 (if not earlier), 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 timely 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 2006, there are 3,539 IPPS hospitals to be included in our analysis. This represents about 59 percent of all Medicare- participating hospitals. The majority of this impact analysis focuses on this set of hospitals. There are also approximately 1,274 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 1,188 specialty hospitals and units that are excluded from the IPPS. These specialty hospitals include psychiatric hospitals and units (now referred to as IPFs), rehabilitation hospitals and units (now referred to as IRFs), long- term care hospitals (now referred to as LTCHs), Religious Non- Medical Health Care Institutions (RNHCIs), children's hospitals, and cancer hospitals. The impacts of our proposed policy changes on these hospitals are discussed below.

V. Effects on Excluded Hospitals and Hospital Units

As of March 2006, there were 1,188 hospitals excluded from the IPPS. Of these 1,188 hospitals, 476 IPFs, 81 children's hospitals, 11 cancer hospitals, and 17 RNHCIs 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

[[Page 24405]]

remaining providers, 217 IRFs and 386 LTCHs, are paid 100 percent of the Federal prospective rate under the IRF PPS and the LTCH PPS, respectively. (We note that, currently, there are 16 LTCHs that are being paid under the LTCH PPS transition blend methodology, which is based in part on a reasonable cost that is subject to a rate-of- increase ceiling under Sec. 413.40. For cost reporting periods that will begin during FY 2007, these LTCHs will no longer receive a portion of their payment that is based in part on a reasonable cost subject to a rate-of-increase ceiling under Sec. 413.40 because, in accordance with Sec. 412.533, LTCHs are paid 100 percent of the adjusted Federal prospective payment amount for cost reporting periods beginning on or after October 1, 2006. In addition, there are 1,317 IPFs (paid on a blend of the IPF PPS per diem payment and the TEFRA reasonable cost-based payment) and 1,011 IRFs (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 93 IPPS excluded hospitals and units in Maryland that are paid in accordance with the waiver at section 1814(b)(3) of the Act.

In the past, hospitals and units excluded from the IPPS have been paid based on their reasonable costs subject to limits as established by the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA). Hospitals that continue to be paid fully on a reasonable cost basis are subject to TEFRA limits for FY 2007. For these hospitals (cancer and children's hospitals), consistent with section 1886(b)(3)(B)(ii) of the Act, the proposed update will be the percentage increase in the FY 2007 IPPS operating market basket, currently estimated to be 3.4 percent. In addition, in accordance with Sec. 403.752(a) of the regulations, RNHCIs are paid under Sec. 413.40, which also uses section 1886(b)(3)(B)(ii) of the Act to update the percentage increase in the rate-of-increase limits. For RNHCIs, the proposed update will be the percentage increase in the FY 2007 IPPS operating market basket increase, currently estimated to be 3.4 percent.

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 2007, the IRF PPS is based on 100 percent of the adjusted Federal IRF prospective payment amount, updated annually. Therefore, these hospitals are not affected 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. Existing LTCHs 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, unless the LTCH elects 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. Under Sec. 412.533, the 5-year transition period for all existing hospitals subject to the LTCH PPS begins with the LTCH's first cost reporting period beginning on or after October 1, 2002, and extends through the LTCH's cost reporting period beginning on or after October 1, 2006. In accordance with Sec. 412.533, for cost reporting periods beginning on or after October 1, 2006, the LTCH PPS transition blend percentages are 100 percent of the Federal prospective payment amount and zero percent of the amount calculated under reasonable cost principles. Therefore, even though FY 2007 is the fifth year of the 5-year transition period established under Sec. 412.533, because the reasonable cost principles amount is zero percent for cost reporting periods beginning during FY 2007, LTCHs will no longer receive a portion of their payment that is based in part on a reasonable cost subject to the rate-to-increase ceiling beginning with cost reporting periods beginning on or after October 1, 2006. Thus, there is no longer a need for an update factor for LTCH's TEFRA target amount for FY 2007 and beyond.

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 IPFs. The final rule implementing the IPF PPS (69 FR 66922) established a 3-year transition to the IPF PPS during which some providers will receive a blend of the IPF PPS per diem payment and the TEFRA reasonable cost-based payment. For purposes of determining what the TEFRA payment to the IPF will be, we updated the IPF's TEFRA target amount by the excluded hospital market basket percentage increase of 3.6 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 Effects of the Proposed Policy Changes Under the IPPS for Operating Costs

A. Basis and Methodology of Estimates

In this proposed rule, we are announcing policy changes and payment rate updates for the IPPS for operating costs. Changes to the capital payments are discussed in section VIII. of this Appendix. Based on the overall percentage change in payments per case estimated using our payment simulation model (a 3.4 percent increase), we estimate that total FY 2007 operating and capital payments will increase $3.33 billion compared to FY 2006 largely due to the statutorily mandated update to IPPS rates. 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 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 2005 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. (However, as we indicated earlier, we are planning to adopt a severity DRG system in FY 2008 (if not earlier) and expect to make adjustments to the standardized amounts to account for anticipated improvements in documentation and coding that may lead to increases in observed but not real case mix). Second, due to the interdependent nature of the IPPS payment components, it is very difficult to precisely quantify the impact associated with each proposed change. Third, we use various sources for the data used to categorize hospitals in the tables. In some cases, particularly the number of beds, there is a fair degree of variation in the data from different sources. We have attempted to construct these variables with the best available source overall. However, for individual hospitals, some miscategorizations are possible.

Using cases from the FY 2005 MedPAR file, we simulated payments under the operating IPPS given various combinations of payment parameters. Any short-term, acute

[[Page 24406]]

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 2007 changes to the capital IPPS are discussed in section VIII. of this Appendix.

The proposed changes discussed separately below are the following:

The effect of a reduced update to the standardized amount for hospitals that do not comply with section 1886(b)(3)(B)(viii) of the Act by submitting quality data in accordance with our requirements.

The effects of the MDH payment changes set forth in section 5003 of Pub. L. 109-171.

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 2003, compared to the FY 2002 wage data.

The effects of the proposed wage and recalibration budget neutrality factors.

The effects 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 2007.

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 2007 policies and MMA-imposed changes relative to payments based on FY 2006 policies.

To illustrate the impacts of the proposed FY 2007 changes, our analysis begins with a FY 2006 baseline simulation model using: The proposed update of 3.4 percent; the FY 2006 DRG GROUPER (version 23.0); the CBSA designations for hospitals based on OMB's June 2003 MSA definitions; the FY 2006 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, and amended by section 5001(a) of Pub. L. 109-171, provides that, for FYs 2005 through 2006, the update factors will be reduced by 0.4 percentage points for any hospital that does not submit quality data. Section 5001(a) of Pub. L. 109- 171 provides that for FY 2007 and subsequent years, the update factor will be reduced by 2.0 percentage points for any hospital that does not submit quality data or that fails the quality data validation process. At the time this impact was prepared, 115 providers did not receive the full market basket rate-of-increate for FY 2006 because they failed the quality data submission process. For purposes of the simulations shown below, we modeled the payment changes for FY 2007 using a reduced update for these 115 hospitals. However, we do not have enough information to determine which hospitals will not receive the full market basket rate-of-increase for FY 2007 at this time.

Each proposed and statutory policy change is then added incrementally to this baseline, finally arriving at an FY 2007 model incorporating all of the proposed changes. This simulation allows us to isolate the effects of each proposed change.

Our final comparison illustrates the percent change in payments per case from FY 2006 to FY 2007. 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 2007 using the most recently forecasted hospital market basket increase for FY 2007 of 3.4 percent. (Hospitals that fail to comply with the quality data submission requirement to receive the full update will receive an update reduced by 2.0 percentage points to 1.4 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 3.4 percent.

A second significant factor that affects changes in hospitals' payments per case from FY 2006 to FY 2007 is the change in MGCRB status from one year to the next. That is, payments may be reduced for hospitals reclassified in FY 2006 that are no longer reclassified in FY 2007. Conversely, payments may increase for hospitals not reclassified in FY 2006 that are reclassified in FY 2007. In some cases, these impacts can be quite substantial, so if a relatively small number of hospitals in a particular category lose their reclassification status, the percentage change in payments for the category may be below the national mean. However, this effect is alleviated by section 1886(d)(10)(D)(v) of the Act, which provides that reclassifications for purposes of the wage index are for a 3- year period.

A third significant factor is that we currently estimate that actual outlier payments during FY 2006 will be 4.7 percent of total DRG payments. When the FY 2006 final rule was published, we projected FY 2006 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 2006 (as discussed in the Addendum to this proposed rule) are reflected in the analyses below comparing our current estimates of FY 2006 payments per case to estimated FY 2007 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 2007. 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 3,522 hospitals included in the analysis. There are 222 fewer hospitals than were included in the impact analysis in the FY 2006 final rule (70 FR 47690).

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 2,517 hospitals located in urban areas included in our analysis. Among these, there are 1,391 hospitals located in large urban areas (populations over 1 million), and 1,126 hospitals in other urban areas (populations of 1 million or fewer). In addition, there are 1,005 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' proposed FY 2007 payment classifications, including any reclassifications under section 1886(d)(10) of the Act. For example, the rows labeled urban, large urban, other urban, and rural show that the number of hospitals paid based on these categorizations after consideration of geographic reclassifications (including reclassifications under 1886(d)(8)(B) and 1886(d)(8)(E) which have implications for capital payments) are 2,539, 1,400, 1,139, and 983, 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 2,449 non-teaching hospitals in our analysis, 836 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 (sole community hospitals (SCHs), rural referral centers (RRCs), and Medicare dependent hospitals (MDHs)), as well as rural hospitals not receiving a special payment designation. There were 140 RRCs, 341 SCHs, 126 MDHs, 80 hospitals that are both SCHs and RRCs and 8 hospitals that are both MDHs and RRCs.

The next two groupings are based on type of ownership and the hospital's Medicare utilization expressed as a percent of total patient days. These data are taken primarily from the FY 2004 Medicare cost reports, if available (otherwise FY 2003 data are used).

The next series of groupings concern the geographic reclassification status of

[[Page 24407]]

hospitals. The first grouping displays all urban hospitals that were reclassified by the MGCRB for FY 2007. The next grouping shows the MGCRB rural reclassifications. The final three rows in Table I contain hospitals located in urban counties, but deemed to be rural under section 1886(d)(8)(E) of the Act, hospitals located in rural counties but deemed to be urban under section 1886(d)(8)(B) of the Act, and hospitals currently reclassified under section 508 of Public Law 108-173, which expires on March 31, 2007.

Table I.--Impact Analysis of Proposed Changes for FY 2007

Wage index Hospital

DRG rel. transition Quality

specific

wts. and for

Out- All FY No. of data rate DRA MDH costs FY 2007 wage hospitals

MGCRB

migration 2007 hospitals difference provisions wts, DRG wage data index moving reclassifications adjustment changes \1\

\2\

\3\ changes \5\ changes from urban

\8\

\9\

\10\ \4\

\6\ to rural \7\ (1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

All Hospitals................. 3,522

0.0

0.1

0.1

0.0

0.0

0.0

0.0

0.1

3.4 By Geographic Location:

Urban hospitals........... 2,517

0.0

0.0 -0.2

0.1 -0.4

0.0

-0.3

0.1

3.0

Large urban areas

1,391

0.0

0.0

0.1

0.0

0.0

0.0

-0.5

0.0

3.4 (populations over 1 million).................

Other urban areas

1,126

0.0

0.0 -0.8

0.1 -0.8

0.0

-0.2

0.1

2.5 (populations of 1 million or fewer)................

Rural hospitals........... 1,005

0.0

0.5

3.0

0.0

2.8

0.3

2.2

0.1

6.7

Bed Size (Urban): 0-99 beds.............

590

-0.1

0.1

0.9

0.1

0.8

0.0

-0.5

0.0

4.1 100-199 beds..........

865

0.0

0.0

1.9

0.2

2.0

0.0

-0.2

0.0

5.2 200-299 beds..........

482

0.0

0.0

0.1

0.1

0.0

0.0

-0.3

0.1

3.4 300-499 beds..........

414

0.0

0.0 -1.1

0.1 -1.2

0.0

-0.4

0.1

2.2 500 or more beds......

166

0.0

0.0 -1.5 -0.1 -1.8

0.0

-0.4

0.0

1.6

Bed Size (Rural): 0-49 beds.............

349

-0.1

0.9

5.8 -0.1

5.7

0.1

0.9

0.2 10.1 50-99 beds............

366

0.0

1.3

4.6

0.0

4.5

0.3

1.1

0.2

9.3 100-149 beds..........

179

0.0

0.1

3.0

0.0

2.9

0.5

2.6

0.1

6.2 150-199 beds..........

64

0.0

0.0

1.2 -0.1

1.0

0.5

3.7

0.1

4.2 200 or more beds......

47

0.0

0.0 -0.1 -0.2 -0.4

0.0

3.3

0.0

2.9

Urban by Region: New England...........

127

0.0

0.0

0.5

0.7

1.0

0.0

0.4

0.0

3.2 Middle Atlantic.......

353

0.0

0.0

0.1

0.2

0.1

0.0

-0.1

0.1

3.0 South Atlantic........

381

0.0

0.0 -0.6 -0.4 -1.1

0.0

-0.4

0.0

2.6 East North Central....

388

0.0

0.0 -0.2

0.2 -0.2

0.0

0.3

0.0

3.0 East South Central....

163

0.0

0.0 -0.7 -0.4 -1.3

0.0

-0.5

0.1

2.5 West North Central....

156

0.0

0.0 -1.2 -0.1 -1.4

0.0

-0.7

0.0

2.1 West South Central....

350

0.0

0.0 -0.5 -0.4 -1.1

0.0

-0.6

0.0

2.6 Mountain..............

143

0.0

0.0 -1.1

0.6 -0.6

0.0

-0.4

0.0

3.0 Pacific...............

404

0.0

0.0

0.7

0.6

1.1

0.0

-0.3

0.1

4.5 Puerto Rico...........

52

0.0

0.0

3.2 -1.4

1.6

0.0

-0.7

0.0

5.0

Rural by Region: New England...........

19

0.0

2.6

1.9 -0.4

1.5

0.0

2.1

0.1

7.7 Middle Atlantic.......

72

0.0

1.2

2.9

0.3

3.1

0.1

2.1

0.0

7.7 South Atlantic........

175

0.0

0.2

3.7

0.0

3.5

0.2

2.3

0.2

6.9 East North Central....

125

0.0

0.6

2.0 -2.0

1.7

0.1

1.7

0.0

5.8 East South Central....

181

0.0

0.2

3.1

0.0

2.9

0.2

2.8

0.1

6.4 West North Central....

118

0.0

0.9

1.9

0.1

2.0

0.0

2.0

0.1

6.3 West South Central....

191

0.0

0.4

3.8 -0.1

3.6

0.6

3.0

0.2

7.1 Mountain..............

80

0.0

0.0

2.7 -0.2

2.5

2.3

0.6

0.1

5.6 Pacific...............

44

0.0

0.3

3.7

0.1

3.8

0.0

1.9

0.1

7.4 By Payment Classification:

Urban hospitals........... 2,539

0.0

0.0 -0.2

0.1 -0.3

0.0

-0.3

0.1

3.0

Large urban areas

1,400

0.0

0.0

0.1

0.0

0.0

0.0

-04

0.0

3.4 (populations over 1 million).................

Other urban areas

1,139

0.0

0.0 -0.7

0.1 -0.8

0.0

-0.2

0.1

2.5 (populations of 1 million or fewer)................

Rural Areas...............

983

0.0

0.5

2.9

0.0

2.7

0.3

2.1

0.1

6.6

Teaching Status: Nonteaching........... 2,449

0.0

0.1

1.3

0.0

1.2

0.0

0.2

0.1

4.8 Fewer than 100

836

0.0

0.0 -0.7

0.0 -0.9

0.0

-0.2

0.0

2.6 residents............ 100 or more residents.

237

0.0

0.0 -0.9

0.2 -0.9

0.0

-0.3

0.0

2.6

Urban DSH: Non-DSH...............

854

0.0

0.1 -0.8

0.0 -1.0

0.0

-0.1

0.0

2.6 100 or more beds...... 1,513

0.0

0.0 -0.1

0.1 -0.2

0.0

-0.3

0.1

3.1 Less than 100 beds....

333

0.0

0.1

3.7

0.3

3.9

0.0

-0.4

0.0

7.2

Rural DSH: SCH...................

383

0.0

0.9

4.4

0.0

4.4

0.3

0.7

0.1

8.7 RRC...................

196

0.0

0.1

1.5 -0.1

1.3

0.2

3.7

0.0

4.6

Other Rural: 100 or more beds......

55

0.0

0.0

4.5

0.2

4.5

1.1

1.0

0.3

7.2 Less than 100 beds....

188

-0.1

0.0

5.8

0.0

5.7

0.4

1.0

0.4

9.1

Urban teaching and DSH: Both teaching and DSH.

809

0.0

0.0 -0.6

0.0 -0.8

0.0

-0.4

0.0

2.5 Teaching and no DSH...

198

0.0

0.0 -1.4

0.1 -1.5

0.0

-0.1

0.1

1.6 No teaching and DSH... 1,037

0.0

0.0

1.3

0.1

1.3

0.0

-0.2

0.1

4.7 No teaching and no DSH

495

0.0

0.0 -0.6 -0.1 -0.9

0.0

-0.3

0.0

2.8

Rural Hospital Types: Non special status

288

-0.1

0.0

5.1

0.1

5.0

0.8

1.0

0.4

8.2 hospitals............

[[Page 24408]]

RRC...................

140

0.0

0.0

1.1 -0.1

0.9

0.3

4.3

0.0

4.3 SCH...................

341

0.0

0.0

4.1

0.0

4.0

0.3

0.5

0.1

7.5 MDH...................

126

0.0

5.9

5.3

0.0

5.2

0.0

0.8

0.1 14.6 SCH and RRC...........

80

0.0

0.0

1.1 -0.2

0.9

0.0

2.2

0.0

4.1 MDH and RRC...........

8

0.0

12.8

2.6

0.0

2.7

0.0

0.8

0.0 17.5

Type of Ownership: Voluntary............. 2,087

0.0

0.1 -0.1

0.1 -0.2

0.0

-0.1

0.1

3.1 Proprietary...........

831

0.0

0.0

0.3 -0.1

0.0

0.1

0.0

0.0

3.7 Government............

604

0.0

0.1

1.2

0.1

1.2

0.0

0.1

0.1

4.7 Medicare Utilization as a Percent of Inpatient Days:

0-25......................

252

0.0

0.0

2.3

0.5

2.6

0.0

-0.3

0.0

5.8

25-50..................... 1,302

0.0

0.0 -0.4

0.0 -0.6

0.0

-0.4

0.0

2.8

50-65..................... 1,490

0.0

0.1

0.5

0.1

0.4

0.0

0.4

0.1

3.9

Over 65...................

459

0.0

0.4

0.5 -0.1

0.2

0.0

0.5

0.1

4.1

Unknown...................

19

-0.2

0.0

3.8

0.5

4.1

0.0

-0.3

0.0

8.2 Urban Hospitals Reclassified

319

0.0

0.0 -0.3

0.2 -0.3

0.0

2.1

0.0

3.1 by the Medicare Geographic Classification Review Board: First Half FY 2007 Reclassifications............ Urban Nonreclassified, First

2,119

0.0

0.0 -0.2

0.0 -0.4

0.0

-0.7

0.1

3.1 Half FY 2007................. All Urban Hospitals

339

0.0

0.0 -0.2

0.1 -0.2

0.0

1.9

0.0

3.2 Reclassified Second Half FY 2007......................... Urban Nonreclassified

2,099

0.0

0.0 -0.2

0.0 -0.4

0.0

-0.7

0.1

3.1 Hospitals Second Half FY 2007 All Rural Hospitals

385

0.0

0.5

1.8

0.0

1.6

0.1

3.8

0.0

5.3 Reclassified Full Year FY 2007......................... Rural Nonreclassified

604

-0.1

0.6

4.8

0.0

4.6

0.6

0.0

0.3

8.8 Hospitals Full Year 2007..... All Section 401 Reclassified

38

0.0

3.0

3.1

0.1

3.2

0.0

-0.3

0.0

9.2 Hospitals.................... Other Reclassified Hospitals

54

-0.1

0.5

4.8

0

4.7

0.0

4.0

0.0

8.7 (Section 1886(d)(8)(B))...... Section 508 Hospitals.........

95

0.0

0.0 -0.4

0.3 -0.2

0.0

-0.2

0.1 0.6

\1\ Because data necessary to classify some hospitals by category were missing, the total number of hospitals in each category may not equal the national total. Discharge data are from FY 2003, and hospital cost report data are from reporting periods beginning in FY 2002 and FY 2001. \2\ This column displays the payment impact of the hospitals that did not submit quality update information. \3\ This column displays the impact of the Deficit Reduction Act section 5003 that apply to Medicare Dependent Hospitals. \4\ This column displays the payment impact of the changes to the V24 GROUPER and the recalibration of the DRG HSRVcc weights based on FY 2005 MedPAR data in accordance with section 1886(d)(4)(C)(iii) of the Act. \5\ This column displays the payment impact of updating the wage index data to the FY 2003 cost report data. \6\ This column displays the payment impact of the budget neutrality factor for DRG and wage index changes data in accordance with section 1886(d)(4)(C)(iii) of the Act and section 1886(d)(3)(E) of the Act. \7\ Shown here are the effects of providing rural hospitals formerly located in urban areas with urban wage index values in FY 2007. The effects reflected here are budget neutral: this column therefore includes the effect of the 0.999591 adjustment that we have applied to the rates to ensure budget neutrality. \8\ Shown here are the effects of geographic reclassifications by the Medicare Geographic Classification Review Board (MGCRB). The effects demonstrate the FY 2007 payment impact of going from no reclassifications to the reclassifications scheduled to be in effect for FY 2007. Reclassification for prior years has no bearing on the payment impacts shown here. This column reflects the geographic budget neutrality factor of 0.991727. \9\ This column displays the impact of the FY 2007 implementation 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. \10\ This column shows changes in payments from FY 2006 to FY 2007. It incorporates all of the changes displayed in Columns 3, 4, 7, 8, and 9 (the changes displayed in Columns 5 and 6 are included in Column 7). It also reflects the impact of the FY 2007 update, changes in hospitals' reclassification status in FY 2007 compared to FY 2006, and the changes in payments as a result of continuing the reclassifications under section 508 of Pub. L. 108-173. The sum of these impacts may be different from the percentage changes shown here due to rounding and interactive effect.

C. Effects on the Hospitals That Failed the Quality Data Submission Process (Column 2)

Column 2 of Table I shows the effect of assigning a reduced update to the standardized amount to hospitals that either fail to submit quality data or fail the data validation requirements. This column shows the effect of paying these providers based on an update of market basket, less 2.0 percentage points (1.4 percent) relative to a full market basket update (3.4 percent), for FY 2007. There are 115 hospitals in this analysis that we expect will not receive the full market basket update for FY 2007. Most of these hospitals are either small rural or small urban hospitals. We project that these hospitals will receive an overall decrease in payments of 0.1 percent from last year's payment.

D. Effects of the DRA Provision Related to MDHs (Column 3)

In Column 3 of Table I, we show the effects of implementing section 5003 of Pub. L. 109-171 for MDHs. Section 5003 requires MDHs to rebase their hospital-specific rate to the FY 2002 cost reporting period, if doing so increases their target amount. It also increases the hospital-specific payment amount from the Federal rate plus 50 percent of the difference between the Federal rate and the hospital- specific amount (presuming the hospital-specific amount exceeds the Federal amount) to the Federal rate plus 75 percent of the difference. In addition, MDHs are no longer subject to the 12- percent cap on their DSH payments, effective FY 2007.

This column compares the FY 2007 payment rates under the section 5003 provisions to payments under the FY 2006 MDH provisions. (The MDH provisions were set to expire at the end of FY 2006 but were extended by section 5003(a)(1)). Overall, hospitals experience a 0.1 percent increase. This is primarily due to the substantial increase in payments to MDH providers; MDH providers experience a 5.9 percent increase while MDH/RRC combination providers experience a 12.8 percent increase.

E. Effects of the Changes to the DRG Reclassifications and Relative Cost-Based Weights (Column 4)

In Column 4 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 in order to reflect changes in treatment patterns, technology, and any other

[[Page 24409]]

factors that may change the relative use of hospital resources.

As discussed in the preamble of this proposed rule, we are proposing to change the relative weight calculation methodology from a charge-based method to a hospital specific, cost center adjusted method. In this column, we compare aggregate payments using the proposed FY 2007 hospital-specific cost weights (GROUPER Version 24) to the FY 2006 DRG relative charge weights (GROUPER Version 23.0). This method is described in more detail in section II of the preamble to this proposed rule. We note that, consistent with section 1886(d)(4)(C)(iii) of the Act, we have applied a budget neutrality factor to ensure that the overall payment impact of the DRG changes (combined with the wage index changes) is budget neutral. This budget neutrality factor of 0.998363 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 4. We have not proposed substantial changes to the FY 2007 GROUPER in this rule so most of the differences observed in this column illustrate the effect of setting the relative weights under the HSRVcc methodology, which is discussed in detail in section II.C. of the preamble to this proposed rule.

In general, surgical DRGs tend to have charges concentrated in ancillary cost center groups while medical DRGs tend to have charges concentrated in routine or intensive care unit (ICU) cost center groups. As discussed in the preamble of this proposed rule, the cost to charge ratios for ancillary cost center groups are lower than the cost to charge ratios for routine and ICU cost center groups, indicating that the charge mark ups for ancillary services are higher. Because the HSRVcc weighting methodology adjusts the weights to remove differential mark-ups in charges, the FY 2007 weights are redistributed among medical and surgical DRGs, which will result in a redistribution of payments among hospitals according to the types of cases they provide. For instance, hospitals that perform more surgical procedures are likely to experience decreases in payments while hospitals with heavy concentrations of medical DRGs are expected to experience increases in payments. Hospitals with a case- mix that is equal to average will see little or no change in payment.

Rural DSH hospitals with less than 100 beds and small rural hospitals (0-49 beds) show the greatest increase in payments of 5.8 percent. Urban hospitals with more than 500 beds and teaching hospitals with no DSH payments have the largest decrease in payments with declines of 1.5 and 1.4 percent respectively. Urban hospitals in West North Central, Mountain, East South Central, South Atlantic, West South Central, and East North Central experience decreases in payment of .2 to 1.2 percent.

F. Effects of Proposed Wage Index Changes (Column 5)

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 2007 is based on data submitted for hospital cost reporting periods beginning on or after October 1, 2002 and before October 1, 2003. The impact of the new data on hospital payments is isolated in Column 5 by holding the other payment parameters constant in this simulation. That is, Column 5 shows the percentage changes in payments when going from a model using the FY 2006 wage index, based on FY 2002 wage data, to a model using the proposed FY 2007 pre-reclassification wage index, based on FY 2003 wage data. The wage data collected on the FY 2003 cost report are the same as the FY 2002 wage data those were used to calculate the FY 2006 wage index.

Column 5 shows the impacts of updating the wage data using FY 2003 cost reports. Overall, the new wage data will lead to a 0.0 percent change for all hospitals and a 0.1 percent increase for hospitals in urban areas. This increase is due to fluctuations in the wage data. Among regions, the largest increase is in the urban New England region, which experiences a 0.7 percent increase. The largest decline from updating the wage data is seen in the Puerto Rico region (a 1.4 percent decrease).

In looking at the wage data itself, the national average hourly wage increased 5.7 percent compared to FY 2006. Therefore, the only manner in which to maintain or exceed the previous year's wage index was to match or exceed the national 5.7 percent increase in average hourly wage. Of the 3,500 hospitals with wage data for both FYs 2006 and 2007, 1,606, or 45.9 percent, also experienced an average hourly wage increase of 5.7 percent or more.

The following chart compares the shifts in wage index values for hospitals for FY 2007 relative to FY 2006. Among urban hospitals, 45 will experience an increase of between 5 percent and 10 percent and 3 will experience an increase of more than 10 percent. No rural hospitals will experience increases greater than 5 percent. However, 996 rural hospitals will experience increases or decreases of less than 5 percent, while 2,380 urban hospitals will experience increases or decreases of less than 5 percent. Sixty urban hospitals will experience decreases in their wage index values of at least 5 percent, but less than 10 percent. Twelve urban hospitals will experience decreases in their wage index values of greater than 10 percent. Four rural hospitals will experience decreases of more than 10 percent.

The following chart shows the projected impact for urban and rural hospitals.

Number of hospitals Percentage change in area wage index values ------------------------- Urban

Rural

Increase more than 10 percent.................

3

0 Increase more than 5 percent and less than 10

45

0 percent...................................... Increase or decrease less than 5 percent......

2,380

996 Decrease more than 5 percent and less than 10

60

0 percent...................................... Decrease more than 10 percent.................

12

4

G. Combined Effects of Proposed DRG and Wage Index Changes, Including Budget Neutrality Adjustment (Column 6)

The impact of the DRG reclassifications 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, in determining the budget neutrality factor, we compared simulated aggregate payments using the FY 2006 DRG relative weights, the blended wage index, and labor share percentage to simulated aggregate payments using the proposed FY 2007 DRG relative weights and wage index.

We computed a wage and DRG recalibration budget neutrality factor of 0.998363. 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 the updated wage index are shown in Column 6. The changes in this column are the sum of the proposed changes in Columns 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.

Small rural hospitals show a 5.7 percent increase in payments that is primarily due to the change to the relative weight methodology used in the DRG recalibration process. Among urban regions, the largest impacts are in the Pacific region and Puerto Rico, with 1.1 and 1.6 percent increases, respectively. The West North Central region experiences the largest decrease of 1.4 percent. Among rural regions, the Pacific region benefits the most with a 3.8 percent increase, while the New England region experiences the smallest increase (1.5 percent).

[[Page 24410]]

H. Effects of the 3-Year Provision Allowing Urban Hospitals That Were Converted to Rural as a Result of the FY 2005 Labor Market Area Changes To Maintain the Wage Index of the Urban Labor Market Area in Which They Were Formerly Located (Column 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 0.999591 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. Effects 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 other bases 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 2007 which affect hospitals' wage index area assignments.

By February 28 of each year, the MGCRB makes reclassification determinations that will be effective for the next fiscal year, which begins on October 1. The MGCRB may approve a hospital's reclassification request for the purpose of using another area's wage index value. The proposed FY 2007 wage index values incorporate all of the MGCRB's reclassification decisions for FY 2007. The wage index values also reflect any decisions made by the CMS Administrator through the appeals and review process through February 28, 2006.

For FY 2007, as stated in the FY 2006 IPPS final rule (70 FR 47382, August 12, 2005), we established procedural rules under section 1886(d)(10)(D)(v) of the Act to address specific circumstances where individual and group reclassifications involve a section 508 hospital. The rules were designed to recognize the special circumstances of section 508 hospital reclassifications ending mid-year during FY 2007 and were intended to allow previously approved reclassifications to continue through March 31, 2007, and new section 1886(d)(10) reclassifications to begin April 1, 2007, upon the conclusion of the section 508 reclassifications. Under these procedural rules, some section 1886(d)(10) hospital reclassifications are only in effect for the second half of the fiscal year.

The first and second half fiscal year section 1886(d)(10) reclassifications permitted under these procedural rules have implications for the calculation of the reclassified wage indices and the reclassification budget neutrality factor. Section 1886(d)(8)(c) of the Act provides requirements for determining the wage index values for hospitals that were reclassified as a result of the MGCRB decisions under 1886(d)(10) of the Act. As provided in the statute, we are required to calculate a separate wage index for hospitals reclassified to an area if including the wage data for the reclassified hospitals would reduce the area wage index by more than 1 percent.

Because of the half-year reclassifications permitted under the procedural rules, in this proposed rule we are proposing to issue two separate wage indexes for affected areas (one effective from October 1, 2006 through March 31, 2007 and a second reclassified wage index effective April 1, 2007 through September 30, 2007). The proposed FY 2007 wage index values are calculated based on the wage data for hospitals reclassified to the area in the respective half of the fiscal year. The impact of this policy is modeled in Column 8 of Table I above.

The overall effect of geographic reclassification is required by section 1886(d)(8)(D) of the Act to be budget neutral. In this proposed rule, we are proposing to calculate one budget neutrality adjustment that reflects the average of the adjustments required for first and second half fiscal year reclassifications, respectively. Therefore, we applied an adjustment of 0.991727 to ensure that the effects of the section 1886(d)(10) reclassifications are budget neutral. (See section II.A. of the Addendum to this proposed rule.)

As a group, rural hospitals benefit from geographic reclassification. We estimate that their payments will rise 2.2 percent as shown 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 0.5 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 0.6 percent for the Mountain region. The largest increases are in the rural East South Central region, with an increase of 2.8 percent, and in the West South Central region, which would experience an increase of 3.0 percent.

Urban hospitals reclassified for the first half of FY 2007 are expected to receive an increase of 2.1 percent and urban hospitals reclassified for the second half of FY 2007 are expected to receive a 1.9 percent increase in payments. The same set of rural hospital providers are reclassified for the entire FY 2007 year and are expected to receive a 3.8 percent increase in payments from the MGCRB changes. Payments to urban hospitals that did not reclassify for either the first or second half of FY 2007 are expected to decrease slightly (by 0.7 percent) due to the MGCRB changes. FY 2007 payments to non-reclassifying rural hospitals are not affected by the MGCRB changes.

J. Effects 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, 321 counties and 586 hospitals qualify to receive a commuting adjustment in FY 2007.

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. Effects of All Changes (Column 10)

Column 10 compares our estimate of payments per case, incorporating all changes reflected in this proposed rule for FY 2007 (including statutory changes), to our estimate of payments per case in FY 2006. This column includes all of the proposed policy changes. Column 10 reflects all FY 2007 changes relative to FY 2006, shown in Columns 2 through 9 and those not applied until the final rates are calculated. The average increase for all hospitals is approximately 3.4 percent. This increase includes the effects of the 3.4 percent market basket update. It also reflects the 0.4 percentage point difference between the projected outlier payments in FY 2006 (5.1 percent of total DRG payments) and the current estimate of the percentage of actual outlier payments in FY 2006 (4.7 percent), as described in the introduction to this Appendix and the Addendum to this proposed rule. As a result, payments are projected to be 0.4 percentage points lower in FY 2006 than originally estimated, resulting in a 0.4 percentage point greater increase for FY 2007 than would otherwise occur. In addition, the impact of section 505 adjustments accounted for a 0.1 percent increase. 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 2006 and FY 2007 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 -0.5 percent.

There might also be interactive effects among the various factors comprising the payment system that we are not able to

[[Page 24411]]

isolate. For these reasons, the values in Column 10 may not equal the product of the percentage changes described above.

The overall change in payments per case for hospitals in FY 2007 would increase by 3.4 percent. Hospitals in urban areas would experience a 3.0 percent increase in payments per case compared to FY 2006. Hospitals in large urban areas would experience a 3.4 percent increase in payments and hospitals in other urban areas would experience a 2.5 percent increase in payments. Hospitals in rural areas, meanwhile, would experience a 6.7 percent payment increase.

Among urban census divisions, the largest payment increases would be 4.6 percent in the Pacific region and 5.0 percent in Puerto Rico. The smallest urban increase would occur in the West North Central region, with an increase of 2.1 percent.

Among rural regions in Column 10, no hospital category would experience overall payment decreases. The New England and Middle Atlantic regions would benefit the most, with 7.7 percent increases. The smallest increase would occur in the Mountain region, with a 5.6 percent increase in payments.

Among special categories of rural hospitals in Column 10, MDH/ RRC providers receive an increase in payments of 17.5 percent and MDH providers receive an increase of 14.6 percent, primarily due to the changes to MDH payments set forth in section 5003 of Pub. L. 109-171. SCHs also see a positive increase of 7.5 percent.

Urban hospitals reclassified for the first half of FY 2007 are anticipated to receive an increase of 3.1 percent, while urban hospitals that reclassified for the second half of FY 2007 are expected to receive an increase of 3.2 percent. The same set of rural hospitals is reclassified for the first and second half of FY 2007. Rural hospitals reclassifying for the entire year of FY 2007 are anticipated to receive a 5.3 percent payment increase. 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 8.7 percent. Hospitals that were reclassified under section 508 of Pub. L. 108-173, which is only effective through March 31, 2007, are expected to receive an increase of 0.6 percent. This is due in large part to the fact that the 508 wage index is only in effect for 6 months of FY 2007. Of the 95 section 508 providers listed in this row, 28 have a reduction in their FY 2007 blended final wage index (relative to their FY 2006 final wage index) of between 5 and 10 percent while 55 others have a reduction of 0 to 5 percent in their wage index values.

L. Effects of Policy on Payment Adjustments for Low-Volume Hospitals

For FY 2007, we are proposing to continue to apply the volume adjustment criteria we specified in the FY 2005 IPPS final rule (69 FR 49099). We expect that two providers would receive the low-volume adjustment for FY 2007. We estimate the impact of these providers receiving the additional 25-percent payment increase to be approximately $90,000.

M. Impact Analysis of Table II

Table II presents the projected impact of the proposed changes for FY 2007 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 2006 with the average estimated per case payments for FY 2007, 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.

Table II.--Impact Analysis of Changes for FY 2007 Operating Prospective Payment System [Payments Per Case]

Average Average FY 2006 FY 2007 All FY Number of payment payment 2007 hospitals per case per case changes; \1\

\1\ (1)

(2)

(3)

(4)

All hospitals............... 3,522 8,529 8,820

3.4 By Geographic Location:

Urban hospitals......... 2,517 8,933 9,201

3.0

Large urban areas

1,391 9,335 9,652

3.4 (populations over 1 million)...............

Other urban areas

1,126 8,449 8,657

2.5 (populations of 1 million or fewer)......

Rural hospitals......... 1,005 6,268 6,685

6.7

Bed Size (Urban): 0-99 beds...........

590 6,736 7,015

4.1 100-199 beds........

865 7,465 7,856

5.2 200-299 beds........

482 8,377 8,666

3.4 300-499 beds........

414 9,437 9,647

2.2 500 or more beds....

166 11,294 11,470

1.6

Bed Size (Rural): 0-49 beds...........

349 5,285 5,817 10.1 50-99 beds..........

366 5,669 6,199

9.3 100-149 beds........

179 6,218 6,604

6.2 150-199 beds........

64 7,053 7,351

4.2 200 or more beds....

47 7,871 8,102

2.9

Urban by Region: New England.........

127 9,406 9,706

3.2 Middle Atlantic.....

353 9,735 10,026

3.0 South Atlantic......

381 8,483 8,702

2.6 East North Central..

388 8,555 8,815

3.0 East South Central..

163 8,252 8,460

2.5 West North Central..

156 8,681 8,860

2.1 West South Central..

350 8,447 8,663

2.6 Mountain............

143 8,872 9,140

3.0 Pacific.............

404 10,705 11,193

4.6 Puerto Rico.........

52 4,187 4,395

5.0

Rural by Region: New England.........

19 8,209 8,838

7.7 Middle Atlantic.....

72 6,283 6,766

7.7 South Atlantic......

175 6,057 6,477

6.9 East North Central..

125 6,482 6,860

5.8 East South Central..

181 6,013 6,396

6.4

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West North Central..

118 6,460 6,864

6.3 West South Central..

191 5,730 6,137

7.1 Mountain............

80 6,723 7,099

5.6 Pacific.............

44 7,707 8,278

7.4 By Payment Classification:

Urban hospitals......... 2,539 8,916 9,185

3.0

Large urban areas

1,400 9,321 9,639

3.4 (populations over 1 million)...............

Other urban areas

1,139 8,426 8,636

2.5 (populations of 1 million or fewer)......

Rural areas.............

983 6,317 6,732

6.6

Teaching Status: Non-teaching........ 2,449 7,131 7,475

4.8 Fewer than 100

836 8,634 8,857

2.6 Residents.......... 100 or more

237 12,590 12,857

2.1 Residents..........

Urban DSH: Non-DSH.............

854 7,716 7,915

2.6 100 or more beds.... 1,513 9,398 9,691

3.1 Less than 100 beds..

333 6,217 6,664

7.2

Rural DSH: SCH.................

383 5,860 6,371

8.7 RRC.................

196 7,013 7,338

4.6 Other Rural:........ 100 or more beds....

55 5,729 6,144

7.2 Less than 100 beds..

188 5,140 5,606

9.1

Urban teaching and DSH: Both teaching and

809 10,329 10,590

2.5 DSH................ Teaching and no DSH.

198 8,614 8,752

1.6 No teaching and DSH. 1,037 7,624 7,982

4.7 No teaching and no

495 7,246 7,446

2.8 DSH................

Rural Hospital Types: Non special status

288 5,367 5,807

8.2 hospitals.......... RRC.................

140 6,982 7,282

4.3 SCH.................

341 6,079 6,535

7.5 MDH.................

126 5,245 6,012 14.6 SCH and RRC.........

80 7,261 7,562

4.1 MDH and RRC.........

8 6,483 7,619 17.5

Type of Ownership: Voluntary........... 2,087 8,658 8,930

3.1 Proprietary.........

831 7,734 8,023

3.7 Government..........

604 8,783 9,192

4.7

Medicare Utilization as a Percent of Inpatient Days: 0-25................

252 12,185 12,897

5.8 25-50............... 1,302 9,712 9,982

2.8 50-65............... 1,490 7,458 7,745

3.9 Over 65.............

459 6,668 6,940

4.1 Unknown.............

19 6,427 6,956

8.2 Hospitals Reclassified by the Medicare Geographic Classification Review Board: FY 2005 Reclassifications.......... Urban Hospitals Reclassified

319 8,750 9,024

3.1 by the Medicare Geographic Classification Review Board: First Half FY 2007 Reclassifications.......... Urban Nonreclassified, First 2,119 8,933 9,212

3.1 Half FY 2007............... All Urban Hospitals

339 8,746 9,027

3.2 Reclassified Second Half FY 2007....................... Urban Nonreclassified

2,099 8,935 9,213

3.1 Hospitals Second Half FY 2007....................... All Rural Hospitals

385 6,782 7,143

5.3 Reclassified Second Half FY 2007....................... Rural Nonreclassified

604 5,616 6,108

8.8 Hospitals Second Half FY 2007....................... All Section 401 Reclassified

38 6,945 7,580

9.2 Hospitals.................. Other Reclassified Hospitals

54 5,871 6,380

8.7 (Section 1886(d)(8)(B)).... Section 508 Hospitals.......

95 9,341 9,401

0.6

\1\ These payment amounts per case do not reflect any estimates of annual case-mix increase.

VII. Effects of Other Proposed Policy Changes

In addition to those proposed changes discussed above that we are able to model using our IPPS payment simulation model, we are making 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 changes are discussed below.

[[Page 24413]]

A. Effects of LTC-DRG Reclassifications and Relative Weights for LTCHs

In section II.F. of the preamble to this proposed rule, we discuss the proposed changes in the LTC-DRG relative weights for FY 2007, which are based on the proposed version 24.0 of the CMS GROUPER (including the proposed changes in the classifications, relative weights and geometric mean length of stay for each LTC- DRG). As also discussed in that same section of this proposed rule, currently, there is no statutory or regulatory requirement that the annual update to the LTC-DRG classifications and relative weights be done in a budget neutral manner. As discussed in the FY 2006 IPPS final rule (70 FR 47701), the LTCH PPS is still in the midst of a transition from a reasonable cost-based payment system to fully Federal PPS payments, during which time LTCH coding and data are still in flux.

The LTCH PPS was implemented for cost reporting periods beginning on or after October 1, 2002 (FY 2003). Therefore, the FY 2005 MedPAR data used to compute the proposed FY 2007 LTC-DRG relative weights are based on LTCH claims data taken from only the second full year of the LTCH PPS. Based on LTCH cases in the December 2005 update of the FY 2005 MedPAR files, we estimate that the proposed changes to the LTC-DRG classifications and relative weights for FY 2007 would result in an aggregate decrease in LTCH PPS payments of approximately 1.4 percent based on the data from the 363 LTCHs in our database. (We note that this estimated aggregate decrease in LTCH PPS payments of approximately 1.4 percent was determined based on the current payment rates and policies established in the RY 2006 LTCH PPS final rule (70 FR 24168 through 24261, May 6, 2005) and do not include any proposed policy or changes presented in the RY 2007 LTCH PPS proposed rule (71 FR 4648- 4779, January 27, 2006).)

When we compared the GROUPER Version 23.0 (FY 2006) LTC-DRG relative weights to the proposed GROUPER Version 24.0 (FY 2007) proposed LTC-DRG relative weights, we found that approximately 62 percent of the LTC-DRGs would have a higher relative weight under Version 23.0, while the remaining approximately 38 percent of the LTC-DRGs would have a higher relative weight under Version 24.0. We also found that, based on FY 2005 LTCH cases, the GROUPER Version 23.0 LTC-DRG relative weights were, on average, approximately 3.1 percent higher than the proposed GROUPER Version 24.0 LTC-DRG relative weights. In addition, based on an analysis of the most recent available LTCH claims data from the FY 2005 MedPAR file, we continue to observe that the average proposed 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 proposed LTC-DRGs with higher relative weights in the prior year are improvements in coding practices, which are typical when moving from a reasonable cost-based payment system to a PPS. The impact of including additional cases with relatively lower charges into LTC-DRGs that had a relatively higher relative weight in the GROUPER Version 23.0 (FY 2006) is a decrease in the average relative weight for those LTC-DRGs in the proposed GROUPER Version 24.0. As noted above in section II.F. of the preamble to this proposed rule, LTCHs are a specialized provider type that typically do not treat a broad spectrum of patients in their facilities with many different diagnoses. While there are 526 valid proposed GROUPER Version 24.0 LTC-DRGs, 191 LTC-DRGs have no LTCH cases. In addition, another 173 LTC-DRGs are categorized as ``low volume'' (that is, have less than 25 cases annually). Consequently, only about 162 LTC-DRGs are used by most LTCHs on a ``regular basis'' (that is, nationally LTCHs discharge, in total, an average of 25 or more of these cases annually).

Of these 162 LTC-DRGs that are used on a ``regular basis,'' we found that approximately 60 percent of the LTC-DRGs would have higher relative weights under GROUPER Version 23.0 in comparison to proposed GROUPER Version 24.0, and the remaining 40 percent of the 162 LTC-DRGs that are used on a ``regular basis'' would have higher relative weights under proposed GROUPER Version 24 in comparison to GROUPER Version 23.0. In addition, about 25 percent of the 162 LTC- DRGs that are used on a ``regular basis'' would experience a decrease in the average charge per case as compared to the average charge per case in that DRG based on FY 2004 data, which generally results in a lower relative weight. Moreover, of the162 LTC-DRGs that are used on a ``regular basis,'' approximately 63 percent of those LTC-DRGs would experience a change in the average charge per case from FY 2004 LTCH data as compared to FY 2005 LTCH data that is less than the increase in overall average LTCH charges across all LTC-DRGs from FY 2004 to FY 2005 of about 8.3 percent. Accordingly, those LTC-DRGs would also have a proposed reduction in their relative weight as compared to the relative weight in FY 2006. For those LTC-DRGs in which the average charge within the LTC-DRG increase is less than 8.3 percent, the proposed relative weights for those LTC-DRGs would 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 significant number of LTC-DRGs with lower proposed relative weights, would result in approximately a 1.4 percent decrease in estimated aggregate LTCH PPS payments.

B. Effects of Proposed New Technology Add-On Payments

In section II.G. of the preamble to this proposed rule, we discuss proposed add-on payments for new medical services and technologies. As explained in that section, we are 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. However, we are still providing an estimate of the payment increases here, as they will have an impact on total payments made in FY 2007. 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 2007 as if every claim with these add-on payments will receive the maximum add-on payment. As discussed in section II.G. of the preamble to this proposed rule, we are not proposing to approve any of the new technology applications that were filed for FY 2007 for new technology add-on payment at this time.

However, we are proposing to continue to make add-on payments in FY 2007 for two technologies that were approved for FY 2006 new technology add-on payments: Restore[reg] Rechargeable Implantable Neurostimulator and GORE TAG. We estimate these payments for these technologies will increase overall FY 2007 payments by $6.01 million and $16.61 million, respectively. The total increase in payments for these two new technologies, approximately $22.6 million, is not reflected in the tables.

C. Effects of Requirements for Hospital Reporting of Quality Data for Annual Hospital Payment Update

In section IV.A. of the preamble to this proposed rule, we discuss new requirements for hospital reporting of quality data based on our continuing experience with this program and recent legislation. Section 5001(a) of Pub. L. 109-171 (DRA) sets out extensive new requirements for the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program. The RHQDAPU program was established to implement section 501(b) of Pub. L. 108-173 (MMA). Section 5001(a) of Pub. L. 109-171 revised the mechanism used to update the standardized amount for payment for hospital inpatient operating costs. New sections 1886(b)(3)(B)(viii)(I) and (II) of the Act provide that the payment update for FY 2007 and each subsequent fiscal year will be reduced by 2.0 percentage points for any ``subsection (d) hospital'' that does not submit certain quality data in a form and manner, and at a time, specified by the Secretary.

We have modeled the payment impact of this change in Table 1 of this Appendix, and discussed it in section VI. of this Appendix. We discuss other policy changes we propose to make to the RHQDAPU program in section IV.A. of the preamble to this proposed rule.

We also note that, for the FY 2007 payment update, hospitals must pass our validation requirement of a minimum of 80 percent reliability, based upon our chart-audit validation process, for the first three quarters of data from CY 2005. These data were due to the QIO Clinical Warehouse by July 15, 2005 (first quarter CY 2005 discharges), November 15, 2005 (second quarter CY 2005 discharges), and February 15, 2005 (third quarter CY 2005 discharges). We have continued our efforts to ensure that QIOs provide assistance to all hospitals that wish to submit data. In the preamble of this

[[Page 24414]]

proposed rule, we are providing additional validation criteria to ensure that the quality data being sent to CMS are accurate. The requirement of 5 charts per hospital will result in approximately 19,000 charts per quarter total submitted to the agency. We reimburse hospitals for the cost of sending charts to the Clinical Data Abstraction Center (CDAC) at the rate of 12 cents per page for copying and approximately $4.00 per chart for postage. Our experience shows that the average chart received at the CDAC is approximately 140 pages. Thus, the agency will have expenditures of approximately $380,000 per quarter to collect the charts. Given that we reimburse for the data collection effort, we believe that a requirement for five charts per hospital per quarter represents a minimal burden to the participating hospital.

D. Effects of Other Proposed Policy Changes Affecting Sole Community Hospitals (SCHs) and Medicare-Dependent, Small Rural Hospitals (MDHs)

In section IV.C. of the preamble to this proposed rule, we discuss the payment changes for MDHs made by section 5003 of Pub. L. 109-171. We modeled the payment impact of these changes in Table 1 of this Appendix and discussed them in section VI. of this Appendix.

In addition, in section IV.C.2. of the preamble to this proposed rule, we discussed a proposed change to the data source and methodology that we would use to compute the volume decrease adjustment for MDHs and SCHs. If certain requirements are met, this adjustment may be made if the hospital's total discharges decrease by more than 5 percent from one cost reporting period to the next. We do not believe that these proposed changes, which would not take effect until FY 2008, will have any significant impact on Medicare payment to these hospitals.

E. Effects of Proposed Policy on Payment for Direct Costs of Graduate Medical Education

1. Determination of Weighted Average GME PRAs for Merged Teaching Hospitals

In section IV.H.2. of the preamble to this proposed rule, we discuss our proposed changes related to determining the weighted average GME PRA for a merged teaching hospital. Our current policy is that when two or more teaching hospitals merge, we determine a weighted PRA for the surviving merged hospital using GME costs and resident data from the base year cost report for each teaching hospital in the merger. We are proposing to revise our policy to determine a merged teaching hospital's PRA by using PRA data and FTE resident data from the most recent settled cost reports of the merging hospitals, rather than using the direct GME cost data from the hospitals' base year cost report. This proposed policy revision is administrative in nature, and we do not foresee that the proposed revision would result in payment increases to merged teaching hospitals.

2. Determination of PRAs for New Teaching Hospitals

In section IV.H.3. of the preamble to this proposed rule, we discuss the methodology for determining the hospital-specific PRA for new teaching hospitals and propose to make a change to the existing regulations at Sec. 413.77(e) in order to specify a base period for certain situations, that is, for new teaching hospitals that did not have residents on duty during the first month of the cost reporting period in which the hospital became a new teaching hospital. The proposed base period for these hospitals would be the next cost reporting period following the cost reporting period where any residents were on duty at the new teaching hospital. Because this proposed change is administrative in nature, we do not foresee that it would result in a financial impact for FY 2007.

3. Requirements for Counting and Appropriate Documentation of FTE Residents

In section IV.H.4. of the preamble to this proposed rule, we are proposing to clarify the policies that apply in determining hospitals' FTE resident counts for Medicare GME payment purposes. Because this is a clarification of existing policy, there is no financial impact for FY 2007.

4. Resident Time Spent in Nonpatient Care Activities as Part of an Approved Residency Program

In section IV.H.5. of the preamble to this proposed rule, we are proposing to clarify our policy that, with respect to residency training in nonhospital settings, only the time residents spend in patient care activities may be counted for purposes of direct GME and IME payments; and with respect to training in the hospital, residents training in all areas of the hospital complex may be counted for direct GME purposes, but may only be counted for IME purposes if the residents are furnishing patient care. Because we are proposing to clarify existing policy, there is no financial impact of this proposed clarification for FY 2007.

F. Effects of Proposed Policy Changes Relating to Emergency Services Under EMTALA

In section IV.J. of the preamble to this proposed rule, we discuss several proposed policy changes under the EMTALA requirements. We are proposing to clarify that any participating hospital with specialized capabilities or facilities, even if it does not have a dedicated emergency department, may not refuse to accept an appropriate transfer if the hospital has the capacity to treat the individual. We note that this proposed revision does not reflect any change in current CMS policy. We further note that the revision would not require hospitals without dedicated emergency departments to open dedicated emergency departments nor would it impose any EMTALA obligation on these hospitals with respect to individuals who come to the hospital as their initial point of entry into the medical system seeking a medical screening examination or treatment for a medical condition. Thus, there would be no impact on Medicare payment policies or practices.

In addition, we are proposing to modify the definition of ``labor'' to state that a woman experiencing contractions is in true labor unless a physician, certified nurse-midwife, or other qualified medical person acting within his or her scope of practice as defined in hospital medical staff bylaws and State law, certifies that, after a reasonable time of observation, the woman is in false labor. The effect of this change would be to have a single, uniform policy on the personnel who are authorized to make a determination as to whether an individual has an emergency medical condition. This proposal would have a Medicare payment effect, if any, only on payments to physicians and nonphysician practitioners under the physician fee schedule. The amount of any impact would be negligible because only a very small number of Medicare beneficiaries are women of childbearing age.

G. Effects of Policy on Rural Community Hospital Demonstration Program

In section IV.L. of the preamble to this proposed rule, we discuss our implementation of section 410A of Pub.L. 108-173 that required the Secretary to establish a demonstration that will modify reimbursement for inpatient services for up to 15 small rural hospitals. Section 410A(c)(2) requires that ``in conducting the demonstration program under this section, the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration program under this section was not implemented.'' As discussed in section IV.L. 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 2007 that will be made to each participating hospital under the demonstration will be approximately $1,021,985. We based this estimate on the recent historical experience of the difference between inpatient cost and payment for hospitals that are participating in the demonstration. For the 9 participating hospitals, the total annual impact of the demonstration program is estimated to be $9,197,870. The proposed adjustment factor to the Federal rate used in calculating Medicare inpatient prospective payments as a result of the demonstration is 0.999905.

H. Effects of Proposed Policy on Hospitals-Within-Hospitals and Satellite Facilities

In section VI.A.5. of the preamble to this proposed rule, we discuss our proposal to revise the regulations for grandfathered HwHs, grandfathered hospital satellites and grandfathered satellite units at Sec. Sec. 412.22(f), 412.22(h)(3), and 412.25(e)(3), respectively, to allow these facilities to reduce their square footage or number of beds without jeopardizing their grandfathered status. We also discuss our proposal to revise the HwH provision at Sec. 412.22(f)(3) that would allow for increases or decreases in square footage, or decreases in the number of beds of the HwH that are made necessary by the relocation of a hospital in order to permit construction or renovation necessary to comply with Federal, State, or local law affecting the physical facility or because of catastrophic events such as fires, floods, earthquakes, or tornadoes.

[[Page 24415]]

Because we are proposing to allow these currently grandfathered HwHs, hospital satellites and satellite units to retain their grandfathered status if they reduce their square footage or number of beds, there would be no effect on the treatment of such hospitals as a result of this proposal. Because payments to HwHs and satellites are made on a per discharge basis (either under a PPS or under reasonable cost principles), if grandfathered HwHs and satellites were to reduce their size in the event this proposal is implemented, the effect of this change would likely be a reduction in Medicare payments to such hospitals and satellites because they would probably have fewer discharges. However, we cannot predict which HwHs or satellite facilities will opt to decrease their size or bed numbers nor can we predict the conditions under which HwHs would have to seek CMS approval for changes in the terms and conditions of their present construction or renovation of square footage or bed numbers made necessary by relocation of a hospital to permit compliance with Federal, State or local law affecting the physical facility or because of catastrophic events, and therefore, we are unable to quantify the impact of these proposed changes.

I. Effects of Proposed Policy Changes to the Methodology for Determining LTCH CCRs and the Reconciliation of LTCH PPS Outlier Payments

In section VI.A.6. of the preamble to this proposed rule, we discuss our proposal to revise and clarify the existing policies governing the determination of LTCHs' CCRs and the reconciliation of high-cost and short-stay outlier payments under the LTCH PPS. Under the LTCH PPS high-cost outlier and short-stay outlier policies, CCRs are used to determine the estimated cost of the case by multiplying the LTCH's overall CCR by the Medicare allowable charges for the case.

In that section, specifically, we present our proposal to revise our methodology for determining the annual LTCH CCR ceiling. Based on the most recent complete IPPS total CCR data, we are proposing a total CCR ceiling of 1.313 under the LTCH PPS effective October 1, 2006. This proposed ceiling was determined based on the same data used to determine the separate proposed IPPS operating CCR ceiling (1.25) and proposed IPPS capital CCR ceiling (0.158). The LTCH CCR ceiling determined under our current ``combined'' methodology would result in a slightly higher LTCH CCR ceiling (that is, 1.25 + 0.158 = 1.408) for FY 2007 compared to the proposed ``total'' CCR ceiling of 1.313 for FY 2007. However, we note that, based on the most recent complete IPPS and LTCH CCR data, there are no LTCHs that currently have a CCR that is greater than the proposed ceiling of 1.313 (the highest LTCH CCR in the database of 363 LTCHs is 1.132). Therefore, based on these data, because no LTCHs currently have a CCR that is in excess of the proposed LTCH CCR ceiling, we believe that there would be no significant impact on LTCH PPS payments based on this proposed policy.

Also in section VI.A.6. of the preamble to this proposed rule, we discuss our proposal to revise our methodology for determining the applicable statewide average LTCH CCRs. Based on the most recent complete IPPS total CCR data, the proposed LTCH PPS statewide average CCRs that would be effective October 1, 2006, are presented in Table 8C of the Addendum to this proposed rule. A comparison of the proposed statewide average total CCRs in Table 8C of the Addendum to this proposed rule to the ``combined'' statewide average CCRs that would be calculated under our existing methodology from the proposed operating PPS statewide average CCRs in Table 8A of the Addendum to this proposed rule and the proposed capital PPS statewide average CCRs in Table 8B of the Addendum to this proposed rule shows that the proposed changes to our methodology for determining LTCH statewide average CCRs would result in minor changes in the average CCR for each state. In particular, the largest decrease in a statewide average CCR (with the exception of Maryland, which would be assigned the national average total CCR as discussed in section VI.A.6 of the preamble of this proposed rule) would be in urban Indiana (-1.9 percent), and there are currently no LTCHs located in Indiana. The largest increase in a statewide average CCR would be in urban District of Columbia (2.8 percent), and there are currently only two LTCHs located in the District of Columbia. Thus, we believe that the proposed change in the methodology for determining the applicable statewide average LTCH CCRs would result in no significant impact on LTCH PPS payments.

In addition, in section VI.A.6 of the preamble of this proposed rule we discussed our proposal to codify in Subpart O of 42 CFR Part 412 the provisions governing the determination of LTCHs' CCRs and the reconciliation of high cost and short-stay outlier payments under the LTCH PPS, including proposed modifications and editorial clarifications to our existing methodology. These proposals are similar or almost identical (except for the minor clarifications and modifications) to our current policy governing the determination of LTCHs' CCRs and the reconciliation of high cost and short-stay outlier payments under the LTCH PPS, and therefore, there would be no expected impact if such policies were codified.

J. Effects of Proposed Policy on Payment for Services Furnished Outside the United States

In section VII. of the preamble to this proposed rule, we discuss our proposed clarification of our regulations regarding payment for Medicare services furnished outside the United States. The clarification proposes to revise references in our regulations that could be read to limit Medicare payment for certain services furnished outside the United States to services furnished in Canada or Mexico, contrary to the provisions of the Act. Only a small fraction of Medicare claims are paid as a result of services furnished outside of the United States. Moreover, we are unaware of any claims for payment that would otherwise satisfy the requirements under the Act that have not been paid due to the language in our current regulations. Therefore, because we are proposing to clarify existing policy, this proposed clarification has little or no financial impact for FY 2007.

K. Effects of Proposed Policy on Limitation on Payments to SNFs

In section IX. of the preamble to this proposed rule, we discuss our proposed implementation of section 5004 of Pub. L. 109-171, which mandated that, for cost reporting periods beginning on or after October 1, 2005, Medicare payments to SNFs for certain otherwise allowable debt amounts attributable to the coinsurance amounts for patients who are not full-benefit dual eligible individuals be reduced by 30 percent. We anticipate that the provisions of section 5004 of Pub. L. 109-171 will result in a decrease in payments to SNFs of $490 million over the 5-year period from FY 2006 to FY 2010.

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 for new capital costs based on a proportion of the capital Federal rate (see Sec. 412.344). As we state in section V. of the preamble of this proposed rule, with the 10-year transition period ending with hospital cost reporting periods beginning on or after October 1, 2001 (FY 2002), beginning in FY 2002 capital prospective payment system payments for most hospitals are based solely on the capital Federal rate. Therefore, we no longer include information on obligated capital costs or projections of old capital costs and new capital costs, which were factors needed to calculate payments during the transition period, for our impact analysis.

In accordance with Sec. 412.312, the basic methodology for determining a capital PPS payment is:

(Standard Federal Rate) x (DRG weight) x (Geographic Adjustment Factor (GAF)) x (Large Urban Add-on, if applicable) x (COLA for hospitals located in Alaska and Hawaii) x (1 + 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 2005 update of the FY 2005 MedPAR file and the December 2005 update of the Provider-Specific File that is used for payment purposes. Although the analyses of

[[Page 24416]]

the changes to the capital prospective payment system do not incorporate cost data, we used the December 2005 update of the most recently available hospital cost report data (FYs 2003-2004) 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 2005 update of the FY 2005 MedPAR file, we simulated payments under the capital PPS for FY 2006 and FY 2007 for a comparison of total payments per case. Any short-term, acute care hospitals not paid under the general IPPS (Indian Health Service hospitals and hospitals in Maryland) are excluded from the simulations.

As we explain in section III.A. of the Addendum to this proposed rule, payments are no longer made under the regular exceptions provision under Sec. Sec. 412.348(b) through (e). Therefore, we no longer use the actuarial capital cost model (described in Appendix B of the August 1, 2001 proposed rule (66 FR 40099)). We modeled payments for each hospital by multiplying the capital Federal rate by the GAF and the hospital's case-mix. We then added estimated payments for indirect medical education, disproportionate share, large urban add-on, and outliers, if applicable. For purposes of this impact analysis, the model includes the following assumptions:

We estimate that the Medicare case-mix index will increase by 1.0 percent in both FYs 2006 and 2007.

We estimate that the Medicare discharges will be 13.5 million in FY 2006 and 13.1 million in FY 2007 for a 3.0 percent decrease from FY 2006 to FY 2007.

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 2007 update is 0.8 percent (see section III.A.1. of the Addendum to this proposed rule).

In addition to the proposed FY 2007 update factor, the proposed FY 2007 capital Federal rate was calculated based on a proposed GAF/DRG budget neutrality factor of 1.0012, a proposed outlier adjustment factor of 0.9513, and a proposed exceptions adjustment factor of 0.9997.

B. Results

We used the actuarial model described above to estimate the potential impact of our proposed changes for FY 2007 on total capital payments per case, using a universe of 3,522 hospitals. As described above, the individual hospital payment parameters are taken from the best available data, including the December 2005 update of the FY 2005 MedPAR file, the December 2005 update to the Provider-Specific File, and the most recent cost report data from the December 2005 update of HCRIS. In Table III, we present a comparison of total payments per case for FY 2006 compared to FY 2007 based on the proposed FY 2007 payment policies. Column 2 shows estimates of payments per case under our model for FY 2006. Column 3 shows estimates of payments per case under our model for FY 2007. Column 4 shows the total percentage change in payments from FY 2006 to FY 2007. The change represented in Column 4 includes the proposed 0.8 percent update to the capital Federal rate, a proposed 0.0 percent increase in case-mix, proposed changes in the adjustments to the capital Federal rate (for example, the effect of the proposed hospital wage index on the GAF), and reclassifications by the MGCRB. The comparisons are provided by: (1) Geographic location; (2) region; and (3) payment classification.

The simulation results show that, on average, capital payments per case can be expected to increase 2.0 percent in FY 2007. In addition to the 0.8 percent increase due to the capital market basket update, this projected increase in capital payments per case is largely attributable to the proposed change in the DRG recalibration process methodology for FY 2007 as discussed in section II.C. of the preamble, and to a lesser extent, an estimated increase in capital PPS outlier payments. The results of our comparisons by geographic location and by region are indicative of the results we expected after applying the proposed changes to the DRG recalibration methodology.

The geographic comparison shows that urban hospitals are expected to experience a 1.7 percent increase in IPPS capital payments per case, while rural hospitals are expected to experience a 4.6 percent increase in capital payments per case. This difference is mostly due to the proposed changes to the methodology used to recalibrate DRGs discussed in section II.C. of the preamble of this proposed rule. As discussed in greater detail in that section of this proposed rule, analysis of our current methodology for setting DRG weights (using gross charges) indicates that bias is introduced into the weighting process. Specifically, we have also observed that ancillary service cost centers, in general, have higher charge markups than routine and ICU service cost centers, and therefore, higher weights for DRGs that use more ancillary services as opposed to DRGs that use more routine services. Surgical DRGs tend to have charges concentrated in ancillary cost center groups while medical DRGs tend to have charges concentrated in routine or ICU cost center groups. The bias in our current methodology results in artificially higher DRG relative weights for hospitals that are generally more expensive, such as teaching hospitals and specialty hospitals. Hospitals with these characteristics are generally found in urban locations.

Since the proposed HSRVcc weighting methodology (discussed in section II.C. of the preamble of this proposed rule) would adjust the weights to remove differential markups in charges, the proposed FY 2007 DRG relative weights are redistributed among medical and surgical DRGs, which translates into a redistribution of payments among hospitals. For instance, hospitals that perform more surgical procedures (such as many urban hospitals) are likely to experience decreases in payments, while hospitals with heavy concentrations of medical DRGs (such as many rural hospitals) are expected to experience increases in payments as a result of this proposed change in our DRG recalibration methodology.

All regions are estimated to receive an increase in total capital payments per case from FY 2006 to FY 2007. Changes by region vary from a minimum increase of 0.7 percent (West North Central urban) to a maximum increase of 6.1 percent (Pacific rural). As previously discussed, the relatively small increase in projected capital payments per discharge for hospitals located in the urban regions and the larger increase for hospitals in rural regions is largely attributable to the proposed changes in the DRG recalibration methodology. Hospitals located in Puerto Rico are expected to experience an increase in total capital payments per case of 2.4 percent. This slightly higher than average increase in payment per case for hospitals located in Puerto Rico is, again, largely due to the proposed changes in the DRG recalibration methodology. By type of ownership, government hospitals are projected to have the largest rate of increase of total payment changes (3.2 percent). Similarly, payments to voluntary and proprietary hospitals are expected to increase 1.8 percent and 2.1 percent, respectively. As noted above, this slightly larger projected increase in capital payments per case for government hospitals is mostly due to the changes in the DRG calibration methodology.

Section 1886(d)(10) of the Act established the MGCRB. Before FY 2005, hospitals could apply to the MGCRB for reclassification for purposes of the standardized amount, wage index, or both. Section 401(c) of Pub. L. 108-173 equalized the standardized amounts under the operating IPPS. Therefore, beginning in FY 2005, there is no longer reclassification for the purposes of the standardized amounts; however, hospitals still may apply for reclassification for purposes of the wage index for FY 2007. Reclassification for wage index purposes also affects the GAF because that factor is constructed from the hospital wage index.

As discussed in section III.H.5. of the preamble of this proposed rule, procedural rules were established in the FY 2006 final rule (70 FR 47382) to recognize the special circumstances of section 508 hospital reclassifications ending mid-year during FY 2007. Under these procedural rules, some Sec. 1886(d)(10) hospital reclassifications are only in effect for the second half of the fiscal year. These half fiscal year reclassifications have implications for the calculation of reclassified wage indices and therefore, affect capital payments since GAF values are calculated from the hospital wage index.

To present the effects of the hospitals being reclassified for FY 2007, we show the average

[[Page 24417]]

payments per case for reclassified hospitals for each half of FY 2007 compared to the average payments per case for the same time period in FY 2006. The reclassified groups are compared to all other nonreclassified hospitals for the same time period. These categories are further identified by urban and rural designation. In general, the average payments per case in the first half of FY 2007 is the same as the average payments per case in the second half of FY 2007 with the exception of urban reclassifications, which increases by 0.1 percent (1.9 percent to 2.0 percent) for the second half of FY 2007. Rural hospitals, both reclassified and non-reclassified, are expected to have the largest increases in payments, although rural non-reclassified hospitals are projected to have the greater increase of 6.3 percent (for both halves of FY 2007) as compared to the 3.5 percent increase for rural reclassified hospitals (for both halves of FY 2007). As explained above in this section, this larger than average increase in payments per case from FY 2006 to FY 2007 for both rural reclassified and non-reclassified hospitals is mostly due to the redistributive effects of the proposed changes in the DRG recalibration methodology. Conversely, for urban hospitals, reclassified (urban) hospitals are projected to have increases of 1.9 percent and 2.0 percent in the first and second halves of FY 2007, respectively, while non-reclassified (urban) hospitals are projected to have a slightly lesser increase of 1.7 percent.

As discussed in section VI.B. of the preamble of this proposed rule, we are proposing a technical revision to Sec. 412.316(b) and Sec. 412.320 to clarify that hospitals reclassified as rural under Sec. 412.103 are not eligible for the large urban add-on or for capital DSH to reflect our historic policy that hospitals reclassified as rural under Sec. 412.103 also are considered rural under capital PPS regulations. Currently, there are 38 hospitals that reclassified under this regulation and only 12 of these hospitals (about 0.3 percent of all IPPS hospitals) would be affected by the proposed technical revisions to sections Sec. 412.316(b) and Sec. 412.320 concerning the treatment of hospitals reclassified as rural under section Sec. 412.103. Based on the most recent available data, we estimate that the impact of these proposed changes would be less than a 0.00001 percent decrease in aggregate IPPS payments.

Table III.--Comparison of Total Payments Per Case [FY 2006 Payments Compared To Proposed FY 2007 Payments]

Average FY Average FY Number of 2006 payments/ 2007 payments/ Change hospitals

case

case

By Geographic Location:

All hospitals...............................

3,522

740

755

2.0

Large urban areas (populations over 1

1,391

823

840

2.1 million)...................................

Other urban areas (populations of 1 million

1,126

729

738

1.2 of fewer)..................................

Rural areas.................................

1,005

512

535

4.6

Urban hospitals.............................

2,517

780

794

1.7 0-99 beds...............................

590

607

624

2.7 100-199 beds............................

865

660

684

3.8 200-299 beds............................

482

735

750

2.0 300-499 beds............................

414

816

823

0.9 500 or more beds........................

166

978

984

0.7

Rural hospitals.............................

1,005

512

535

4.6 0-49 beds...............................

349

422

454

7.6 50-99 beds..............................

366

472

501

6.3 100-149 beds............................

179

514

537

4.3 150-199 beds............................

64

567

582

2.7 200 or more beds........................

47

630

642

1.8 By Region:

Urban by Region.............................

2,517

780

794

1.7 New England.............................

127

831

853

2.7 Middle Atlantic.........................

353

844

862

2.1 South Atlantic..........................

381

746

754

1.1 East North Central......................

388

766

781

1.9 East South Central......................

163

713

720

0.9 West North Central......................

156

769

775

0.7 West South Central......................

350

729

737

1.1 Mountain................................

143

787

799

1.6 Pacific.................................

404

899

926

3.0 Puerto Rico.............................

52

342

351

2.4

Rural by Region.............................

1,005

512

535

4.6 New England.............................

19

685

709

3.5 Middle Atlantic.........................

72

516

539

4.5 South Atlantic..........................

175

497

522

5.0 East North Central......................

125

544

566

4.2 East South Central......................

181

475

496

4.4 West North Central......................

118

533

555

4.1 West South Central......................

191

470

494

5.1 Mountain................................

80

535

554

3.5 Pacific.................................

44

615

652

6.1 By Payment Classification:

All hospitals...............................

3,522

740

755

2.0

Large urban areas (populations over 1

1,400

821

839

2.1 million)...................................

Other urban areas (populations of 1 million

1,139

728

737

1.3 of fewer)..................................

Rural areas.................................

983

513

536

4.5

Teaching Status............................. Non-teaching............................

2,449

621

640

3.0 Fewer than 100 Residents................

836

753

762

1.2 100 or more Residents...................

237

1,075

1,090

1.4 Urban DSH: 100 or more beds....................

1,513

806

821

1.8

[[Page 24418]]

Less than 100 beds..................

333

542

572

5.6 Rural DSH: Sole Community (SCH/EACH)...........

383

465

493

6.1 Referral Center (RRC/EACH)..........

196

567

585

3.0 Other Rural: 100 or more beds................

55

469

496

5.8 Less than 100 beds..............

188

425

457

7.4

Urban teaching and DSH: Both teaching and DSH...................

809

884

896

1.4 Teaching and no DSH.....................

198

792

798

0.7 No teaching and DSH.....................

1,037

658

678

3.1 No teaching and no DSH..................

495

682

691

1.3

Rural Hospital Types: Non special status hospitals............

288

448

477

6.6 RRC/EACH................................

40

575

590

2.6 SCH/EACH................................

341

479

507

5.8 Medicare-dependent hospitals (MDH)......

126

433

463

6.9 SCH, RRC and EACH.......................

80

577

596

3.3 Hospitals Reclassified by the Medicare Geographic Classification Review Board:

FY2007 Reclassifications: All Urban Reclassified 1st Half.........

316

767

782

1.9 All Urban Non-Reclassified 1st Half.....

2,178

783

796

1.7 All Rural Reclassified 1st Half.........

373

556

576

3.5 All Rural Non-Reclassified 1st Half.....

563

451

480

6.3 All Urban Reclassified 2nd Half.........

374

785

801

2.0 All Urban Non-Reclassified 2nd Half.....

2,120

780

793

1.7 All Rural Reclassified 2nd Half.........

373

556

576

3.5 All Rural Non-Reclassified 2nd Half.....

563

451

480

6.3 All Section 401 Reclassified Hospitals..

38

516

537

4.1 Other Reclassified Hospitals (Section

54

513

544

6.1 1886(d)(8)(B)).........................

Type of Ownership: Voluntary...............................

2,087

757

770

1.8 Proprietary.............................

831

670

685

2.1 Government..............................

604

727

751

3.2

Medicare Utilization as a Percent of Inpatient Days: 0-25....................................

252

970

1,016

4.7 25-50...................................

1,302

838

851

1.5 50-65...................................

1,490

655

670

2.4 Over 65.................................

459

589

601

2.1

IX. Alternatives Considered

This proposed rule contains a range of policies, including some proposals related to specific DRA and MMA provisions. The preamble of this proposed rule provides descriptions of the statutory provisions that are addressed, identifies those policies when discretion has been exercised, presents rationale for our decisions and, where relevant, alternatives that were considered.

X. Overall Conclusion

The changes in this proposed rule would affect all classes of hospitals. Some hospitals are expected to experience significant gains and others less significant gains, but overall hospitals are projected to experience positive updates in IPPS payments in FY 2007. Table I of section VI of this Appendix demonstrates the estimated distributional impact of the IPPS budget neutrality requirements for DRG and wage index changes, for the hold harmless transition for rural hospitals formerly classified as urban, and for the wage index reclassifications under the MGCRB. Table I also shows an overall increase of 3.4 percent in operating payments, which, in conjunction with the estimated 2.0 percent increase in capital payments to IPPS providers shown in Table III of section VIII of this Appendix, should result in a net increase of $3.33 billion to IPPS providers. The discussions presented in the previous pages, in combination with the rest of this proposed rule, constitute a regulatory impact analysis.

XI. Accounting Statement

As required by OMB Circular A-4 (available at http://www.whitehousegov/omb/circulars/a004/a-4.pdf ), in Table IV below, we

have prepared an accounting statement showing the classification of the expenditures associated with the provisions of this proposed rule. This table provides our best estimate of the increase in Medicare payments on providers as a result of the proposed changes to the IPPS, the LTCH case-mix, and the limitation on payments to SNFs for bad debt presented in this rule. All expenditures are classified as transfers to Medicare providers.

Table IV.--Accounting Statement: Classification of Estimated Expenditures from FY 2006 to FY 2007

Category

Transfers

Annualized Monetized Transfers......... $3.809 Billion.

[[Page 24419]]

From Whom to Whom...................... Federal Government to IPPS Medicare Providers, LTCHs, and SNFs.

Total.............................. $3.809 Billion.

XII. Executive Order 12866

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

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

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

I. Background

Section 1886(e)(4)(A) of the Act requires that the Secretary, taking into consideration the recommendations of the Medicare Payment Advisory Commission (MedPAC), recommend update factors for inpatient hospital services for each fiscal year that take into account the amounts necessary for the efficient and effective delivery of medically appropriate and necessary care of high quality. Under section 1886(e)(5)(B) of the Act, we are required to publish the proposed and final update factors recommended by the Secretary in the proposed and final IPPS rules respectively. Accordingly, this Appendix provides the recommendations of appropriate update factors for the IPPS standardized amount, the hospital-specific rates for SCHs and MDHs, and the rate-of-increase limits for hospitals and hospital units excluded from the IPPS. We also discuss our response to MedPAC's recommended update factors for inpatient hospital services.

II. Inpatient Hospital Update for FY 2007

Section 1886(b)(3)(B)(i)(XX) of the Act, as amended by section 5001(a) of Pub. L. 109-171, sets the FY 2007 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)(viii) of the Act. For hospitals that do not provide these data, the update is equal to the market basket percentage increase less 2.0 percentage points. Consistent with current law, based on the Office of the Actuary's first quarter 2006 forecast of the FY 2007 market basket increase, we are estimating that the FY 2007 update to the standardized amount will be 3.4 percent (that is, the current estimate of the market basket rate-of-increase) for hospitals in all areas, provided the hospital submits quality data in accordance with our rules. For hospitals that do not submit quality data, we are estimating that the update to the standardized amount will be 1.4 percent (that is, the current estimate of the market basket rate-of- increase minus 2.0 percentage points).

Section 1886(b)(3)(B)(iv) of the Act sets the FY 2007 percentage increase in the hospital-specific rates applicable to SCHs and MDHs equal to the rate set forth in section 1886(b)(3)(B)(i) of the Act (that is, the same update factor as for all other hospitals subject to the IPPS, or the rate-of-increase in the market basket). Therefore, the update to the hospital-specific rates applicable to SCHs and MDHs is also estimated to be 3.4 percent.

Section 1886(b)(3)(B)(ii) of the Act is used for purposes of determining the percentage increase in the rate-of-increase limits for children's and cancer hospitals. Section 1886(b)(3)(B)(ii) of the Act sets the percentage increase in the rate-of-increase limits equal to the market basket percentage increase for years after FY 2002. In accordance with Sec. 403.752(a) of the regulations, RNHCIs are paid under Sec. 413.40, which also uses section 1886(b)(3)(B)(ii) of the Act to update the percentage increase in the rate-of-increase limits. Section 1886(j)(3)(C) of the Act addresses the increase factor for the Federal prospective payment rate of IRFs. Section 123 of Pub. L. 106-113, as amended by section 307(b) of Pub. L. 106-554, provides the statutory authority for updating payment rates under the LTCH PPS. In addition, section 124 of the BBRA provides the statutory authority for updating the payment rates of IPFs. Under this broad authority, IPFs that are not defined as new under Sec. 412.426(c) will be paid under a blend methodology for cost reporting periods beginning on or after January 1, 2005, through June 30, 2008. The blend methodology consists of a blend of the estimated Federal per diem payment amount and a facility-specific payment amount. Under the authority of section 124 of the BBRA, the estimated Federal per diem payment amount is updated and the facility-specific payment is updated in accordance with 42 CFR Part 413, which uses section 1886(b)(3)(B)(ii) of the Act to determine the percentage increase in the rate-of-increase limits. New IPFs are paid based on 100 percent of the Federal per diem payment amount, which is updated under the authority of section 124 of the BBRA.

In addition, some LTCHs and IPFs are transitioning to 100 percent of the Federal rate and currently receive a blend of reasonable cost-based payments computed under the TEFRA methodology and their respective Federal payment rates. As discussed below, the transition ends for LTCHs (not defined as new and that have not elected to be paid under 100 percent of the Federal rate) for cost reporting periods beginning on or after October 1, 2006. Therefore, because no portion of LTCHs' prospective payments will be based on reasonable costs for cost reporting periods beginning on or after October 1, 2006, we are not proposing an FY 2007 rate-of-increase adjustment under section 1886(b)(3)(B)(ii) of the Act for LTCHs. Any IPFs that receive reasonable cost-based payments will have that portion of its payments determined subject to the TEFRA rate-of- increase limits for FY 2007.

Currently, children's hospitals, cancer hospitals and RNHCIs are the remaining three types of hospitals still reimbursed fully under reasonable costs. As we discuss in section IV. of the Addendum to this proposed rule, we are proposing to provide an estimate of the FY 2007 IPPS operating market basket percentage increase (3.4 percent) that will be used to update the target limits for children's hospitals, cancer hospitals, and RNHCIs.

Effective since cost reporting periods beginning FY 2003, LTCHs have been paid under the LTCH PPS, which was implemented with a 5- year transition period for LTCHs not defined as new under Sec. 412.23(e)(4) (hereafter referred to as ``existing''). (Refer to 67 FR 55954, August 30, 2002.) An existing LTCH could have elected 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. During this transition period, if an existing LTCH did not elect to be paid 100 percent of the Federal prospective payment rate, it received a payment which consisted of a blend of its reasonable cost-based payment (subject to the TEFRA rate-of-increase limits) and the Federal prospective payment rate. Because the transition period ends with LTCH cost reporting periods beginning on or after October 1, 2006, those LTCHs who now receive blended payments will be paid based on 100 percent of the Federal prospective rate.

Effective for cost reporting periods beginning on or after January 1, 2005, IPFs are paid under the IPF PPS. IPF PPS payments are based on a Federal per diem rate that is based on the sum of the average routine operating, ancillary, and capital costs for each patient day of psychiatric care in an IPF, adjusted for budget neutrality. During a transition period between January 1, 2005 and January 1, 2008, existing IPFs are paid based on a blend of the reasonable cost-based payments, subject to the TEFRA limit, and the Federal per diem base rate. For cost reporting periods beginning on or after January 1, 2008, IPFs will be paid based on 100 percent of the Federal per diem rate. For purposes of the update factor for FY 2007, the portion of the IPF PPS transitional blend payment based on reasonable costs would be determined by updating the IPF's TEFRA limit by the current estimate of the excluded

[[Page 24420]]

hospital market basket, which is estimated to be 3.6 percent. The estimated update to the Federal per diem rate for July 1, 2006, through June 30, 2007, was provided in the RY 2007 IPF proposed rule (71 FR 3620).

IRFs are paid under the IRF PPS for cost reporting periods beginning on or after January 1, 2002. For cost reporting periods beginning on or after October 1, 2002 (FY 2003), and thereafter, the Federal prospective payments to IRFs are based on 100 percent of the adjusted Federal IRF prospective payment amount, updated annually. (Refer to the IRF final rule (69 FR 45721).)

III. Secretary's Recommendation

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, as we stated in the FY 2006 proposed rule, we are no longer including this analysis in our recommendation for the update (70 FR 23672, May 4, 2005).

MedPAC is recommending an inpatient hospital update equal to the market basket rate of increase for FY 2007 minus an adjustment factor of 0.45 percentage points. The 0.45 percentage point reduction represents half of estimated productivity growth in the general economy for 2007 that the Commission expects the hospital industry to achieve. MedPAC's rationale for this update recommendation is described in more detail below. Using the 2006 first quarter forecast from the Office of the Actuary of the FY 2007 market basket increase and an adjustment factor based on the FY 2007 President's budget, we are recommending an update to the standardized amount of 2.95 percent (that is, the market basket rate-of-increase of 3.4 minus an adjustment factor of 0.45 percentage points). Our update recommendation is the same as MedPAC's.

In addition to making a recommendation for IPPS hospitals, in accordance with section 1886(e)(4)(A) of the Act, we are also recommending update factors for all other types of hospitals. Using the 2006 first quarter forecast from the Office of the Actuary of the FY 2007 market basket increase and an adjustment factor based on the FY 2007 President's budget, for FY 2007, for SCHs and MDHs, we are recommending an update of 2.95 percent.

For FY 2007, for children's hospitals, cancer hospitals, and RNHCIs, based on the first quarter forecast from the Office of the Actuary of the FY 2007 market basket increase and an adjustment factor from the FY 2007 President's budget, we are also recommending an update of 2.95 percent to the target limits.

For IPFs that are currently paid a blend of reasonable cost- based (subject to the TEFRA limits) and Federal prospective payment amounts, based on the latest estimate from the Office of the Actuary and an adjustment factor from the FY 2007 President's budget, we are recommending an update factor of 3.15 percent for the portion of the payment that is based on reasonable costs, subject to the TEFRA limits.

We 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. In the Secretary's Report to Congress this year, the Secretary recommended the President's FY 2007 update of 2.95 percent (3.4 percent minus an adjustment factor of 0.45 percentage points) for the market basket update for the TEFRA portion of IPF blended payment rates. The difference between the update recommendation in the Secretary's Report to Congress and the update we are recommending in this proposed rule (3.15 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 recommendation was developed.

Consistent with our proposal in the RY 2007 LTCH PPS proposed rule (71 FR 4667, January 27, 2006), we are recommending the Federal rate remain unchanged for RY 2007. In the RY 2007 IPF PPS proposed rule (71 FR 3620, January 23, 2006), we proposed an update factor of 4.5 percent to the IPF PPS for RY 2007. The proposed update reflects an increase from the 18-month period beginning January 1, 2005, when the IPF PPS was first adopted. Consistent with the RY 2007 IPF proposed rule, we are recommending an update factor of 4.5 percent for inpatient psychiatric facilities. Finally, consistent with the President's FY 2007 budget, we are recommending the Federal rate to the IRF PPS remain unchanged for FY 2007.

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 2006 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.

Despite a projected negative overall Medicare margin of -2.2 percent in 2006, the Commission recommended an update to the hospital inpatient rates equal to the increase in the hospital market basket minus an adjustment factor of 0.45 percentage points. The 0.45 percentage point reduction represents half of an estimate of productivity growth in the general economy for 2007 that the Commission expects the hospital industry to achieve.

MedPAC noted that, notwithstanding negative overall Medicare margins, most of the indicators of Medicare payment adequacy to hospitals are positive, including beneficiaries' access to care, increased access to capital, and service volume increases. MedPAC also noted that Medicare payment rates should cover the costs of efficient hospitals and that, ``more efficient hospitals may not be performing as poorly as the [hospital] industry's aggregate margin would suggest.''

Response: We agree with MedPAC and are also recommending an inpatient hospital update equal to the market basket minus an adjustment factor of 0.45 percentage points. However, we note that the law would need to be changed in order for the MedPAC recommendation and our update recommendation to be applied. Without a change in law, we will update the IPPS rates by the full market basket, which we currently estimate to be 3.4 percent for FY 2007, for hospitals that submit quality data that meet our validation requirements. For all other hospitals, the IPPS update will equal the market basket minus 2.0 percentage points.

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.

[[Page 24421]]

Appendix C.--Combinations of Proposed Consolidated Severity-Adjusted DRGs

Consolidated Type

MDC severity- Consolidated severity- adjusted DRG adjusted DRG description

S.................

0

1 LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT SOI 1 & 2. S.................

0

2 LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT SOI 3. S.................

0

3 LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT SOI 4. S.................

0

4 HEART &/OR LUNG TRANSPLANT SOI 1 & 2. S.................

0

5 HEART &/OR LUNG TRANSPLANT SOI 3. S.................

0

6 HEART &/OR LUNG TRANSPLANT SOI 4. S.................

0

7 BONE MARROW TRANSPLANT SOI 1. S.................

0

8 BONE MARROW TRANSPLANT SOI 2. S.................

0

9 BONE MARROW TRANSPLANT SOI 3. S.................

0

10 BONE MARROW TRANSPLANT SOI 4. S.................

0

11 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W EXTENSIVE PROCEDURE SOI 1 & 2. S.................

0

12 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W EXTENSIVE PROCEDURE SOI 3. S.................

0

13 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W EXTENSIVE PROCEDURE SOI 4. S.................

0

14 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W/O EXTENSIVE PROCEDURE SOI 1 & 2. S.................

0

15 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W/O EXTENSIVE PROCEDURE SOI 3. S.................

0

16 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W/O EXTENSIVE PROCEDURE SOI 4. S.................

0

17 PANCREAS TRANSPLANT SOI 1 & 2. S.................

0

18 PANCREAS TRANSPLANT SOI 3. S.................

0

19 PANCREAS TRANSPLANT SOI 4. S.................

1

20 NERVOUS SYSTEM PROCDURES SOI 4. S.................

1

21 CRANIOTOMY FOR TRAUMA SOI 1. S.................

1

22 CRANIOTOMY FOR TRAUMA SOI 2. S.................

1

23 CRANIOTOMY FOR TRAUMA SOI 3. S.................

1

24 CRANIOTOMY EXCEPT FOR TRAUMA SOI 1. S.................

1

25 CRANIOTOMY EXCEPT FOR TRAUMA SOI 2. S.................

1

26 CRANIOTOMY EXCEPT FOR TRAUMA SOI 3. S.................

1

27 VENTRICULAR SHUNT PROCEDURES SOI 1. S.................

1

28 VENTRICULAR SHUNT PROCEDURES SOI 2. S.................

1

29 VENTRICULAR SHUNT PROCEDURES SOI 3. S.................

1

30 SPINAL PROCEDURES SOI 1. S.................

1

31 SPINAL PROCEDURES SOI 2. S.................

1

32 SPINAL PROCEDURES SOI 3. S.................

1

33 EXTRACRANIAL VASCULAR PROCEDURES SOI 1. S.................

1

34 EXTRACRANIAL VASCULAR PROCEDURES SOI 2. S.................

1

35 EXTRACRANIAL VASCULAR PROCEDURES SOI 3. S.................

1

36 OTHER NERVOUS SYSTEM & RELATED PROCEDURES SOI 1. S.................

1

37 OTHER NERVOUS SYSTEM & RELATED PROCEDURES SOI 2. S.................

1

38 OTHER NERVOUS SYSTEM & RELATED PROCEDURES SOI 3. M.................

1

39 NERVOUS SYSTEM MEDICAL DIAGNOSES EXCEPT INFECTIONS SOI 4. M.................

1

40 INFECTIONS OF NERVOUS SYSTEM SOI 4. M.................

1

41 SPINAL DISORDERS & INJURIES SOI 1. M.................

1

42 SPINAL DISORDERS & INJURIES SOI 2. M.................

1

43 SPINAL DISORDERS & INJURIES SOI 3. M.................

1

44 NERVOUS SYSTEM MALIGNANCY SOI 1. M.................

1

45 NERVOUS SYSTEM MALIGNANCY SOI 2. M.................

1

46 NERVOUS SYSTEM MALIGNANCY SOI 3. M.................

1

47 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS SOI 1. M.................

1

48 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS SOI 2. M.................

1

49 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS SOI 3. M.................

1

50 MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES SOI 1. M.................

1

51 MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES SOI 2. M.................

1

52 MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES SOI 3. M.................

1

53 INTRACRANIAL HEMORRHAGE SOI 1. M.................

1

54 INTRACRANIAL HEMORRHAGE SOI 2. M.................

1

55 INTRACRANIAL HEMORRHAGE SOI 3. M.................

1

56 CVA & PRECEREBRAL OCCLUSION W INFARCT SOI 1. M.................

1

57 CVA & PRECEREBRAL OCCLUSION W INFARCT SOI 2. M.................

1

58 CVA & PRECEREBRAL OCCLUSION W INFARCT SOI 3. M.................

1

59 NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT SOI 1. M.................

1

60 NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT SOI 2. M.................

1

61 NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT SOI 3. M.................

1

62 TRANSIENT ISCHEMIA SOI 1. M.................

1

63 TRANSIENT ISCHEMIA SOI 2. M.................

1

64 TRANSIENT ISCHEMIA SOI 3. M.................

1

65 PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS SOI 1. M.................

1

66 PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS SOI 2. M.................

1

67 PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS SOI 3. M.................

1

68 BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM SOI 1. M.................

1

69 BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM SOI 2.

[[Page 24422]]

M.................

1

70 BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM SOI 3. M.................

1

71 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS SOI 1. M.................

1

72 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS SOI 2. M.................

1

73 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS SOI 3. M.................

1

74 VIRAL MENINGITIS SOI 1. M.................

1

75 VIRAL MENINGITIS SOI 2. M.................

1

76 VIRAL MENINGITIS SOI 3. M.................

1

77 NONTRAUMATIC STUPOR & COMA SOI 1. M.................

1

78 NONTRAUMATIC STUPOR & COMA SOI 2. M.................

1

79 NONTRAUMATIC STUPOR & COMA SOI 3. M.................

1

80 SEIZURE SOI 1. M.................

1

81 SEIZURE SOI 2. M.................

1

82 SEIZURE SOI 3. M.................

1

83 MIGRAINE & OTHER HEADACHES SOI 1. M.................

1

84 MIGRAINE & OTHER HEADACHES SOI 2. M.................

1

85 MIGRAINE & OTHER HEADACHES SOI 3. M.................

1

86 HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE SOI 1. M.................

1

87 HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE SOI 2. M.................

1

88 HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE SOI 3. M.................

1

89 BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA 2,000 GRAMS WITHOUT SIGNIFICANT PROBLEMS SOI 1 & 2.

[[Page 24431]]

M................. 15

697 NEONATE > 2,000 GRAMS WITHOUT SIGNIFICANT PROBLEMS SOI 3 & 4. S................. 16

698 PROCEDURES OF BLOOD & BLOOD- FORMING ORGANS SOI 4. S................. 16

699 SPLENECTOMY SOI 1. S................. 16

700 SPLENECTOMY SOI 2. S................. 16

701 SPLENECTOMY SOI 3. S................. 16

702 OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS SOI 1. S................. 16

703 OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS SOI 2. S................. 16

704 OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS SOI 3. M................. 16

705 ANEMIA & DIAGNOSES OF BLOOD & BLOOD-FORMING ORGANS SOI 4. M................. 16

706 MAJOR HEMATOLOGIC/IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS & COAGUL SOI 1. M................. 16

707 MAJOR HEMATOLOGIC/IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS & COAGUL SOI 2. M................. 16

708 MAJOR HEMATOLOGIC/IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS & COAGUL SOI 3. M................. 16

709 COAGULATION & PLATELET DISORDERS SOI 1. M................. 16

710 COAGULATION & PLATELET DISORDERS SOI 2. M................. 16

711 COAGULATION & PLATELET DISORDERS SOI 3. M................. 16

712 SICKLE CELL ANEMIA CRISIS SOI 1. M................. 16

713 SICKLE CELL ANEMIA CRISIS SOI 2. M................. 16

714 SICKLE CELL ANEMIA CRISIS SOI 3. M................. 16

715 OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING ORGANS SOI 1. M................. 16

716 OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING ORGANS SOI 2. M................. 16

717 OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING ORGANS SOI 3. S................. 17

718 PROCEDURES FOR LYMPHATIC/ HEMATOPOIETIC/OTHER NEOPLASMS SOI 4. S................. 17

719 MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/ OTHER NEOPLASMS SOI 1. S................. 17

720 MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/ OTHER NEOPLASMS SOI 2. S................. 17

721 MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/ OTHER NEOPLASMS SOI 3. S................. 17

722 OTHER O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/ OTHER NEOPLASMS SOI 1. S................. 17

723 OTHER O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/ OTHER NEOPLASMS SOI 2. S................. 17

724 OTHER O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/ OTHER NEOPLASMS SOI 3. M................. 17

725 LEUKEMIA, LYMPHOMA, MYELOMA, CHEMOTHERAPY, AND RADIOTHERAPY SOI 4. M................. 17

726 ACUTE LEUKEMIA SOI 1. M................. 17

727 ACUTE LEUKEMIA SOI 2. M................. 17

728 ACUTE LEUKEMIA SOI 3. M................. 17

729 LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA SOI 1. M................. 17

730 LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA SOI 2. M................. 17

731 LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA SOI 3. M................. 17

732 RADIOTHERAPY SOI 1. M................. 17

733 RADIOTHERAPY SOI 2. M................. 17

734 RADIOTHERAPY SOI 3. M................. 17

735 CHEMOTHERAPY SOI 1. M................. 17

736 CHEMOTHERAPY SOI 2. M................. 17

737 CHEMOTHERAPY SOI 3. M................. 17

738 LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR SOI 1. M................. 17

739 LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR SOI 2. M................. 17

740 LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR SOI 3. M................. 17

741 LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR SOI 4. S................. 18

742 INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE SOI 4. S................. 18

743 INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE SOI 1. S................. 18

744 INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE SOI 2. S................. 18

745 INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE SOI 3. S................. 18

746 POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROCEDURE SOI 1. S................. 18

747 POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROCEDURE SOI 2. S................. 18

748 POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROCEDURE SOI 3. M................. 18

749 INFECTIOUS & PARASITIC DISEASES SOI 4. M................. 18

750 SEPTICEMIA & DISSEMINATED INFECTIONS SOI 1. M................. 18

751 SEPTICEMIA & DISSEMINATED INFECTIONS SOI 2. M................. 18

752 SEPTICEMIA & DISSEMINATED INFECTIONS SOI 3. M................. 18

753 POST-OPERATIVE, POST- TRAUMATIC, OTHER DEVICE INFECTIONS SOI 1. M................. 18

754 POST-OPERATIVE, POST- TRAUMATIC, OTHER DEVICE INFECTIONS SOI 2. M................. 18

755 POST-OPERATIVE, POST- TRAUMATIC, OTHER DEVICE INFECTIONS SOI 3. M................. 18

756 FEVER SOI 1. M................. 18

757 FEVER SOI 2. M................. 18

758 FEVER SOI 3. M................. 18

759 VIRAL ILLNESS SOI 1. M................. 18

760 VIRAL ILLNESS SOI 2. M................. 18

761 VIRAL ILLNESS SOI 3. M................. 18

762 OTHER INFECTIOUS & PARASITIC DISEASES SOI 1. M................. 18

763 OTHER INFECTIOUS & PARASITIC DISEASES SOI 2. M................. 18

764 OTHER INFECTIOUS & PARASITIC DISEASES SOI 3. S................. 19

765 MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE SOI 1. S................. 19

766 MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE SOI 2.

[[Page 24432]]

S................. 19

767 MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE SOI 3. S................. 19

768 MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE SOI 4. M................. 19

769 MAJOR DEPRESSIVE, SCHIZOPHRENIA & BIPOLAR DISORDERS SOI 1. M................. 19

770 MAJOR DEPRESSIVE, SCHIZOPHRENIA & BIPOLAR DISORDERS SOI 2. M................. 19

771 MAJOR DEPRESSIVE, SCHIZOPHRENIA & BIPOLAR DISORDERS SOI 3. M................. 19

772 MAJOR DEPRESSIVE, SCHIZOPHRENIA & BIPOLAR DISORDERS SOI 4. M................. 19

773 ORGANIC MENTAL HEALTH DISTURBANCES SOI 1. M................. 19

774 ORGANIC MENTAL HEALTH DISTURBANCES SOI 2. M................. 19

775 ORGANIC MENTAL HEALTH DISTURBANCES SOI 3. M................. 19

776 ORGANIC MENTAL HEALTH DISTURBANCES SOI 4. M................. 19

777 OTHER MENTAL HEALTH DISORDERS SOI 1. M................. 19

778 OTHER MENTAL HEALTH DISORDERS SOI 2. M................. 19

779 OTHER MENTAL HEALTH DISORDERS SOI 3. M................. 19

780 OTHER MENTAL HEALTH DISORDERS SOI 4. M................. 20

781 DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE SOI 1 & 2. M................. 20

782 DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE SOI 3 & 4. M................. 20

783 DRUG ABUSE & DEPENDENCE DIAGNOSES SOI 1. M................. 20

784 DRUG ABUSE & DEPENDENCE DIAGNOSES SOI 2. M................. 20

785 DRUG ABUSE & DEPENDENCE DIAGNOSES SOI 3. M................. 20

786 DRUG ABUSE & DEPENDENCE DIAGNOSES SOI 4. S................. 21

787 O.R. PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT SOI 1. S................. 21

788 O.R. PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT SOI 2. S................. 21

789 O.R. PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT SOI 3. S................. 21

790 O.R. PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT SOI 4. M................. 21

791 INJURIES, POISONINGS & TOXIC EFFECTS OF DRUGS DIAGNOSES SOI 4. M................. 21

792 ALLERGIC REACTIONS SOI 1. M................. 21

793 ALLERGIC REACTIONS SOI 2. M................. 21

794 ALLERGIC REACTIONS SOI 3. M................. 21

795 POISONING OF MEDICINAL AGENTS SOI 1. M................. 21

796 POISONING OF MEDICINAL AGENTS SOI 2. M................. 21

797 POISONING OF MEDICINAL AGENTS SOI 3. M................. 21

798 OTHER COMPLICATIONS OF TREATMENT SOI 1. M................. 21

799 OTHER COMPLICATIONS OF TREATMENT SOI 2. M................. 21

800 OTHER COMPLICATIONS OF TREATMENT SOI 3. M................. 21

801 OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES SOI 1. M................. 21

802 OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES SOI 2. M................. 21

803 OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES SOI 3. S................. 22

804 BURN PROCEDURES SOI 4. S................. 22

805 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W SKIN GRAFT SOI 1. S................. 22

806 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W SKIN GRAFT SOI 2. S................. 22

807 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W SKIN GRAFT SOI 3. M................. 22

808 BURN DIAGNOSES SOI 4. M................. 22

809 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT SOI 1. M................. 22

810 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT SOI 2. M................. 22

811 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT SOI 3. M................. 22

812 PARTIAL THICKNESS BURNS W OR W/O SKIN GRAFT SOI 1. M................. 22

813 PARTIAL THICKNESS BURNS W OR W/O SKIN GRAFT SOI 2. M................. 22

814 PARTIAL THICKNESS BURNS W OR W/O SKIN GRAFT SOI 3. S................. 23

815 PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE SOI 1. S................. 23

816 PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE SOI 2. S................. 23

817 PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE SOI 3. S................. 23

818 PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE SOI 4. M................. 23

819 REHABILITATION / AFTERCARE / CONVALESCENCE EXCEPT NEONATAL AFTERCARE SOI 4. M................. 23

820 REHABILITATION SOI 1. M................. 23

821 REHABILITATION SOI 2. M................. 23

822 REHABILITATION SOI 3. M................. 23

823 SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS SOI 1. M................. 23

824 SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS SOI 2. M................. 23

825 SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS SOI 3. M................. 23

826 OTHER AFTERCARE & CONVALESCENCE SOI 1. M................. 23

827 OTHER AFTERCARE & CONVALESCENCE SOI 2. M................. 23

828 OTHER AFTERCARE & CONVALESCENCE SOI 3. M................. 24

829 HIV DIAGNOSES SOI 4. M................. 24

830 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS SOI 1 & 2. M................. 24

831 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS SOI 3. M................. 24

832 HIV W MAJOR HIV RELATED CONDITION SOI 1 & 2. M................. 24

833 HIV W MAJOR HIV RELATED CONDITION SOI 3. M................. 24

834 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS SOI 1 & 2. M................. 24

835 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS SOI 3. M................. 24

836 HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND SOI 1.

[[Page 24433]]

M................. 24

837 HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND SOI 2. M................. 24

838 HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND SOI 3. S................. 25

839 MULTIPLE SIGNIFICANT TRAUMA PROCEDURES SOI 4. S................. 25

840 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA SOI 1 & 2. S................. 25

841 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA SOI 3. S................. 25

842 EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA SOI 1 & 2. S................. 25

843 EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA SOI 3. S................. 25

844 MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA SOI 1 & 2. S................. 25

845 MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA SOI 3. M................. 25

846 MULTIPLE SIGNIFICANT TRAUMA W/ O O.R. PROCEDURE SOI 1 & 2. M................. 25

847 MULTIPLE SIGNIFICANT TRAUMA W/ O O.R. PROCEDURE SOI 3. M................. 25

848 MULTIPLE SIGNIFICANT TRAUMA W/ O O.R. PROCEDURE SOI 4. S................. 25

987 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS SOI 1. S................. 25

988 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS SOI 2. S................. 25

989 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS SOI 3. S................. 25

990 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS SOI 4. S................. 25

991 NON MAJOR PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS SOI 4. S................. 25

992 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS SOI 1. S................. 25

993 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS SOI 2. S................. 25

994 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS SOI 3. S................. 25

995 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS SOI 1. S................. 25

996 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS SOI 2. S................. 25

997 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS SOI 3. 26

998 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS. 26

999 UNGROUPABLE.

M = Medical. S = Surgical. SOI = Severity of Illness Subclass

Appendix D.--Crosswalk of Proposed Consolidated Severity-Adjusted DRGs To Respective APR DRGs

Consolidated TYPE

MDC severity- Consolidated severity- APR DRG SOI APR DRG description adjusted DRG adjusted DRG description

S.................

0

1 LIVER TRANSPLANT AND/OR

001

1 LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT

INTESTINAL TRANSPLANT SOI 1 & 2.

SOI 1. S.................

0

1 LIVER TRANSPLANT AND/OR

001

2 LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT

INTESTINAL TRANSPLANT SOI 1 & 2.

SOI 2. S.................

0

2 LIVER TRANSPLANT AND/OR

001

3 LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT

INTESTINAL TRANSPLANT SOI 3.

SOI 3. S.................

0

3 LIVER TRANSPLANT AND/OR

001

4 LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT

INTESTINAL TRANSPLANT SOI 4.

SOI 4. S.................

0

4 HEART &/OR LUNG

002

1 HEART &/OR LUNG TRANSPLANT SOI 1 & 2.

TRANSPLANT SOI 1. S.................

0

4 HEART &/OR LUNG

002

2 HEART &/OR LUNG TRANSPLANT SOI 1 & 2.

TRANSPLANT SOI 2. S.................

0

5 HEART &/OR LUNG

002

3 HEART &/OR LUNG TRANSPLANT SOI 3.

TRANSPLANT SOI 3. S.................

0

6 HEART &/OR LUNG

002

4 HEART &/OR LUNG TRANSPLANT SOI 4.

TRANSPLANT SOI 4. S.................

0

7 BONE MARROW TRANSPLANT

003

1 BONE MARROW TRANSPLANT SOI 1.

SOI 1. S.................

0

8 BONE MARROW TRANSPLANT

003

2 BONE MARROW TRANSPLANT SOI 2.

SOI 2. S.................

0

9 BONE MARROW TRANSPLANT

003

3 BONE MARROW TRANSPLANT SOI 3.

SOI 3. S.................

0

10 BONE MARROW TRANSPLANT

003

4 BONE MARROW TRANSPLANT SOI 4.

SOI 4. S.................

0

11 TRACHEOSTOMY W LONG TERM 004

1 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W

MECHANICAL VENTILATION EXTENSIVE PROCEDURE SOI

W EXTENSIVE PROCEDURE 1 & 2.

SOI 1. S.................

0

11 TRACHEOSTOMY W LONG TERM 004

2 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W

MECHANICAL VENTILATION EXTENSIVE PROCEDURE SOI

W EXTENSIVE PROCEDURE 1 & 2.

SOI 2. S.................

0

12 TRACHEOSTOMY W LONG TERM 004

3 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W

MECHANICAL VENTILATION EXTENSIVE PROCEDURE SOI

W EXTENSIVE PROCEDURE 3.

SOI 3. S.................

0

13 TRACHEOSTOMY W LONG TERM 004

4 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W

MECHANICAL VENTILATION EXTENSIVE PROCEDURE SOI

W EXTENSIVE PROCEDURE 4.

SOI 4. S.................

0

14 TRACHEOSTOMY W LONG TERM 005

1 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W/

MECHANICAL VENTILATION O EXTENSIVE PROCEDURE

W/O EXTENSIVE PROCEDURE SOI 1 & 2.

SOI 1.

[[Page 24434]]

S.................

0

14 TRACHEOSTOMY W LONG TERM 005

2 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W/

MECHANICAL VENTILATION O EXTENSIVE PROCEDURE

W/O EXTENSIVE PROCEDURE SOI 1 & 2.

SOI 2. S.................

0

15 TRACHEOSTOMY W LONG TERM 005

3 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W/

MECHANICAL VENTILATION O EXTENSIVE PROCEDURE

W/O EXTENSIVE PROCEDURE SOI 3.

SOI 3. S.................

0

16 TRACHEOSTOMY W LONG TERM 005

4 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W/

MECHANICAL VENTILATION O EXTENSIVE PROCEDURE

W/O EXTENSIVE PROCEDURE SOI 4.

SOI 4. S.................

0

17 PANCREAS TRANSPLANT SOI 1 006

1 PANCREAS TRANSPLANT SOI & 2.

1. S.................

0

17 PANCREAS TRANSPLANT SOI 1 006

2 PANCREAS TRANSPLANT SOI & 2.

2. S.................

0

18 PANCREAS TRANSPLANT SOI 3 006

3 PANCREAS TRANSPLANT SOI 3. S.................

0

19 PANCREAS TRANSPLANT SOI 4 006

4 PANCREAS TRANSPLANT SOI 4. S.................

1

20 NERVOUS SYSTEM PROCDURES 020

4 CRANIOTOMY FOR TRAUMA SOI 4.

SOI 4. S.................

1

20 NERVOUS SYSTEM PROCDURES 021

4 CRANIOTOMY EXCEPT FOR SOI 4.

TRAUMA SOI 4. S.................

1

20 NERVOUS SYSTEM PROCDURES 022

4 VENTRICULAR SHUNT SOI 4.

PROCEDURES SOI 4. S.................

1

20 NERVOUS SYSTEM PROCDURES 023

4 SPINAL PROCEDURES SOI 4. SOI 4. S.................

1

20 NERVOUS SYSTEM PROCDURES 024

4 EXTRACRANIAL VASCULAR SOI 4.

PROCEDURES SOI 4. S.................

1

20 NERVOUS SYSTEM PROCDURES 026

4 OTHER NERVOUS SYSTEM & SOI 4.

RELATED PROCEDURES SOI 4. S.................

1

21 CRANIOTOMY FOR TRAUMA SOI 020

1 CRANIOTOMY FOR TRAUMA 1.

SOI 1. S.................

1

22 CRANIOTOMY FOR TRAUMA SOI 020

2 CRANIOTOMY FOR TRAUMA 2.

SOI 2. S.................

1

23 CRANIOTOMY FOR TRAUMA SOI 020

3 CRANIOTOMY FOR TRAUMA 3.

SOI 3. S.................

1

24 CRANIOTOMY EXCEPT FOR

021

1 CRANIOTOMY EXCEPT FOR TRAUMA SOI 1.

TRAUMA SOI 1. S.................

1

25 CRANIOTOMY EXCEPT FOR

021

2 CRANIOTOMY EXCEPT FOR TRAUMA SOI 2.

TRAUMA SOI 2. S.................

1

26 CRANIOTOMY EXCEPT FOR

021

3 CRANIOTOMY EXCEPT FOR TRAUMA SOI 3.

TRAUMA SOI 3. S.................

1

27 VENTRICULAR SHUNT

022

1 VENTRICULAR SHUNT PROCEDURES SOI 1.

PROCEDURES SOI 1. S.................

1

28 VENTRICULAR SHUNT

022

2 VENTRICULAR SHUNT PROCEDURES SOI 2.

PROCEDURES SOI 2. S.................

1

29 VENTRICULAR SHUNT

022

3 VENTRICULAR SHUNT PROCEDURES SOI 3.

PROCEDURES SOI 3. S.................

1

30 SPINAL PROCEDURES SOI 1.. 023

1 SPINAL PROCEDURES SOI 1. S.................

1

31 SPINAL PROCEDURES SOI 2.. 023

2 SPINAL PROCEDURES SOI 2. S.................

1

32 SPINAL PROCEDURES SOI 3.. 023

3 SPINAL PROCEDURES SOI 3. S.................

1

33 EXTRACRANIAL VASCULAR

024

1 EXTRACRANIAL VASCULAR PROCEDURES SOI 1.

PROCEDURES SOI 1. S.................

1

34 EXTRACRANIAL VASCULAR

024

2 EXTRACRANIAL VASCULAR PROCEDURES SOI 2.

PROCEDURES SOI 2. S.................

1

35 EXTRACRANIAL VASCULAR

024

3 EXTRACRANIAL VASCULAR PROCEDURES SOI 3.

PROCEDURES SOI 3. S.................

1

36 OTHER NERVOUS SYSTEM &

026

1 OTHER NERVOUS SYSTEM & RELATED PROCEDURES SOI 1.

RELATED PROCEDURES SOI 1. S.................

1

37 OTHER NERVOUS SYSTEM &

026

2 OTHER NERVOUS SYSTEM & RELATED PROCEDURES SOI 2.

RELATED PROCEDURES SOI 2. S.................

1

38 OTHER NERVOUS SYSTEM &

026

3 OTHER NERVOUS SYSTEM & RELATED PROCEDURES SOI 3.

RELATED PROCEDURES SOI 3. M.................

1

39 NERVOUS SYSTEM MEDICAL

040

4 SPINAL DISORDERS & DIAGNOSES EXCEPT

INJURIES SOI 4. INFECTIONS SOI 4. M.................

1

39 NERVOUS SYSTEM MEDICAL

041

4 NERVOUS SYSTEM DIAGNOSES EXCEPT

MALIGNANCY SOI 4. INFECTIONS SOI 4. M.................

1

39 NERVOUS SYSTEM MEDICAL

042

4 DEGENERATIVE NERVOUS DIAGNOSES EXCEPT

SYSTEM DISORDERS EXC INFECTIONS SOI 4.

MULT SCLEROSIS SOI 4. M.................

1

39 NERVOUS SYSTEM MEDICAL

043

4 MULTIPLE SCLEROSIS & DIAGNOSES EXCEPT

OTHER DEMYELINATING INFECTIONS SOI 4.

DISEASES SOI 4. M.................

1

39 NERVOUS SYSTEM MEDICAL

044

4 INTRACRANIAL HEMORRHAGE DIAGNOSES EXCEPT

SOI 4. INFECTIONS SOI 4. M.................

1

39 NERVOUS SYSTEM MEDICAL

045

4 CVA & PRECEREBRAL DIAGNOSES EXCEPT

OCCLUSION W INFARCT SOI INFECTIONS SOI 4.

4. M.................

1

39 NERVOUS SYSTEM MEDICAL

046

4 NONSPECIFIC CVA & DIAGNOSES EXCEPT

PRECEREBRAL OCCLUSION W/ INFECTIONS SOI 4.

O INFARCT SOI 4.

[[Page 24435]]

M.................

1

39 NERVOUS SYSTEM MEDICAL

047

4 TRANSIENT ISCHEMIA SOI DIAGNOSES EXCEPT

4. INFECTIONS SOI 4. M.................

1

39 NERVOUS SYSTEM MEDICAL

048

4 PERIPHERAL, CRANIAL & DIAGNOSES EXCEPT

AUTONOMIC NERVE INFECTIONS SOI 4.

DISORDERS SOI 4. M.................

1

39 NERVOUS SYSTEM MEDICAL

051

4 VIRAL MENINGITIS SOI 4. DIAGNOSES EXCEPT INFECTIONS SOI 4. M.................

1

39 NERVOUS SYSTEM MEDICAL

052

4 NONTRAUMATIC STUPOR & DIAGNOSES EXCEPT

COMA SOI 4. INFECTIONS SOI 4. M.................

1

39 NERVOUS SYSTEM MEDICAL

053

4 SEIZURE SOI 4. DIAGNOSES EXCEPT INFECTIONS SOI 4. M.................

1

39 NERVOUS SYSTEM MEDICAL

054

4 MIGRAINE & OTHER DIAGNOSES EXCEPT

HEADACHES SOI 4. INFECTIONS SOI 4. M.................

1

39 NERVOUS SYSTEM MEDICAL

055

4 HEAD TRAUMA W COMA >1 HR DIAGNOSES EXCEPT

OR HEMORRHAGE SOI 4. INFECTIONS SOI 4. M.................

1

39 NERVOUS SYSTEM MEDICAL

056

4 BRAIN CONTUSION/ DIAGNOSES EXCEPT

LACERATION & INFECTIONS SOI 4.

COMPLICATED SKULL FX, COMA 1 HR 055

1 HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE SOI 1.

OR HEMORRHAGE SOI 1. M.................

1

87 HEAD TRAUMA W COMA >1 HR 055

2 HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE SOI 2.

OR HEMORRHAGE SOI 2. M.................

1

88 HEAD TRAUMA W COMA >1 HR 055

3 HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE SOI 3.

OR HEMORRHAGE SOI 3. M.................

1

89 BRAIN CONTUSION/

056

1 BRAIN CONTUSION/ LACERATION & COMPLICATED

LACERATION & SKULL FX, COMA 2499G W MAJOR PROBLEMS SOI 1 & 2.

MAJOR CARDIOVASCULAR PROCEDURE SOI 1. M................. 15

692 FULL TERM NEONATE WITH

630

2 NEONATE BIRTHWT >2499G W MAJOR PROBLEMS SOI 1 & 2.

MAJOR CARDIOVASCULAR PROCEDURE SOI 2. M................. 15

692 FULL TERM NEONATE WITH

631

1 NEONATE BIRTHWT >2499G W MAJOR PROBLEMS SOI 1 & 2.

OTHER MAJOR PROCEDURE SOI 1. M................. 15

692 FULL TERM NEONATE WITH

631

2 NEONATE BIRTHWT >2499G W MAJOR PROBLEMS SOI 1 & 2.

OTHER MAJOR PROCEDURE SOI 2. M................. 15

692 FULL TERM NEONATE WITH

633

1 NEONATE BIRTHWT >2499G W MAJOR PROBLEMS SOI 1 & 2.

MAJOR ANOMALY SOI 1. M................. 15

692 FULL TERM NEONATE WITH

633

2 NEONATE BIRTHWT >2499G W MAJOR PROBLEMS SOI 1 & 2.

MAJOR ANOMALY SOI 2. M................. 15

692 FULL TERM NEONATE WITH

634

1 NEONATE, BIRTHWT >2499G MAJOR PROBLEMS SOI 1 & 2.

W RESP DIST SYND/OTH MAJ RESP COND SOI 1. M................. 15

692 FULL TERM NEONATE WITH

634

2 NEONATE, BIRTHWT >2499G MAJOR PROBLEMS SOI 1 & 2.

W RESP DIST SYND/OTH MAJ RESP COND SOI 2. M................. 15

692 FULL TERM NEONATE WITH

636

1 NEONATE BIRTHWT >2499G W MAJOR PROBLEMS SOI 1 & 2.

CONGENITAL/PERINATAL INFECTION SOI 1. M................. 15

692 FULL TERM NEONATE WITH

636

2 NEONATE BIRTHWT >2499G W MAJOR PROBLEMS SOI 1 & 2.

CONGENITAL/PERINATAL INFECTION SOI 2. M................. 15

693 FULL TERM NEONATE WITH

630

3 NEONATE BIRTHWT >2499G W MAJOR PROBLEMS SOI 3 & 4.

MAJOR CARDIOVASCULAR PROCEDURE SOI 3. M................. 15

693 FULL TERM NEONATE WITH

630

4 NEONATE BIRTHWT >2499G W MAJOR PROBLEMS SOI 3 & 4.

MAJOR CARDIOVASCULAR PROCEDURE SOI 4. M................. 15

693 FULL TERM NEONATE WITH

631

3 NEONATE BIRTHWT >2499G W MAJOR PROBLEMS SOI 3 & 4.

OTHER MAJOR PROCEDURE SOI 3. M................. 15

693 FULL TERM NEONATE WITH

631

4 NEONATE BIRTHWT >2499G W MAJOR PROBLEMS SOI 3 & 4.

OTHER MAJOR PROCEDURE SOI 4. M................. 15

693 FULL TERM NEONATE WITH

633

3 NEONATE BIRTHWT >2499G W MAJOR PROBLEMS SOI 3 & 4.

MAJOR ANOMALY SOI 3. M................. 15

693 FULL TERM NEONATE WITH

633

4 NEONATE BIRTHWT >2499G W MAJOR PROBLEMS SOI 3 & 4.

MAJOR ANOMALY SOI 4. M................. 15

693 FULL TERM NEONATE WITH

634

3 NEONATE, BIRTHWT >2499G MAJOR PROBLEMS SOI 3 & 4.

W RESP DIST SYND/OTH MAJ RESP COND SOI 3. M................. 15

693 FULL TERM NEONATE WITH

634

4 NEONATE, BIRTHWT >2499G MAJOR PROBLEMS SOI 3 & 4.

W RESP DIST SYND/OTH MAJ RESP COND SOI 4. M................. 15

693 FULL TERM NEONATE WITH

636

3 NEONATE BIRTHWT >2499G W MAJOR PROBLEMS SOI 3 & 4.

CONGENITAL/PERINATAL INFECTION SOI 3. M................. 15

693 FULL TERM NEONATE WITH

636

4 NEONATE BIRTHWT >2499G W MAJOR PROBLEMS SOI 3 & 4.

CONGENITAL/PERINATAL INFECTION SOI 4.

[[Page 24464]]

M................. 15

694 NEONATE WITH OTHER

639

1 NEONATE BIRTHWT >2499G W SIGNIFICANT PROBLEMS SOI

OTHER SIGNIFICANT 1 & 2.

CONDITION SOI 1. M................. 15

694 NEONATE WITH OTHER

639

2 NEONATE BIRTHWT >2499G W SIGNIFICANT PROBLEMS SOI

OTHER SIGNIFICANT 1 & 2.

CONDITION SOI 2. M................. 15

695 NEONATE WITH OTHER

639

3 NEONATE BIRTHWT >2499G W SIGNIFICANT PROBLEMS SOI

OTHER SIGNIFICANT 3 & 4.

CONDITION SOI 3. M................. 15

695 NEONATE WITH OTHER

639

4 NEONATE BIRTHWT >2499G W SIGNIFICANT PROBLEMS SOI

OTHER SIGNIFICANT 3 & 4.

CONDITION SOI 4. M................. 15

696 NEONATE >2,000 GRAMS

626

1 NEONATE BWT 2000-2499G, WITHOUT SIGNIFICANT

NORMAL NEWBORN OR PROBLEMS SOI 1 & 2.

NEONATE W OTHER PROBLEM SOI 1. M................. 15

696 NEONATE >2,000 GRAMS

626

2 NEONATE BWT 2000-2499G, WITHOUT SIGNIFICANT

NORMAL NEWBORN OR PROBLEMS SOI 1 & 2.

NEONATE W OTHER PROBLEM SOI 2. M................. 15

696 NEONATE >2,000 GRAMS

640

1 NEONATE BIRTHWT >2499G, WITHOUT SIGNIFICANT

NORMAL NEWBORN OR PROBLEMS SOI 1 & 2.

NEONATE W OTHER PROBLEM SOI 1. M................. 15

696 NEONATE >2,000 GRAMS

640

2 NEONATE BIRTHWT >2499G, WITHOUT SIGNIFICANT

NORMAL NEWBORN OR PROBLEMS SOI 1 & 2.

NEONATE W OTHER PROBLEM SOI 2. M................. 15

697 NEONATE >2,000 GRAMS

626

3 NEONATE BWT 2000-2499G, WITHOUT SIGNIFICANT

NORMAL NEWBORN OR PROBLEMS SOI 3 & 4.

NEONATE W OTHER PROBLEM SOI 3. M................. 15

697 NEONATE >2,000 GRAMS

626

4 NEONATE BWT 2000-2499G, WITHOUT SIGNIFICANT

NORMAL NEWBORN OR PROBLEMS SOI 3 & 4.

NEONATE W OTHER PROBLEM SOI 4. M................. 15

697 NEONATE >2,000 GRAMS

640

3 NEONATE BIRTHWT >2499G, WITHOUT SIGNIFICANT

NORMAL NEWBORN OR PROBLEMS SOI 3 & 4.

NEONATE W OTHER PROBLEM SOI 3. M................. 15

697 NEONATE >2,000 GRAMS

640

4 NEONATE BIRTHWT >2499G, WITHOUT SIGNIFICANT

NORMAL NEWBORN OR PROBLEMS SOI 3 & 4.

NEONATE W OTHER PROBLEM SOI 4. S................. 16

698 PROCEDURES OF BLOOD &

650

4 SPLENECTOMY SOI 4. BLOOD-FORMING ORGANS SOI 4. S................. 16

698 PROCEDURES OF BLOOD &

651

4 OTHER PROCEDURES OF BLOOD-FORMING ORGANS SOI

BLOOD & BLOOD-FORMING 4.

ORGANS SOI 4. S................. 16

699 SPLENECTOMY SOI 1........ 650

1 SPLENECTOMY SOI 1. S................. 16

700 SPLENECTOMY SOI 2........ 650

2 SPLENECTOMY SOI 2. S................. 16

701 SPLENECTOMY SOI 3........ 650

3 SPLENECTOMY SOI 3. S................. 16

702 OTHER PROCEDURES OF BLOOD 651

1 OTHER PROCEDURES OF & BLOOD-FORMING ORGANS

BLOOD & BLOOD-FORMING SOI 1.

ORGANS SOI 1. S................. 16

703 OTHER PROCEDURES OF BLOOD 651

2 OTHER PROCEDURES OF & BLOOD-FORMING ORGANS

BLOOD & BLOOD-FORMING SOI 2.

ORGANS SOI 2. S................. 16

704 OTHER PROCEDURES OF BLOOD 651

3 OTHER PROCEDURES OF & BLOOD-FORMING ORGANS

BLOOD & BLOOD-FORMING SOI 3.

ORGANS SOI 3. M................. 16

705 ANEMIA & DIAGNOSES OF

660

4 MAJOR HEMATOLOGIC/ BLOOD & BLOOD-FORMING

IMMUNOLOGIC DIAG EXC ORGANS SOI 4.

SICKLE CELL CRISIS & COAGUL SOI 4. M................. 16

705 ANEMIA & DIAGNOSES OF

661

4 COAGULATION & PLATELET BLOOD & BLOOD-FORMING

DISORDERS SOI 4. ORGANS SOI 4. M................. 16

705 ANEMIA & DIAGNOSES OF

662

4 SICKLE CELL ANEMIA BLOOD & BLOOD-FORMING

CRISIS SOI 4. ORGANS SOI 4. M................. 16

705 ANEMIA & DIAGNOSES OF

663

4 OTHER ANEMIA & DISORDERS BLOOD & BLOOD-FORMING

OF BLOOD & BLOOD- ORGANS SOI 4.

FORMING ORGANS SOI 4. M................. 16

706 MAJOR HEMATOLOGIC/

660

1 MAJOR HEMATOLOGIC/ IMMUNOLOGIC DIAG EXC

IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS &

SICKLE CELL CRISIS & COAGUL SOI 1.

COAGUL SOI 1. M................. 16

707 MAJOR HEMATOLOGIC/

660

2 MAJOR HEMATOLOGIC/ IMMUNOLOGIC DIAG EXC

IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS &

SICKLE CELL CRISIS & COAGUL SOI 2.

COAGUL SOI 2. M................. 16

708 MAJOR HEMATOLOGIC/

660

3 MAJOR HEMATOLOGIC/ IMMUNOLOGIC DIAG EXC

IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS &

SICKLE CELL CRISIS & COAGUL SOI 3.

COAGUL SOI 3. M................. 16

709 COAGULATION & PLATELET

661

1 COAGULATION & PLATELET DISORDERS SOI 1.

DISORDERS SOI 1. M................. 16

710 COAGULATION & PLATELET

661

2 COAGULATION & PLATELET DISORDERS SOI 2.

DISORDERS SOI 2.

[[Page 24465]]

M................. 16

711 COAGULATION & PLATELET

661

3 COAGULATION & PLATELET DISORDERS SOI 3.

DISORDERS SOI 3. M................. 16

712 SICKLE CELL ANEMIA CRISIS 662

1 SICKLE CELL ANEMIA SOI 1.

CRISIS SOI 1. M................. 16

713 SICKLE CELL ANEMIA CRISIS 662

2 SICKLE CELL ANEMIA SOI 2.

CRISIS SOI 2. M................. 16

714 SICKLE CELL ANEMIA CRISIS 662

3 SICKLE CELL ANEMIA SOI 3.

CRISIS SOI 3. M................. 16

715 OTHER ANEMIA & DISORDERS 663

1 OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING

OF BLOOD & BLOOD- ORGANS SOI 1.

FORMING ORGANS SOI 1. M................. 16

716 OTHER ANEMIA & DISORDERS 663

2 OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING

OF BLOOD & BLOOD- ORGANS SOI 2.

FORMING ORGANS SOI 2. M................. 16

717 OTHER ANEMIA & DISORDERS 663

3 OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING

OF BLOOD & BLOOD- ORGANS SOI 3.

FORMING ORGANS SOI 3. S................. 17

718 PROCEDURES FOR LYMPHATIC/ 680

4 MAJOR O.R. PROCEDURES HEMATOPOIETIC/OTHER

FOR LYMPHATIC/ NEOPLASMS SOI 4.

HEMATOPOIETIC/OTHER NEOPLASMS SOI 4. S................. 17

718 PROCEDURES FOR LYMPHATIC/ 681

4 OTHER O.R. PROCEDURES HEMATOPOIETIC/OTHER

FOR LYMPHATIC/ NEOPLASMS SOI 4.

HEMATOPOIETIC/OTHER NEOPLASMS SOI 4. S................. 17

719 MAJOR O.R. PROCEDURES FOR 680

1 MAJOR O.R. PROCEDURES LYMPHATIC/HEMATOPOIETIC/

FOR LYMPHATIC/ OTHER NEOPLASMS SOI 1.

HEMATOPOIETIC/OTHER NEOPLASMS SOI 1. S................. 17

720 MAJOR O.R. PROCEDURES FOR 680

2 MAJOR O.R. PROCEDURES LYMPHATIC/HEMATOPOIETIC/

FOR LYMPHATIC/ OTHER NEOPLASMS SOI 2.

HEMATOPOIETIC/OTHER NEOPLASMS SOI 2. S................. 17

721 MAJOR O.R. PROCEDURES FOR 680

3 MAJOR O.R. PROCEDURES LYMPHATIC/HEMATOPOIETIC/

FOR LYMPHATIC/ OTHER NEOPLASMS SOI 3.

HEMATOPOIETIC/OTHER NEOPLASMS SOI 3. S................. 17

722 OTHER O.R. PROCEDURES FOR 681

1 OTHER O.R. PROCEDURES LYMPHATIC/HEMATOPOIETIC/

FOR LYMPHATIC/ OTHER NEOPLASMS SOI 1.

HEMATOPOIETIC/OTHER NEOPLASMS SOI 1. S................. 17

723 OTHER O.R. PROCEDURES FOR 681

2 OTHER O.R. PROCEDURES LYMPHATIC/HEMATOPOIETIC/

FOR LYMPHATIC/ OTHER NEOPLASMS SOI 2.

HEMATOPOIETIC/OTHER NEOPLASMS SOI 2. S................. 17

724 OTHER O.R. PROCEDURES FOR 681

3 OTHER O.R. PROCEDURES LYMPHATIC/HEMATOPOIETIC/

FOR LYMPHATIC/ OTHER NEOPLASMS SOI 3.

HEMATOPOIETIC/OTHER NEOPLASMS SOI 3. M................. 17

725 LEUKEMIA, LYMPHOMA,

690

4 ACUTE LEUKEMIA SOI 4. MYELOMA, CHEMOTHERAPY, AND RADIOTHERAPY SOI 4. M................. 17

725 LEUKEMIA, LYMPHOMA,

691

4 LYMPHOMA, MYELOMA & NON- MYELOMA, CHEMOTHERAPY,

ACUTE LEUKEMIA SOI 4. AND RADIOTHERAPY SOI 4. M................. 17

725 LEUKEMIA, LYMPHOMA,

692

4 RADIOTHERAPY SOI 4. MYELOMA, CHEMOTHERAPY, AND RADIOTHERAPY SOI 4. M................. 17

725 LEUKEMIA, LYMPHOMA,

693

4 CHEMOTHERAPY SOI 4. MYELOMA, CHEMOTHERAPY, AND RADIOTHERAPY SOI 4. M................. 17

726 ACUTE LEUKEMIA SOI 1..... 690

1 ACUTE LEUKEMIA SOI 1. M................. 17

727 ACUTE LEUKEMIA SOI 2..... 690

2 ACUTE LEUKEMIA SOI 2. M................. 17

728 ACUTE LEUKEMIA SOI 3..... 690

3 ACUTE LEUKEMIA SOI 3. M................. 17

729 LYMPHOMA, MYELOMA & NON- 691

1 LYMPHOMA, MYELOMA & NON- ACUTE LEUKEMIA SOI 1.

ACUTE LEUKEMIA SOI 1. M................. 17

730 LYMPHOMA, MYELOMA & NON- 691

2 LYMPHOMA, MYELOMA & NON- ACUTE LEUKEMIA SOI 2.

ACUTE LEUKEMIA SOI 2. M................. 17

731 LYMPHOMA, MYELOMA & NON- 691

3 LYMPHOMA, MYELOMA & NON- ACUTE LEUKEMIA SOI 3.

ACUTE LEUKEMIA SOI 3. M................. 17

732 RADIOTHERAPY SOI 1....... 692

1 RADIOTHERAPY SOI 1. M................. 17

733 RADIOTHERAPY SOI 2....... 692

2 RADIOTHERAPY SOI 2. M................. 17

734 RADIOTHERAPY SOI 3....... 692

3 RADIOTHERAPY SOI 3. M................. 17

735 CHEMOTHERAPY SOI 1....... 693

1 CHEMOTHERAPY SOI 1. M................. 17

736 CHEMOTHERAPY SOI 2....... 693

2 CHEMOTHERAPY SOI 2. M................. 17

737 CHEMOTHERAPY SOI 3....... 693

3 CHEMOTHERAPY SOI 3. M................. 17

738 LYMPHATIC & OTHER

694

1 LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS

MALIGNANCIES & OF UNCERTAIN BEHAVIOR

NEOPLASMS OF UNCERTAIN SOI 1.

BEHAVIOR SOI 1.

[[Page 24466]]

M................. 17

739 LYMPHATIC & OTHER

694

2 LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS

MALIGNANCIES & OF UNCERTAIN BEHAVIOR

NEOPLASMS OF UNCERTAIN SOI 2.

BEHAVIOR SOI 2. M................. 17

740 LYMPHATIC & OTHER

694

3 LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS

MALIGNANCIES & OF UNCERTAIN BEHAVIOR

NEOPLASMS OF UNCERTAIN SOI 3.

BEHAVIOR SOI 3. M................. 17

741 LYMPHATIC & OTHER

694

4 LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS

MALIGNANCIES & OF UNCERTAIN BEHAVIOR

NEOPLASMS OF UNCERTAIN SOI 4.

BEHAVIOR SOI 4. S................. 18

742 INFECTIOUS & PARASITIC

710

4 INFECTIOUS & PARASITIC DISEASES W O.R.

DISEASES INCLUDING HIV PROCEDURE SOI 4.

W O.R. PROCEDURE SOI 4. S................. 18

742 INFECTIOUS & PARASITIC

711

4 POST-OP, POST-TRAUMA, DISEASES W O.R.

OTHER DEVICE INFECTIONS PROCEDURE SOI 4.

W O.R. PROCEDURE SOI 4. S................. 18

743 INFECTIOUS & PARASITIC

710

1 INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W

DISEASES INCLUDING HIV O.R. PROCEDURE SOI 1.

W O.R. PROCEDURE SOI 1. S................. 18

744 INFECTIOUS & PARASITIC

710

2 INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W

DISEASES INCLUDING HIV O.R. PROCEDURE SOI 2.

W O.R. PROCEDURE SOI 2. S................. 18

745 INFECTIOUS & PARASITIC

710

3 INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W

DISEASES INCLUDING HIV O.R. PROCEDURE SOI 3.

W O.R. PROCEDURE SOI 3. S................. 18

746 POST-OP, POST-TRAUMA,

711

1 POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS

OTHER DEVICE INFECTIONS W O.R. PROCEDURE SOI 1.

W O.R. PROCEDURE SOI 1. S................. 18

747 POST-OP, POST-TRAUMA,

711

2 POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS

OTHER DEVICE INFECTIONS W O.R. PROCEDURE SOI 2.

W O.R. PROCEDURE SOI 2. S................. 18

748 POST-OP, POST-TRAUMA,

711

3 POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS

OTHER DEVICE INFECTIONS W O.R. PROCEDURE SOI 3.

W O.R. PROCEDURE SOI 3. M................. 18

749 INFECTIOUS & PARASITIC

720

4 SEPTICEMIA & DISEASES SOI 4.

DISSEMINATED INFECTIONS SOI 4. M................. 18

749 INFECTIOUS & PARASITIC

721

4 POST-OPERATIVE, POST- DISEASES SOI 4.

TRAUMATIC, OTHER DEVICE INFECTIONS SOI 4. M................. 18

749 INFECTIOUS & PARASITIC

722

4 FEVER SOI 4. DISEASES SOI 4. M................. 18

749 INFECTIOUS & PARASITIC

723

4 VIRAL ILLNESS SOI 4. DISEASES SOI 4. M................. 18

749 INFECTIOUS & PARASITIC

724

4 OTHER INFECTIOUS & DISEASES SOI 4.

PARASITIC DISEASES SOI 4. M................. 18

750 SEPTICEMIA & DISSEMINATED 720

1 SEPTICEMIA & INFECTIONS SOI 1.

DISSEMINATED INFECTIONS SOI 1. M................. 18

751 SEPTICEMIA & DISSEMINATED 720

2 SEPTICEMIA & INFECTIONS SOI 2.

DISSEMINATED INFECTIONS SOI 2. M................. 18

752 SEPTICEMIA & DISSEMINATED 720

3 SEPTICEMIA & INFECTIONS SOI 3.

DISSEMINATED INFECTIONS SOI 3. M................. 18

753 POST-OPERATIVE, POST-

721

1 POST-OPERATIVE, POST- TRAUMATIC, OTHER DEVICE

TRAUMATIC, OTHER DEVICE INFECTIONS SOI 1.

INFECTIONS SOI 1. M................. 18

754 POST-OPERATIVE, POST-

721

2 POST-OPERATIVE, POST- TRAUMATIC, OTHER DEVICE

TRAUMATIC, OTHER DEVICE INFECTIONS SOI 2.

INFECTIONS SOI 2. M................. 18

755 POST-OPERATIVE, POST-

721

3 POST-OPERATIVE, POST- TRAUMATIC, OTHER DEVICE

TRAUMATIC, OTHER DEVICE INFECTIONS SOI 3.

INFECTIONS SOI 3. M................. 18

756 FEVER SOI 1.............. 722

1 FEVER SOI 1. M................. 18

757 FEVER SOI 2.............. 722

2 FEVER SOI 2. M................. 18

758 FEVER SOI 3.............. 722

3 FEVER SOI 3. M................. 18

759 VIRAL ILLNESS SOI 1...... 723

1 VIRAL ILLNESS SOI 1. M................. 18

760 VIRAL ILLNESS SOI 2...... 723

2 VIRAL ILLNESS SOI 2. M................. 18

761 VIRAL ILLNESS SOI 3...... 723

3 VIRAL ILLNESS SOI 3. M................. 18

762 OTHER INFECTIOUS &

724

1 OTHER INFECTIOUS & PARASITIC DISEASES SOI 1.

PARASITIC DISEASES SOI 1. M................. 18

763 OTHER INFECTIOUS &

724

2 OTHER INFECTIOUS & PARASITIC DISEASES SOI 2.

PARASITIC DISEASES SOI 2. M................. 18

764 OTHER INFECTIOUS &

724

3 OTHER INFECTIOUS & PARASITIC DISEASES SOI 3.

PARASITIC DISEASES SOI 3. S................. 19

765 MENTAL ILLNESS DIAGNOSIS 740

1 MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE SOI 1.

W O.R. PROCEDURE SOI 1.

[[Page 24467]]

S................. 19

766 MENTAL ILLNESS DIAGNOSIS 740

2 MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE SOI 2.

W O.R. PROCEDURE SOI 2. S................. 19

767 MENTAL ILLNESS DIAGNOSIS 740

3 MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE SOI 3.

W O.R. PROCEDURE SOI 3. S................. 19

768 MENTAL ILLNESS DIAGNOSIS 740

4 MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE SOI 4.

W O.R. PROCEDURE SOI 4. M................. 19

769 MAJOR DEPRESSIVE,

750

1 SCHIZOPHRENIA SOI 1. SCHIZOPHRENIA & BIPOLAR DISORDERS SOI 1. M................. 19

769 MAJOR DEPRESSIVE,

751

1 MAJOR DEPRESSIVE SCHIZOPHRENIA & BIPOLAR

DISORDERS & OTHER/ DISORDERS SOI 1.

UNSPECIFIED PSYCHOSES SOI 1. M................. 19

769 MAJOR DEPRESSIVE,

753

1 BIPOLAR DISORDERS SOI 1. SCHIZOPHRENIA & BIPOLAR DISORDERS SOI 1. M................. 19

770 MAJOR DEPRESSIVE,

750

2 SCHIZOPHRENIA SOI 2. SCHIZOPHRENIA & BIPOLAR DISORDERS SOI 2. M................. 19

770 MAJOR DEPRESSIVE,

751

2 MAJOR DEPRESSIVE SCHIZOPHRENIA & BIPOLAR

DISORDERS & OTHER/ DISORDERS SOI 2.

UNSPECIFIED PSYCHOSES SOI 2. M................. 19

770 MAJOR DEPRESSIVE,

753

2 BIPOLAR DISORDERS SOI 2. SCHIZOPHRENIA & BIPOLAR DISORDERS SOI 2. M................. 19

771 MAJOR DEPRESSIVE,

750

3 SCHIZOPHRENIA SOI 3. SCHIZOPHRENIA & BIPOLAR DISORDERS SOI 3. M................. 19

771 MAJOR DEPRESSIVE,

751

3 MAJOR DEPRESSIVE SCHIZOPHRENIA & BIPOLAR

DISORDERS & OTHER/ DISORDERS SOI 3.

UNSPECIFIED PSYCHOSES SOI 3. M................. 19

771 MAJOR DEPRESSIVE,

753

3 BIPOLAR DISORDERS SOI 3. SCHIZOPHRENIA & BIPOLAR DISORDERS SOI 3. M................. 19

772 MAJOR DEPRESSIVE,

750

4 SCHIZOPHRENIA SOI 4. SCHIZOPHRENIA & BIPOLAR DISORDERS SOI 4. M................. 19

772 MAJOR DEPRESSIVE,

751

4 MAJOR DEPRESSIVE SCHIZOPHRENIA & BIPOLAR

DISORDERS & OTHER/ DISORDERS SOI 4.

UNSPECIFIED PSYCHOSES SOI 4. M................. 19

772 MAJOR DEPRESSIVE,

753

4 BIPOLAR DISORDERS SOI 4. SCHIZOPHRENIA & BIPOLAR DISORDERS SOI 4. M................. 19

773 ORGANIC MENTAL HEALTH

757

1 ORGANIC MENTAL HEALTH DISTURBANCES SOI 1.

DISTURBANCES SOI 1. M................. 19

774 ORGANIC MENTAL HEALTH

757

2 ORGANIC MENTAL HEALTH DISTURBANCES SOI 2.

DISTURBANCES SOI 2. M................. 19

775 ORGANIC MENTAL HEALTH

757

3 ORGANIC MENTAL HEALTH DISTURBANCES SOI 3.

DISTURBANCES SOI 3. M................. 19

776 ORGANIC MENTAL HEALTH

757

4 ORGANIC MENTAL HEALTH DISTURBANCES SOI 4.

DISTURBANCES SOI 4. M................. 19

777 OTHER MENTAL HEALTH

752

1 DISORDERS OF PERSONALITY DISORDERS SOI 1.

& IMPULSE CONTROL SOI 1. M................. 19

777 OTHER MENTAL HEALTH

754

1 DEPRESSION EXCEPT MAJOR DISORDERS SOI 1.

DEPRESSIVE DISORDER SOI 1. M................. 19

777 OTHER MENTAL HEALTH

755

1 ADJUSTMENT DISORDERS & DISORDERS SOI 1.

NEUROSES EXCEPT DEPRESSIVE DIAGNOSES SOI 1. M................. 19

777 OTHER MENTAL HEALTH

756

1 ACUTE ANXIETY & DELIRIUM DISORDERS SOI 1.

STATES SOI 1. M................. 19

777 OTHER MENTAL HEALTH

758

1 CHILDHOOD BEHAVIORAL DISORDERS SOI 1.

DISORDERS SOI 1. M................. 19

777 OTHER MENTAL HEALTH

759

1 EATING DISORDERS SOI 1. DISORDERS SOI 1. M................. 19

777 OTHER MENTAL HEALTH

760

1 OTHER MENTAL HEALTH DISORDERS SOI 1.

DISORDERS SOI 1. M................. 19

778 OTHER MENTAL HEALTH

752

2 DISORDERS OF PERSONALITY DISORDERS SOI 2.

& IMPULSE CONTROL SOI 2. M................. 19

778 OTHER MENTAL HEALTH

754

2 DEPRESSION EXCEPT MAJOR DISORDERS SOI 2.

DEPRESSIVE DISORDER SOI 2. M................. 19

778 OTHER MENTAL HEALTH

755

2 ADJUSTMENT DISORDERS & DISORDERS SOI 2.

NEUROSES EXCEPT DEPRESSIVE DIAGNOSES SOI 2. M................. 19

778 OTHER MENTAL HEALTH

756

2 ACUTE ANXIETY & DELIRIUM DISORDERS SOI 2.

STATES SOI 2. M................. 19

778 OTHER MENTAL HEALTH

758

2 CHILDHOOD BEHAVIORAL DISORDERS SOI 2.

DISORDERS SOI 2.

[[Page 24468]]

M................. 19

778 OTHER MENTAL HEALTH

759

2 EATING DISORDERS SOI 2. DISORDERS SOI 2. M................. 19

778 OTHER MENTAL HEALTH

760

2 OTHER MENTAL HEALTH DISORDERS SOI 2.

DISORDERS SOI 2. M................. 19

779 OTHER MENTAL HEALTH

752

3 DISORDERS OF PERSONALITY DISORDERS SOI 3.

& IMPULSE CONTROL SOI 3. M................. 19

779 OTHER MENTAL HEALTH

754

3 DEPRESSION EXCEPT MAJOR DISORDERS SOI 3.

DEPRESSIVE DISORDER SOI 3. M................. 19

779 OTHER MENTAL HEALTH

755

3 ADJUSTMENT DISORDERS & DISORDERS SOI 3.

NEUROSES EXCEPT DEPRESSIVE DIAGNOSES SOI 3. M................. 19

779 OTHER MENTAL HEALTH

756

3 ACUTE ANXIETY & DELIRIUM DISORDERS SOI 3.

STATES SOI 3. M................. 19

779 OTHER MENTAL HEALTH

758

3 CHILDHOOD BEHAVIORAL DISORDERS SOI 3.

DISORDERS SOI 3. M................. 19

779 OTHER MENTAL HEALTH

759

3 EATING DISORDERS SOI 3. DISORDERS SOI 3. M................. 19

779 OTHER MENTAL HEALTH

760

3 OTHER MENTAL HEALTH DISORDERS SOI 3.

DISORDERS SOI 3. M................. 19

780 OTHER MENTAL HEALTH

752

4 DISORDERS OF PERSONALITY DISORDERS SOI 4.

& IMPULSE CONTROL SOI 4. M................. 19

780 OTHER MENTAL HEALTH

754

4 DEPRESSION EXCEPT MAJOR DISORDERS SOI 4.

DEPRESSIVE DISORDER SOI 4. M................. 19

780 OTHER MENTAL HEALTH

755

4 ADJUSTMENT DISORDERS & DISORDERS SOI 4.

NEUROSES EXCEPT DEPRESSIVE DIAGNOSES SOI 4. M................. 19

780 OTHER MENTAL HEALTH

756

4 ACUTE ANXIETY & DELIRIUM DISORDERS SOI 4.

STATES SOI 4. M................. 19

780 OTHER MENTAL HEALTH

758

4 CHILDHOOD BEHAVIORAL DISORDERS SOI 4.

DISORDERS SOI 4. M................. 19

780 OTHER MENTAL HEALTH

759

4 EATING DISORDERS SOI 4. DISORDERS SOI 4. M................. 19

780 OTHER MENTAL HEALTH

760

4 OTHER MENTAL HEALTH DISORDERS SOI 4.

DISORDERS SOI 4. M................. 20

781 DRUG & ALCOHOL ABUSE OR

770

1 DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST

DEPENDENCE, LEFT MEDICAL ADVICE SOI 1 & 2.

AGAINST MEDICAL ADVICE SOI 1. M................. 20

781 DRUG & ALCOHOL ABUSE OR

770

2 DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST

DEPENDENCE, LEFT MEDICAL ADVICE SOI 1 & 2.

AGAINST MEDICAL ADVICE SOI 2. M................. 20

782 DRUG & ALCOHOL ABUSE OR

770

3 DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST

DEPENDENCE, LEFT MEDICAL ADVICE SOI 3 & 4.

AGAINST MEDICAL ADVICE SOI 3. M................. 20

782 DRUG & ALCOHOL ABUSE OR

770

4 DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST

DEPENDENCE, LEFT MEDICAL ADVICE SOI 3 & 4.

AGAINST MEDICAL ADVICE SOI 4. M................. 20

783 DRUG ABUSE & DEPENDENCE

772

1 ALCOHOL & DRUG DIAGNOSES SOI 1.

DEPENDENCE W REHAB OR REHAB/DETOX THERAPY SOI 1. M................. 20

783 DRUG ABUSE & DEPENDENCE

773

1 OPIOID ABUSE & DIAGNOSES SOI 1.

DEPENDENCE SOI 1. M................. 20

783 DRUG ABUSE & DEPENDENCE

774

1 COCAINE ABUSE & DIAGNOSES SOI 1.

DEPENDENCE SOI 1. M................. 20

783 DRUG ABUSE & DEPENDENCE

775

1 ALCOHOL ABUSE & DIAGNOSES SOI 1.

DEPENDENCE SOI 1. M................. 20

783 DRUG ABUSE & DEPENDENCE

776

1 OTHER DRUG ABUSE & DIAGNOSES SOI 1.

DEPENDENCE SOI 1. M................. 20

784 DRUG ABUSE & DEPENDENCE

772

2 ALCOHOL & DRUG DIAGNOSES SOI 2.

DEPENDENCE W REHAB OR REHAB/DETOX THERAPY SOI 2. M................. 20

784 DRUG ABUSE & DEPENDENCE

773

2 OPIOID ABUSE & DIAGNOSES SOI 2.

DEPENDENCE SOI 2. M................. 20

784 DRUG ABUSE & DEPENDENCE

774

2 COCAINE ABUSE & DIAGNOSES SOI 2.

DEPENDENCE SOI 2. M................. 20

784 DRUG ABUSE & DEPENDENCE

775

2 ALCOHOL ABUSE & DIAGNOSES SOI 2.

DEPENDENCE SOI 2. M................. 20

784 DRUG ABUSE & DEPENDENCE

776

2 OTHER DRUG ABUSE & DIAGNOSES SOI 2.

DEPENDENCE SOI 2.

[[Page 24469]]

M................. 20

785 DRUG ABUSE & DEPENDENCE

772

3 ALCOHOL & DRUG DIAGNOSES SOI 3.

DEPENDENCE W REHAB OR REHAB/DETOX THERAPY SOI 3. M................. 20

785 DRUG ABUSE & DEPENDENCE

773

3 OPIOID ABUSE & DIAGNOSES SOI 3.

DEPENDENCE SOI 3. M................. 20

785 DRUG ABUSE & DEPENDENCE

774

3 COCAINE ABUSE & DIAGNOSES SOI 3.

DEPENDENCE SOI 3. M................. 20

785 DRUG ABUSE & DEPENDENCE

775

3 ALCOHOL ABUSE & DIAGNOSES SOI 3.

DEPENDENCE SOI 3. M................. 20

785 DRUG ABUSE & DEPENDENCE

776

3 OTHER DRUG ABUSE & DIAGNOSES SOI 3.

DEPENDENCE SOI 3. M................. 20

786 DRUG ABUSE & DEPENDENCE

772

4 ALCOHOL & DRUG DIAGNOSES SOI 4.

DEPENDENCE W REHAB OR REHAB/DETOX THERAPY SOI 4. M................. 20

786 DRUG ABUSE & DEPENDENCE

773

4 OPIOID ABUSE & DIAGNOSES SOI 4.

DEPENDENCE SOI 4. M................. 20

786 DRUG ABUSE & DEPENDENCE

774

4 COCAINE ABUSE & DIAGNOSES SOI 4.

DEPENDENCE SOI 4. M................. 20

786 DRUG ABUSE & DEPENDENCE

775

4 ALCOHOL ABUSE & DIAGNOSES SOI 4.

DEPENDENCE SOI 4. M................. 20

786 DRUG ABUSE & DEPENDENCE

776

4 OTHER DRUG ABUSE & DIAGNOSES SOI 4.

DEPENDENCE SOI 4. S................. 21

787 O.R. PROCEDURE FOR OTHER 791

1 O.R. PROCEDURE FOR OTHER COMPLICATIONS OF

COMPLICATIONS OF TREATMENT SOI 1.

TREATMENT SOI 1. S................. 21

788 O.R. PROCEDURE FOR OTHER 791

2 O.R. PROCEDURE FOR OTHER COMPLICATIONS OF

COMPLICATIONS OF TREATMENT SOI 2.

TREATMENT SOI 2. S................. 21

789 O.R. PROCEDURE FOR OTHER 791

3 O.R. PROCEDURE FOR OTHER COMPLICATIONS OF

COMPLICATIONS OF TREATMENT SOI 3.

TREATMENT SOI 3. S................. 21

790 O.R. PROCEDURE FOR OTHER 791

4 O.R. PROCEDURE FOR OTHER COMPLICATIONS OF

COMPLICATIONS OF TREATMENT SOI 4.

TREATMENT SOI 4. M................. 21

791 INJURIES, POISONINGS &

811

4 ALLERGIC REACTIONS SOI TOXIC EFFECTS OF DRUGS

4. DIAGNOSES SOI 4. M................. 21

791 INJURIES, POISONINGS &

812

4 POISONING OF MEDICINAL TOXIC EFFECTS OF DRUGS

AGENTS SOI 4. DIAGNOSES SOI 4. M................. 21

791 INJURIES, POISONINGS &

813

4 OTHER COMPLICATIONS OF TOXIC EFFECTS OF DRUGS

TREATMENT SOI 4. DIAGNOSES SOI 4. M................. 21

791 INJURIES, POISONINGS &

815

4 OTHER INJURY, POISONING TOXIC EFFECTS OF DRUGS

& TOXIC EFFECT DIAGNOSES SOI 4.

DIAGNOSES SOI 4. M................. 21

791 INJURIES, POISONINGS &

816

4 TOXIC EFFECTS OF NON- TOXIC EFFECTS OF DRUGS

MEDICINAL SUBSTANCES DIAGNOSES SOI 4.

SOI 4. M................. 21

792 ALLERGIC REACTIONS SOI 1. 811

1 ALLERGIC REACTIONS SOI 1. M................. 21

793 ALLERGIC REACTIONS SOI 2. 811

2 ALLERGIC REACTIONS SOI 2. M................. 21

794 ALLERGIC REACTIONS SOI 3. 811

3 ALLERGIC REACTIONS SOI 3. M................. 21

795 POISONING OF MEDICINAL

812

1 POISONING OF MEDICINAL AGENTS SOI 1.

AGENTS SOI 1. M................. 21

796 POISONING OF MEDICINAL

812

2 POISONING OF MEDICINAL AGENTS SOI 2.

AGENTS SOI 2. M................. 21

797 POISONING OF MEDICINAL

812

3 POISONING OF MEDICINAL AGENTS SOI 3.

AGENTS SOI 3. M................. 21

798 OTHER COMPLICATIONS OF

813

1 OTHER COMPLICATIONS OF TREATMENT SOI 1.

TREATMENT SOI 1. M................. 21

799 OTHER COMPLICATIONS OF

813

2 OTHER COMPLICATIONS OF TREATMENT SOI 2.

TREATMENT SOI 2. M................. 21

800 OTHER COMPLICATIONS OF

813

3 OTHER COMPLICATIONS OF TREATMENT SOI 3.

TREATMENT SOI 3. M................. 21

801 OTHER INJURY, POISONING & 815

1 OTHER INJURY, POISONING TOXIC EFFECT DIAGNOSES

& TOXIC EFFECT SOI 1.

DIAGNOSES SOI 1. M................. 21

801 OTHER INJURY, POISONING & 816

1 TOXIC EFFECTS OF NON- TOXIC EFFECT DIAGNOSES

MEDICINAL SUBSTANCES SOI 1.

SOI 1. M................. 21

802 OTHER INJURY, POISONING & 815

2 OTHER INJURY, POISONING TOXIC EFFECT DIAGNOSES

& TOXIC EFFECT SOI 2.

DIAGNOSES SOI 2. M................. 21

802 OTHER INJURY, POISONING & 816

2 TOXIC EFFECTS OF NON- TOXIC EFFECT DIAGNOSES

MEDICINAL SUBSTANCES SOI 2.

SOI 2. M................. 21

803 OTHER INJURY, POISONING & 815

3 OTHER INJURY, POISONING TOXIC EFFECT DIAGNOSES

& TOXIC EFFECT SOI 3.

DIAGNOSES SOI 3. M................. 21

803 OTHER INJURY, POISONING & 816

3 TOXIC EFFECTS OF NON- TOXIC EFFECT DIAGNOSES

MEDICINAL SUBSTANCES SOI 3.

SOI 3. S................. 22

804 BURN PROCEDURES SOI 4.... 841

4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT SOI 4.

[[Page 24470]]

S................. 22

804 BURN PROCEDURES SOI 4.... 842

4 FULL THICKNESS BURNS W SKIN GRAFT SOI 4. S................. 22

805 EXTENSIVE 3RD DEGREE OR

841

1 EXTENSIVE 3RD DEGREE FULL THICKNESS BURNS W

BURNS W SKIN GRAFT SOI SKIN GRAFT SOI 1.

1. S................. 22

805 EXTENSIVE 3RD DEGREE OR

842

1 FULL THICKNESS BURNS W FULL THICKNESS BURNS W

SKIN GRAFT SOI 1. SKIN GRAFT SOI 1. S................. 22

806 EXTENSIVE 3RD DEGREE OR

841

2 EXTENSIVE 3RD DEGREE FULL THICKNESS BURNS W

BURNS W SKIN GRAFT SOI SKIN GRAFT SOI 2.

2. S................. 22

806 EXTENSIVE 3RD DEGREE OR

842

2 FULL THICKNESS BURNS W FULL THICKNESS BURNS W

SKIN GRAFT SOI 2. SKIN GRAFT SOI 2. S................. 22

807 EXTENSIVE 3RD DEGREE OR

841

3 EXTENSIVE 3RD DEGREE FULL THICKNESS BURNS W

BURNS W SKIN GRAFT SOI SKIN GRAFT SOI 3.

3. S................. 22

807 EXTENSIVE 3RD DEGREE OR

842

3 FULL THICKNESS BURNS W FULL THICKNESS BURNS W

SKIN GRAFT SOI 3. SKIN GRAFT SOI 3. M................. 22

808 BURN DIAGNOSES SOI 4..... 843

4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/ O SKIN GRAFT SOI 4. M................. 22

808 BURN DIAGNOSES SOI 4..... 844

4 PARTIAL THICKNESS BURNS W OR W/O SKIN GRAFT SOI 4. M................. 22

809 EXTENSIVE 3RD DEGREE OR

843

1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O

FULL THICKNESS BURNS W/ SKIN GRAFT SOI 1.

O SKIN GRAFT SOI 1. M................. 22

810 EXTENSIVE 3RD DEGREE OR

843

2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O

FULL THICKNESS BURNS W/ SKIN GRAFT SOI 2.

O SKIN GRAFT SOI 2. M................. 22

811 EXTENSIVE 3RD DEGREE OR

843

3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O

FULL THICKNESS BURNS W/ SKIN GRAFT SOI 3.

O SKIN GRAFT SOI 3. M................. 22

812 PARTIAL THICKNESS BURNS W 844

1 PARTIAL THICKNESS BURNS OR W/O SKIN GRAFT SOI 1.

W OR W/O SKIN GRAFT SOI 1. M................. 22

813 PARTIAL THICKNESS BURNS W 844

2 PARTIAL THICKNESS BURNS OR W/O SKIN GRAFT SOI 2.

W OR W/O SKIN GRAFT SOI 2. M................. 22

814 PARTIAL THICKNESS BURNS W 844

3 PARTIAL THICKNESS BURNS OR W/O SKIN GRAFT SOI 3.

W OR W/O SKIN GRAFT SOI 3. S................. 23

815 PROCEDURE W DIAG OF

850

1 PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH

REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE

CONTACT W HEALTH SOI 1.

SERVICE SOI 1. S................. 23

816 PROCEDURE W DIAG OF

850

2 PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH

REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE

CONTACT W HEALTH SOI 2.

SERVICE SOI 2. S................. 23

817 PROCEDURE W DIAG OF

850

3 PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH

REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE

CONTACT W HEALTH SOI 3.

SERVICE SOI 3. S................. 23

818 PROCEDURE W DIAG OF

850

4 PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH

REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE

CONTACT W HEALTH SOI 4.

SERVICE SOI 4. M................. 23

819 REHABILITATION/AFTERCARE/ 860

4 REHABILITATION SOI 4. CONVALESCENCE EXCEPT NEONATAL AFTERCARE SOI 4. M................. 23

819 REHABILITATION/AFTERCARE/ 861

4 SIGNS, SYMPTOMS & OTHER CONVALESCENCE EXCEPT

FACTORS INFLUENCING NEONATAL AFTERCARE SOI 4.

HEALTH STATUS SOI 4. M................. 23

819 REHABILITATION/AFTERCARE/ 862

4 OTHER AFTERCARE & CONVALESCENCE EXCEPT

CONVALESCENCE SOI 4. NEONATAL AFTERCARE SOI 4. M................. 23

819 REHABILITATION/AFTERCARE/ 863

4 NEONATAL AFTERCARE SOI CONVALESCENCE EXCEPT

4. NEONATAL AFTERCARE SOI 4. M................. 23

820 REHABILITATION SOI 1..... 860

1 REHABILITATION SOI 1. M................. 23

821 REHABILITATION SOI 2..... 860

2 REHABILITATION SOI 2. M................. 23

822 REHABILITATION SOI 3..... 860

3 REHABILITATION SOI 3. M................. 23

823 SIGNS, SYMPTOMS & OTHER

861

1 SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING

FACTORS INFLUENCING HEALTH STATUS SOI 1.

HEALTH STATUS SOI 1.

[[Page 24471]]

M................. 23

824 SIGNS, SYMPTOMS & OTHER

861

2 SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING

FACTORS INFLUENCING HEALTH STATUS SOI 2.

HEALTH STATUS SOI 2. M................. 23

825 SIGNS, SYMPTOMS & OTHER

861

3 SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING

FACTORS INFLUENCING HEALTH STATUS SOI 3.

HEALTH STATUS SOI 3. M................. 23

826 OTHER AFTERCARE &

862

1 OTHER AFTERCARE & CONVALESCENCE SOI 1.

CONVALESCENCE SOI 1. M................. 23

826 OTHER AFTERCARE &

863

1 NEONATAL AFTERCARE SOI CONVALESCENCE SOI 1.

1. M................. 23

827 OTHER AFTERCARE &

862

2 OTHER AFTERCARE & CONVALESCENCE SOI 2.

CONVALESCENCE SOI 2. M................. 23

827 OTHER AFTERCARE &

863

2 NEONATAL AFTERCARE SOI CONVALESCENCE SOI 2.

2. M................. 23

828 OTHER AFTERCARE &

862

3 OTHER AFTERCARE & CONVALESCENCE SOI 3.

CONVALESCENCE SOI 3. M................. 23

828 OTHER AFTERCARE &

863

3 NEONATAL AFTERCARE SOI CONVALESCENCE SOI 3.

3. M................. 24

829 HIV DIAGNOSES SOI 4...... 890

4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS SOI 4. M................. 24

829 HIV DIAGNOSES SOI 4...... 892

4 HIV W MAJOR HIV RELATED CONDITION SOI 4. M................. 24

829 HIV DIAGNOSES SOI 4...... 893

4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS SOI 4. M................. 24

829 HIV DIAGNOSES SOI 4...... 894

4 HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND SOI 4. M................. 24

830 HIV W MULTIPLE MAJOR HIV 890

1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS SOI 1

RELATED CONDITIONS SOI & 2.

1. M................. 24

830 HIV W MULTIPLE MAJOR HIV 890

2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS SOI 1

RELATED CONDITIONS SOI & 2.

2. M................. 24

831 HIV W MULTIPLE MAJOR HIV 890

3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS SOI 3.

RELATED CONDITIONS SOI 3. M................. 24

832 HIV W MAJOR HIV RELATED

892

1 HIV W MAJOR HIV RELATED CONDITION SOI 1 & 2.

CONDITION SOI 1. M................. 24

832 HIV W MAJOR HIV RELATED

892

2 HIV W MAJOR HIV RELATED CONDITION SOI 1 & 2.

CONDITION SOI 2. M................. 24

833 HIV W MAJOR HIV RELATED

892

3 HIV W MAJOR HIV RELATED CONDITION SOI 3.

CONDITION SOI 3. M................. 24

834 HIV W MULTIPLE

893

1 HIV W MULTIPLE SIGNIFICANT HIV RELATED

SIGNIFICANT HIV RELATED CONDITIONS SOI 1 & 2.

CONDITIONS SOI 1. M................. 24

834 HIV W MULTIPLE

893

2 HIV W MULTIPLE SIGNIFICANT HIV RELATED

SIGNIFICANT HIV RELATED CONDITIONS SOI 1 & 2.

CONDITIONS SOI 2. M................. 24

835 HIV W MULTIPLE

893

3 HIV W MULTIPLE SIGNIFICANT HIV RELATED

SIGNIFICANT HIV RELATED CONDITIONS SOI 3.

CONDITIONS SOI 3. M................. 24

836 HIV W ONE SIGNIF HIV COND 894

1 HIV W ONE SIGNIF HIV OR W/O SIGNIF RELATED

COND OR W/O SIGNIF COND SOI 1.

RELATED COND SOI 1. M................. 24

837 HIV W ONE SIGNIF HIV COND 894

2 HIV W ONE SIGNIF HIV OR W/O SIGNIF RELATED

COND OR W/O SIGNIF COND SOI 2.

RELATED COND SOI 2. M................. 24

838 HIV W ONE SIGNIF HIV COND 894

3 HIV W ONE SIGNIF HIV OR W/O SIGNIF RELATED

COND OR W/O SIGNIF COND SOI 3.

RELATED COND SOI 3. S................. 25

839 MULTIPLE SIGNIFICANT

910

4 CRANIOTOMY FOR MULTIPLE TRAUMA PROCEDURES SOI 4.

SIGNIFICANT TRAUMA SOI 4. S................. 25

839 MULTIPLE SIGNIFICANT

911

4 EXTENSIVE ABDOMINAL/ TRAUMA PROCEDURES SOI 4.

THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA SOI 4. S................. 25

839 MULTIPLE SIGNIFICANT

912

4 MUSCULOSKELETAL & OTHER TRAUMA PROCEDURES SOI 4.

PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA SOI 4. S................. 25

840 CRANIOTOMY FOR MULTIPLE

910

1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA SOI 1

SIGNIFICANT TRAUMA SOI & 2.

1. S................. 25

840 CRANIOTOMY FOR MULTIPLE

910

2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA SOI 1

SIGNIFICANT TRAUMA SOI & 2.

2. S................. 25

841 CRANIOTOMY FOR MULTIPLE

910

3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA SOI 3.

SIGNIFICANT TRAUMA SOI 3. S................. 25

842 EXTENSIVE ABDOMINAL/

911

1 EXTENSIVE ABDOMINAL/ THORACIC PROCEDURES FOR

THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA

MULT SIGNIFICANT TRAUMA SOI 1 & 2.

SOI 1. S................. 25

842 EXTENSIVE ABDOMINAL/

911

2 EXTENSIVE ABDOMINAL/ THORACIC PROCEDURES FOR

THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA

MULT SIGNIFICANT TRAUMA SOI 1 & 2.

SOI 2.

[[Page 24472]]

S................. 25

843 EXTENSIVE ABDOMINAL/

911

3 EXTENSIVE ABDOMINAL/ THORACIC PROCEDURES FOR

THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA

MULT SIGNIFICANT TRAUMA SOI 3.

SOI 3. S................. 25

844 MUSCULOSKELETAL & OTHER

912

1 MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE

PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA SOI 1

SIGNIFICANT TRAUMA SOI & 2.

1. S................. 25

844 MUSCULOSKELETAL & OTHER

912

2 MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE

PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA SOI 1

SIGNIFICANT TRAUMA SOI & 2.

2. S................. 25

845 MUSCULOSKELETAL & OTHER

912

3 MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE

PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA SOI 3.

SIGNIFICANT TRAUMA SOI 3. M................. 25

846 MULTIPLE SIGNIFICANT

930

1 MULTIPLE SIGNIFICANT TRAUMA W/O O.R.

TRAUMA W/O O.R. PROCEDURE SOI 1 & 2.

PROCEDURE SOI 1. M................. 25

846 MULTIPLE SIGNIFICANT

930

2 MULTIPLE SIGNIFICANT TRAUMA W/O O.R.

TRAUMA W/O O.R. PROCEDURE SOI 1 & 2.

PROCEDURE SOI 2. M................. 25

847 MULTIPLE SIGNIFICANT

930

3 MULTIPLE SIGNIFICANT TRAUMA W/O O.R.

TRAUMA W/O O.R. PROCEDURE SOI 3.

PROCEDURE SOI 3. M................. 25

848 MULTIPLE SIGNIFICANT

930

4 MULTIPLE SIGNIFICANT TRAUMA W/O O.R.

TRAUMA W/O O.R. PROCEDURE SOI 4.

PROCEDURE SOI 4. S................. 25

987 EXTENSIVE PROCEDURE

950

1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL

UNRELATED TO PRINCIPAL DIAGNOSIS SOI 1.

DIAGNOSIS SOI 1. S................. 25

988 EXTENSIVE PROCEDURE

950

2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL

UNRELATED TO PRINCIPAL DIAGNOSIS SOI 2.

DIAGNOSIS SOI 2. S................. 25

989 EXTENSIVE PROCEDURE

950

3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL

UNRELATED TO PRINCIPAL DIAGNOSIS SOI 3.

DIAGNOSIS SOI 3. S................. 25

990 EXTENSIVE PROCEDURE

950

4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL

UNRELATED TO PRINCIPAL DIAGNOSIS SOI 4.

DIAGNOSIS SOI 4. S................. 25

991 NON MAJOR PROCEDURE

951

4 MODERATELY EXTENSIVE UNRELATED TO PRINCIPAL

PROCEDURE UNRELATED TO DIAGNOSIS SOI 4.

PRINCIPAL DIAGNOSIS SOI 4. S................. 25

991 NON MAJOR PROCEDURE

952

4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL

UNRELATED TO PRINCIPAL DIAGNOSIS SOI 4.

DIAGNOSIS SOI 4. S................. 25

992 MODERATELY EXTENSIVE

951

1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO

PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS SOI

PRINCIPAL DIAGNOSIS SOI 1.

1. S................. 25

993 MODERATELY EXTENSIVE

951

2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO

PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS SOI

PRINCIPAL DIAGNOSIS SOI 2.

2. S................. 25

994 MODERATELY EXTENSIVE

951

3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO

PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS SOI

PRINCIPAL DIAGNOSIS SOI 3.

3. S................. 25

995 NONEXTENSIVE PROCEDURE

952

1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL

UNRELATED TO PRINCIPAL DIAGNOSIS SOI 1.

DIAGNOSIS SOI 1. S................. 25

996 NONEXTENSIVE PROCEDURE

952

2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL

UNRELATED TO PRINCIPAL DIAGNOSIS SOI 2.

DIAGNOSIS SOI 2. S................. 25

997 NONEXTENSIVE PROCEDURE

952

3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL

UNRELATED TO PRINCIPAL DIAGNOSIS SOI 3.

DIAGNOSIS SOI 3. 26

998 PRINCIPAL DIAGNOSIS

955

0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE

INVALID AS DISCHARGE DIAGNOSIS.

DIAGNOSIS. 26

999 UNGROUPABLE.............. 956

0 UNGROUPABLE.

M = Medical. S = Surgical. SOI = Severity of Illness Subclass

[FR Doc. 06-3629 Filed 4-12-06; 4:22 pm]

BILLING CODE 4120-01-P

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