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 Department of Health and Human Services Centers for Medicare & Medicaid Services 42 CFR Parts 411, 412, 413, and 489
[CMS-1533-P]
RIN 0938-AO70
 AGENCY: Centers for Medicare and Medicaid Services (CMS), HHS.
 ACTION: Proposed rule.
 SUMMARY: We are proposing to revise the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs to implement changes arising from our continuing experience with these systems, and to implement certain provisions made by the Deficit Reduction Act of 2005 (Pub. L. 109-171), the Medicare Improvements and Extension Act under Division B, Title I of the Tax Relief and Health Care Act of 2006 (Pub. L. 109-432), and the Pandemic and All-Hazards Preparedness Act (Pub. L. 109-417). In addition, in the Addendum to this proposed rule, we describe the proposed changes to the amounts and factors used to determine the rates for Medicare hospital inpatient services for operating costs and capital-related costs. We also are setting forth proposed rate-of-increase limits for certain hospitals and hospital units excluded from the IPPS that are paid in full or in part on a reasonable cost basis subject to these limits or that have a portion of a prospective payment system payment based on reasonable cost principles. These proposed changes would be applicable to discharges occurring on or after October 1, 2007. In this proposed rule, we discuss our proposals to further refine the diagnosis-related group (DRG) system under the IPPS to better recognize severity of illness among patients—for FY 2008, we are proposing to adopt a Medicare Severity DRG (MS-DRG) classification system for the IPPS. We are also proposing to use the structure of the proposed MS-DRG system for the LTCH prospective payment system (referred to as MS-LTC-DRGs) for FY 2008. Among the other policy changes that we are proposing to make are changes related to: Limited revisions of the reclassification of cases to proposed MS-DRGs, the proposed relative weights for the proposed MS-LTC-DRGs; the wage data, including the occupational mix data, used to compute the wage index; applications for new technologies and medical services add-on payments; payments to hospitals for the indirect costs of graduate medical education; submission of hospital quality data; provisions governing application of sanctions relating to the Emergency Medical Treatment and Labor Act of 1986 (EMTALA); provisions governing disclosure of physician ownership in hospitals and patient safety measures; and provisions relating to services furnished to beneficiaries in custody of penal authorities.
 DATES: To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on June 12, 2007.
 ADDRESSES: In commenting, please refer to file code CMS-1533-P. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission. You may submit comments in one of three ways (no duplicates, please): 1. 
                            *Electronically.*
                             You may submit electronic comments on specific issues in this regulation to 
                            *http://www.cms.hhs.gov/​eRulemaking*. Click on the link “Submit electronic comments on CMS regulations with an open comment period”. (Attachments should be in Microsoft Word, WordPerfect, or Excel; however, we prefer Microsoft Word.) 2. 
                            *By regular mail.*
                             You may mail written comments (one original and two copies) to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services,  Attention: CMS-1533-P, P.O. Box 8011, Baltimore, MD 21244-1850. Please allow sufficient time for mailed comments to be received before the close of the comment period. 3. 
                            *By express or overnight mail.*
                             You may send written comments (one original and two copies) to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1533-P, Mail Stop C4-26-05, 7500 Security Boulevard,  Baltimore, MD 21244-1850. 4. 
                            *By hand or courier.*
                             If you prefer, you may deliver (by hand or courier) your written comments (one original and two copies) before the close of the comment period to one of the following addresses. If you intend to deliver your comments to the Baltimore address, please call telephone number (410) 786-7195 in advance to schedule your arrival with one of our staff members. Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201, or 7500 Security Boulevard, Baltimore, MD 21244-1850. (Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons without Federal Government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain proof of filing by stamping in and retaining an extra copy of the comments being filed.) Comments mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period. *Submission of comments on paperwork requirements.*
                             You may submit comments on this document's paperwork requirements by mailing your comments to the addresses provided at the end of the “Collection of Information Requirements” section in this document. For information on viewing public comments, see the beginning of the 
                            **SUPPLEMENTARY INFORMATION**
                             section.
 FOR FURTHER INFORMATION CONTACT:  Marc Hartstein, (410) 786-4548, Operating Prospective Payment, Diagnosis-Related Groups (DRGs), Wage Index, New Medical Services and Technology Add-On Payments, and Hospital Geographic Reclassifications Issues Tzvi Hefter, (410) 786-4487, Capital Prospective Payment, Excluded Hospitals, Graduate Medical Education, Critical Access Hospitals, and Long-Term Care (LTC)-DRG Issues Siddhartha Mazumdar, (410) 786-6673, Rural Community Hospital Demonstration Issues Sheila Blackstock, (410) 786-3502, Quality Data for Annual Payment Update Issues Thomas Valuck, (410) 786-7479, Hospital Value-Based Purchasing Issues Jacqueline Proctor, (410) 786-8852, Disclosure of Physician Ownership in Hospitals and Patient Safety Measures Issues Fred Grabau, (410) 786-0206, Services to Beneficiaries in Custody of Penal Authorities Issues


SUPPLEMENTARY INFORMATION: *Submitting Comments:*
                         We welcome comments from the public on all issues set forth in this rule to assist us in fully considering issues and developing policies. You can assist us by referencing the file code CMS-1533-P 
                        ( print page 24681)
                        and the specific “issue identifier” that precedes the section on which you choose to comment. *Inspection of Public Comments:*
                         All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. We post all comments received before the close of the comment period on the following Web site as soon as possible after they have been received: 
                        *http://www.cms.hhs.gov/​eRulemaking*. Click on the link “Electronic Comments on CMS Regulations” on that Web site to view public comments. Comments received timely will also be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1-800-743-3951. Electronic Access This 
                        **Federal Register**
                         document is also available from the Federal Register online database through GPO Access, a service of the U.S. Government Printing Office. Free public access is available on a Wide Area Information Server (WAIS) through the Internet and via asynchronous dial-in. Internet users can access the database by using the World Wide Web; the Superintendent of Documents' home page address is 
                        *http://www.gpoaccess.gov/​*, by using local WAIS client software, or by telnet to swais.access.gpo.gov, then login as guest (no password required). Dial-in users should use communications software and modem to call (202) 512-1661; type swais, then login as guest (no password required). Acronyms AHA American Hospital Association AHIMA American Health Information Management Association AHRQ Agency for Health Care Research and Quality AMI Acute myocardial infarction AOA American Osteopathic Association APR DRG All Patient Refined Diagnosis Related Group System ASC Ambulatory surgical center ASP Average sales price AWP Average wholesale price BBA Balanced Budget Act of 1997, Pub. L. 105-33 BBRA  Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Balanced Budget Refinement Act of 1999, Pub. L. 106-113 BIPA Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Benefits Improvement and Protection Act of 2000, Pub. L. 106-554 BLS Bureau of Labor Statistics CAH Critical access hospital CART CMS Abstraction & Reporting Tool CBSAs Core-based statistical areas CC Complication or comorbidity CCR Cost-to-charge ratio CDAC Clinical Data Abstraction Center CIPI Capital input price index CPI Consumer price index CMI Case-mix index CMS Centers for Medicare & Medicaid Services CMSA Consolidated Metropolitan Statistical Area COBRA Consolidated Omnibus Reconciliation Act of 1985, Pub. L. 99-272 CPI Consumer price index CY Calendar year DRA Deficit Reduction Act of 2005, Pub. L. 109-171 DRG Diagnosis-related group DSH Disproportionate share hospital ECI Employment cost index EMR Electronic medical record EMTALA Emergency Medical Treatment and Labor Act of 1986, Pub. L. 99-272 FDA Food and Drug Administration FFY Federal fiscal year FIPS Federal information processing standards FQHC Federally qualified health center FTE Full-time equivalent FY Fiscal year GAAP Generally Accepted Accounting Principles GAF Geographic Adjustment Factor GME Graduate medical education HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems HCFA Health Care Financing Administration HCRIS Hospital Cost Report Information System HHA Home health agency HHS Department of Health and Human Services HIC Health insurance card HIPAA Health Insurance Portability and Accountability Act of 1996, Pub. L. 104-191 HIPC Health Information Policy Council HIS Health information system HIT Health information technology HMO Health maintenance organization HSA Health savings account HSCRC Maryland Health Services Cost Review Commission HSRV Hospital-specific relative value HSRVcc Hospital-specific relative value cost center HQA Hospital Quality Alliance HQI Hospital Quality Initiative ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modification ICD-10-PCS International Classification of Diseases, Tenth Edition, Procedure Coding System IHS Indian Health Service IME Indirect medical education IOM Institute of Medicine IPF Inpatient psychiatric facility IPPS Acute care hospital inpatient prospective payment system IRF Inpatient rehabilitation facility JCAHO Joint Commission on Accreditation of Healthcare Organizations LAMCs Large area metropolitan counties LTC-DRG Long-term care diagnosis-related group LTCH Long-term care hospital MAC Medicare Administrative Contractor MCC  Major complication or comorbidity MCE Medicare Code Editor MCO Managed care organization MCV Major cardiovascular condition MDC Major diagnostic category MDH Medicare-dependent, small rural hospital MedPAC Medicare Payment Advisory Commission MedPAR Medicare Provider Analysis and Review File MEI Medicare Economic Index MGCRB Medicare Geographic Classification Review Board MIEA-TRHCA Medicare Improvements and Extension Act, Division B of the Tax Relief and Health Care Act of 2006, Pub. L. 109-432 MMA Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L. 108-173 MPN Medicare provider number MRHFP Medicare Rural Hospital Flexibility Program MSA Metropolitan Statistical Area NAICS North American Industrial Classification System NCD National coverage determination NCHS National Center for Health Statistics NCQA National Committee for Quality Assurance NCVHS National Committee on Vital and Health Statistics NECMA New England County Metropolitan Areas NQF National Quality Forum NTIS National Technical Information Service NVHRI National Voluntary Hospital Reporting Initiative OES Occupational employment statistics OIG Office of the Inspector General OMB Executive Office of Management and Budget O.R. Operating room OSCAR Online Survey Certification and Reporting (System) PRM Provider Reimbursement Manual PPI Producer price index PMSAs Primary metropolitan statistical areas PPS Prospective payment system PRA Per resident amount ProPAC Prospective Payment Assessment Commission PRRB Provider Reimbursement Review Board PS&R Provider Statistical and Reimbursement (System) QIG Quality Improvement Group, CMS QIO Quality Improvement Organization RHC Rural health clinic RHQDAPU Reporting hospital quality data for annual payment update RNHCI Religious nonmedical health care institution 
                            ( print page 24682) RRC Rural referral center RUCAs Rural-urban commuting area codes RY Rate year SAF Standard Analytic File SCH Sole community hospital SFY State fiscal year SIC Standard Industrial Classification SNF Skilled nursing facility SOCs Standard occupational classifications SOM State Operations Manual SSA Social Security Administration SSI Supplemental Security Income TEFRA Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-248 UHDDS Uniform hospital discharge data set VBP Value-based purchasing Table of Contents I. Background A. Summary 1. Acute Care Hospital Inpatient Prospective Payment System (IPPS) 2. Hospitals and Hospital Units Excluded From the IPPS a. Inpatient Rehabilitation Facilities (IRFs) b. Long-Term Care Hospitals (LTCHs) c. Inpatient Psychiatric Facilities (IPFs) 3. Critical Access Hospitals (CAHs) 4. Payments for Graduate Medical Education (GME) B. Provisions of the Deficit Reduction Act of 2005 (DRA) C. Provisions of the Medicare Improvements and Extension Act Under Division B of the Tax Relief and Health Care Act of 2006 D. Provisions of the Pandemic and All-Hazards Preparedness Act E. Major Contents of this Proposed Rule 1. Proposed DRG Reclassifications and Recalibrations of Relative Weights 2. Proposed Changes to the Hospital Wage Index 3. Other Decisions and Proposed Changes to the IPPS for Operating Costs and GME Costs 4. Proposed Changes to the IPPS for Capital-Related Costs 5. Proposed Changes to the Payment Rate for Excluded Hospitals and Hospital Units: Rate-of-Increase Percentages 6. Services Furnished to Beneficiaries in Custody of Penal Authorities 7. Determining Proposed Prospective Payment Operating and Capital Rates and Rate-of-Increase Limits 8. Impact Analysis 9. Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services 10. Discussion of Medicare Payment Advisory Commission Recommendations II. Proposed Changes to DRG Classifications and Relative Weights A. Background B. DRG Reclassifications 1. General 2. Yearly Review for Making DRG Changes C. MedPAC Recommendations for Revisions to the IPPS DRG System D. Refinement of DRGs Based on Severity of Illness 1. Evaluation of Alternative Severity-Adjusted DRG Systems a. Overview of Alternative DRG Classification Systems b. Comparative Performance in Explaining Variation in Resource Use c. Payment Accuracy and Case-Mix Impact d. Issues for Future Consideration 2. Development of Proposed Medicare Severity DRGs (MS-DRGs) a. Comprehensive Review of the CC List b. Chronic Diagnosis Codes c. Acute Diagnosis Codes d. Prior Research on Subdivisions of CCs Into Multiple Categories e. Proposed Medicare Severity DRGs (MS-DRGs) 3. Dividing Proposed MS-DRGs on the Basis of the CCs and MCCs 4. Conclusion 5. Impact of the Proposed MS-DRGs 6. Changes to Case-Mix Index (CMI) from the Proposed MS-DRGs 7. Effect of the Proposed MS-DRGs on the Outlier Threshold 8. Effect of the Proposed MS-DRGs on the Postacute Care Transfer Policy E. Refinement of the Relative Weight Calculation 1. Summary of RTI's Report on Charge Compression 2. RTI Recommendations a. Short-Term Recommendations b. Medium-Term Recommendations c. Long-Term Recommendations F. Hospital-Acquired Conditions, Including Infections 1. General 2. Legislative Requirements 3. Public Input 4. Collaborative Effort 5. Criteria for Selection of the Hospital-Acquired Conditions 6. Proposed Selection of Hospital-Acquired Conditions 7. Other Issues G. Proposed Changes to the Specific DRG Classifications 1. Pre-MDC: Intestinal Transplantations 2. MDC 1 (Diseases and Disorders of the Nervous System) a. Implantable Neurostimulators b. Intracranial Stents 3. MDC 3 (Diseases and Disorders of the Ear, Nose, Mouth, and Throat)—Cochler Implants 4. MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue) a. Hip and Knee Replacements b. Spinal Fusions c. Spinal Disc Devices d. Other Spinal DRGs 5. MDC 17 (Myeloproliferative Diseases and Disorders, Poorly Differentiated Neoplasm): Endoscopic Procedures 6. Medicare Code Editor (MCE) Changes a. Non-Covered Procedure Edit: Code 00.62 (Percutaneous Angioplasty or Atherectomy of Intracranial Vessel(s)) b. Non-Specific Principal Diagnosis Edit 7 and Non-Specific O.R. Procedures Edit 10 c. Limited Coverage Edit 17 7. Surgical Hierarchies 8. CC Exclusion List Proposed for FY 2008 a. Background b. Proposed CC Exclusions List for FY 2008 9. Review of Procedure Codes in CMS DRGs 468, 476, and 477 a. Moving Procedure Codes From CMS DRG 468 (Proposed MS-DRGs 981 Through 983) or CMS DRG 477 (Proposed MS-DRGs 987 Through 989) to MDCs b. Reassignment of Procedures Among CMS DRGs 468, 476, and 477 (Proposed MS-DRG 981 Through 983, 984 Through 986, and 987 Through 989) c. Adding Diagnosis or Procedure Codes to MDCs 10. Changes to the ICD-9-CM Coding System 11. Other Issues a. Seizures and Headaches b. Devices That Are Replaced Without Cost or Where Credit for a Replaced Device Is Furnished to the Hospital H. Recalibration of DRG Weights I. Proposed MS-LTC-DRG Reclassifications and Relative Weights for LTCHs for FY 2008 1. Background 2. Proposed Changes in the LTC-DRG Classifications a. Background b. Patient Classifications Into DRGs 3. Development of the Proposed FY 2008 MS-LTC-DRG Relative Weights a. General Overview of Development of the Proposed MS-LTC-DRG Relative Weights b. Data c. Hospital-Specific Relative Value Methodology d. Proposed Treatment of Severity Levels in Developing Relative Weights e. Proposed Low-Volume MS-LTC-DRGs 4. Steps for Determining the Proposed FY 2008 MS-LTC-DRG Relative Weights J. Proposed Add-On Payments for New Services and Technologies 1. Background 2. Public Input Before Publication of a Notice of Proposed Rulemaking on Add-On Payments 3. FY 2008 Status of Technologies Approved for FY 2007 Add-On Payments a. Endovascular Graft Repair of the Thoracic Aorta b. Restore®
                             Rechargeable Implantable Neurostimulators c. X STOP Interspinous Process Decompression System 4. FY 2008 Application for New Technology Add-On Payments 5. Technical Correction III. Proposed Changes to the Hospital Wage Index A. Background B. Core-Based Statistical Areas for the Hospital Wage Index C. Proposed Occupational Mix Adjustment to the Proposed FY 2008 Wage Index 1. Development of Data for the Proposed FY 2008 Occupational Mix Adjustment 2. Timeline for the Collection, Review, and Correction of the Occupational Mix Data 3. Calculation of the Proposed Occupational Mix Adjustment for FY 2008 4. Proposed 2007-2008 Occupational Mix Survey for the FY 2010 Wage Index D. Worksheet S-3 Wage Data for the Proposed FY 2008 Wage Index 1. Included Categories of Costs 
                            ( print page 24683) 2. Contract Labor for Indirect Patient Care Services 3. Excluded Categories of Costs 4. Use of Wage Index Data by Providers Other Than Acute Care Hospitals Under the IPPS E. Verification of Worksheet S-3 Wage Data F. Wage Index for Multicampus Hospitals G. Computation of the Proposed FY 2008 Unadjusted Wage Index 1. Method for Computing the Proposed FY 2008 Unadjusted Wage Index 2. Expiration of the Imputed Floor 3. CAHs Reverting Back to IPPS Hospitals and Raising the Rural Floor 4. Application of Rural Floor Budget Neutrality H. Analysis and Implementation of the Proposed Occupational Mix Adjustment and the Proposed FY 2008 Occupational Mix Adjusted Wage Index I. Revisions to the Proposed Wage Index Based on Hospital Redesignations 1. General 2. Effects of Reclassification/Redesignation 3. FY 2008 MGCRB Reclassifications 4. Hospitals That Applied for Reclassification Effective in FY 2008 and Reinstating Reclassifications in FY 2008 5. Clarification of Policy on Reinstating Reclassifications 6. “Fallback” Reclassifications 7. Geographic Reclassification Issues for Multicampus Hospitals 8. Redesignations of Hospitals under Section 1886(d)(8)(B) of the Act 9. Reclassifications Under Section 1886(d)(8)(B) of the Act 10. New England Deemed Counties 11. Reclassifications under Section 508 of Pub. L. 108-173 12. Other Issues J. Proposed FY 2008 Wage Index Adjustment Based on Commuting Patterns of Hospital Employees K. Process for Requests for Wage Index Data Corrections L. Labor-Related Share for the Proposed Wage Index for FY 2008 M. Wage Index Study Required Under Pub. L. 109-432 N. Proxy for the Hospital Market Basket IV. Other Decisions and Proposed Changes to the IPPS for Operating Costs and GME Costs A. Reporting of Hospital Quality Data for Annual Hospital Payment Update 1. Background 2. FY 2008 Quality Measures 3. New Quality Measures and Data Submission Requirements for FY 2009 and Subsequent Years a. Proposed New Quality Measures for FY 2009 and Subsequent Years b. Data Submission 4. Retiring or Modifying RHQDAPU Program Quality Measures 5. Procedures for the RHQDAPU Program for FY 2008 and FY 2009 a. Procedures for Participating in the RHQDAPU Program b. Chart Validation Requirements c. Data Validation and Attestation d. Public Display e. Reconsideration and Appeal Procedures f. RHQDAPU Program Withdrawal Requirements 6. Electronic Medical Records 7. New Hospitals B. Development of the Medicare Hospital Value-Based Purchasing Plan C. Rural Referral Centers (RRCs) 1. Proposed Annual Update of RRC Status Criteria a. Case-Mix Index b. Discharges 2. Acquired Rural Status of RRCs D. Indirect Medical Education (IME) Adjustment 1. Background 2. IME Adjustment Factor for FY 2008 3. Time Spent by Residents on Vacation or Sick Leave and in Orientation a. Background b. Vacation and Sick Leave Time c. Orientation Activities d. Proposed Regulation Changes E. Hospital Emergency Services Under EMTALA 1. Background 2. Recent Legislation Affecting EMTALA Implementation a. Secretary's Authority to Waive Requirements During National Emergencies b. Provisions of the Pandemic and All-Hazards Preparedness Act c. Proposed Revisions to the EMTALA Regulations F. Disclosure of Physician Ownership in Hospitals and Patient Safety Measures 1. Disclosure of Physician Ownership in Hospitals 2. Patient Safety Measures G. Rural Community Hospital Demonstration Program V. Proposed Changes to the IPPS for Capital-Related Costs A. Background B. Proposed Policy Change VI. Proposed Changes for Hospitals and Hospital Units Excluded From the IPPS A. Payments to Existing and New Excluded Hospitals and Hospital Units B. Separate PPS for IRFs C. Separate PPS for LTCHs D. Separate PPS for IPFs E. Determining Proposed LTCH Cost-to-Charge Ratios (CCRs) Under the LTCH PPS VII. Services Furnished to Beneficiaries in Custody of Penal Authorities VIII. MedPAC Recommendations IX. Other Required Information A. Requests for Data From the Public B. Collection of Information Requirements C. Response to Public Comments Regulation Text Addendum—Proposed Schedule of Standardized Amounts, Update Factors, and Rate-of-Increase Percentages Effective With Cost Reporting Periods Beginning On or After October 1, 2007 I. Summary and Background II. Proposed Changes to the Prospective Payment Rates for Hospital Inpatient Operating Costs for FY 2008 A. Calculation of the Proposed Adjusted Standardized Amount 1. Standardization of Base-Year Costs or Target Amounts 2. Computing the Proposed Average Standardized Amount 3. Updating the Proposed Average Standardized Amount 4. Other Adjustments to the Average Standardized Amount a. Proposed Recalibration of DRG Weights and Updated Wage Index—Budget Neutrality Adjustment b. Reclassified Hospitals—Budget Neutrality Adjustment c. Case-Mix Budget Neutrality Adjustment d. Outliers e. Proposed Rural Community Hospital Demonstration Program Adjustment (Section 410A of Pub. L. 108-173) 5. Proposed FY 2008 Standardized Amount B. Proposed Adjustments for Area Wage Levels and Cost-of-Living 1. Proposed Adjustment for Area Wage Levels 2. Proposed Adjustment for Cost-of-Living in Alaska and Hawaii C. Proposed DRG Relative Weights D. Calculation of the Proposed Prospective Payment Rates for FY 2008 1. Federal Rate 2. Hospital-Specific Rate (Applicable Only to SCHs and MDHs) a. Calculation of Hospital-Specific Rate b. Updating the FY 1982, FY 1987, FY 1996, and FY 2002 Hospital-Specific Rates for FY 2008 3. General Formula for Calculation of Proposed Prospective Payment Rates for Hospitals Located in Puerto Rico Beginning On or After October 1, 2007 and Before October 1, 2008 a. Puerto Rico Rate b. National Rate III. Proposed Changes to Payment Rates for Acute Care Hospital Inpatient Capital-Related Costs for FY 2008 A. Determination of Proposed Federal Hospital Inpatient Capital-Related Prospective Payment Rate Update 1. Projected Capital Standard Federal Rate Update a. Description of the Update Framework b. Comparison of CMS and MedPAC Update Recommendation 2. Proposed Outlier Payment Adjustment Factor 3. Proposed Budget Neutrality Adjustment Factor for Changes in DRG Classifications and Weights and the GAF 4. Proposed Exceptions Payment Adjustment Factor 5. Proposed Capital Standard Federal Rate for FY 2008 6. Proposed Special Capital Rate for Puerto Rico Hospitals B. Calculation of the Proposed Inpatient Capital-Related Prospective Payments for FY 2008 C. Capital Input Price Index 1. Background 2. Forecast of the CIPI for FY 2008 IV. Proposed Changes to Payment Rates for Excluded Hospitals and Hospital Units: Rate-of-Increase Percentages A. Payments to Existing Excluded Hospitals and Units B. New Excluded Hospitals and Units 
                            ( print page 24684) V. Tables Table 1A—National Adjusted Operating Standardized Amounts, Labor/Nonlabor (69.7 Percent Labor Share/30.3 Percent Nonlabor Share If Wage Index Is Greater Than 1) Table 1B—National Adjusted Operating Standardized Amounts, Labor/Nonlabor (62 Percent Labor Share/38 Percent Nonlabor Share If Wage Index Is Less Than or Equal to 1) Table 1C—Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor Table 1D—Capital Standard Federal Payment Rate Table 2—Hospital Case-Mix Indexes for Discharges Occurring in Federal Fiscal Year 2006; Hospital Wage Indexes for Federal Fiscal Year 2008; Hospital Average Hourly Wages for Federal Fiscal Years 2006 (2002 Wage Data), 2007 (2003 Wage Data), and 2008 (2004 Wage Data); and 3-Year Average of Hospital Average Hourly Wages Table 3A—FY 2008 and 3-Year Average Hourly Wage for Urban Areas by CBSA Table 3B—FY 2008 and 3-Year Average Hourly Wage for Rural Areas by CBSA Table 4A—Wage Index and Capital Geographic Adjustment Factor (GAF) for Urban Areas by CBSA—FY 2008 Table 4B—Wage Index and Capital Geographic Adjustment Factor (GAF) for Rural Areas by CBSA—FY 2008 Table 4C—Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That Are Reclassified by CBSA—FY 2008 Table 4F—Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF) by CBSA—FY 2008 Table 4J—Out-Migration Wage Adjustment—FY 2008 Table 5—List of Proposed Medicare Severity Diagnosis-Related Groups (MS-DRGs), Relative Weighting Factors, and Geometric and Arithmetic Mean Length of Stay Table 6A—New Diagnosis Codes Table 6B—New Procedure Codes Table 6C—Invalid Diagnosis Codes Table 6D—Invalid Procedure Codes Table 6E—Revised Diagnosis Code Titles Table 6F—Revised Procedure Code Titles Table 6G—Additions to the CC Exclusion List (Available only through the Internet on the CMS Web site at: 
                            *http://www.cms.hhs.gov/​AcuteInpatientPPS/​*) Table 6H—Deletions from the CC Exclusion List (Available only through the Internet on the CMS Web site at: 
                            *http://www.cms.hhs.gov/​AcuteInpatientPPS/​*) Table 6I—Complete List of Complication and Comorbidity (CC) Exclusions (Available only through the Internet on the CMS Web site at: 
                            *http://www.cms.hhs.gov/​AcuteInpatientPPS/​*) Table 6J—Major Complication and Comorbidity (MCC) List Table 6K—Complications and Comorbidity (CC) List Table 7A—Medicare Prospective Payment System Selected Percentile Lengths of Stay: FY 2006 MedPAR Update—December 2006 GROUPER V24.0 CMS-DRGs Table 7B—Medicare Prospective Payment System Selected Percentile Lengths of Stay: FY 2006 MedPAR Update—December 2006 GROUPER V25.0 CMS DRGs Table 8A—Proposed Statewide Average Operating Cost-to-Charge Ratios—March 2007 Table 8B—Proposed Statewide Average Capital Cost-to-Charge Ratios—March 2007 Table 8C—Proposed Statewide Average Total Cost-to-Charge Ratios for LTCHs—March 2007 Table 9A—Hospital Reclassifications and Redesignations—FY 2008 Table 9C—Hospitals Redesignated as Rural under Section 1886(d)(8)(E) of the Act—FY 2008 Table 10—Geometric Mean Plus the Lesser of .75 of the National Adjusted Operating Standardized Payment Amount (Increased to Reflect the Difference Between Costs and Charges) or .75 of One Standard Deviation of Mean Charges by Proposed Medicare Severity Diagnosis-Related Groups (MS-DRGs)—March 2007 Table 11—Proposed FY 2008 MS-LTC-DRGs, Relative Weights, Geometric Average Length of Stay, and 5/6ths of the Geometric Average Length of Stay Appendix A—Regulatory Impact Analysis I. Overall Impact II. Objectives III. Limitations on Our Analysis IV. Hospitals Included In and Excluded From the IPPS V. Effects on Excluded Hospitals and Hospital Units VI. Quantitative Effects of the Proposed Policy Changes Under the IPPS for Operating Costs A. Basis and Methodology of Estimates B. Analysis of Table I C. Effects of the Proposed Changes to the DRG Reclassifications and Relative Cost-Based Weights (Column 2) D. Effects of Proposed Wage Index Changes (Column 3) E. Combined Effects of Proposed DRG and Wage Index Changes (Column 4) F. Effects of the Expiration of the 3-Year Provision Allowing Urban Hospitals That Were Converted to Rural as a Result of the FY 2005 Labor Market Area Changes to Maintain the Wage Index of the Urban Labor Market Area in Which They Were Formerly Located (Column 5) G. Effects of MGCRB Reclassifications (Column 6) H. Effects of the Adjustment to the Application of the Rural Floor (Column 7) I. Effects of Expiration of the Imputed Rural Floor (Column 8) J. Effects of the Expiration of Section 508 of Pub. L. 108-173 (Column 9) K. Effects of the Proposed Wage Index Adjustment for Out-Migration (Column 10) L. Effects of All Proposed Changes With CMI Adjustment Prior to Assumed Growth (Column 11) M. Effects of All Proposed Changes With CMI Adjustment and Assumed Growth (Column 12) N. Effects of Proposed Policy on Payment Adjustment for Low-Volume Hospitals O. Impact Analysis of Table II VII. Effects of Other Proposed Policy Changes A. Effects of Proposed Policy on Hospital-Acquired Conditions, Including Infections B. Effects of Proposed MS-LTC-DRG Reclassifications and Relative Weights for LTCHs C. Effects of Proposed New Technology Add-On Payments D. Effects of Requirements for Hospital Reporting of Quality Data for Annual Hospital Payment Update E. Effects of Proposed Policy on Cancellation of Classification of Acquired Rural Status and Rural Referral Centers F. Effects of Proposed Policy Change on Payment for Indirect Graduate Medical Education G. Effects of Proposed Policy Changes Relating to Emergency Services Under EMTALA H. Effects of Proposed Policy on Disclosure of Physician Ownership in Hospitals and Patient Safety Measures I. Effects of Implementation of Rural Community Hospital Demonstration Program J. Effects of Proposed Policy Changes on Services Furnished to Beneficiaries in Custody of Penal Authorities VIII. Effects of Proposed Changes in the Capital IPPS A. General Considerations B. Results IX. Alternatives Considered X. Overall Conclusion XI. Accounting Statement XII. Executive Order 12866 Appendix B—Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services I. Background II. Inpatient Hospital Update for FY 2008 III. Secretary's Recommendation IV. MedPAC Recommendation for Assessing Payment Adequacy and Updating Payments in Traditional Medicare I. Background A. Summary 1. Acute Care Hospital Inpatient Prospective Payment System (IPPS) Section 1886(d) of the Social Security Act (the Act) sets forth a system of payment for the operating costs of acute care hospital inpatient stays under Medicare Part A (Hospital Insurance) based on prospectively set rates. Section 1886(g) of the Act requires the Secretary to pay for the capital-related costs of hospital inpatient stays under a prospective payment system (PPS). Under these PPSs, Medicare payment for hospital inpatient operating and capital-related costs is made at 
                        ( print page 24685)
                        predetermined, specific rates for each hospital discharge. Discharges are classified according to a list of diagnosis-related groups (DRGs). The base payment rate is comprised of a standardized amount that is divided into a labor-related share and a nonlabor-related share. The labor-related share is adjusted by the wage index applicable to the area where the hospital is located; and if the hospital is located in Alaska or Hawaii, the nonlabor-related share is adjusted by a cost-of-living adjustment factor. This base payment rate is multiplied by the DRG relative weight. If the hospital treats a high percentage of low-income patients, it receives a percentage add-on payment applied to the DRG-adjusted base payment rate. This add-on payment, known as the disproportionate share hospital (DSH) adjustment, provides for a percentage increase in Medicare payments to hospitals that qualify under either of two statutory formulas designed to identify hospitals that serve a disproportionate share of low-income patients. For qualifying hospitals, the amount of this adjustment may vary based on the outcome of the statutory calculations. If the hospital is an approved teaching hospital, it receives a percentage add-on payment for each case paid under the IPPS, known as the indirect medical education (IME) adjustment. This percentage varies, depending on the ratio of residents to beds. Additional payments may be made for cases that involve new technologies or medical services that have been approved for special add-on payments. To qualify, a new technology or medical service must demonstrate that it is a substantial clinical improvement over technologies or services otherwise available, and that, absent an add-on payment, it would be inadequately paid under the regular DRG payment. The costs incurred by the hospital for a case are evaluated to determine whether the hospital is eligible for an additional payment as an outlier case. This additional payment is designed to protect the hospital from large financial losses due to unusually expensive cases. Any outlier payment due is added to the DRG-adjusted base payment rate, plus any DSH, IME, and new technology or medical service add-on adjustments. Although payments to most hospitals under the IPPS are made on the basis of the standardized amounts, some categories of hospitals are paid the higher of a hospital-specific rate based on their costs in a base year (the higher of FY 1982, FY 1987, FY 1996, or FY 2002) or the IPPS rate based on the standardized amount. For example, sole community hospitals (SCHs) are the sole source of care in their areas, and Medicare-dependent, small rural hospitals (MDHs) are a major source of care for Medicare beneficiaries in their areas. Both of these categories of hospitals are afforded this special payment protection in order to maintain access to services for beneficiaries. (Until FY 2007, an MDH has received the IPPS rate plus 50 percent of the difference between the IPPS rate and its hospital-specific rate if the hospital-specific rate is higher than the IPPS rate. In addition, an MDH does not have the option of using FY 1996 as the base year for its hospital-specific rate. As discussed below, for discharges occurring on or after October 1, 2007, but before October 1, 2011, an MDH will receive the IPPS rate plus 75 percent of the difference between the IPPS rate and its hospital-specific rate, if the hospital-specific rate is higher than the IPPS rate.) Section 1886(g) of the Act requires the Secretary to pay for the capital-related costs of inpatient hospital services “in accordance with a prospective payment system established by the Secretary.” The basic methodology for determining capital prospective payments is set forth in our regulations at 42 CFR 412.308 and 412.312. Under the capital IPPS, payments are adjusted by the same DRG for the case as they are under the operating IPPS. Capital IPPS payments are also adjusted for IME and DSH, similar to the adjustments made under the operating IPPS. In addition, hospitals may receive outlier payments for those cases that have unusually high costs. The existing regulations governing payments to hospitals under the IPPS are located in 42 CFR part 412, subparts A through M. 2. Hospitals and Hospital Units Excluded From the IPPS Under section 1886(d)(1)(B) of the Act, as amended, certain specialty hospitals and hospital units are excluded from the IPPS. These hospitals and units are: rehabilitation hospitals and units; long-term care hospitals (LTCHs); psychiatric hospitals and units; children's hospitals; and cancer hospitals. Religious nonmedical health care institutions (RNHCIs) are also excluded from the IPPS. Various sections of the Balanced Budget Act of 1997 (Pub. L. 105-33), the Medicare, Medicaid and SCHIP [State Children's Health Insurance Program] Balanced Budget Refinement Act of 1999 (Pub. L. 106-113), and the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (Pub. L. 106-554) provide for the implementation of PPSs for rehabilitation hospitals and units (referred to as inpatient rehabilitation facilities (IRFs)), LTCHs, and psychiatric hospitals and units (referred to as inpatient psychiatric facilities (IPFs)), as discussed below. Children's hospitals, cancer hospitals, and RNHCIs continue to be paid solely under a reasonable cost-based system. The existing regulations governing payments to excluded hospitals and hospital units are located in 42 CFR parts 412 and 413. a. Inpatient Rehabilitation Facilities (IRFs) Under section 1886(j) of the Act, as amended, rehabilitation hospitals and units (IRFs) have been transitioned from payment based on a blend of reasonable cost reimbursement subject to a hospital-specific annual limit under section 1886(b) of the Act and the adjusted facility Federal prospective payment rate for cost reporting periods beginning on or after January 1, 2002 through September 30, 2002, to payment at 100 percent of the Federal rate effective for cost reporting periods beginning on or after October 1, 2002. IRFs subject to the blend were also permitted to elect payment based on 100 percent of the Federal rate. The existing regulations governing payments under the IRF PPS are located in 42 CFR part 412, subpart P. b. Long-Term Care Hospitals (LTCHs) Under the authority of sections 123(a) and (c) of Pub. L. 106-113 and section 307(b)(1) of Pub. L. 106-554, the LTCH PPS was effective for a LTCH's first cost reporting period beginning on or after October 1, 2002. LTCHs that do not meet the definition of “new” under § 412.23(e)(4) are paid, during a 5-year transition period, a LTCH prospective payment that is comprised of an increasing proportion of the LTCH Federal rate and a decreasing proportion based on reasonable cost principles. Those LTCHs that did not meet the definition of “new” could elect to be paid based on 100 percent of the Federal prospective payment rate instead of a blended payment in any year during the 5-year transition. For cost reporting periods beginning on or after October 1, 2006, all LTCHs are paid 100 percent of the Federal rate. The existing regulations governing payment under the LTCH PPS are located in 42 CFR part 412, subpart O. c. Inpatient Psychiatric Facilities (IPFs) Under the authority of sections 124(a) and (c) of Pub. L. 106-113, inpatient 
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                        psychiatric facilities (IPFs) (formerly psychiatric hospitals and psychiatric units of acute care hospitals) are paid under the IPF PPS. Under the IPF PPS, some IPFs are transitioning from being paid for inpatient hospital services based on a blend of reasonable cost-based payment and a Federal per diem payment rate, effective for cost reporting periods beginning on or after January 1, 2005. For cost reporting periods beginning on or after January 1, 2008, all IPFs will be paid 100 percent of the Federal per diem payment amount. The existing regulations governing payment under the IPF PPS are located in 42 CFR 412, subpart N. 3. Critical Access Hospitals (CAHs) Under sections 1814, 1820, and 1834(g) of the Act, payments are made to critical access hospitals (CAHs) (that is, rural hospitals or facilities that meet certain statutory requirements) for inpatient and outpatient services based on 101 percent of reasonable cost. Reasonable cost is determined under the provisions of section 1861(v)(1)(A) of the Act and existing regulations under 42 CFR parts 413 and 415. 4. Payments for Graduate Medical Education (GME) Under section 1886(a)(4) of the Act, costs of approved educational activities are excluded from the operating costs of inpatient hospital services. Hospitals with approved graduate medical education (GME) programs are paid for the direct costs of GME in accordance with section 1886(h) of the Act; the amount of payment for direct GME costs for a cost reporting period is based on the hospital's number of residents in that period and the hospital's costs per resident in a base year. The existing regulations governing payments to the various types of hospitals are located in 42 CFR part 413. B. Provisions of the Deficit Reduction Act of 2005 (DRA) The Deficit Reduction Act of 2005 (DRA), Pub. L. 109-171, made a number of changes to the Act relating to prospective payments to hospitals and other providers for inpatient services. This proposed rule would implement amendments made by (1) section 5001(a), which, effective for FY 2007 and subsequent years, expands the requirements for hospital quality data reporting; and (2) section 5001(c), which requires the Secretary to select, by October 1, 2007, at least two hospital-acquired conditions that meet certain specified criteria that will be subject to a quality adjustment in DRG payments during FY 2008. In this proposed rule, we also discuss our development of a plan to implement, beginning with FY 2009, a value-based purchasing plan for section 1886(d) hospitals, in accordance with the requirements of section 5001(b) of Pub. L. 109-171. C. Provisions of the Medicare Improvements and Extension Act Under Division B of the Tax Relief and Health Care Act of 2006 In this proposed rule, we discuss the provisions of section 106(b)(1) of the Medicare Improvements and Extensions Act under Division B, Title I of the Tax Relief and Health Care Act of 2006 (MIEA-TRHCA), Pub. L. 109-432, which requires MedPAC to submit to Congress, not later than June 30, 2007, a report on the Medicare wage index classification system applied under the Medicare Prospective Payment System. Section 106(b) of the MIEA-TRHCA requires the report to include any alternatives that MedPAC recommends to the method to compute the wage index under section 1886(d)(3)(E) of the Act. In addition, we discuss the provisions of section 106(b)(2) of the MIEA-TRHCA, which instructs the Secretary of Health and Human Services, taking into account MedPAC's recommendations on the Medicare wage index classification system, to include in the FY 2009 IPPS proposed rule one or more proposals to revise the wage index adjustment applied under section 1886(d)(3)(E) of the Act for purposes of the IPPS. We note that we published a notice in the 
                        **Federal Register**
                         on March 23, 2007 (72 FR 13799) that addressed the provisions of section 106(a) of the MIEA-TRHCA relating to the extension of geographic reclassifications of hospitals under section 508 of Pub. L. 108-173 (that expired on March 31, 2007) through September 30, 2007. D. Provisions of the Pandemic and All-Hazards Preparedness Act On December 19, 2006, Congress enacted the Pandemic and All-Hazards Preparedness Act, Pub. L. 109-417. Section 302(b) of Pub. L. 109-417 makes two specific changes that affect EMTALA implementation in emergency areas during an emergency period. Specifically section 302(b)(1)(A) of Pub. L. 109-417 amended section 1135(b)(3)(B) of the Act to state that sanctions may be waived for the direction or relocation of an individual for screening where, in the case of a public health emergency that involves a pandemic infections disease, that direction or relocation occurs pursuant to a State pandemic preparedness plan. In addition, sections 302(b)(1)(B) and (b)(1)(C) of Pub. L. 109-417 amended section 1135(b)(3)(B) of the Act to state that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the duration of a waiver or modification under section 1135(b)(3) of the Act (relating to EMTALA) shall be determined in accordance with section 1135(e) of the Act as that subsection applies to public health emergencies. In this proposed rule, we are proposing to make changes to the EMTALA regulations to conform them to the sanction waiver provisions of section 302(b) of Pub. L. 109-417. E. Major Contents of This Proposed Rule In this proposed rule, we are setting forth proposed changes to the Medicare IPPS for operating costs and for capital-related costs in FY 2008. We also are setting forth proposed changes relating to payments for IME costs and payments to certain hospitals and units that continue to be excluded from the IPPS and paid on a reasonable cost basis. The changes being proposed would be effective for discharges occurring on or after October 1, 2007, unless otherwise noted. The following is a summary of the major changes that we are proposing to make: 1. Proposed DRG Reclassifications and Recalibrations of Relative Weights We are proposing to adopt a Medicare Severity DRG (MS-DRG) classification system for the IPPS to better recognize severity of illness. We present the methodology we used to establish the proposed MS-DRGs and discuss our efforts to further analyze alternative severity-adjusted DRG systems and to refine the relative weight calculations for DRGs. We present a proposed listing and discussion of hospital-acquired conditions, including infections, which we have evaluated and are considering for selection to be subject to the statutorily required quality adjustment in DRG payments for FY 2008. We are proposing limited annual revisions to the DRG classification system in the following areas: intestinal transplants, neurostimulators, intracranial stents, cochlear implants, knee and hip replacements, spinal fusions and spinal disc devices, and endoscopic procedures. We are presenting our reevaluation of certain FY 2007 applicants for add-on payments for high-cost new medical services and technologies, and our analysis of the FY 2008 applicant 
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                        (including public input, as directed by Pub. L. 108-173, obtained in a town hall meeting). We are proposing the annual update of the long-term care diagnosis-related group (LTC-DRG) classifications and relative weights for use under the LTCH PPS for FY 2008. We are proposing that the LTC-DRGs would be revised to mirror the proposed MS-DRGs for the IPPS. 2. Proposed Changes to the Hospital Wage Index In section III. of the preamble to this proposed rule, we are proposing revisions to the wage index and the annual update of the wage data. Specific issues addressed include the following: The FY 2008 wage index update, using wage data from cost reporting periods that began during FY 2004.
                    Analysis and implementation of the proposed FY 2008 occupational mix adjustment to the wage index.
                    Proposed changes relating to expiration of the imputed floor for the wage index and application of budget neutrality for the rural floor.
                    Proposed changes in determining the wage index for multicampus hospitals.
                    The proposed revisions to the wage index based on hospital redesignations and reclassifications, including reclassifications for multicampus hospitals.
                    The proposed adjustment to the wage index for FY 2008 based on commuting patterns of hospital employees who reside in a county and work in a different area with a higher wage index.
                    The timetable for reviewing and verifying the wage data that will be in effect for the proposed FY 2008 wage index.
                    The labor-related share for the FY 2008 wage index, including the labor-related share for Puerto Rico. 3. Other Decisions and Proposed Changes to the IPPS for Operating Costs and GME Costs In section IV. of the preamble to this proposed rule, we discuss a number of provisions of the regulations in 42 CFR Parts 412, 413, and 489, including the following: The reporting of hospital quality data as a condition for receiving the full annual payment update increase.
                    Development of the Medicare value-based purchasing plan and scheduled “listening sessions.”
                    The proposed updated national and regional case-mix values and discharges for purposes of determining RRC status and a proposed policy change relating to the acquired rural status of RRCs.
                    The statutorily-required IME adjustment factor for FY 2008 and a proposed policy change relating to determining counts of residents on vacation or sick leave and in orientation for IME and direct GME purposes.
                    Proposed changes relating to waiver of sanctions for requirements for emergency services for hospitals under EMTALA during national emergency.
                    Proposed policy changes relating to disclosure to patients of physician ownership of hospitals and patient safety measures.
                    Discussion of the fourth year of implementation of the Rural Community Hospital Demonstration Program. 4. Proposed Changes to the IPPS for Capital-Related Costs In section V. of the preamble to this proposed rule, we discuss the payment policy requirements for capital-related costs and capital payments to hospitals and propose changes relating to adjustments to the Federal capital rate to address continuous large positive margins. 5. Proposed Changes to the Payment Rates for Excluded Hospitals and Hospital Units: Rate-of-Increase Percentages In section VI. of the preamble to this proposed rule, we discuss payments to excluded hospitals and hospital units, and proposed changes for determining LTCH CCRs under the LTCH PPS. 6. Services Furnished to Beneficiaries in Custody of Penal Authorities In section VII. of the preamble to this proposed rule, we clarify when individuals are considered to be in “custody” for purposes of Medicare payment for services furnished to beneficiaries who are under penal authorities. 7. Determining Proposed Prospective Payment Operating and Capital Rates and Rate-of-Increase Limits In the Addendum to this proposed rule, we set forth proposed changes to the amounts and factors for determining the FY 2008 prospective payment rates for operating costs and capital-related costs. We also establish the proposed threshold amounts for outlier cases. In addition, we address the proposed update factors for determining the rate-of-increase limits for cost reporting periods beginning in FY 2008 for hospitals and hospital units excluded from the PPS. 8. Impact Analysis In Appendix A of this proposed rule, we set forth an analysis of the impact that the proposed changes would have on affected hospitals. 9. Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services In Appendix B of this proposed rule, as required by sections 1886(e)(4) and (e)(5) of the Act, we provided our recommendations of the appropriate percentage changes for FY 2008 for the following: A single average standardized amount for all areas for hospital inpatient services paid under the IPPS for operating costs (and hospital-specific rates applicable to SCHs and MDHs).
                    Target rate-of-increase limits to the allowable operating costs of hospital inpatient services furnished by hospitals and hospital units excluded from the IPPS. 10. Discussion of Medicare Payment Advisory Commission Recommendations Under section 1805(b) of the Act, MedPAC is required to submit a report to Congress, no later than March 1 of each year, in which MedPAC reviews and makes recommendations on Medicare payment policies. MedPAC's March 2007 recommendation concerning hospital inpatient payment policies addressed the update factor for inpatient hospital operating costs and capital-related costs under the IPPS and for hospitals and distinct part hospital units excluded from the IPPS. This recommendation is addressed in Appendix B of this proposed rule. For further information relating specifically to the MedPAC March 2007 reports or to obtain a copy of the reports, contact MedPAC at (202) 220-3700 or visit MedPAC's Web site at: 
                        *http://www.medpac.gov*. II. Proposed Changes to DRG Classifications and Relative Weights (If you choose to comment on issues in this section, please include the caption “DRG Reclassifications” at the beginning of your comment.) A. Background Section 1886(d) of the Act specifies that the Secretary shall establish a classification system (referred to as DRGs) for inpatient discharges and adjust payments under the IPPS based on appropriate weighting factors assigned to each DRG. Therefore, under the IPPS, we pay for inpatient hospital services on a rate per discharge basis that varies according to the DRG to 
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                        which a beneficiary's stay is assigned. The formula used to calculate payment for a specific case multiplies an individual hospital's payment rate per case by the weight of the DRG to which the case is assigned. Each DRG weight represents the average resources required to care for cases in that particular DRG, relative to the average resources used to treat cases in all DRGs. Congress recognized that it would be necessary to recalculate the DRG relative weights periodically to account for changes in resource consumption. Accordingly, section 1886(d)(4)(C) of the Act requires that the Secretary adjust the DRG classifications and relative weights at least annually. These adjustments are made to reflect changes in treatment patterns, technology, and any other factors that may change the relative use of hospital resources. B. DRG Reclassifications 1. General As discussed in the preamble to the FY 2007 IPPS final rule (71 FR 47881 through 47971), we are focusing our efforts in FY 2008 on making significant reforms to the IPPS consistent with the recommendations made by MedPAC in its “Report to the Congress, Physician-Owned Specialty Hospitals” in March 2005. MedPAC recommended that the Secretary refine the entire DRG system by taking into account severity of illness and applying hospital-specific relative value (HSRV) weights to DRGs.[1]
                        
                         We began this reform process by adopting cost-based weights over a 3-year transition period beginning in FY 2007 and making interim changes to the DRG system for FY 2007 by creating 20 new CMS DRGs and modifying 32 others across 13 different clinical areas involving nearly 1.7 million cases. As described below in more detail, these refinements are intermediate steps towards comprehensive reform of both the relative weights and the DRG system that is occurring as we undertake further study. Currently, cases are classified into CMS DRGs for payment under the IPPS based on the principal diagnosis, up to eight additional diagnoses, and up to six procedures performed during the stay. In a small number of DRGs, classification is also based on the age, sex, and discharge status of the patient. The diagnosis and procedure information is reported by the hospital using codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). The process of forming the DRGs was begun by dividing all possible principal diagnoses into mutually exclusive principal diagnosis areas, referred to as Major Diagnostic Categories (MDCs). The MDCs were formed by physician panels as the first step toward ensuring that the DRGs would be clinically coherent. The diagnoses in each MDC correspond to a single organ system or etiology and, in general, are associated with a particular medical specialty. Thus, in order to maintain the requirement of clinical coherence, no final DRG could contain patients in different MDCs. Most MDCs are based on a particular organ system of the body. For example, MDC 6 is Diseases and Disorders of the Digestive System. This approach is used because clinical care is generally organized in accordance with the organ system affected. However, some MDCs are not constructed on this basis because they involve multiple organ systems (for example, MDC 22 (Burns)). For FY 2007, cases are assigned to one of 538 DRGs in 25 MDCs. The table below lists the 25 MDCs. Major Diagnostic Categories (MDCs)
1
Diseases and Disorders of the Nervous System.2
Diseases and Disorders of the Eye.3
Diseases and Disorders of the Ear, Nose, Mouth, and Throat.4
Diseases and Disorders of the Respiratory System.5
Diseases and Disorders of the Circulatory System.6
Diseases and Disorders of the Digestive System.7
Diseases and Disorders of the Hepatobiliary System and Pancreas.8
Diseases and Disorders of the Musculoskeletal System and Connective Tissue.9
Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast.10
Endocrine, Nutritional and Metabolic Diseases and Disorders.11
Diseases and Disorders of the Kidney and Urinary Tract.12
Diseases and Disorders of the Male Reproductive System.13
Diseases and Disorders of the Female Reproductive System.14
Pregnancy, Childbirth, and the Puerperium.15
Newborns and Other Neonates with Conditions Originating in the Perinatal Period.16
Diseases and Disorders of the Blood and Blood Forming Organs and Immunological Disorders.17
Myeloproliferative Diseases and Disorders and Poorly Differentiated Neoplasms.18
Infectious and Parasitic Diseases (Systemic or Unspecified Sites).19
Mental Diseases and Disorders.20
Alcohol/Drug Use and Alcohol/Drug Induced Organic Mental Disorders.21
Injuries, Poisonings, and Toxic Effects of Drugs.22
Burns.23
Factors Influencing Health Status and Other Contacts with Health Services.24
Multiple Significant Trauma.25
Human Immunodeficiency Virus Infections.
 In general, cases are assigned to an MDC based on the patient's principal diagnosis before assignment to a DRG. However, for FY 2007, there are 9 DRGs to which cases are directly assigned on the basis of ICD-9-CM procedure codes. These DRGs are for heart transplant or implant of heart assist systems, liver and/or intestinal transplants, bone marrow transplants, lung transplants, simultaneous pancreas/kidney transplants, pancreas transplants, and 
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                        for tracheostomies. Cases are assigned to these DRGs before they are classified to an MDC. The table below lists the nine current pre-MDCs. Pre-Major Diagnostic Categories (Pre-MDCs)
DRG 103
Heart Transplant or Implant of Heart Assist System.DRG 480
Liver Transplant and/or Intestinal Transplant.DRG 481
Bone Marrow Transplant.DRG 482
Tracheostomy for Face, Mouth, and Neck Diagnoses.DRG 495
Lung Transplant.DRG 512
Simultaneous Pancreas/Kidney Transplant.DRG 513
Pancreas Transplant.DRG 541
ECMO or Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except for Face, Mouth, and Neck Diagnosis with Major O.R.DRG 542
Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except for Face, Mouth, and Neck Diagnosis without Major O.R.
 Once the MDCs were defined, each MDC was evaluated to identify those additional patient characteristics that would have a consistent effect on the consumption of hospital resources. Because the presence of a surgical procedure that required the use of the operating room would have a significant effect on the type of hospital resources used by a patient, most MDCs were initially divided into surgical DRGs and medical DRGs. Surgical DRGs are based on a hierarchy that orders operating room (O.R.) procedures or groups of O.R. procedures by resource intensity. Medical DRGs generally are differentiated on the basis of diagnosis and age (0 to 17 years of age or greater than 17 years of age). Some surgical and medical DRGs are further differentiated based on the presence or absence of a complication or comorbidity (CC). Generally, nonsurgical procedures and minor surgical procedures that are not usually performed in an operating room are not treated as O.R. procedures. However, there are a few non-O.R. procedures that do affect DRG assignment for certain principal diagnoses. An example is extracorporeal shock wave lithotripsy for patients with a principal diagnosis of urinary stones. Once the medical and surgical classes for an MDC were formed, each diagnosis class was evaluated to determine if complications, comorbidities, or the patient's age would consistently affect the consumption of hospital resources. Physician panels classified each diagnosis code based on whether the diagnosis, when present as a secondary condition, would be considered a substantial CC. A substantial CC was defined as a condition which, because of its presence with a specific principal diagnosis, would cause an increase in the length of stay by at least one day in at least 75 percent of the patients. Each medical and surgical class within an MDC was tested to determine if the presence of any substantial CC would consistently affect the consumption of hospital resources. A patient's diagnosis, procedure, discharge status, and demographic information is entered into the Medicare claims processing systems and subjected to a series of automated screens called the Medicare Code Editor (MCE). The MCE screens are designed to identify cases that require further review before classification into a DRG. After patient information is screened through the MCE and any further development of the claim is conducted, the cases are classified into the appropriate DRG by the Medicare GROUPER software program. The GROUPER program was developed as a means of classifying each case into a DRG on the basis of the diagnosis and procedure codes and, for a limited number of DRGs, demographic information (that is, sex, age, and discharge status). After cases are screened through the MCE and assigned to a DRG by the GROUPER, the PRICER software calculates a base DRG payment. The PRICER calculates the payment for each case covered by the IPPS based on the DRG relative weight and additional factors associated with each hospital, such as IME and DSH adjustments. These additional factors increase the payment amount to hospitals above the base DRG payment. The records for all Medicare hospital inpatient discharges are maintained in the Medicare Provider Analysis and Review (MedPAR) file. The data in this file are used to evaluate possible DRG classification changes and to recalibrate the DRG weights. However, in the FY 2000 IPPS final rule (64 FR 41500), we discussed a process for considering non-MedPAR data in the recalibration process. In order for us to consider using particular non-MedPAR data, we must have sufficient time to evaluate and test the data. The time necessary to do so depends upon the nature and quality of the non-MedPAR data submitted. Generally, however, a significant sample of the non-MedPAR data should be submitted by mid-October for consideration in conjunction with the next year's proposed rule. This date allows us time to test the data and make a preliminary assessment as to the feasibility of using the data. Subsequently, a complete database should be submitted by early December for consideration in conjunction with the next year's proposed rule. In this IPPS proposed rule for FY 2008, we are proposing to adopt significant changes to the current DRGs. As described in detail below, we are proposing significant improvement in the DRG system to recognize severity of illness and resource usage by proposing to adopt Medicare Severity DRGs (MS-DRGs). The changes we are proposing in this proposed rule would be reflected in the FY 2008 GROUPER, Version 25.0, and would be effective for discharges occurring on or after October 1, 2007. Unless otherwise noted in this proposed rule, our DRG analysis is based on data from the December 2006 update of the FY 2006 MedPAR file, which contains hospital bills received through December 31, 2006, for discharges occurring in FY 2006. 2. Yearly Review for Making DRG Changes Many of the changes to the DRG classifications we make annually are the result of specific issues brought to our attention by interested parties. We encourage individuals with concerns about DRG classifications to bring those concerns to our attention in a timely manner so they can be carefully considered for possible inclusion in the annual proposed rule and, if included, may be subjected to public review and comment. Therefore, similar to the timetable for interested parties to submit non-MedPAR data for consideration in 
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                        the DRG recalibration process, concerns about DRG classification issues should be brought to our attention no later than early December in order to be considered and possibly included in the next annual proposed rule updating the IPPS. The actual process of forming the DRGs was, and will likely continue to be, highly iterative, involving a combination of statistical results from test data combined with clinical judgment. We describe in detail below the process we used to develop the proposed MS-DRGs. In addition, in deciding whether to make further modification to the proposed MS-DRGs for particular circumstances brought to our attention, we would consider whether the resource consumption and clinical characteristics of the patients with a given set of conditions are significantly different than the remaining patients in the proposed MS-DRG. We would evaluate patient care costs using average charges and lengths of stay as proxies for costs and rely on the judgment of our medical officers to decide whether patients are clinically distinct or similar to other patients in the MS-DRG. In evaluating resource costs, we would consider both the absolute and percentage differences in average charges between the cases we would select for review and the remainder of cases in the MS-DRG. We also would consider variation in charges within these groups; that is, whether observed average differences were consistent across patients or attributable to cases that were extreme in terms of charges or length of stay, or both. Further, we also would consider the number of patients who will have a given set of characteristics and generally would prefer not to create a new DRG unless it would include a substantial number of cases. C. MedPAC Recommendations for Revisions to the IPPS DRG System In the FY 2006 and FY 2007 IPPS final rules, we discussed a number of recommendations made by MedPAC regarding revisions to the DRG system used under the IPPS (70 FR 47473 through 47482 and 71 FR 47881 through 47939). In Recommendations 1-3 in the 2005 Report to Congress on Physician-Owned Specialty Hospitals, MedPAC recommended that CMS: Refine the current DRGs to more fully capture differences in severity of illness among patients.
                    Base the DRG relative weights on the estimated cost of providing care.
                    Base the weights on the national average of the hospital-specific relative values (HSRVs) for each DRG (using hospital-specific costs to derive the HSRVs).
                    Adjust the DRG relative weights to account for differences in the prevalence of high-cost outlier cases.
                    Implement the case-mix measurement and outlier policies over a transitional period. As we noted in the FY 2006 IPPS final rule, we had insufficient time to complete a thorough evaluation of these recommendations for full implementation in FY 2006. However, we did adopt severity-weighted cardiac DRGs in FY 2006 to address public comments on this issue and the specific concerns of MedPAC regarding cardiac surgery DRGs. We also indicated that we planned to further consider all of MedPAC's recommendations and thoroughly analyze options and their impacts on the various types of hospitals in the FY 2007 IPPS proposed rule. For FY 2007, we began this process. In the FY 2007 IPPS proposed rule, we proposed to adopt Consolidated Severity DRGs (CS DRGs) for FY 2008 (if not earlier). However, based on public comments received on the FY 2007 IPPS proposed rule, we decided not to adopt the CS DRGs. Rather, we decided to make interim changes to the existing DRGs for FY 2007 by creating 20 new DRGs involving 13 different clinical areas that would significantly improve the CMS DRG system's recognition of severity of illness. We also modified 32 DRGs to better capture differences in severity. The new and revised DRGs were selected from 40 existing CMS DRGs that contain 1,666,476 cases and represent a number of body systems. In creating these 20 new DRGs, we deleted 8 and modified 32 existing DRGs. We indicated that these interim steps for FY 2007 were being taken as a prelude to more comprehensive changes to better account for severity in the DRG system by FY 2008. In the FY 2007 IPPS final rule, we indicated our intent to pursue further DRG reform through two initiatives. First, we announced that we were in the process of engaging a contractor to assist us with evaluating alternative DRG systems that were raised as potential alternatives to the CS DRGs in the public comments. Second, we indicated our intent to review over 13,000 ICD-9-CM diagnosis codes as part of making further refinements to the current CMS DRGs to better recognize severity of illness based on the work that CMS (then HCFA) did in the mid-1990's to adopt severity DRGs. We describe in detail below the progress we have made on these two initiatives, our proposed actions for FY 2008, and our plans for continued analysis of reform of the DRG system for FY 2009. We note that revising the DRGs to better recognize severity of illness has implications for the outlier threshold, the application of the postacute care transfer policy, the measurement of real case-mix versus apparent case-mix, and the IME and the DSH adjustments. We discuss these implications in more detail in the following sections. In the FY 2007 IPPS proposed rule, we discussed MedPAC's recommendations to move to a cost-based HSRV weighting methodology beginning with the FY 2007 IPPS proposed rule. Although we proposed to adopt HSRV weights for FY 2007, we decided not to adopt the proposed methodology in the final rule after considering the public comments. Instead, in the FY 2007 IPPS final rule, we adopted a cost-based weighting methodology without the hospital-specific portion of the methodology. The cost weights are being adopted over a 3-year transition period in 1/3 increments between FY 2007 and FY 2009. In addition, in the FY 2007 IPPS final rule, we indicated our intent to further study the hospital-specific methodology as well as other issues brought to our attention with respect to the cost weights. There was significant concern in the public comments that we account for charge compression or the practice of applying a higher charge markup over costs to lower cost than higher cost items and services, if we are to develop relative weights based on cost. Further, public commenters expressed concern about potential inconsistencies between how costs and charges are reported on the Medicare cost reports and charges on the Medicare claims. In the FY 2007 IPPS final rule, we used costs and charges from the cost report to determine departmental level cost-to-charge ratios (CCRs) to apply to charges on the Medicare claims to determine the cost weights. The commenters were concerned about potential distortions to the cost weights that would result from inconsistent reporting between the cost reports and the Medicare claims. After publication of the FY 2007 IPPS final rule, we entered into a contract with RTI International to study both charge compression and to what extent our methodology for calculating DRG relative weights is affected by inconsistencies between how hospitals report costs and charges on the cost report and how hospitals report charges on individual claims. Further, as part of its study of alternative DRG systems, the 
                        ( print page 24691)
                        RAND Corporation is analyzing the HSRV cost-weighting methodology. As we present below, we believe that revisions to the DRG system to better recognize severity of illness and changes to the relative weights based on costs rather than charges are improving the accuracy of the payment rates in the IPPS. We agree with MedPAC that these refinements should be pursued. Although we continue to caution that any system that groups cases will always present some opportunities for providers to specialize in cases they believe to have higher margins, we believe that the changes we have adopted and the continuing reforms we are proposing to adopt for FY 2008 will improve payment accuracy and reduce financial incentives to create specialty hospitals. D. Refinement of DRGs Based on Severity of Illness (If you choose to comment on issues in this section, please include the caption “DRG Reform and Proposed MS-DRGs” at the beginning of your comment.) For purposes of the following discussions, the term “CMS DRGs” means the DRG system we currently use under the IPPS; the term “Medicare-Severity DRGs (MS-DRGs)” means the revisions that we are proposing to make to the current CMS DRGs to better recognize severity of illness and resource use based on case complexity. Although we have found the terms “CMS DRGs” and “MS-DRGs” useful to distinguish the current DRG system from the DRGs that we are proposing to adopt for FY 2008, we are interested in public comments on how to best refer to both the current DRGs and the proposed DRGs to avoid confusion and improve clarity. 1. Evaluation of Alternative Severity-Adjusted DRG Systems In the FY 2007 IPPS final rule, we stated our intent to engage a contractor to assist us with an evaluation of alternative DRG systems that may better recognize severity than the current CMS DRGs. We noted it was possible that some of the alternative systems would better recognize severity of illness and are based on the current CMS DRGs. We further stated that if we were to develop a clinical severity concept using the current CMS DRGs as the starting point, it was possible that several of the issues raised by commenters (in response to the CS DRGs, which, in the FY 2007 IPPS proposed rule, we proposed to adopt for FY 2008 or earlier) would no longer be a concern. We noted that if we were to propose adoption of severity DRGs for FY 2008, we would consider the issues raised by commenters on last year's proposed rule as we continued to make further refinements to account for complexity as well as severity to better reflect relative resource use. We stated that we believed it was likely that at least one of several alternative severity-adjusted DRG systems suggested for review (or potentially a system we would develop ourselves) would be suitable to achieve our goal of improving payment accuracy beginning in FY 2008. On September 1, 2006, we awarded a contract to the RAND Corporation to perform an evaluation of alternative severity-adjusted DRG classification systems. RAND is evaluating several alternative DRG systems based on how well they are suited to classifying and making payments for inpatient hospital services provided to Medicare patients. Each system is being assessed on its ability to differentiate among severity of illness. A final report is due on or before September 1, 2007. RAND's draft interim report focused on the following criteria: Severity-adjusted DRG classification systems: —How well does each classification system explain variation in resource use? —How would the classification system affect a hospital's patient mix? —Are the groupings manageable, administratively feasible and understandable?
                    Payment accuracy—What are the payment implications of selected models? In response to our request, several vendors of DRG systems submitted their products for evaluation. The following products are currently being evaluated by RAND: 3M/Health Information Systems (HIS) CMS DRGs modified for AP-DRG Logic (CMS + AP-DRGs)
                    Consolidated Severity-Adjusted DRGs (CS DRGs) Health Systems Consultants (HSC) Refined DRGs (HSC-DRGs) HSS/Ingenix All-Payer Severity DRGs with Medicare modifications (MM-APS-DRGs) Solucient Solucient Refined DRGs (Sol-DRGs) Vendors submitted their commercial (off-the-shelf) software to RAND in late September 2006. The five systems were compared to the CMS DRGs that were in effect as of October 1, 2006 (FY 2007). RAND assigned FY 2004 and FY 2005 Medicare discharges from acute care hospitals to the FY 2007 CMS DRGs and to each of the alternative severity-adjusted DRG systems. RAND's initial analysis provided an overview of each alternative DRG classification system, their comparative performance in explaining variation in resource use, differences in DRG grouping logic, and case-mix change. A Technical Expert Panel comprised of individuals representing academic institutions, hospital associations, and MedPAC was formed in October 2006. The members received the preliminary draft report of RAND's alternative severity-adjusted DRG systems evaluation in early January 2007. The panel met with RAND and CMS on January 18, 2007, to discuss the preliminary draft report and to provide additional comments. RAND incorporated items raised by the panel into its preliminary draft report and submitted a revised interim report to CMS in mid-March 2007. CMS posted RAND's interim report on the CMS Web site in late March 2007. Interested individuals can view RAND's interim report on the CMS Web site at: 
                        *http://www.cms.hhs.gov/​Reports/​downloads/​Wynn0307.pdf.* At this time, RAND has not completed its final evaluation. RAND's interim report reflects its preliminary evaluation of the alternative DRG systems using the criteria described above. In the project's second phase, RAND will continue to evaluate alternative DRG systems as well as to compare performance using HSRVs. As RAND has not completed its evaluation of alternative DRG systems, we are not ready at this time to propose use of one of the alternative DRG systems being evaluated for Medicare in FY 2008. Further, even if RAND had completed its evaluation, we would need to explore whether any transition issues would need to be resolved before we are ready to propose adopting an alternative DRG system. Among other issues, we would need to evaluate the legal and contractual issues associated with adopting a proprietary DRG product. Although vendors for four of the five systems have indicated a willingness to make their products available in the public domain, we believe it is likely there would need to be some discussion as to whether there would be any limitations (such as the source code as well as the DRG logic) on the availability of the DRG systems to hospitals or competing vendors. Further, we would need to resolve contractual issues for updates and maintenance of an alternative DRG system and consider how they interact with our current ongoing contract to maintain the CMS DRGs. There may be further system conversion issues that we have not yet considered. The RAND 
                        ( print page 24692)
                        contract will be complete by September 1, 2007. Once RAND completes its work, we believe we will be in a better position to evaluate whether it would be appropriate to propose to adopt one of the five alternative DRG systems for purposes of the IPPS. As discussed later in this proposed rule, we are proposing to adopt MS-DRGs beginning with FY 2008. The MS-DRGs are the result of modifications to the CMS DRGs to better account for severity. While we are proposing to implement the MS-DRGs on October 1, 2007, we believe the MS-DRGs should be evaluated by RAND. We have instructed RAND to evaluate the proposed MS-DRGs using the same criteria that it is applying to the other DRG systems. As described below, we believe the proposed MS-DRGs represent a substantial improvement in the recognition of severity of illness and resource consumption. For this reason, we are proposing to adopt MS-DRGs for FY 2008. As stated earlier, a final report is expected from RAND by September 1, 2007. This report will include further analysis of the five alternative DRG systems and the additional evaluation of the MS-DRGs. We look forward to reviewing RAND's final report that will provide a comprehensive evaluation of each severity DRG system that has been examined. We anticipate that after this process is completed, we will have the necessary information to decide our next steps in the reform of the IPPS. Meanwhile, we are proposing to adopt the MS-DRGs for FY 2008 and are providing the following update on RAND's progress in evaluating alternative DRG systems. We invite public comment regarding RAND's preliminary analysis of each vendor-supplied alternative severity-adjusted DRG system described below. a. Overview of Alternative DRG Classification Systems Analysis of how each of the five severity-adjusted DRG systems performs began by using the current CMS DRGs as a baseline. Two of the five systems (CS DRGs and MM-APS-DRGs) are derivatives of all-patient severity-adjusted DRG systems that have been modified by their developers for the Medicare population and two of the systems (HSC-DRGs and Sol-DRGs) are all-patient systems that incorporate severity levels into the CMS DRGs. The CMS-AP-DRGs are a combination of CMS DRGs and a modification for the Medicare population of the major CC severity groupings used in the AP-DRG system. (The AP-DRG system was developed by 3M/HIS specifically for the State of New York to capture the non-Medicare population.) Table A below shows how each of the five alternative severity-adjusted systems classifies patients into base DRGs and their corresponding severity levels. Table A.—Logic of CMS and Alternative DRG Systems
Classification element
CMS DRG
CMS+AP-DRG
HSC-DRG
Sol--DRG
MM-APS-DRG
Con-APR-DRGNumber of MDCs
25
25
25
25
25
25Number of Pre-MDC base DRGs
9
9
9
9
9
7Number of base DRGs
379
379
215 ADRGs
248 ADRGs
361
379Total number of Pre-MDC DRGs
9
9
30
27
27
9Total number of DRGs
538
602
1,274
1,261
915
859Number of CC (severity) subclasses
2
3
3 (medical) or 4 (surgical)
3 (medical) or 4 (surgical)
3
4CC subclasses
With CC without CC for selected base DRGs
Without CC With CC for selected base DRGs and With MCC across DRGs within MDC
No CC, Class C CC, Class B CC, Class A CC (surgical only)
Minor/no substantial CCs, moderate CCs, MCCs, catastrophic CCs (surgical only)
Without CC, with CC with MCC with some collapsing at base DRG level
Minor, moderate, major, severe with some collapsing at DRG level.Multiple CCs recognized
No
No
No
No
Yes (in computation of weights
Yes.CC assignment specific to base DRG
Mostly no
Mostly no
Mostly no
Mostly no
No
Yes.Logic of CC subdivision
Presence/absence
Presence/absence
Presence/absence
Presence/absence
Presence/absence
18-step process.Logic of MDC assignment
Principal diagnosis
Principal diagnosis
Principal diagnosis
Principal diagnosis
Principal diagnosis
Principal diagnosis with rerouting.Death used in DRG assignment
Yes (in selected DRGs)
Yes (in selected DRGs)
Yes (includes “early death” DRGs)
Yes (includes “early death” DRGs)
Yes (in selected DRGs)
No.Complications of care are CCs
Yes
Yes
Yes
Yes
Yes, when recognized as a CC No, when CC represents “poor medical care”
Few.
 RAND's preliminary evaluation of the logic for each system demonstrated the following: Four systems add severity levels to the base CMS DRGs; the CS DRGs add severity levels to base APR-DRGs, which are comparable but not identical to the base CMS DRGs. Both the CS DRGs and MM-APS-DRGs collapse some base DRGs with low Medicare volume.( print page 24693)
                    The HSC-DRGs and the Sol-DRGs use uniform severity levels for each base DRG (three for medical and four for surgical). The general structure of the MM-APS-DRG logic includes three severity levels for each base DRG, but some severity levels for the same base DRG are consolidated to address Medicare low-volume DRGs and monotonicity issues. Monotonicity is when the average costs for a severity group consistently rise as the severity level of the group increases. For example, in a monotonic system, if within a base DRG there are three severity groups and level 1 severity is less than level 2 severity and level 2 severity is less than level 3 severity, the average costs for a level 3 case would be greater than the average costs for a level 2 case, which would be greater than the average costs for a level 1 case. The general structure of the CS DRGs includes four severity levels for each base DRG. However, severity level consolidations occur to address Medicare low-volume DRGs and monotonicity. The CS DRGs consolidate both adjacent severity levels for the same base DRG and the same severity level across multiple base DRGs (especially for severity level 4).
                    Under the CMS+AP-DRGs and MM-APS-DRGs, each diagnosis is assigned a uniform CC-severity level across all base DRGs (other than CCs on the exclusion list for specific principal diagnoses). The remaining systems assign diagnoses to CC-severity level classifications by groups of DRGs.
                    Under the grouping logic used by all systems other than the CS DRGs, each discharge is assigned to the highest severity level of any secondary diagnosis. The CS DRGs adjust the initial severity level assignment based on other factors, including the presence of additional CCs. None of the other systems adjust the severity level classification for additional factors or CCs. However, the MM-APS-DRG system handles additional CCs through an enhanced relative weight.
                    The HSC-DRGs and the Sol-DRGs have a medical “early death” DRG within each MDC.
                    The CS DRGs do not use death in the grouping logic. In addition, most complications of care do not affect the DRG assignment. b. Comparative Performance in Explaining Variation in Resource Use In evaluating the comparative performance of each alternative DRG system, RAND used MedPAR data from FY 2004 and FY 2005. RAND excluded data from CAHs, Indian Health Service (IHS) hospitals, and hospitals that have all-inclusive rate charging practices. Consistent with CMS practice, RAND did not exclude data from Maryland hospitals, which operate under an IPPS waiver. Records that failed edits for data consistency or that had missing variables that were needed to determine standardized costs were also excluded. RAND reported that evaluation of each alternative severity-adjusted DRG system is a complex process due to differences in how each of the severity levels are applied, the number of severity-adjusted DRGs in each system, and the average number of discharges assigned to each DRG. In addition, the manner in which the DRGs for patients 0-17 years of age are assigned in the severity-adjusted systems affects the number of low-volume DRGs using Medicare discharges. Low-volume, severity-adjusted DRGs can affect the relative performance of a classification system. However, the percentage of Medicare discharges assigned to these DRGs is small—approximately 0.7 percent in the HSC-DRG and Sol-DRG systems compared to 0.1 percent in the CMS DRGs. In determining how much within-DRG variation exists for each alternative severity-adjusted DRG system, RAND calculated the mean standardized cost, standard deviation, and coefficient of variation for each DRG among the systems. The coefficient of variation (CV) is the standard deviation divided by the mean. The CV allowed RAND to compare the variation of populations that contain significantly different mean values. Preliminary results of the comparison demonstrate that all five severity-adjusted systems reduce the amount of variation within DRGs. The HSC-DRGs and Sol-DRGs have a slightly higher proportion of patients assigned to DRGs with a CV<76 percent but also have a higher proportion of patients assigned to DRGs with a CV≥100 percent. The CS DRGs had a slightly lower percentage of patients assigned to DRGs with a CV<76 percent than the other severity-adjusted systems. The MM-APS-DRGs, CS DRGs, and CMS+AP-DRGs all have fewer than 2 percent of patients assigned to DRGs with a CV≥100 percent. RAND utilized a general linear regression model to evaluate how well each severity-adjusted DRG system explains variation in costs per case. The initial results demonstrate that all five severity-adjusted DRG systems predict cost better than the CMS DRGs. The CS DRGs have higher adjusted R2
                         values (explanatory power) than the other severity-adjusted systems in nearly every MDC. In general, the adjusted R2
                         value for the CS DRGs is 0.4458, a 13-percent improvement over the adjusted R2
                         value for the CMS DRGs. The HSC-DRGs demonstrate an 11-percent improvement, while the adjusted R2
                         values for the MM-APS-DRGs and Sol-DRGs are 10.0 percent and 9.7 percent higher respectively, than the CMS DRG R2
                         value. The CMS+AP-DRGs show the smallest improvement, nearly 8 percent. Another aspect of RAND's evaluation was to identify the validity of each alternative DRG system as a measurement for resource costs. For a base DRG, the severity levels should be monotonic; that is, the mean cost per discharge should increase simultaneously with an increase in the severity level. A distinction between patient groups and varying treatment costs should be accomplished by the severity levels. RAND studied the percentage differences and absolute differences in cost between the severity levels within the base DRGs for each system under evaluation. For the two systems (CMS+AP-DRGs and CS DRGs) that include several base DRGs, RAND assigned those discharges to the lower severity level base DRG. Following that methodology, RAND was able to calculate how much more costly the discharges assigned to the consolidated or lower severity levels were than the discharges in the base DRG assigned to the next higher severity level. Preliminary results demonstrate that, overall, monotonicity is not a factor across the alternative DRG systems. There are only a small percentage of discharges that are assigned to nonmonotonic DRGs. When a DRG is nonmonotonic, the mean cost in the higher severity level is less than the mean cost in the lower severity level. Using the data from severity of illness levels 1 through 3 (except for the MM-APS-DRGs, which do not have a severity of illness level 3), RAND calculated the discharge-weighted mean cost difference between severity levels and the mean ratio of the cost per discharge for the higher severity level to the adjacent lower severity level. The greatest cost discrimination was present in the higher severity levels versus the lower severity levels across all the systems. The mean cost difference between severity of illness level 1 and severity of illness level 0 was reported to be less than $2,000 for all the severity-adjusted systems. The CMS+AP DRGs have the least amount of cost discrimination between severity levels ($2,117), while the MM-APS-DRG system has the highest mean cost difference ($2,385). The remaining systems demonstrated equivalent percentage cost differences between the 
                        ( print page 24694)
                        severity levels as shown in Table B below.  In examining whether each of the alternative DRG systems provided stability in the relative weights from year to year, RAND compared the relative weights derived from the MedPAR data in FY 2004 to the relative weights data from FY 2005. RAND's preliminary results demonstrate that generally, across all the systems, only a small percentage of DRGs had greater than a 5 percent change in relative weights. The HSC-DRGs and Sol-DRGs had a higher proportion of DRGs with a greater than 5 percent change in relative weights than the other systems. Fewer than 10 percent of the DRGs in the remaining systems had relative weight changes greater than 10 percent. In addition to differences in the number of DRGs and the methodology of assigning the severity levels, RAND noted additional factors that may affect the comparative performance of each alternative severity-adjusted DRG system. For further details and discussion, we encourage readers to view RAND's full interim report on the CMS Web site at: 
                        *http://www.cms.hhs.gov/​Reports/​downloads/​Wynn0307.pdf.* c. Payment Accuracy and Case-Mix Impact Similar to how CMS established the relative weights in the FY 2007 IPPS final rule, RAND used standardized costs as determined by the national CCR and the FY 2005 MedPAR data to construct relative weights for each of the DRG systems being evaluated. RAND analyzed the effect of variations in the 
                        ( print page 24695)
                        explanatory power on the distribution of Medicare payments for each system under evaluation. The preliminary findings indicate payment accuracy is improved by each severity-adjusted system by redistributing payment from lower-cost discharges to higher-cost discharges. However, the total payment redistribution across systems differs and reflects the payment impact of improved explanatory power. Although these findings are estimates, the percent of total payment redistributed was the least under the CMS+AP-DRGs (7.1 percent) and the most under the CS DRGs (11.9 percent). Table C shows changes in case-mix index (CMI) by hospital category across alternative severity-adjusted DRG systems. Preliminary results demonstrate that under the severity-adjusted systems, urban hospitals have a higher average CMI than under the CMS DRGs, and rural hospitals have a lower CMI. The analysis suggests that any system adopted to better recognize severity of illness with a budget neutrality constraint will result in payment redistribution that can be expected to benefit urban hospitals at the expense of rural hospitals. This impact occurs because patients treated in urban hospitals are generally more severely ill than patients in rural hospitals and the CMS DRGs are not currently recognizing the full extent of these differences. For purposes of the study, RAND assumed no behavioral changes in coding practice or the types of patients treated. The shift in case-mix (CMI) is greatest with the CS DRGs. The CMI for rural hospitals is 2.4 percent lower than under the CMS DRGs. The CMI for large urban (hospitals located in CBSAs with greater than 1 million population) and other urban hospitals is 0.6 percent and 0.1 percent higher, respectively, for the CS DRGs. The CMI generally increases for larger hospitals and decreases for smaller hospitals. Under the CMS+AP-DRG, HSC-DRG, and Sol-DRG systems, greater than 70 percent of hospitals would experience less than a 2.5 percent change in their CMI. Under the MM-APS-DRG and Con-APR-DRG systems, 65 and 45 percent of hospitals, respectively, would experience less than a 2.5 percent change. The percentage of hospitals experiencing less than a 5 percent change is significant across all of the CMS-based DRG systems. Teaching hospitals commonly treat a higher number of complex cases. However, depending on the severity-adjusted DRG system being analyzed, the impact will vary. In the CMS+AP-DRG, HSC-DRG, and MM-APS-DRG systems, facilities with large teaching programs (100 or more residents) demonstrated a larger increase than those facilities with smaller teaching programs. Under the Sol-DRG system, facilities with large teaching programs would experience a 0.1 percent increase, while facilities with the smaller teaching programs would experience a 0.2 percent increase. The CS DRGs showed similar results for hospitals with large teaching programs, but hospitals with the smaller teaching programs would experience an increase of 0.7 percent, relative to the CMS DRGs. RAND found that CMI would decline for nonteaching hospitals from severity adjusted DRGs, from a 0.2 percent decrease under the HSC-DRGs and Sol-DRGs compared to a 0.5 percent decrease under the CS DRGs. Table C.—CMI Change in Alternative DRG Systems Relative to the CMS DRG CMI
N 
                                 hospitals
N 
                                 discharges
CMS 
                                 DRG  
                                 CMI
Percentage change from CMS-DRG-CMICMS + AP-DRG
HSC-DRG
Sol-DRG
MM-APS-DRG
Con-APR-DRGALL
3,890
12,165,763
1.00
0.0
0.0
0.0
0.0
0.0By Geographic Location:Large urban areas (pop>1 million)
1,485
5,715,356
1.02
0.5
0.4
0.3
0.6
0.6Other urban areas (pop<1 million)
1,186
4,578,447
1.04
−0.2
−0.2
−0.1
−0.2
0.1Rural hospitals
1,219
1,871,960
0.84
−1.3
−0.9
−1.0
−1.4
−2.4Bed Size (Urban):0-99 beds
685
611,139
0.91
−1.0
−1.1
−1.1
−1.3
−1.6100-199 beds
875
2,346,922
0.93
0.0
0.1
0.0
0.1
0.0200-299 beds
511
2,446,737
1.00
0.1
0.2
0.3
0.3
0.6300-499 beds
433
2,965,216
1.08
0.3
0.3
0.3
0.4
0.8500 or more beds
167
1,923,789
1.17
0.6
0.3
0.2
0.4
0.4Bed Size (Rural):0-49 beds
543
330,242
0.73
−2.5
−2.1
−2.2
−2.7
−5.050-99 beds
398
595,599
0.80
−1.4
−1.0
−1.1
−1.6
−2.7100-149 beds
160
415,367
0.85
−1.1
−0.7
−0.8
−1.2
−2.0150-199 beds
69
260,910
0.91
−0.8
−0.6
−0.7
−0.8
−1.5200 or more beds
49
269,842
0.99
−0.6
−0.1
−0.1
−0.6
−0.5Urban by Region:New England
129
541,471
0.99
0.1
−0.2
−0.5
−0.5
−0.6Middle Atlantic
370
1,621,488
1.00
0.0
−0.4
−0.5
−0.3
−1.5South Atlantic
432
2,208,336
1.04
0.5
0.7
0.7
0.7
1.4East North Central
410
1,856,164
1.03
0.6
0.7
0.6
0.8
1.5East South Central
168
696,943
1.06
−0.2
−0.2
−0.2
−0.2
−0.3West North Central
164
657,322
1.08
−0.3
−0.3
0.0
−0.3
0.3West South Central
369
1,115,411
1.05
0.1
0.0
0.1
0.3
0.5Mountain
153
465,093
1.08
0.4
0.2
0.5
0.4
1.0Pacific
423
1,016,135
1.03
0.0
−0.2
−0.1
−0.1
0.2Puerto Rico
53
115,440
0.87
−1.1
−1.4
−0.1
−1.2
−5.1Rural by Region:New England
34
49,842
0.90
−0.6
−0.6
−0.5
−1.1
−0.6Middle Atlantic
68
139,639
0.85
−1.1
−0.7
−0.7
−1.3
−1.5South Atlantic
191
409,116
0.82
−0.8
−0.4
−0.5
−0.9
−1.8East North Central
163
290,069
0.87
−1.1
−0.7
−0.9
−1.3
−1.8East South Central
201
328,326
0.82
−1.5
−0.9
−1.1
−1.4
−3.2( print page 24696)West North Central
184
240,449
0.87
−1.6
−1.2
−1.1
−1.8
−2.5West South Central
227
266,419
0.80
−2.1
−1.8
−1.9
−2.0
−4.3Mountain
91
80,219
0.85
−1.2
−1.0
−0.4
−1.3
−1.2Pacific
60
67,881
0.86
−0.9
−1.0
−1.1
−1.4
−1.6Teaching Status:Non-teaching
2,791
6,115,193
0.92
−0.4
−0.2
−0.2
−0.4
−0.5Fewer than 100 Residents
853
4,061,451
1.04
0.1
0.2
0.2
0.2
0.7100 or more Residents
246
1,989,119
1.16
0.8
0.3
0.1
0.5
0.0Urban DSH:Non-DSH
778
2,574,640
1.02
−0.1
0.0
0.1
−0.2
0.5100 or more beds
1,541
7,378,095
1.05
0.3
0.2
0.2
0.4
0.4Less than 100 beds
352
341,068
0.82
−0.9
−0.8
−1.0
−1.1
−2.0Rural DSH:Non-DSH
238
300,747
0.87
−1.4
−1.0
−0.9
−1.7
−1.9SCH
402
599,823
0.83
−1.3
−1.0
−1.0
−1.4
−2.4RRC
132
466,395
0.92
−0.8
−0.3
−0.5
−0.7
−1.4Other Rural:100 or more beds
60
135,146
0.80
−0.9
−0.8
−1.2
−1.3
−2.0Less than 100 beds
387
369,849
0.74
−2.1
−1.6
−1.7
−2.2
−4.3Urban teaching and DSH:Both teaching and DSH
829
4,705,476
1.09
0.5
0.3
0.3
0.5
0.5Teaching and no DSH
204
1,108,092
1.06
0.0
0.1
0.0
−0.1
0.4No teaching and DSH
1,064
3,013,687
0.95
−0.1
0.1
0.0
0.1
0.1No teaching and no DSH
574
1,466,548
1.00
−0.2
−0.1
0.1
−0.3
0.5Rural Hospital Types:RRC
145
519,808
0.92
−0.8
−0.4
−0.5
−0.7
−1.4SCH
423
457,119
0.79
−1.6
−1.2
−1.2
−1.7
−3.0MDH
180
164,453
0.75
−2.1
−1.7
−1.7
−2.3
−4.1SCH and RRC
76
266,027
0.92
−0.9
−0.7
−0.7
−1.1
−1.3MDH and RRC
8
19,746
0.85
−1.4
−0.6
−0.8
−1.6
−1.9Other Rural
387
444,807
0.77
−1.6
−1.2
−1.4
−1.8
−3.3
 RAND also noted that changes in coding patterns or behaviors could improve payments with each severity adjusted DRG system. Increases in CMI after adopting the system could be the result of improved coding rather than increases in actual patient severity. Although the State of Maryland's experience using the APR-DRG system is an indicator, coding behaviors are expected to vary under alternative systems according to RAND. Therefore, the risk of case-mix growth due to improved documentation and coding exists with any system. However, RAND advises that the amount of risk can be assessed based on the logic of the DRG system and result in anticipated changes in coding behavior. RAND found that the CMS+AP-DRG system may have the lowest risk of case-mix increase, while the CS DRGs present the greatest risk. The remaining systems under evaluation demonstrated equivalent risk, based on the DRG logic and other features specific to each system. In section II.D.2.c. of the preamble of this proposed rule, the CMI impact under the proposed MS-DRGs using the State of Maryland's experience and data is described in detail. RAND's final report will include a comparison of the CMI impact under the proposed MS-DRG system with the CMI impact of the other alternative severity-adjusted DRG systems. d. Other Issues for Consideration RAND was asked to examine whether each of the alternative severity-adjusted DRG systems under evaluation appear to contain logic that is manageable, administratively feasible, and understandable. Although its evaluation is not yet complete, RAND's preliminary results describe the extent to which those features are present in the grouping logic of each system. A brief summary of these findings and other discussion points follow. For more complete details of the grouping logic for each system evaluated, we encourage readers to review RAND's interim report at the following Web site: 
                        *http://www.cms.hhs.gov/​Reports/​downloads/​Wynn0307.pdf.* To increase and promote understanding of a DRG classification system, the grouping logic should include a uniform structure. With the exception of the CS DRGs, RAND found that there is uniformity in the hierarchical structure for assigning discharges to MDCs, DRGs, and severity levels for each system evaluated. The CS DRGs utilize a complex rerouting logic and severity of illness level assignment. However, the result is a higher explanatory power that accounts for limitations in the current system. Therefore, due to the complexities associated with that system, it may not easily be understood. However, if the results yield clinically coherent groups of patients with comparable costs, RAND concluded that the system may be worth exploring further. The HSC-DRG and Sol-DRG grouping logic uses a standard number of severity levels for each base DRG, although the result is an increase in the number of low-volume DRGs. The standard severity level structure provides increased understanding, although as mentioned previously, low-volume, severity-adjusted DRGs can affect the relative performance of a classification system. The MM-APS-DRGs and CS DRGs use standard DRG severity levels. However, the method of collapsing DRGs varies due to the modifications made for Medicare use. By only collapsing DRGs to determine relative weights, RAND 
                        ( print page 24697)
                        notes it is possible to preserve the underlying DRG structure, which perhaps would lead to a more understandable system. As stated earlier, there are also several transition issues that require attention when evaluating alternative severity-adjusted DRG systems. In determining how manageable, administratively feasible, and understandable the systems being evaluated are, consideration should be given to how they crosswalk or map to the current CMS DRGs. Because four of the systems under evaluation are based on the underlying CMS DRG grouping logic to establish their base DRGs (CMS+AP-DRGs, HSC-DRGs, Sol-DRGs, and MM-APS-DRGs), the CMS DRGs are able to crosswalk smoothly to these severity-adjusted DRGs. Conversely, crosswalking in reverse or backward mapping from the CMS+AP DRGs to the CMS DRGs is problematic due to the discharges in one severity level of the CMS+AP-DRG system compared to several base CMS DRGs. As expected, the CS DRGs do not crosswalk easily to the CMS DRGs due to the complex grouping logic. The MM-APS-DRGs pose unique complications as well due to the large number (over 1,000) of DRGs. System updates are another important factor that may have serious implications. All of the DRG systems RAND evaluated were reported to make annual updates to reflect ICD-9-CM coding changes. However, the CC severity level assignments for each system have not routinely been reviewed and revised. The review of the CC exclusion list and severity level assignments should be reviewed where appropriate to reflect current patterns of care, according to RAND. Accessibility to each of the severity-adjusted DRG system's logic and software is also a concern. Each system RAND analyzed is currently maintained as a proprietary product. In general, all of the vendors indicated a willingness to place their product in the public domain, under certain terms. As such, we believe it is likely there would need to be discussion as to whether there would be any limitations (such as the source code as well as the DRG logic) on the availability of the DRG systems to hospitals or competing vendors. The intent of each vendor to provide public access to its grouper logic and software is described in further detail in RAND's interim report. The RAND contract will be complete by September 1, 2007. The final report will include evaluation of the proposed MS-DRGs, with further analysis of the five alternative severity-adjusted DRG classification systems. RAND will also study various approaches to estimating costs and developing relative weights, as well as the payment impacts of alternative methodologies. Again, we invite public comment on RAND's preliminary analysis of the alternative severity-adjusted DRG systems. The interim report can be viewed on the CMS Web site at: 
                        *http://www.cms.hhs.gov/​Reports/​downloads/​Wynn0307.pdf.* 2. Development of Proposed Medicare Severity DRGs (MS-DRGs) As discussed previously, we are committed to continuing our efforts of making refinements to the current CMS DRGs to better recognize severity of illness. In the FY 2007 final rule, we stated that we had begun a comprehensive review of over 13,000 diagnosis codes to determine which codes should be classified as CCs when present as a secondary diagnosis. We stated that we would also build on the severity DRG work we performed in the mid-1990's. We received a number of public comments on last year's proposed rule that supported the refinement of the current CMS DRGs so that they better capture severity. We also committed to performing a more broad based analysis of the entire DRG system to better recognize severity of illness. As a result of this broad based analysis, we developed the proposed MS-DRGs. The proposed MS-DRGs represent a comprehensive approach to applying a severity of illness stratification for Medicare patients throughout the DRGs. As discussed in section II.D.5. of the preamble of this proposed rule, the proposed MS-DRGs maintain the significant advancements in identifying medical technology made to the DRGs in past years. At the same time, they greatly improve our ability to identify groups of patients with varying levels of severity using secondary diagnoses. Further, they improve our ability to assign patients to different DRG severity levels based on resource use that is independent of the patient's secondary diagnosis—referred to in this discussion as “complexity.” We are proposing to adopt the MS-DRGs for FY 2008 and submit the system to RAND as part of its evaluation of alternative DRG systems. We encourage comments on both our proposed methodology as well as on the resulting proposed DRG structure. a. Comprehensive Review of the CC List Our efforts to better recognize severity of illness began with a comprehensive review of the CC list. Currently, 115 DRGs are split based on the presence or absence of a CC. For these DRGs, the presence of a CC assigns the discharge to a higher weighted DRG. The list of diagnoses designated as a CC was initially created at Yale University in 1980-1981 as part of the project to develop an ICD-9-CM version of the DRGs. The researchers at Yale University developed the ICD-9-CM DRGs using national hospital data with diagnoses and procedures coded in ICD-9-CM from the second half of 1979. Because hospitals only began reporting ICD-9-CM codes in 1979, discharge abstracts at that time were much less likely to fully report all secondary diagnoses. As a result, the Yale University researchers developed a liberal definition of a CC as any secondary diagnosis that “would cause an increase in length of stay by at least 1 day in at least 75 percent of the patients.” Because of the likely underreporting of secondary diagnoses in the 1979 data, the Yale University researchers also used age as a surrogate for identifying patients with a CC. The original version of the ICD-9-CM DRGs assigned patients to a CC DRG if they had a secondary diagnosis on the CC list or if the patient was 70 years or older. With the implementation of the IPPS in FY 1984, the coding of secondary diagnoses by hospitals dramatically improved. During the first 4 years of the IPPS, the CC definition included the age 70 criterion. With the improved coding and reporting of diagnoses associated with the implementation of the IPPS, the use of age as a surrogate for CCs was no longer necessary. Thus, beginning in FY 1988, the age 70 criterion was removed from the CC definition and a CC DRG was defined exclusively by the presence of a secondary diagnosis on the CC list. Except for new diagnosis codes that were added to ICD-9-CM after FY 1984 (for example, HIV), the CC list of diagnoses currently used in the CMS DRGs is virtually identical to the CC list created at Yale University. However, there have been dramatic changes not only in the accuracy and completeness of the coding of secondary diagnoses but also in the characteristics of patients admitted to hospitals and the practice patterns within hospitals as well. Since the implementation of the IPPS, Medicare average length of stay has dropped dramatically from 9.8 days in 1983 to 5.7 days in 2005. The economic incentives inherent in DRGs motivated a change in practice patterns to discharge patients earlier from the hospital. These changes were facilitated by the increased availability of postacute care services, such as nursing homes and home health services, which 
                        ( print page 24698)
                        allowed problems previously requiring continued hospitalization to be effectively treated outside the acute care hospital. Furthermore, there has also been a dramatic shift to outpatient surgery that avoids costly inpatient stays. Many surgical procedures formerly performed in the hospital are now routinely performed on an outpatient basis. As a result, patients admitted to the hospital today are on average more likely to have a CC than when the IPPS was implemented. The net effect of better coding of secondary diagnoses, reductions in hospital length of stay, increased availability of postacute care services, and the shift to outpatient care is that most patients (nearly 80 percent) admitted to a hospital now have a CC. As a result of the changes that have occurred during the 22 years since the implementation of the IPPS, the CC list as currently defined has lost much of its power to discriminate hospital resource use. Currently, 115 CMS DRGs have a CC subdivision. Up until FY 2002, the number of DRGs with a CC subdivision remained essentially unchanged from the original FY 1984 version of the DRGs. As a means of improving the payment accuracy of the DRGs, beginning with the FY 2002 DRG update, each base CMS DRG without a CC subdivision was evaluated to determine if a CC subdivision was warranted. Over the past five DRG updates, only seven base CMS DRGs have had a CC subdivision added. The primary constraint preventing a significant increase in the number of base CMS DRGs with a CC subdivision is the low number of patients that would be assigned to the non-CC group. Thus, the expansion of the number of CMS DRGs subdivided based on a CC is constrained because the vast majority of patients would be assigned to the CC group and few patients would be assigned to the non-CC group. To remedy these problems, we reviewed each of the 13,549 secondary diagnosis codes to evaluate their assignment as a CC or non-CC using statistical information from the Medicare claims data and applying medical judgment based on current clinical practice. We refer to this list in this section as the “revised CC list.” The need for a revised CC list prompted a reexamination of the secondary diagnoses that qualify as a CC. Our intent was to better distinguish cases that are likely to result in increased hospital resource use based on secondary diagnosis. Using a combination of mathematical data and the judgment of our medical officers, we included the condition on the CC list if it could demonstrate that its presence would lead to substantially increased hospital resource use. Diagnoses may require increased hospital resource use because of a need for such services as: Intensive monitoring (for example, an intensive care unit (ICU) stay).
                    Expensive and technically complex services (for example, heart transplant).
                    Extensive care requiring a greater number of caregivers (for example, nursing care for a quadriplegic). There are 3,326 diagnosis codes on the current CC list. Our 2006 review of the CC list reduced the number of diagnosis codes on the CC list to 2,583. Based on the current CC list, 77.6 percent of patients have at least one CC present. Based on the revised CC list from our 2007 review, the percent of patients having at least one CC present would be reduced to 41.24 percent. b. Chronic Diagnosis Codes The 1979 data used in the original formation of the CC list often did not have the manifestations of a chronic disease fully coded. As a result, the CC list included many chronic diseases with a broad range of manifestations. Such chronic illness diagnoses usually do not cause a significant increase in hospital resource use unless there is an acute exacerbation present or there is a significant deterioration in the underlying chronic condition. Therefore, in the revised CC list, we removed chronic diseases without a significant acute manifestation. Recognition of the impact of the chronic disease is accomplished by separately coding the acute manifestation. For example, the mitral valve disease codes (codes 396.0 through 396.9) are assigned to the current CC list. However, unless the mitral valve abnormalities are associated with other diagnoses indicating acute deterioration, such as acute congestive heart failure, acute pulmonary edema, or respiratory failure, they would not be expected to significantly increase hospital resource use. Therefore, the revised CC list did not include the mitral valve codes. Recognition of the contribution of mitral valve disease to the complexity of hospital care would be accomplished by separately coding those diseases on the CC list that are associated with an acute exacerbation or deterioration of the mitral valve disease. The revised CC list applied the criterion that chronic diagnoses having a broad range of manifestations are not assigned to the CC list as long as there are codes available that allow the acute manifestations of the disease to be coded separately. For some diseases, there are ICD-9-CM codes that explicitly include a specification of the acute exacerbation of the underlying disease. For example, for congestive heart failure, the following codes specify an acute exacerbation of the congestive heart failure: 428.21, Acute systolic heart failure
                    428.41, Acute systolic and diastolic heart failure
                    428.43, Acute on chronic systolic heart failure
                    428.31, Acute diastolic heart failure
                    428.33, Acute on chronic diastolic heart failure These congestive heart failure codes are included on the revised CC List. However, the following congestive heart failure codes do not indicate an acute exacerbation and are not included in the revised CC list: 428.0, Congestive heart failure not otherwise specified
                    428.1, Left heart failure
                    428.20, Systolic heart failure not otherwise specified
                    428.22, Chronic systolic heart failure
                    428.32, Chronic diastolic heart failure
                    428.40, Systolic and diastolic heart failure
                    428.9, Heart failure not otherwise specified As a result of this approach, most chronic diseases were not assigned to the revised CC list. In general, a significant acute manifestation of the chronic disease must be present and coded for the patient to be assigned a CC. We made exceptions for diagnosis codes that indicate a chronic disease in which the underlying illness has reached an advanced stage or is associated with systemic physiologic decompensation and debility. The presence of such advanced chronic diseases, even in the absence of a separately coded acute manifestation, significantly adds to the treatment complexity of the patient. Thus, the presence of the advanced chronic disease inherently makes the reason for admission more difficult to treat. For example, under the revised CC list, stage IV, V, or end-stage chronic renal failure (codes 585.4 through 585.6) are designated as a CC, but stage I through III chronic renal failure (codes 585.1 through 585.3) are not. For obesity, a body mass index over 35 (codes V85.35 through V85.4) is a CC, but a body mass index between 19 and 35 is not. End-stage renal failure and extreme obesity are examples of chronic diseases for which the advanced stage of the disease is clearly specified. However, for most major chronic diseases, the stage of the disease is not clearly specified in the code. These 
                        ( print page 24699)
                        codes were evaluated based on the consistency and intensity of the physiologic decompensation and debility associated with the chronic disease. For example, quadriplegia (codes 344.00 through 344.09) requires extensive care with a substantial increase in nursing services and more intensive monitoring. Therefore, quadriplegia is considered a CC in the revised CC list. c. Acute Diagnosis Codes Examples of acute diseases included on the revised CC list included acute myocardial infarction (AMI), cerebrovascular accident (CVA) or stroke, acute respiratory failure, acute renal failure, pneumonia and septicemia. These six diseases are representative of the types of illnesses we included on the revised CC list. Other acute diseases were designated as a CC if their impact on hospital resource use would be expected to be comparable to these representative acute diseases. For example, acute endocarditis was included on the CC list but urinary tract infection was not. The revised CC list is essentially comprised of significant acute disease, acute exacerbations of significant chronic diseases, advanced or end stage chronic diseases and chronic diseases associated with extensive debility. Compared to the existing CC list, the revised CC list requires a secondary diagnosis to have a consistently greater impact on hospital resource. The following Table D compares the current CC list and the revised CC list. There are 3,326 diagnosis codes on the current CC list. The CC revisions reduce the number of diagnosis codes on the CC list to 2,583. Based on the current CC list, 77.6 percent of patients have at least one CC present, using FY 2006 MedPAR data. Based on the revised CC list, the percent of patients having at least one CC present is reduced to 40.34 percent. The revised CC list increases the difference in average charges between patients with and without a CC by 56 percent ($15,236 versus $9,743). Table D.—Comparison of Current CC List and Revised CC List
Current CC list
Revised CC listCodes designated as a CC
3,326
2,583Percent of patients with one or more CCs
77.66
40.34Percent of patients with no CC
22.34
59.66Average charge of patients with one or more CCs
$24,538
$31,451Average charge of patients with no CCs
$14,795
$16,215
 The analysis above suggests that merely reviewing and updating the CC list can lead to significant improvements in the ability of the CMS DRGs to recognize severity of illness. Although we could potentially adopt this one change to better recognize severity of illness in the CMS DRGs, we have undertaken additional analyses that further refine secondary diagnoses into MCCs, CCs and non-CCs as described below. d. Prior Research on Subdivision of CCs into Multiple Categories (1) Refined DRGs During the mid-1980s, CMS (then HCFA) funded a project at Yale University to revise the use of CCs in the CMS DRGs. The Yale University project mapped all secondary diagnoses that were considered a CC in the CMS DRGs into 136 secondary diagnosis groups, each of which was assigned a CC complexity level. For surgical patients, each of the 136 secondary diagnosis groups was assigned to 1 of 4 CC complexity levels (non-CC, moderate CC, MCC, and catastrophic CC). For medical patients, each of the 136 secondary diagnosis groups was assigned to 1 of 3 CC complexity levels (non-CC, moderate/MCC, and catastrophic CC). All age subdivisions and CC subdivisions in the DRGs were eliminated and replaced by the four CC subgroups for surgical patients, or the three CC subgroups for medical patients. The Yale University project did not reevaluate the categorization of secondary diagnosis as a CC versus a non-CC. Only the diagnoses on the standard CC list were used to create the moderate, major, and catastrophic subgroups. All secondary diagnoses in a secondary diagnosis group were assigned the same level, and a patient was assigned to the subgroup corresponding to the highest level secondary diagnosis. The number of secondary diagnoses had no effect on the subgroup assigned to the patient (that is, multiple secondary diagnoses at one level did not cause a patient to be assigned to a higher subgroup). The DRG system developed by the Yale University project demonstrated that a subdivision of the CCs into multiple subclasses would improve the predictability of hospital costs. (2) 1994 Severity DRGs We also examined the work we performed in the mid-1990's to revise the CMS DRGs to better capture severity. In 1993, we reevaluated the use of CCs within the CMS DRGs. The reevaluation excluded the CMS DRGs associated with pregnancy, newborn, and pediatric patients (MDCs 14 and 15 and DRGs defined based on age 0-17). The major CC list from the AP-DRGs that are used for Medicaid payment by New York and other States was used to identify an initial list of MCCs. Using Medicare data, we reevaluated the categorization of each secondary diagnosis as a non-CC, CC, or an MCC. The end result was that 111 diagnoses that were non-CCs in the standard CMS DRGs were made a CC, 220 diagnoses that were a CC were made a non-CC, and 395 CCs were considered an MCC. All CC splits in the CMS DRGs were eliminated, and an additional 24 DRGs were merged together. The resulting base CMS DRGs were then subdivided into three, two, or no subgroups based on an analysis of Medicare data. The result was 84 DRGs with no subgroups, 124 DRGs with two subgroups, and 85 DRGs with three subgroups. An additional 63 pregnancy, newborn, and pediatric DRGs not evaluated resulted in a total of 652 DRGs. A patient was assigned to the CC subgroup corresponding to the highest level secondary diagnosis. Multiple secondary diagnoses at one level did not cause a patient to be assigned to a higher subgroup. The categorization of a diagnosis as non-CC, CC, or MCC was uniform across the CMS DRGs, and there were no modifications for specific DRGs. As part of the FY 1995 IPPS proposed rule, we made a complete file of the revised DRG descriptions available to the public. However, we never adopted the revised DRGs (55 FR 27756). e. Proposed Medicare Severity DRGs (MS-DRGs) We had several options in developing a refinement to the current CMS DRGs to better recognize increased resource use due to severity of illness. One 
                        ( print page 24700)
                        option would involve simply taking the work performed in 1994 and then updating it with all the code changes that have taken place since then. We were reluctant to do this because of changes in medical practices as well as the substantial change in ICD-9-CM codes since that time. Another option would be to build on current CMS DRGs which include a number of advancements that better identify medical practices and technologies. Many commenters on the FY 2007 IPPS proposed rule urged us to take the latter approach because they believed the current base CMS DRGs clearly differentiate between the complexities of varying surgical procedures and medical devices. Therefore, we chose the option of developing a new severity DRG system based on the current CMS DRGs. The development of the 1994 Severity DRGs involved three steps: Consolidation of existing DRGs into base DRGs.
                    Categorization of each diagnosis as an MCC, CC, or non-CC.
                    Subdivision of each base DRG into subclasses based on CCs. We reviewed and revised each of the three steps and applied them to our current CMS DRGs to develop DRGs that better identify severity of illness among Medicare patients. We refer to this proposed system as the Medicare Severity DRGs (MS-DRGs). The purpose of the proposed MS-DRGs is to more accurately stratify groups of Medicare patients with varying levels of severity. (1) Consolidation of Existing CMS DRGs Into Proposed Base MS-DRGs The first step in our process was the consolidation of existing CMS DRGs into new proposed base MS-DRGs. We combined together the 115 pairs of CMS DRGs that are subdivided based on the presence of a CC. We further consolidated the CMS DRGs that are split on the basis of a major cardiovascular condition, AMI with and without major complication (CMS DRGs 121 and 122), and cardiac catheterization with and without complex diagnoses (CMS DRGs 124 and 125). We also consolidated the three pairs of burn CMS DRGs that were defined based on the presence of a CC or a significant trauma (CMS DRGs 506 and 507; 508 and 509; and 510 and 511). Next, we consolidated the 43 pediatric CMS DRGs that are defined based on age less than or equal to 17. These pediatric CMS DRGs contain a very low volume of Medicare patients. As shown in Table 10 of the FY 2007 IPPS final rule (71 FR 48318), only two of these pediatric CMS DRGs contained more than 100 patients (CMS DRGs 298 and 333). Seventeen of these pediatric DRGs had no patients (CMS DRGs 30, 33, 41, 48, 54, 58, 137, 252, 255, 282, 330, 340, 343, 393, 405, 446, and 448). As we have stated frequently, our primary focus in maintaining the CMS DRGs is to serve the Medicare population. We do not have the data or the expertise to maintain the DRGs in clinical areas that are not relevant to the Medicare population. We continue to encourage users of the CMS DRGs (or MS-DRGs if adopted) to make relevant adaptations if they are being used for a non-Medicare patient population. In addition to the pediatric CMS DRGs defined by the age of the patient, there are a number of CMS DRGs that relate primarily to the pediatric or adult population that have very low volume in the Medicare population, such as male sterilization, tubal interruptions, circumcisions, tonsillectomies, and myringotomies. These CMS DRGs were consolidated into the most clinically similar proposed MS-DRG. Over the past two decades, the site of service for some elective procedures such as carpal tunnel release, cataract extraction, and laparoscopy has shifted from the inpatient to the outpatient setting, resulting in the CMS DRGs associated with these procedures having very low volume. These CMS DRGs were also consolidated into the most clinically similar proposed MS-DRG. In addition, there were some clinically related CMS DRGs that had significant Medicare patient volume but had no significant difference in resource use. For example, thyroid (CMS DRG 290) and parathyroid (CMS DRG 289) procedures were virtually identical in terms of hospital resource use and were, therefore, consolidated. In total, 34 of these CMS DRGs were consolidated. The DRG consolidations are summarized in Table E below. Four pairs of proposed MS-DRGs (223 and 224; 228 and 229; 323 and 324; and 551 and 552) were defined based on the presence of a CC or some other condition. For example, proposed MS-DRG 323 is defined based on the presence of a CC or the performance of extracorporeal shock wave lithotripsy. For these proposed MS-DRGs, the CC condition was removed and the pair of DRGs remains separate but defined based only on the other condition (that is, proposed MS-DRG 323 became urinary stones with extracorporeal shock wave lithotripsy). As was done in the 1994 severity DRG work, we did not consolidate any of the CMS DRGs for maternity or newborn cases. Before proceeding further, we made one additional change to a base DRG assignment after completing these consolidations. We assigned cranial-facial bone procedures to a proposed new base DRG (Cranial/Facial Bone Procedures). These cases were previously assigned to DRGs 52 and 55 through 63. Table E below shows how DRGs in the CMS DRGs (Version 24.0) were consolidated into proposed new base MS-DRGs. We refer readers to section II.D.2. of the preamble of this proposed rule for a detailed discussion of CCs and MCCs under the proposed MS-DRGs. Table E.—DRG Consolidation
CMS-DRG Version 24.0
DRG description
Proposed 2008 MS-DRG
Proposed new base MS-DRGs description6 
                                 7,8
Carpal Tunnel Release 
                                 Peripheral & Cranial Nerve & Other Nervous System Procedure
40 
                                 41  
                                 42
Peripheral & Cranial Nerve & Other Nervous System Procedure with MCC, with CC, and without CC/MCC.36 
                                 38  
                                 39  
                                 42
Retinal Procedures 
                                 Primary Iris Procedures  
                                 Lens Procedures with or without Vitrectomy  
                                 Intraocular Procedures Except Retina, Iris & Lens
116 
                                 117
Intraocular Procedures with and without CC/MCC.43 
                                 46,47,48
Hyphema 
                                 Other Disorders of the Eye
124 
                                 125
Other Disorders of the Eye with and without MCC.( print page 24701)50 
                                 51
Sialoadenectomy 
                                 Salivary Gland Procedures Except Sialoadenectomy
139
Salivary Gland Procedures.52 
                                 55
Cleft Lip & Palate Repair 
                                 Miscellaneous Ear, Nose, Mouth & Throat Procedures
133 
                                 134
Other Ear, Nose, Mouth & Throat O.R. Procedures with and without CC/MCC.56 
                                 57,58  
                                 59,60  
                                 61,62  
                                 63
Rhinoplasty 
                                 Tonsillectomy & Adenoidectomy  Procedure, Except  Tonsillectomy &/or  Adenoidectomy Only  
                                 Tonsillectomy &/or Adenoidectomy Only  
                                 Myringotomy with Tube Insertion  
                                 Other Ear, Nose, Mouth & Throat O.R. Procedures
131 
                                 132
New DRG—Cranial/Facial Bone Procedures with and  without CC/MCC.67 
                                 68,69,70  
                                 71
Epiglottitis 
                                 Otitis Media & Upper Respiratory Infection  
                                 Laryngotracheitis
152 
                                 153
Otitis Media & Upper Respiratory Infection with  and without MCC.72 
                                 73,74
Nasal, Trauma & Deformity 
                                 Other Ear, Nose, Mouth & Throat  Diagnoses
154 
                                 155  
                                 156
Other Ear, Nose, Mouth & Throat Diagnoses with MCC,  with CC, without CC/MCC.185,186 
                                 187
Dental & Oral Diseases Except Extractions & Restorations 
                                 Dental Extractions & Restorations
157 
                                 158  
                                 159
Dental & Oral Diseases with MCC, with CC,  without CC/MCC.199 
                                 200
Hepatobiliary Diagnostic Procedure for Malignancy 
                                 Hepatobiliary Diagnostic Procedure for Non-Malignancy
420 
                                 421  
                                 422
Hepatobiliary Diagnostic Procedures with MCC, with CC, without  CC/MCC.244,245 
                                 246
Bone diseases & Specific Arthropathies 
                                 Non-Specific Arthropathies
553 
                                 554
Bone Diseases & Arthropathies with and  without MCC.259,260 
                                 261  
                                 262
Subtotal Mastectomy for Malignancy* Breast Procedures for Non-Malignancy Except Biopsy & Local  Excision  
                                 Breast Biopsy & Local Excision for Non-Malignancy
584 
                                 585
Breast Biopsy, Local Excision & Other Breast  Procedures with and without  CC/MCC.267 
                                 268  
                                 269,270
Perianal & Pilonidal Procedures 
                                 Skin, Subcutaneous Tissue & Breast Plastic Procedures  
                                 Other Skin, Subcutaneous Tissue & Breast Procedure
579 
                                 580  
                                 581
Other Skin, Subcutaneous Tissue & Breast  Procedures with MCC,  with CC, without  CC/MCC.289 
                                 290  
                                 291
Parathyroid Procedures 
                                 Thyroid Procedures  
                                 Thyroglossal Procedures
625 
                                 626  
                                 627
Thyroid, Parathyroid & Thyroglossal Procedures  with MCC, with CC,  without CC/MCC.294 
                                 295
Diabetes > 35 
                                 Diabetes < 35
637 
                                 638  
                                 639
Diabetes with MCC, with CC, without CC/MCC.338 
                                 339,340
Testes Procedures for Malignancy 
                                 Testes Procedures, Non-Malignancy
711 
                                 712
Testes Procedures with and without CC/MCC.342,343
Circumcision

Procedure 64.0 changed to non-O.R. Cases with only this procedure will go to medical DRGs.351 
                                 352
Sterilization, Male 
                                 Other Male Reproductive System Diagnoses
729 
                                 730
Other Male Reproductive System Diagnoses with and without CC/MCC.361 
                                 362  
                                 363  
                                 364
Laparoscopy & Incisional Tubal Interruption 
                                 Endoscopic Tubal Interruption  
                                 D&C, Conization & Radio-Implant, for Malignancy  
                                 D&C, Conization Except for Malignancy  
                                 History of Malignancy with Endoscopy
744 
                                 745
D&C, Conization, Laparascopy & Tubal Interruption with and without CC/MCC.411 
                                 412  
                                 413,414
History of Malignancy without Endoscopy 
                                 Other Myeloproliferative Disease or Poorly Differentiated Neoplasm Diagnosis
843 
                                 844  
                                 845
Other Myeloproliferative Disease or Poorly Differentiated Neoplasm Diagnosis with MCC, with CC, without CC/MCC.( print page 24702)465 
                                 466
Aftercare with History of Malignancy as Secondary Diagnosis 
                                 Aftercare without History of Malignancy as Secondary Diagnosis
949 
                                 950
Aftercare with and without CC/MCC.*Codes 85.22 and 85.23 in CMS DRGs 259 and 260 were moved to proposed MS-DRG 582 and 583.
 As summarized in the Table F, the consolidation resulted in the formation of 335 proposed base MS-DRGs. Table F.—Consolidation of Current CMS DRGs Into Proposed MS-DRGs
NumberCurrent CMS DRGs
538Elimination of CC subgroups
−114Elimination of MCC subgroups
−7Elimination of CC complexity subgroups
−5Elimination of age 0-17 subgroups
−43Consolidation due to volume or resource similarity
−34New DRG
+1Revised Base DRGs
311Newborn, maternity and error DRGs
+24Base DRGs for severity subdivision
335
 The end result of the consolidation of the CMS DRGs in the proposed MS-DRGs was similar to the consolidation performed in the 1994 severity DRGs. The 1994 DRG consolidations resulted in 356 base DRGs plus 2 error DRGs. The number of the 1994 base DRGs is different because new CMS DRGs have been added since 1994, the 43 age 0-17 pediatric CMS DRGs were not consolidated, and some of the volume shifts to outpatient care had not yet occurred in 1994. In the 1994 severity DRGs, 24 DRGs were consolidated due to volume or resource similarity. Sixteen of these 1994 DRG consolidations are included in the 34 consolidations done in the 2007 consolidations. However, due to concerns expressed by our physician consultants, 8 of the DRG consolidations from 1994 were not done. For example, interstitial lung disease (DRGs 92 and 93) was not consolidated with simple pneumonia and pleurisy (DRGs 89, 90, 91) as was done in the 1994 consolidations. (2) Categorization of Diagnoses We decided to establish three different levels of CC severity into which we would subdivide the diagnosis codes. The proposed three levels are MCC, CC, and non-CC. Diagnosis codes classified as MCCs reflect the highest level of severity. The next level of severity includes diagnosis codes classified as CCs. The lowest level is for non-CCs. Non-CCs are diagnosis codes that do not significantly affect severity of illness and resource use. Therefore, secondary diagnoses that are non-CCs do not affect the DRG assignment under either the current CMS DRGs or the proposed MS-DRGs. The categorization of diagnoses as an MCC, CC, or non-CC was accomplished using an iterative approach in which each diagnosis was evaluated to determine the extent to which its presence as a secondary diagnosis resulted in increased hospital resource use. In order to begin this iterative process, we started with an initial categorization of each diagnosis as an MCC, CC, or non-CC. As noted previously the 1994 CC revision began by separating CCs into MCC and CC based on the AP-DRG major CCs. One way to begin this iterative process would have been to use the 1994 CC categorization. However, the 1994 CC categorization was based on FY 1992 data and ICD-9-CM diagnosis codes, which now are 15 years old. Since 1992, 1,897 new diagnoses codes have been added, and 346 diagnoses codes have been deleted. Because the revised CC list (explained in section II.C.2.a. of this preamble) was based on current ICD-9-CM codes and used recent data, we decided to utilize the revised CC list rather than the 1994 categorization as our starting point for determining whether each secondary diagnosis should be an MCC, a CC, or a non-CC. The revised CC list categorizes each diagnosis as a CC or a non-CC. We decided to use this list in combination with the categorization under the AP-DRGs and the APR DRGs. The AP-DRGs and the APR-DRGs are updated annually with current codes and provide a good comparison source to use with the revised CC list. We designated as an MCC any diagnosis that was a CC in the revised CC list and was an AP-DRG major CC and was an APR DRG default severity level 3 (major) or 4 (extensive). We designated as a non-CC any diagnosis that was a non-CC in the revised CC list and was an AP-DRG non-CC and was an APR DRG default severity level of 1 (minor). Any diagnoses that did not meet either of the above two criteria was designated as a CC. The only exception to our approach was for diagnoses related to newborns, maternity, and congenital anomalies. These diagnoses are very low volume in the Medicare population and were not reviewed for purposes of creating the revised CC list. We used the APR DRGs to categorize these diagnoses. For newborn, obstetric, and congenital anomaly diagnoses, we designated the APR DRG default severity level 3 (major) and 4 (extreme) diagnoses as an MCC, the APR-DRG default severity level 2 (moderate) diagnoses as a CC, and the APR DRG default severity 1 (minor) diagnoses as a non-CC. Table G summarizes the number of codes in each CC category. Table G.—Initial Categorization of CC Codes
Number of codesMCC
1,096CC
4,221Non-CC
8,232Total
13,549
 This initial CC categorization of diagnosis codes was used to begin the iterative process of determining the proposed final CC categorization for each diagnosis code. (3) Additional CC Exclusions For some CMS DRGs, the presence of specific secondary diagnoses affects the base DRG assignment. For example, in MDC 5 (Diseases and Disorders of the Circulatory System), the presence of an AMI code as the principal diagnosis or as a secondary diagnosis will cause the patient to be assigned to the AMI DRGs (CMS DRGs 121 through 123). Therefore, if the AMI code is present as 
                        ( print page 24703)
                        a secondary diagnosis, it should not be used to assign the CC category for a patient because it is redundant within the definition of the base DRG. Similarly, for MDC 24 (Multiple Significant Trauma), specific combinations of significant trauma as principal or secondary diagnosis cause the assignment to the multiple trauma DRGs (CMS DRGs 484 through 487). Therefore, any secondary diagnosis of trauma is redundant with the definition of the multiple trauma DRGs and should not be used to determine the CC category for a patient. Any secondary diagnoses that are used to assign a specific proposed base MS-DRG were excluded from the determination of the CC category for patients assigned to that proposed base MS-DRG. (4) Analysis of Secondary Diagnoses The 311 proposed base MS-DRGs (335 total base DRGs minus the MDC 14, MDC 5, and error DRGs) were subdivided into three CC subgroups. Patients were assigned to the subgroup corresponding to the most extreme CC present). All but four of the proposed base MS-DRGs had strictly monotonically increasing average charges across the three CC subgroups (that is, average charges progressively increased from the non-CC to the CC to the MCC subgroups). The four proposed MS-DRGs that failed to have monotonically increasing charges all had at least one CC subgroup with very low volume. For example, the non-CC subgroup for the pancreas transplant DRG (CMS DRG 513) had only 2 cases. The overall statistics by CC subgroup for the 311 proposed base MS-DRG is contained in Table H. Patients in the MCC subgroup have average charges that are nearly double the average charge for patients in the CC subgroup. The CC subgroup with the largest number of patients is the non-CC subgroup with 41.1 percent of the patients. Table H.—Overall Statistics for Proposed MS-DRGs Excluding Those in MDCs 14 and 15
CC subgroup
Number of cases
Percent
Average chargesMajor
2,604,696
22.2
$44,246CC
4,293,744
36.6
24,131Non-CC
4,818,411
41.1
18,435
 In order to evaluate the initial assignment of secondary diagnoses to the three CC subclasses, we devised a system that determined the impact on resource use of each secondary diagnosis. For each secondary diagnosis, we measured the impact in resource use for the following three subsets of patients: (a) Patients with no other secondary diagnosis or with all other secondary diagnoses that are non-CCs. (b) Patients with at least one other secondary diagnosis that is a CC but none that is an MCC. (c) Patients with at least one other secondary diagnosis that is an MCC. Numerical resource impact values were assigned for each diagnosis as follows: Value
Meaning0
Significantly below expected value for the non-CC subgroup.1
Approximately equal to expected value for the non-CC subgroup.2
Approximately equal to expected value for the CC subgroup.3
Approximately equal to expected value for the MCC subgroup.4
Significantly above the expected value for the MCC subgroup.
 Each diagnosis for which Medicare data were available was evaluated to determine its impact on resource use and to determine the most appropriate CC subclass (non-CC, CC, or MCC) assignment. In order to make this determination, the average charge for each subset of cases was compared to the expected charge for cases in that subset. The following format was used to evaluate each diagnosis: Code
Diagnosis
Cnt1
C1
Cnt2
C2
Cnt3
C3
 Count (Cnt) is the number of patients in each subset and C1, C2, and C3 are a measure of the impact on resource use of patients in each of the subsets. The C1, C2, and C3 values are a measure of the ratio of average charges for patients with these conditions to the expected average charge across all cases. The C1 value reflects a patient with no other secondary diagnosis or with all other secondary diagnoses that are non-CCs. The C2 value reflects a patient with at least one other secondary diagnosis that is a CC but none that is a major CC. The C3 value reflects a patient with at least one other secondary diagnosis that is a major CC. A value close to 1.0 in the C1 field would suggest that the code produces the same expected value as a non-CC diagnosis. That is, average charges for the case are similar to the expected average charges for that subset and the diagnosis is not expected to increase resource usage. A higher value in the C1 (or C2 and C3) field suggests more resource usage is associated with the diagnosis and an increased likelihood that it is more like a CC or major CC than a non-CC. Thus, a value close to 2.0 suggests the condition is more like a CC than a non-CC but not as significant in resource usage as an MCC. A value close to 3.0 suggests the condition is expected to consume resources more similar to an MCC than a CC or non-CC. For example, a C1 value of 1.8 for a secondary diagnosis means that for the subset of patients who have the secondary diagnosis and have either no other secondary diagnosis present, or all the other secondary diagnoses present are non-CCs, the impact on resource use of the secondary diagnoses is greater than the expected value for a non-CC by an amount equal to 80 percent of the difference between the expected value of a CC and a non-CC (that is, the impact on resource use of the secondary diagnosis is closer to a CC than a non-CC). Table I below shows examples of the results. 
                        ( print page 24704) Table I.—Examples of Impact on Resource Use of Secondary Diagnoses
Code
Cnt1
C1
CntC2
C2
Cnt3
C3
CC subclass401.1, Benign essential hypertension
12,308
0.955
40,113
1.715
5,297
2.384
Non-CC.530.81, Esophageal reflux
294,673
0.986
917,058
1.639
122,076
2.302
Non-CC560.1, Paralytic Ileus
10,651
1.466
87,788
2.320
51,303
3.226
CC491.20, Obstructive chronic bronchitis
7,003
1.416
32,276
2.193
13,355
3.035
CC410.71, Subendocardial infarction initial episode
1,657
2.245
30,226
2.778
42,862
3.232
MCC518.81, Acute respiratory failure
5,332
2.096
118,937
2.936
223,054
3.337
MCC
 The resource use impact reports were produced for all diagnoses except obstetric, newborn, and congenital anomalies (10,690 diagnoses). These mathematical constructs were used as guides in conjunction with the judgment of our clinical staff to classify each secondary diagnosis reviewed as an MCC, CC or non-CC. Our clinical panel reviewed the resource use impact reports and modified 14.9 percent of the initial CC subclass assignments as summarized in Table J below. The rows in the table are the initial CC subclass categories and the columns are the final CC subclass categories. Table J.—CC Subclass Modifications
Initial CC subclass
Final CC subclass
Total
PercentMCC
CC
Non-CCMCC
847
62
0
909
8.5CC
542
2,579
737
3,858
36.1Non-CC
0
272
5,651
5,923
55.4Total
1,389
2,913
6,388
10,690Percent
13.0
27.2
59.8
 Of the diagnoses initially designated as an MCC, 6.8 percent were made a CC (62/909), and of the diagnoses initially designated as non-CC, 4.6 percent were made a CC (272/5,923). The major shift occurred in the diagnoses initially assigned to the CC subclass. Fourteen percent of the diagnoses initially designated as a CC were made an MCC (542/3858), and 19.1 percent of the diagnoses initially designated a CC were made a non-CC (737/3,858). In determining the CC subclass assigned to a diagnosis, imprecise codes were, in general, not assigned to the MCC or CC subclass. For example, the congestive heart failure codes have the following CC subclass assignments: Code
CC subclass assignment428.21, Acute systolic heart failure
MCC428.41, Acute systolic & diastolic heart failure
MCC428.43, Acute on chronic systolic heart failure
MCC428.31, Acute diastolic heart failure
MCC428.33, Acute on chronic diastolic heart failure
MCC428.1, Left heart failure
CC428.20, Systolic heart failure NOS
CC428.22, Chronic systolic heart failure
CC428.32, Chronic diastolic heart failure
CC428.40, Systolic & diastolic heart failure
CC428.0, Congestive heart failure NOS
NonCC428.9, Heart failure NOS
Non-CC
 The acute heart failure codes are MCCs, and the chronic heart failure codes are CCs. However, Not Otherwise Specified (NOS) heart failure codes are non-CCs. Thus, the precise type of heart failure must be specified in order for an MCC or CC to be assigned. There are currently 13,549 ICD-9-CM diagnosis codes. The External Cause of Injury and Poisoning codes (E800—E999) and congenital codes were not included in our current CC review for the proposed MS-DRGs. We excluded the External Cause of Injury and Poisoning codes (E codes) from consideration as an MCC or a CC because they describe how an injury occurred, and not the exact nature of the injury. For instance, if a patient fell on the deck of a boat and fractured his or her skull, one would assign an E code to describe the fall on the boat. A separate diagnosis code would be assigned to describe the exact nature of any resulting injury such as a contusion, fractured bone, or skull fracture and concussion. A patient would be assigned to a severity level based on the exact nature of the injury and not the manner in which the injury occurred. Therefore, we decided not to classify any of the E codes as either an MCC or a CC. The congenital codes describe abnormalities when a baby is born. At times, a beneficiary may live with these congenital abnormalities for years without a problem. The congenital abnormalities may later lead to complications that require hospital admissions. Should these congenital abnormalities lead to medical problems that result in a hospital admission for a Medicare beneficiary, the exact nature of the condition being treated would also be assigned a code. This more precise code would be evaluated to determine whether or not it was an MCC or a CC. Therefore, we decided not to classify congenital abnormality codes as an MCC or a CC, but to instead use the other reported diagnosis codes that better describe the reason for the admission. Excluding the external cause of injury codes, we reviewed 10,690 diagnosis codes. As was done in our 1994 severity proposal, diagnoses that were closely associated with patient mortality were assigned different CC subclasses, depending on whether the patient lived or died. These diagnoses are: 427.41, Ventricular fibrillation( print page 24705) 427.5, Cardiac arrest 785.51, Cardiogenic shock 785.59, Other shock without mention of trauma 799.1, Respiratory arrest Resource use for patients with these diagnoses who were discharged alive was consistent with an MCC. Resource use for patients with these diagnoses who died was consistent with a non-CC. Further, most patients who died could legitimately have one of these diagnoses coded. As a result, these diagnoses are assigned an MCC subclass for patients who lived and a non-CC subclass for patients who died. For some secondary diagnoses assigned to the CC subclass, our medical consultants identified specific clinical situations in which the diagnosis should not be considered a CC. In such clinical situations, the CC exclusion list was used to exclude the secondary diagnosis from consideration in determining the CC subgroup essentially making the secondary diagnosis a non-CC. For example, primary cardiomyopathy (code 425.4) is designated as a CC. However, for patients admitted for congestive heart failure, our medical consultants believed that primary cardiomyopathy should be treated as a non-CC. In order to accomplish that, the congestive heart failure principal diagnoses were added to the CC exclusion list for primary cardiomyopathy as a secondary diagnosis. The list of diagnosis codes that we are proposing to classify as an MCC is included in Table 6J in the Addendum of this proposed rule. The diagnosis codes that we are proposing to classify as a CC are included in Table 6K in the Addendum of this proposed rule. The proposed E-codes, which are diagnosis codes used to classify external causes of injury and poisoning, are not included in this list. All proposed E-codes are designated as non-CCs under the current CMS DRG system and our evaluation supports this non-CC designation as appropriate. 3. Dividing Proposed MS-DRGs on the Basis of the CCs and MCCs In developing the proposed MS-DRGs, two of our major goals were to create DRGs that would more accurately reflect the severity of the cases assigned to them and to create groups that would have sufficient volume so that meaningful and stable payment weights could be developed. As noted above, we excluded the CMS DRGs in MDCs 14 and 15 from consideration because these DRGs are low volume. As stated previously, we do not have the expertise or data to maintain the CMS DRGs for newborns, pediatric, and maternity patients. We continue to maintain MDCs 14 and 15 without modification in order to have MS-DRGs available for these patients in the rare instance where there is a Medicare beneficiary admitted for maternity or newborn care. In designating a proposed MS-DRG as one that will be subdivided into subgroups based on the presence of a CC or MCC, we developed a set of criteria to facilitate our decision-making process. In order to warrant creation of a CC or major CC subgroup within a base MS-DRG, the subgroup had to meet all of the following five criteria: A reduction in variance of charges of at least 3 percent.
                    At least 5 percent of the patients in the MS-DRG fall within the CC or MCC subgroup.
                    At least 500 cases are in the CC or MCC subgroup.
                    There is at least a 20-percent difference in average charges between subgroups.
                    There is a $4,000 difference in average charge between subgroups. Our objective in developing these criteria was to create homogeneous subgroups that are significantly different from one another in terms of resource use, that have enough volume to be meaningful, and that improve our ability to explain variance in resource use. These criteria are essentially the same criteria we used in our 1994 severity analysis. To begin our analysis, we subdivided each of the base MS-DRGs into three subgroups: non-CC, CC, and MCC. Each subgroup was then analyzed in relation to the other two subgroups using the volume, charge, and reduction in variance criteria. The criteria were applied in the following hierarchical manner: If a three-way subdivision met the criteria, we subdivided the base MS-DRG into three CC subgroups.
                    If only one type of two-way subdivisions met the criteria, we subdivided the base MS-DRG into two CC subgroups based on the type of two-way subdivision that met the criteria.
                    If both types of two-way subdivisions met the criteria, we subdivided the base MS-DRG into two CC subgroups based on the type of two-way subdivision with the highest R2
                         (most explanatory power to explain the difference in average charges).
                    Otherwise, we did not subdivide the base MS-DRG into CC subgroups. For any given base MS-DRG, our evaluation in some cases showed that a subdivision between a non-CC and a combined CC/MCC subgroup was all that was warranted (that is, there was not a great enough difference between the CC and MCC subgroups to justify separate CC and MCC subgroups). Conversely, in some cases, even though an MCC subgroup was warranted, there was not a sufficient difference between the non-CC and CC subgroups to justify separate non-CC and CC subgroups. Based on this methodology, a base MS-DRG may be subdivided according to the following three alternatives, rather than the current “with CC” and “without CC” division. DRGs with three subgroups (MCC, CC, and non-CC).
                    DRGs with two subgroups consisting of an MCC subgroup but with the CC and non-CC subgroups combined. We refer to these groups as “with MCC” and “without MCC.”
                    DRGs with two subgroups consisting of a non-CC subgroup but with the CC and MCC subgroups combined. We refer to these two groups as “with CC/MCC” and “without CC/MCC.” As a result of the application of these criteria, 745 proposed MS-DRGs were created as shown in the following table. Table K.—Number of CC Subgroups
Subgroups
Number of proposed  base MS-DRGs
Number of proposed MS-DRGsNo Subgroups
53
53Three subgroups
152
456Two subgroups: major CC and CC; non-CC
63
126Two subgroups: non-CC and CC; major CC
43
86Subtotal
311
721MDC 14
22
22( print page 24706)Error DRGs
2
2Total
335
745
 The 745 proposed MS-DRGs represent an increase over the 652 DRGs created in our 1994 CC revision analysis. The increase in the number of DRGs is primarily the result of an increase in the number of proposed base MS-DRGs that are subdivided into three CC subgroups. The distribution of patients across the different types of CC subdivisions is contained in Table L below. The table shows that 51.7 percent of the patients are assigned to base MS-DRGs with three CC subgroups, and only 11.8 percent of the patients are assigned to base MS-DRGs with no CC subgroups. Table L.—Distribution of Patients by Type of CC Subdivision
CC subdivision
Count
PercentNone
1,382,810
11.8(MCC and CC), Non-CC
629,639
5.4MCC, (CC and Non-CC)
3,650,321
31.2MCC, CC, and Non-CC
6,054,081
51.7
 Using Medicare charge data (without applying any criteria to remove statistical outlier cases), the reduction in variance (R2
                        ) was computed for current CMS DRGs, the MS-DRGs with all 311 base MS-DRGs subdivided into 3 CC subgroups, and the MS-DRGs collapsed into 745 DRGs. Table L below shows that the R2
                         for the proposed MS-DRGs with all 311 base MS-DRGs subdivided into 3 CC subgroups (957 DRGs composed of 311 base MS-DRGs subdivided into 3 CC subgroups plus an additional 22 MDC 14 and MDC 15 DRGs as well as 2 error DRGs) is 10.62 percent higher than the current CMS DRGs. Collapsing the 957 proposed MS-DRGs down to 745 proposed MS-DRGs lowers this increase in R2
                         slightly to 9.41 percent. Although adopting a 3-way split for each base MS-DRG would produce a DRG system with higher explanatory power, the 957 MS-DRGs would not meet the criteria we specified above for subdividing each base DRG. The criteria we specified above would create a monotonic DRG system. We believe that the value of having a monotonic DRG system outweighs the slight decrease in explanatory power. For this reason, we are proposing to adopt the 745 MS-DRGs. Table M.—Explanatory Power (R2
                            ) for Proposed MS-DRGs
R2
Percent changeCurrent CMS DRG
36.192007 CMS Severity DRGs with 3 CC Subgroups
40.03
10.622007 CMS Severity DRGs Collapsed to 714 DRGs
39.59
9.41
 4. Conclusion We believe the proposed MS-DRGs represent a substantial improvement over the current CMS DRGs in their ability to differentiate cases based on severity of illness and resource consumption. As developed, the proposed MS-DRGs increase the number of DRGs by 207, while maintaining the reasonable patient volume in each DRG. The proposed MS-DRGs increase the explanation of variance in hospital resource use relative to the current CMS DRGs by 9.41 percent. Further, the data shown below in Table N and Table O illustrate how assignment of cases to different severity of illness subclasses improves in the proposed MS-DRGs relative to the CMS DRGs. Table N.—Overall Statistics for CMS DRGs
CC subclass—Current CMS DRG
Percent
Average chargesOne or more CCs
77.66
$24,538Non-CC
22.34
14,795
 Table O.—Overall Statistics for Proposed MS-DRGs
CC subgroup
Number of cases
Percent
Average chargesMCC
2,607,351
22.2
$44,219CC
4,298,362
36.6
24,115Non-CC
4,826,980
41.1
18,416
 Under the current CMS DRGs, 78 percent of cases are assigned to the highest severity levels (CC) and the remaining 22 percent are assigned to the lowest severity level (non-CC). Applying the three severity subclasses to FY 2006 data would result in approximately 22 percent of patients being assigned to the severity subgroup with the highest level of severity (MCC), 41 percent being assigned to the lowest severity subclass (non-CC), and the remaining 37 percent being assigned to the middle severity subclass (CC). Adding the new MCC subgroup greatly enhances our ability to identify and reimburse hospitals for treating patients with high levels of severity. As Table N above shows, the 
                        ( print page 24707)
                        new subgroups also have significantly different resource requirements. The MCC subgroup contains patients with average charges almost twice as large as for those in the CC group ($44,219 compared to $24,115). In addition to resulting in improvements in the DRG system's recognition of severity of illness, we believe the proposed MS-DRGs are responsive to the public comments that were made on last year's IPPS proposed rule with respect to how we should undertake further DRG reform. In the FY 2007 IPPS final rule, we identified three major concerns in the public comments about our proposed adoption of CS DRGs: We received comments after the FY 2007 IPPS final rule suggesting that further adjustments are needed to the proposed DRG system. The commenters believed that the CS DRGs did not incorporate many of the changes to the DRG assignments that have been made over the year to the CMS DRGs. There was significant interest in the public comments in either revising the CS DRGs to reflect these changes or using the CMS DRGs at the starting point to better recognize severity. We believe that the proposed MS-DRGs discussed in this proposed rule are responsive to these suggestions. The proposed MS-DRGs use the CMS DRGs as the starting point for revising the DRGs to better recognize resource complexity and severity of illness. We are generally retaining all of the refinements and improvements that have been made to the base DRGs over the years that recognize the significant advancements in medical technology and changes to medical practice. At the same time, the proposed MS-DRGs greatly improve our ability to identify groups of patients with varying levels of severity. They retain all of the improvements made to the DRGs over the years, while providing a more equitable basis for hospital payment. We received many comments about the potential use of a proprietary DRG system. The comments about the CS DRGs raised compelling issues about the potential government use of a proprietary system including concerns about the availability, price, and transparency of the source code, logic and documentation of the DRG system. The commenters noted that CMS makes available these resources in the public domain for purchase through the National Technical Information Service at nominal fees to cover costs. The commenters urged CMS not to adopt a proprietary DRG system that would not be available on the same terms as the current CMS DRGs. There are no proprietary issues associated with the proposed MS-DRGs in this proposed rule. The proposed MS-DRGs would be available on the same terms as the current CMS DRGs through the National Technical Information Service. We also received other comments concerning the use of CS DRGs. The commenters stated that no alternatives to CS DRGs had been evaluated. The commenters suggested that alternative DRG systems can better recognize severity than the CS DRGs and should be evaluated before CMS decides which system to adopt. We currently have a contract with the RAND Corporation to evaluate several alternative DRG systems. We believe it is premature to propose adopting one of the systems as RAND has not yet completed its evaluation. However, we believe the proposed MS-DRGs should be part of this process and have asked RAND to evaluate the proposed MS-DRGs with other DRG products that have been submitted for review. Although we are proposing to adopt the MS-DRGs for FY 2008, this decision would not preclude us from adopting any of the systems being evaluated by RAND for FY 2009. As indicated above, we believe the proposed MS-DRGs offer significant improvements to the DRG system without many of the liabilities the public commenters identified with the CS DRGs. Thus, we believe the proposed MS-DRGs offer significant improvements in recognition of severity of illness and complexity of resources and are proposing to adopt them for FY 2008. However, we are continuing our evaluation of alternative DRG systems that can better recognize severity of illness and resource consumption and have submitted the proposed MS-DRGs to RAND for further evaluation. 5. Impact of the Proposed MS-DRGs Unlike the CS DRGs we proposed last year for FY 2008, the payment impacts from the MS-DRGs we are proposing to adopt this year would largely be redistributive within each base MS-DRG. Such a result occurs because we collapse the current CC/non-CC, age and other distinctions that exist in the CMS DRGs and redivide them based on MCCs, CCs, and non-CCs. Thus, within each proposed base MS-DRG, some cases will be paid more and some less, but the base MS-DRGs are retained so there is no redistribution between types of cases as would have occurred under the proposed CS DRGs. We encourage readers to review Table 5 in the Addendum to this proposed rule for a list of the proposed MS-DRGs and the proposed respective relative weight from the revisions we are proposing to better recognize severity of illness to better understand how payment for cases within each base MS-DRG will be affected. As indicated above, all of the severity DRG systems being evaluated by RAND can be expected to result in similar redistributions in case-mix among hospitals. The payment models used by RAND and CMS (and RTI as well) all assume static utilization. That is, payment impact models simulate the effects of a change in policy, assuming no change to Medicare utilization. Any system adopted to better recognize severity of illness with a budget neutrality constraint will result in case-mix changes that can be expected to benefit urban hospitals at the expense of rural hospitals. This impact occurs because patients treated in urban hospitals are generally more severely ill than patients in rural hospitals and the CMS DRGs are not currently recognizing the full extent of these differences. Similarly, there will be differential impacts among other categories of hospitals (for example, teaching, disproportionate share, large urban, and other urban hospitals) depending on the mix of cases that each hospital treats. The impact of the proposed MS-DRGs can be expected to have similar effects on case-mix as the DRG systems being analyzed by RAND. In addition, we believe that it is important to note that the MS-DRGs are proposed to be adopted for FY 2008 at the same time that we are phasing in cost weights. In the FY 2007 IPPS final rule, we adopted cost weights over a 3-year transition period in 
                        1/3
                         increments. Thus, the full impact of adopting cost weights will not be incorporated into IPPS payments until FY 2009. Nevertheless, we believe it is important to consider together the effect on case-mix of the fully phased-in cost weights and proposed MS-DRGs to get a complete understanding of how IPPS payment reforms would affect case-mix for different categories of hospitals from FY 2007 through FY 2009. For instance, using cost weights are estimated to increase payments to rural hospitals (see 71 FR 47917). In FY 2007, we are paying hospitals using a blend of 
                        1/3
                         cost and 
                        2/3
                         charge relative weights. In FY 2008, we will pay hospitals using a blend of 
                        2/3
                         cost and 
                        1/3
                         charge relative weights. In FY 2009, we will pay hospitals using 100 percent cost relative weights. Therefore, there will likely be some additional increases in payments to rural hospitals from the final year of the transition to fully implemented cost weights that are not 
                        ( print page 24708)
                        illustrated in the table in the impact section of this proposed rule. 6. Changes to Case-Mix Index (CMI) From the Proposed MS-DRGs After the 1983 implementation of the IPPS DRG classification system, CMS observed unanticipated growth in inpatient hospital case-mix (the average relative weight of all inpatient hospital cases), which we use as a proxy measurement for severity of illness. We had projected the rate of growth in case-mix for the period 1981 to 1984 to be 3.4 percent. The realized rate of growth during this period, which included the introduction of the IPPS, was 8.4 percent, a variance in excess of 1.6 percent per year. The unexpected growth in payments was due to increases in the hospital case-mix index (CMI) beyond the previously projected trend. Hospitals' CMI values measure the expected treatment cost of the mix of patients treated by a particular hospital. There are three factors that determine changes in a hospital's CMI: (a) Admitting and treating a more resource intensive patient-mix (due, for example, to technical changes that allow treatment of previously untreatable conditions and/or an aging population); (b) Providing services (such as higher cost surgical treatments, medical devices, and imaging services) on an inpatient basis that previously were more commonly furnished in an outpatient setting; and (c) Changes in documentation (more complete medical records) and coding practice (more accurate and complete coding of the information contained in the medical record). We note that changes in patient-mix and medical practice signal 
                        *real*
                         changes in underlying resource utilization and cost of treatment. While these changes may have occurred in response to incentives from IPPS policies, they represent real changes in resource needs. In contrast, changes in CMI as a result of improved documentation and coding do not represent real increases in underlying resource demands. For the implementation of the IPPS in 1983, improved documentation and coding were found to be the primary cause in the underprojection of CMI increases, accounting for as much as 2 percent in the annual rate of CMI growth observed post-PPS.[2] The Medicare Trustees Technical Review Panel [3]
                        
                         has previously determined the annual measured change in CMI for inpatient hospital services to oscillate around an underlying real trend of 1 percent annual growth. In 1991 the Medicare specific trend in real CMI growth was found in a then-HCFA funded study [4]
                        
                         to be within a range of 1 to 1.4 percent. In the annual study conducted by CMS, there has been no evidence to support a real case-mix increase in excess of the annually projected 1 percent upper bound in the period. MedPAC findings have echoed this with its recent study of real case-mix change finding growth rates for years 2002, 2003, and 2004 of 1 percent, 0.6 percent, and 0.4 percent, respectively.[5] We believe that adoption of the MS-RGs proposed in this proposed rule would create a risk of increased aggregate levels of payment as a result of increased documentation and coding. MedPAC notes that “refinements in DRG definitions have sometimes led to substantial unwarranted increase in payments to hospitals, reflecting more complete reporting of patients' diagnoses and procedures.” MedPAC further notes that “refinements to the DRG definitions and weights would substantially strengthen providers' incentives to accurately report patients' comorbidities and complications.” To address this issue, MedPAC recommended that the Secretary “project the likely effect of reporting improvements on total payments and make an offsetting adjustment to the national average base payment amounts.” [6] The Secretary has broad discretion under section 1886(d)(3)(A)(vi) of the Act to adjust the standardized amount so as to eliminate the effect of changes in coding or classification of discharges that do not reflect real changes in case-mix. While we modeled the changes to the DRG system and relative weights to ensure budget neutrality, we are concerned that the large increase in the number of DRGs will provide opportunities for hospitals to do more accurate documentation and coding of information contained in the medical record. Coding that has no effect on payment under the current CMS DRGs may result in a case being assigned to a higher paid DRG under the proposed MS-DRGs. Thus, more accurate and complete documentation and coding may occur because it will result in higher payments under the proposed MS-DRGs. We believe the potential for more accuate and complete documentation and coding will apply equally under the acute IPPS as well as under the LTCH PPS because the same DRGs are used for both payment systems. Thus, the analysis below will apply to both the IPPS and the LTCH PPS. CMS in the past has adjusted standardized amounts under the IRF PPS to account for case-mix increases due to improvements in documentation and coding. In 2004, RAND [7]
                        
                         published a technical report as part of the followup to the implementation of the IRF PPS. The initial weights used within the IRF PPS were based on a mix of CY 1999 and CY 1998 data. The study reviewed the changes between this base data set and the IRF PPS implementation year of 2002. The report found that the weight per discharge for IRFs had grown by 3.4 percent between the CY 1999 data set and the CY 2002 data set. In a detailed analysis of both statistical patterns in acute stay records and directly measured coding behaviors, RAND found that the level of case-mix increase associated with documentation and coding-induced changes in the transition year ranged between 1.9 and 5.8 percent, with the upper end of the estimate associated with real declines in resource use. (We note that RAND revised its report in late 2005 to reflect an upper bound of 5.9 percent, instead of the 5.8 percent that we reported in the FY 2006 IRF PPS proposed and final rules.) We used the results of this analysis to justify a 1.9 percent adjustment to payment rates for IRFs in FY 2006 (70 FR 47904) and a 2.6 percent adjustment to payment rates for IRFs in FY 2007 (71 FR 48370), for a combined total adjustment of 4.5 percent. The implementation year was marked by the transitioning of hospitals to the IRF PPS payment based on cost reports beginning January 1, 2002, and staggered to October 1, 2002. A combination of increased familiarity with the system by providers and the staggered transition could mean that documentation and coding-induced case-mix change continued as hospitals experienced ongoing changes in the early years of the IRF PPS and as the 
                        ( print page 24709)
                        incentives within the system were more widely recognized. We also recognize that significant changes in IRF patient populations may be occurring as a result of recent regulatory changes, such as the phase-in of the 75 percent rule compliance percentage. We intend to continue analyzing changes in coding and case-mix closely, using the most current available data, as part of our ongoing monitoring of the IRF PPS and, based on this analysis, we intend to propose additional payment refinements for IRFs in the future as the analysis indicates such adjustments are warranted. Furthermore, as part of our analysis of this issue, we considered the recent experience of the State of Maryland with adopting the APR DRG system. Maryland introduced APR DRGs for payment for three teaching hospitals in 2000. Between State fiscal years (SFYs) 2001 and 2005,[8]
                        
                         the remaining hospitals continued to be paid using modified CMS DRGs. In June 2004, the remaining hospitals were notified that Maryland would expand the use of APR DRGs throughout its all payer charge-per-case system beginning in July 2005. Hospitals in Maryland improved coding and documentation in response to the adoption of APR DRGs. As a result of this improved documentation and coding, reported CMI increased at a greater rate than real CMI. Given the similarity between coding incentives using the APR DRGs in Maryland and the MS-DRGs that are being proposed for Medicare, we analyzed Maryland data to develop an adjustment for improved documentation and coding. For the Maryland analysis, we assume that, in SFY 2005, those hospitals not already being paid under the APR DRG system began acting as if the transition to the new DRG logic had already taken place. This assumption is supported by the following facts: (a) Maryland hospitals were reporting to the Health Services and Cost Review Commission (HSCRC), Maryland's governing body of its all-payer ratesetting system) using the APR DRG GROUPER in 2005; (b) hospitals were provided training in coding under the APR DRG GROUPER; (c) hospitals had access to reports based on APR DRG logic; and (d) hospitals were given large amounts of feedback as to their performance under the GROUPER by the HSCRC relative to peer hospitals. The incentives for Maryland hospitals are to code as completely and accurately as possible because, beginning in July 2005, all Maryland hospitals were paid using APR DRGs. SFY 2005 was an important year in Maryland, as it marked the beginning of the 2-year period of transition after which a hospital's revenues were reduced if coding was not as complete as a peer hospital. Under the current CMS DRGs, each secondary diagnosis code is recognized as either a CC or non-CC. Hospitals in Maryland and nationally for Medicare only needed to code one secondary diagnosis as a CC when paid using CMS DRGs for the patient to be assigned to a higher weighted DRG split based on the presence or absence of a CC. Under the APR DRGs, each secondary diagnosis is designated as minor, moderate, major, or extreme. Under the proposed MS-DRGs, each secondary diagnosis is designated as a non-CC, CC, or MCC. Hospitals in Maryland have incentives under the APR DRGs to code until a case is assigned to the highest of the four severity levels within a base DRG. Under the proposed MS-DRGs, hospitals will have incentives to code until a case is assigned to one of up to three severity levels within a base DRG. Although the APR DRGs and the proposed MS-DRGs may be different, we believe that hospitals have the same incentive under both systems to code as completely as possible. For this reason, we believe that the Maryland experience is a reasonable basis for projecting behavioral changes in the wider national hospital population for the first 2 years of the MS-DRGs. We believe the analysis presented below provides a reasonable analysis of the potential growth in CMI due to improved documentation and coding. In addition to the similarity between coding incentives under the proposed MS-DRGs and the APR DRGs, we note that Maryland is an all-payer State; therefore, hospitals are paid by all third party payers—not just the State's Medicaid program—using the APR DRGs. Coding has been very important for each hospital's overall revenue for many years, and the incentives are uniform across all third party payers. The transition to APR DRGs was known well in advance of the actual date and, as stated above, hospitals were provided training in coding under the APR DRGs. It is reasonable to expect that hospitals' experience with improved documentation and coding will occur over a period of at least 2 years. Thus, the experience in Maryland may be similar to expectations for case-mix growth for the nation as a whole. Finally, in reviewing the results from Maryland, we note that three large teaching hospitals began using APR DRGs prior to SFY 2005. These facilities generally treat a wider variety of patients with higher acuity that gives them a greater potential for increasing coding under the APR DRG system than other hospitals throughout Maryland. Because these hospitals were paid using the APR DRGs earlier than other Maryland hospitals, we believe data for them need to be analyzed from an earlier time period. However, based on the consultations with the HSCRC, we believe there were special issues with one of these hospitals that may have made its case-mix growth during the early years of the transition to the APR DRGs atypical of the other teaching hospitals.[9]
                        
                         Therefore, we did not separately analyze the data for this hospital from the earlier time period and, as stated below, included its data with the rest of Maryland hospitals. As part of its contract with CMS, 3M Health Information Systems reviewed the Maryland data in the context of our proposed changes to adopt MS-DRGs. 3M grouped Medicare cases in Maryland through both the CMS DRGs Version 24.0 and the MS-DRGs that we are proposing to adopt for FY 2008. At our request, 3M deleted two of the three early transition hospitals from the data. It compared the results of the observed growth in case-mix from these data to the same process applied to Medicare data, excluding Maryland hospitals. The MedPAR data file for Federal fiscal year (FFY) 2006 (October 2005 through September 2006) was used to create relative weights for both CMS DRG Version 24.0 and the proposed MS-DRGs. The MedPAR data file contained 12,794,280 records. In constructing the weights, the following edits were used: Cases with zero covered charges or length of stay were excluded.
                    Cases with length of stay greater than 2 years were excluded.
                    Only hospitals contained in the impact file for the FY 2007 IPPS final rule were included.( print page 24710) The latter criterion excluded providers reimbursed outside of the IPPS, including Maryland hospitals, from the weight calculation. 3M employed standardized charge-based relative weights developed in accordance with the CMS methodology. Cost-based weights were not used and no adjustment to the charge weights was made for application of CMS transfer and postacute care transfer payment policy. 3M further grouped 2 years of MedPAR data from FY 2004 and FY 2005, using CMS DRG Version 24.0 and the proposed MS-DRGs for hospitals nationally. Using 2 years of MedPAR data with one version of each DRG system further required 3M to make adjustments to the data to reflect revisions to ICD-9-CM codes that are made each year. MedPAR data for Maryland IPPS acute care providers within the IPPS data set were similarly assigned to the proposed MS-DRGs and CMS DRGs for FYs 2004 through 2006. Each Maryland record, exclusive of the two early transition teaching hospitals for the 3 observed years (SFY 2004 to SFY 2006), was assigned to a proposed MS-DRG based on the ICD-9-CM codes the hospital submitted. The same results were obtained from data at the national level using the proposed MS-DRGs. Further, we obtained data from the HSCRC showing the weighted average increase in case-mix for calendar years 2001 to 2003 for the two large academic medical centers that began an early transition to the APR DRGs. In addition, we also obtained case-mix increases under the CMS DRGs for FYs 2004 through 2006. The Medicare Actuary examined the data below: Table Q.—Maryland and National Data Used for Case-Mix Adjustment Analysis
FY 2004 to 2005
FY 2005 to 2006
FY 2004 to 2006Rest of Maryland MS-DRG CMI Δ
2.30%
2.57%
4.93%CY 2000 to FY 2003Early Transition Hospitals
4.4
6.7
11.4National MS-DRG CMI Δ
0.47
2.65
3.13National CMS DRG CMI Δ
−0.04
1.20
1.16Blend of MS-DRG & CMS DRG Δ using 0.47 Percent for 2005 and 1.2 Percent for 2006


1.68Difference between Maryland Early Transition Hospitals and National Data


9.58Difference between Rest of Maryland and National Data


3.20Medicare Actuary Estimate (75%/25%) between Early Transition and Rest of Maryland


4.8
 The data above show that case-mix for hospitals increased by 4.93 percent from SFYs 2004 to 2006, during which Maryland adopted the APR DRGs for most hospitals. Case-mix for the two large teaching hospitals that were paid using the APR DRGs earlier than other hospitals in the State increased by 11.4 percent from SFYs 2001 to 2003. The weighted average increase in Maryland from these two categories of hospitals is 5.58 percent. Case-mix using the proposed MS-DRGs would have increased 0.47 percent in FY 2005 and 2.65 percent in FY 2006. Nationally, Medicare case-mix using the CMS DRGs decreased by 0.04 percent in FY 2005 and increased by 1.2 percent in FY 2006. The Actuary calculated a Medicare case-mix increase nationally over 2 years using a blend of these data from proposed MS-DRGs for FY 2005 and national Medicare data for FY 2006 from the CMS DRGs. The Actuary did not use either the −0.04 percent for the CMS DRGs or the 2.65 percent for the proposed MS-DRGs to create this blended case-mix because these figures appeared atypical to national trends. Therefore, the Actuary dropped one atypically high and low number from each of the 2 years of data and calculated an average increase of 1.68 percent from FY 2004 to FY 2006. These data demonstrate that the measure of average CMI for Medicare cases is growing more rapidly within Maryland than nationally. Case-mix for the Maryland teaching hospitals and the rest of Maryland increased 9.58 percent and 3.20 percent more, respectively, than the national average over 2 years, suggesting that improved documentation and coding lead to perceived, but not real, changes in case-mix. The Actuary noted that the case-mix increase in Maryland for two large teaching hospitals over a 2-year period was much higher in the early years of the APR DRGs than other Maryland hospitals (11.4 percent compared to 4.93 percent for the rest of Maryland). Further, teaching hospitals generally treat cases with higher acuity than other hospitals and have more opportunity to improve coding and documentation to increase case-mix than other hospitals. Teaching hospitals also represent a higher proportion of national Medicare data than they do of the data in Maryland. The two early transition teaching hospitals in Maryland account for approximately 10 percent of the Medicare discharges in Maryland. Nationally, teaching hospitals account for approximately 50 percent of Medicare discharges. Therefore, the Actuary believes that the teaching hospitals should be given a higher weight in the national data than they represent in Maryland. However, like other hospitals, teaching hospitals vary in size and patient-mix and not all have the same opportunity to improve documentation and coding. Therefore, we believe the weight given to teaching hospitals should be higher than the 10 percent for the two early transition hospitals in Maryland but lower than the 50 percent of discharges that they account for in Maryland. The Actuary gave a weight of 25 percent for teaching hospitals and 75 percent for the rest of Maryland to the excess growth in case-mix over the national average and estimates that an adjustment of 4.8 percent will be necessary to maintain budget neutrality for the transition to the MS-DRGs. This analyis reflects our current estimate of the necessary adjustment needed to maintain budget neutrality for improvements in documentation and coding that lead to increases in case-mix. Consistent with the statute, we will compare the actual increase in case-mix due to documentation and coding to our projection once we have actual data to revise the Actuary's estimate and the adjustment we make to the standardized amounts. Based on the Actuary's analysis, using the Secretary's authority under section 1886(d)(3)(A)(vi) of the Act to adjust the standardized amount to eliminate the effect of changes in coding or classification of discharges that do not reflect real changes in case-mix, we are proposing to reduce the IPPS 
                        ( print page 24711)
                        standardized amounts by 2.4 percent each year for FY 2008 and FY 2009. We are considering proposing a 4.8 percent adjustment for FY 2008. However, we believe it would be appropriate to provide a transition because we would be making a significant adjustment to the standardized amounts. We are interested in public comments on whether we should apply the proposed adjustment in a single year, over 2 years, or in different increments than 
                        1/2
                         of the adjustment each year. Section 1886(d)(3)(A)(vi) of the Act further gives the Secretary authority to revisit adjustments to the standardized amounts for changes in coding or classification of discharges that were based on estimates in a future year. Consistent with the statute, we will compare the actual increase in case-mix due to documentation and coding to our projection once we have actual data for FY 2008 and FY 2009 for the FY 2010 and FY 2011 IPPS rules. At that time, if necessary, we may make a further adjustment to the standardized amounts to account for the difference between our projection and actual data. Under section 123(a)(1) of Pub. L. 105-33, as amended by section 307(b) of Pub. L. 106-554, we are also proposing to adjust the DRG relative weights that are used for the LTCH PPS by −2.4 percent (0.976) in FYs 2008 and 2009 to account for the anticipated increase in case mix from improved documentation and coding. This proposed budget neutrality adjustment is necessary to ensure that estimated aggregate LTCH PPS payments would be neither greater than nor less than the estimated aggregate LTCH PPS payments that would have been made without the proposed LTC-DRG reclassification and update of the relative weights. As discussed earlier with regards to the IPPS, we have estimated that a 2.4 percent adjustment is needed to maintain budget neutrality. We believe an adjustment of at least 2.4 percent for both FYs 2008 and 2009 is appropriate under the LTCH PPS because LTCHs have an average inpatient length of stay greater than 25 days and due to the comorbidities of these patients, LTCHs will have a significantly increased opportunity to better code for these paitents under the proposed MS-LTC-DRG system. In the LTCH proposed rule (72 FR 4793) for rate year (RY) 2008, we proposed to update the LTCH standardized amounts by 0.71 percent. The proposed changes to the LTCH standardized amounts will be effective on July 1. However, the proposed changes to adopt MS-LTC-DRGs for LTCHs would not be effective until October 1 if finalized. Because changes to the LTCH standardized amounts for RY 2008 are already being set through a separate rulemaking process and are effective on July 1 instead of October 1, we decided that the adjustment for increases in case mix due to improvements and documentation and coding should be applied to the LTCH relative weights rather than the standardized amounts. 7. Effect of the Proposed MS-DRGs on the Outlier Threshold To qualify for outlier payments, a case must have costs greater than Medicare's payment rate for the case plus a “fixed loss” or cost threshold. The statute requires that the Secretary set the cost threshold so that outlier payments for any year are projected to be not less than 5 percent or more than 6 percent of total operating DRG payments plus outlier payments. The Secretary is required by statute to reduce the average standardized amount by a factor to account for the estimated proportion of total DRG payments made to outlier cases. Historically, the Secretary has set the cost threshold so that 5.1 percent of estimated IPPS payments are paid as outliers. The FY 2007 cost outlier threshold is $24,485. Therefore, for any given case, a hospital's charge adjusted to cost by its hospital-specific CCR must exceed Medicare's DRG payment by $24,485 for the case to receive cost outlier payments. Adoption of the proposed MS-DRGs will have an effect on calculation of the outlier threshold. For this proposed rule, we analyzed how the outlier threshold would be affected by adopting the proposed MS-DRGs. Using FY 2005 MedPAR data, we have simulated the effect of the proposed MS-DRGs on the outlier threshold. By increasing the number of DRGs from 538 to 745 to better recognize severity of illness, the proposed MS-DRGs would be providing increased payment that better recognizes complexity and severity of illness for cases that are currently paid as outliers. That is, many cases that are high-cost outlier cases under the current CMS DRG system would be paid using an MCC DRG under the proposed MS-DRGs and could potentially be paid as nonoutlier cases. For this reason, we expected the proposed FY 2008 outlier threshold to decline from its FY 2007 level of $24,485. We are proposing an FY 2008 outlier threshold of $23,015. In section II.A.4. of the Addendum to this proposed rule, we provide a more detailed explanation of how we determined the proposed FY 2008 cost outlier threshold. 8. Effect of the Proposed MS-DRGs on the Postacute Care Transfer Policy Existing regulations at § 412.4(a) define discharges under the IPPS as situations in which a patient is formally released from an acute care hospital or dies in the hospital. Section 412.4(b) defines transfers from one acute care hospital to another. Section 412.4(c) establishes the conditions under which we consider a discharge to be a transfer for purposes of our postacute care transfer policy. In transfer situations, each transferring hospital is paid a per diem rate for each day of the stay, not to exceed the full DRG payment that would have been made if the patient had been discharged without being transferred. The per diem rate paid to a transferring hospital is calculated by dividing the full DRG payment by the geometric mean length of stay for the DRG. Based on an analysis that showed that the first day of hospitalization is the most expensive (60 FR 45804), our policy provides for payment that is double the per diem amount for the first day (§ 412.4(f)(1)). Transfer cases are also eligible for outlier payments. The outlier threshold for transfer cases is equal to the fixed-loss outlier threshold for nontransfer cases, divided by the geometric mean length of stay for the DRG, multiplied by the length of stay for the case, plus one day. The purpose of the IPPS postacute care transfer payment policy is to avoid providing an incentive for a hospital to transfer patients to another hospital early in the patients' stay in order to minimize costs while still receiving the full DRG payment. The transfer policy adjusts the payments to approximate the reduced costs of transfer cases. Beginning with FY 2006 IPPS, the regulations at § 412.4 specified that, effective October 1, 2005, we make a DRG subject to the postacute care transfer policy if, based on Version 23.0 of the DRG Definitions Manual (FY 2006), using data from the March 2005 update of FY 2004 MedPAR file, the DRG meets the following criteria: The DRG had a geometric mean length of stay of at least 3 days;
                    The DRG had at least 2,050 postacute care transfer cases; and
                    At least 5.5 percent of the cases in the DRG were discharged to postacute care prior to the geometric mean length of stay for the DRG. In addition, if the DRG was one of a paired set of DRGs based on the presence or absence of a CC or major cardiovascular condition (MCV), both paired DRGs would be included if either one met the three criteria above. 
                        ( print page 24712) If a DRG met the above criteria based on the Version 23.0 DRG Definitions Manual and FY 2004 MedPAR data, we made the DRG subject to the postacute care transfer policy. We noted in the FY 2006 final rule that we would not revise the list of DRGs subject to the postacute care transfer policy annually unless we make a change to a specific CMS DRG. We established this policy to promote certainty and stability in the postacute care transfer payment policy. Annual reviews of the list of CMS DRGs subject to the policy would likely lead to great volatility in the payment methodology with certain DRGs qualifying for the policy in one year, deleted the next year, only to be reinstated the following year. However, we noted that, over time, as treatment practices change, it was possible that some CMS DRGs that qualified for the policy will no longer be discharged with great frequency to postacute care. Similarly, we explained that there may be other CMS DRGs that at that time had a low rate of discharges to postacute care, but which might have very high rates in the future. The regulations at § 412.4 further specify that if a DRG did not exist in Version 23.0 of the DRG Definitions Manual or a DRG included in Version 23.0 of the DRG Definitions Manual is revised, the DRG will be a qualifying DRG if it meets the following criteria based on the version of the DRG Definitions Manual in use when the new or revised DRG first became effective, using the most recent complete year of MedPAR data: The total number of discharges to postacute care in the DRG must equal or exceed the 55th percentile for all DRGs; and
                    The proportion of short-stay discharges to postacute care to total discharges in the DRG exceeds the 55th percentile for all DRGs. A short-stay discharge is a discharge before the geometric mean length of stay for the DRG. A DRG also is a qualifying DRG if it is paired with another DRG based on the presence or absence of a CC or MCV that meets either of the above two criteria. The MS-DRGs that we are proposing to adopt for FY 2008 are a significant revision to the current CMS DRG system. Because the proposed new MS-DRGs are not reflected in Version 23.0 of the DRG Definitions Manual, consistent with § 412.4, we will need to recalculate the 55th percentile thresholds in order to determine which proposed MS-DRGs, if adopted, would be subject to the postacute care transfer policy. Further, under the proposed MS-DRGs, the subdivisions within the base DRGs will be different than those under the current CMS DRGs. Unlike the current CMS DRGs, the proposed MS-DRGs are not divided based on the presence or absence of a CC or MCV. Rather, the proposed MS-DRGs have up to three subdivisions based on: (1) The presence of a MCC; (2) the presence a CC; or (3) the absence of either an MCC or CC. Consistent with our existing policy under which both DRGs in a CC/non-CC pair are qualifying DRGs if one of the pair qualifies, we are proposing that each MS-DRG that shares a base MS-DRG would be a qualifying DRG if one of the MS-DRGs that shares the base DRG qualifies. We are proposing to revise § 412.4(d)(3)(ii) to codify this proposed policy. Similarly, we believe that the proposed changes to adopt MS-DRGs also necessitate a revision to one of the criteria used in § 412.4(f)(5) of the regulations to determine whether a DRG meets the criteria for payment under the “special payment methodology.” Under the special payment methodology, a case subject to the special payment methodology that is transferred early to a postacute care setting will be paid 50 percent of the total IPPS payment plus the average per diem for the first day of the stay. Fifty percent of the per diem amount will be paid for each subsequent day of the stay, up to the full MS-DRG payment amount. A CMS DRG is currently subject to the special payment methodology if it meets the criteria of § 412.4(f)(5). Section 412.4(f)(5)(iv) specifies that if a DRG meets the criteria specified under § 412.4(f)(5)(i) through (f)(5)(iii), any DRG that is paired with it based on the presence or absence of a CC or MCV is also subject to the special payment methodology. Given that this criterion would no longer be applicable under the proposed MS-DRGs, we are proposing to add a new § 412.4(f)(6) that includes a DRG in the special payment methodology if it is part of a CC/non-CC MCV/non-MCV pair. We are proposing to update this criterion so that it conforms to the proposed changes to adopt MS-DRGs for FY 2008. The proposed revision would make an MS-DRG subject to the special payment methodology if it shares a base MS-DRG with an MS-DRG that meets the criteria for receiving the special payment methodology. Section 412.4(f)(3) states that the postacute care transfer policy does not apply to CMS DRG 385 for newborns who die or are transferred. We are proposing to make a conforming change to this paragraph to reflect that this CMS DRG would become MS-DRG 789 (Neonates, Died or Transferred to Another Acute Care Facility) under our proposed DRG changes for FY 2008. These revisions do not constitute a change to the application of the postacute care transfer policy. Therefore, any savings attributed to the postacute care transfer policy would be unchanged as a result of adopting the MS-DRGs. Consistent with section 1886(d)(4)(C)(iii) of the Act, aggregate payments from adoption of the proposed MS-DRGs cannot be greater or less than those that would have been made had we not proposed to make any DRG changes. We are also proposing technical changes to §§ 412.4(f)(5)(i) and (f)(5)(iv) to correct a cross-reference and a typographical error, respectively. E. Refinement of the Relative Weight Calculation (If you choose to comment on issues in this section, please include the caption “DRGs: Relative Weight Calculations” at the beginning of your comment.) In the FY 2007 IPPS final rule (71 FR 47882), effective for FY 2007, we began to implement significant revisions to Medicare's inpatient hospital rates by basing the relative weights on hospitals' estimated costs rather than on charges. This reform was one of several measured steps to improve the accuracy of Medicare's payment for inpatient stays that include using costs rather than charges to set the relative weights and making refinements to the current DRGs so they better account for the severity of the patient's condition. Prior to FY 2007, we used hospital charges as a proxy for hospital resource use in setting the relative weights. Both MedPAC and CMS have found that the limitations of charges as a measure of resource use include the fact that hospitals cross-subsidize departmental services in many different ways that bear little relation to cost, frequently applying a lower charge markup to routine and special care services than to ancillary services. In MedPAC's 2005 Report to the Congress on Physician-Owned Specialty Hospitals, MedPAC found that hospitals charge much more than their costs for some types of services (such as operating room time, imaging services and supplies) than others (such as room and board and routine nursing care).[10]
                        
                         Our analysis of the MedPAC report in the FY 2007 IPPS proposed rule (71 FR 24006) produced consistent findings. In the FY 2007 IPPS proposed rule, we proposed to implement cost-based weights incorporating aspects of a 
                        ( print page 24713)
                        methodology recommended by MedPAC, which we called the hospital-specific relative value cost center (HSRVcc) methodology. MedPAC indicated that an HSRVcc methodology would reduce the effect of cost differences among hospitals that may be present in the national relative weights due to differences in case-mix adjusted costs. After studying Medicare cost report data, we proposed to establish 10 national cost center categories from which to compute 10 national CCRs based upon broad hospital accounting definitions. We made several important changes to the HSRVcc methodology that MedPAC recommended using in its March 2005 Report to the Congress on Physician-Owned Specialty Hospitals. We refer readers to the FY 2007 IPPS proposed rule (71 FR 24007 through 24011) for an explanation and our reasons for the modification to MedPAC's methodology. In its public comments on the FY 2007 IPPS proposed rule, MedPAC generally agreed with the adaptations we made to its methodology, with the exception of expanding the number of distinct hospital department CCRs being used from 10 to 13 and basing the CCRs on Medicare-specific costs and charges.[11] We did not finalize the HSRVcc methodology for FY 2007 because of concerns raised in the public comments on the FY 2007 IPPS proposed rule (71 FR 47882 through 47898). Rather, we adopted a cost-weighting methodology without the hospital-specific relative weight feature. We also expanded the number of distinct hospital departments with CCRs from 10 to 13. We indicated our intent to study whether to adopt the HSRVcc methodology after we had the opportunity to further consider some of the issues raised in the public comments. In the interim, we adopted a cost-weighting methodology over a 3-year transition period, substantially mitigating the redistributive payment impacts illustrated in the proposed rule, while we engaged a contractor to assist us with evaluating the HSRVcc methodology. Some public commenters raised concerns about potential bias in cost weights due to “charge compression,” which is the practice of applying a lower percentage markup to higher cost services and a higher percentage markup to lower cost services. These commenters were concerned that our proposed weighting methodology may undervalue high cost items and overvalue low cost items if a single CCR is applied to items of widely varying costs in the same cost center. The commenters suggested that the HSRVcc methodology would exacerbate the effect of charge compression on the final relative weights. One of the commenters suggested an analytic technique of using regression analysis to identify adjustments that could be made to the CCRs to better account for charge compression. We indicated our interest in researching whether a rigorous model should allow an adjustment for charge compression to the extent that it exists. We engaged a contractor, RTI International (RTI), to study several issues with respect to the cost weights, including charge compression, and to review the statistical model provided to us by the commenter for adjusting the weights to account for it. We discuss RTI's findings in detail below. Commenters also suggested that the cost report data used in the cost methodology are outdated, not consistent across hospitals, and do not account for the costs of newer technologies such as medical devices. However, the relationship between costs and charges (not costs alone) is the important variable in setting the relative weights under this new system. Older cost reports also do not include the hospital's higher charges for these same medical devices. Therefore, it cannot be known whether the CCR for the more recent technologies will differ from those we are using to set the relative weights. The use of national average cost center CCRs rather than hospital-specific CCRs may mitigate potential inconsistencies in hospital cost reporting. Nevertheless, we agree that it is important to review how hospitals report costs and charges on the cost reports and on the Medicare claims and asked RTI to further study this issue as well. In summary, we proposed to adopt HSRVcc relative weights for FY 2007 using national average CCRs for 10 hospital departments. Based on public comments concerned about charge compression and the accuracy of cost reporting, we decided not to finalize the HSRVcc methodology, but adopted costs weights without the hospital-specific feature. In response to comments from MedPAC, we expanded the number of hospital cost centers used in calculating the national CCRs from 10 to 13. Finally, we decided to implement the cost-based weighting methodology gradually, by blending the cost and charge weights over a 3-year transition period beginning with FY 2007, while we further studied many of the issues raised in the public comments. We refer readers to the FY 2007 IPPS final rule (71 FR 47882) for more details on our final policy for calculating the cost-based DRG relative weights. 1. Summary of RTI's Report on Charge Compression In August 2006, we awarded a contract to RTI to study the effects of charge compression in calculating DRG relative weights. The purpose of the study was to develop more accurate estimates of the costs of Medicare inpatient hospital stays that can be used in calculating the relative weights per DRG. RTI was asked to assess the potential for bias in relative weights due to CCR differences within the 13 CCR groups used in calculating the cost-based DRG relative weights and to develop an analysis plan that explored alternative methods of estimating costs, with the objective of better aligning the charges and costs used in those calculations. RTI was asked to consider methods of reducing the variation in CCRs across services within cost centers by: Modifying existing cost centers and/or creating new costs centers.
                    Using statistical methods, such as the regression adjustment for charge compression. Some commenters on the FY 2007 IPPS proposed rule suggested that we use a regression adjustment to account for charge compression. As part of its contract, RTI convened a Technical Expert Panel composed of individuals representing academic institutions, hospital associations, medical device manufacturers, and MedPAC. The members of the panel met on October 27, 2006, to evaluate RTI's analytic plan, to identify other areas that are likely to be affected by compression or aggregation problems, and to propose suggestions for adjustments for charge compression. We posted RTI's draft interim report on the CMS Web site in March 2007. For more information, interested individuals can view RTI's report at the following Web site: 
                        *http://cms.hhs.gov/​reports/​downloads/​Dalton.pdf.* As the first step in its analysis, RTI compared the reported Medicare program charge amounts from the cost reports to the total Medicare charges summed across all claims filed by providers. Using cost and charge data from the most recent available Medicare cost reports and inpatient claims from IPPS hospitals, RTI was charged with performing an analysis to determine how well the MedPAR charges matched the cost report charges used to compute CCRs. The accuracy of the DRG cost estimates is directly affected by this match because MedPAR charges are multiplied by CCRs to estimate cost. RTI found consistent matching of charges 
                        ( print page 24714)
                        from the Medicare cost report to charges grouped in the MedPAR claims for some cost centers but there appeared to be problems with others. For example, RTI found that the data between the cost report and the claims matched well for total discharges, days, covered charges, nursing unit charges, pharmacy, and laboratory. However, there appeared to be inconsistent reporting between the cost reports and the claims data for charges in several ancillary departments (medical supplies, operating room, cardiology, and radiology). For example, the data suggested that hospitals often include costs and charges for devices and other medical supplies within the Medicare cost report cost centers for Operating Room, Radiology or Cardiology instead of the Medical Supplies cost center. RTI found that some charge mismatching results from the way in which charges are grouped in the MedPAR file. Examples include the intermediate care nursing charges being grouped with intensive care nursing charges, and electroencephalography (EEG) charges being grouped with laboratory charges. RTI suggested that reclassifying intermediate care charges from the intensive care unit to the routine cost center could address the former problem. As the second step in its analysis, RTI reviewed the existing cost centers that are combined into the 13 groups used in calculating the national average CCRs. RTI identified CCRs with potential aggregation problems and considered whether separating the charge groups could result in more accurate cost conversion at the DRG level. The analysis led RTI to calculate separate CCRs for Emergency Room and Blood and Blood Administration, both of which had been included in “Other Services” in FY 2007. During this second step, RTI noted that a variation of charge compression is also present in inpatient nursing services because most patients are charged a single type of accommodation rate per day that is linked to the type of nursing unit (routine, intermediate, or intensive), but not to the hours of nursing services given to individual patients. Unlike the situation with charge compression in ancillary service areas, there are virtually no detailed charge codes that can distinguish patient nursing care use. Therefore, any potential bias cannot be empirically evaluated or adjustments made without additional data. Next, RTI examined individual revenue codes within the cost centers and used regression analysis to determine whether certain revenue codes in the same cost center had significantly different markup rates. Those revenue codes include devices, prosthetics, implants within the Medical Supplies cost center, IV Solutions within the Drugs cost center, CT scanning and MRI within the Radiology cost center, Cardiac Catheterization within the Cardiology cost center, and Intermediate Care Units within the Routine Nursing Care cost center. Devices, prosthetics, and implants within the Medical Supplies cost center have a lower markup and, as a result, a higher CCR than the remainder of the medical supplies group according to RTI's analysis. Within the Drugs CCR, IV Solutions have a much higher markup and much lower CCR than the other drugs included in the category. Within the Radiology CCR, CT scanning and MRI have higher markups and lower CCRs than the remaining radiology services. RTI's results for Cardiac Catheterization and Intermediate Care Units were ambiguous due to data problems. RTI's analysis also determined the impact of the disaggregated CCRs on the relative weights. Differences in CCRs alone do not necessarily alter the DRG relative weights. The impact on the relative weights is the result of the interaction of CCR differences and DRG differences in the proportions of the services with different CCRs. In FY 2007, we calculated relative weights using CCRs for 13 hospital departments. The RTI analysis suggests expanding the number of distinct hospital department CCRs from 13 to 19. Of the additional six CCRs, two would result from separating the Emergency Department and Blood (Products and Administration) from the residual “Other Services” category. Four additional CCRs would result from applying a regression method similar to a method suggested in last year's public comments to three existing categories: supplies, radiology, and drugs. This method, as adapted by RTI, used detailed coding of charges to disaggregate hospital cost centers and derive separate, predicted alternative CCRs for the disaggregated services. RTI's analysis suggests splitting Medical Supplies into one CCR for devices, implants, and prosthetics and one CCR for Other Supplies; splitting Radiology into one CCR for MRIs, one CCR for CT scans, and one CCR for Other Radiology; and splitting Drugs into one CCR for IV Solutions and one CCR for Other Drugs. RTI's draft report provides the potential impacts of adopting these changes to the CCRs. We note that RTI's analysis was based on Version 24.0 of the CMS DRGs. Because the proposed MS-DRGs were under development for the FY 2008 IPPS proposed rule, they were unavailable to RTI for their analysis. The results of RTI's analysis may be different if applied to the proposed MS-DRGs. However, it seems reasonable to believe that the impact of RTI's suggestions will be consistent using Version 24.0 of the CMS DRGs and the proposed MS-DRGs, as both systems generally use the same base DRGs while applying different subdivisions to recognize severity of illness. Of all the adjusted CCRs, the largest impact on weights came from accounting for charge compression in medical supplies for devices and implants. The impact on weights from accounting for CCR differences among drugs was modest. The impact of splitting MRI and CT scanning from the radiology CCR was greater than the impact of modifying the Drugs CCRs, but less than the impact of splitting the medical supplies group. Separating Emergency Department and Blood Products and Administration from the “Other Services” category would raise the CCR for other services in the group. RTI found that disaggregating cost centers may have a mitigating effect on the impact of transitioning from charge-based weights to cost-based weights. That is, the changes being suggested by RTI will generally offset (fully or more than fully in some cases or in part in other cases) the impacts of fully implemented cost weights that we are adopting over the FY 2007-FY 2009 transition period. Thus, RTI's analysis suggests that expanding the number of distinct hospital department CCRs used to calculate cost weights from 13 to 19 will generally increase the relative weights for surgical DRGs and decrease them for the medical DRGs compared to the fully implemented cost-based weights to which we began transitioning in FY 2007. 2. RTI Recommendations In its report, RTI provides recommendations for the short term, medium term, and long term, to mitigate aggregation bias in the calculation of relative weights. We summarize RTI's recommendations below and respond to each of them. a. Short-Term Recommendations Most of RTI's short-term recommendations have already been described above. The most immediate changes that RTI recommends implementing include expanding from 13 distinct hospital department CCRs to 19 by: 
                        ( print page 24715) Disaggregating “Emergency Room” and “Blood and Blood Products” from the “Other Services” cost center;
                    Establishing regression-based estimates as a temporary or permanent method for disaggregating the Medical Supplies, Drugs, and Radiology cost centers; and
                    Reclassifying intermediate care charges from the intensive care unit cost center to the routine cost center. We believe these recommendations have significant potential to address issues of charge compression and potential mismatches between how costs and charges are reported in the cost reports and on the Medicare claims. RTI's recommendations show significant promise in the short term for addressing issues raised in the public comments on the cost weights in the FY 2007 IPPS proposed rule. However, in the time available for the development of this proposed rule, we have been unable to investigate how RTI's recommended changes may interact with other potential changes to the DRGs and to the method of calculating the DRG relative weights. As we noted above, RTI's analysis was done on the Version 24.0 of the CMS DRGs and not the MS-DRGs we are proposing for FY 2008. For this proposed rule, we were not able to examine the combined impacts of the proposed MS-DRGs and RTI's recommendations. In addition, we believe it is also important to consider that, in the FY 2007 IPPS final rule (71 FR 47897), we anticipated undertaking further analysis of the HSRVcc methodology over the next year in conjunction with the research we were to do on charge compression. Analysis of the HSRVcc methodology will be part of the second phase of the RAND study of alternative DRG systems to be completed by September 1, 2007, that has not been completed in time for this proposed rule. As a result, we have also been unable to consider the effects of the HSRVcc methodology together with the proposed MS-DRGs and RTI's recommendations. Finally, we note that in order to complete the analysis in time for this proposed rule, RTI's study used only inpatient hospital claims. However, hospital ancillary departments typically include both inpatient and outpatient services within the same department and only a single CCR covering both inpatient and outpatient services can be calculated from Medicare cost reports. Although we believe that applying the regression method used by RTI to only inpatient services is unlikely to have had much impact for the adjustments recommended by RTI, the preferred approach would be to apply the regression method to the combined inpatient and outpatient services. The latter approach would ensure that any potential CCR adjustments in the IPPS would be consistent with potential CCR adjustments in the OPPS. We hope to expand their analysis to incorporate outpatient services during the coming year. For all of these reasons, we are not proposing to adopt RTI's recommendations for FY 2008. Although we are not proposing to adopt RTI's recommendations for FY 2008, we are interested in public comments on expanding from 13 CCRs to 19 CCRs. Again, we note that RTI's analysis suggests significant improvements that could result in the cost weights from adopting its recommendations to adjust for charge compression. Therefore, we are also interested in public comments on whether we should proceed to adopt the RTI recommended changes for FY 2008 in the absence of a detailed analysis of how the relative weights would change if we were to address charge compression while simultaneously adopting an HSRVcc methodology together with the proposed MS-DRGs. Given the change in the impacts that were illustrated in last year's FY 2007 IPPS final rule (71 FR 47915-47916), going from a hospital-specific to a nonhospital-specific cost-weighting methodology, we believe that sequentially adjusting for charge compression and later adopting an HSRVcc methodology could create the potential for instability in IPPS payments over the next 2 years (that is, payments for surgical DRGs would increase and payment for medical DRGs would decrease if we were adopt the RTI recommended changes for FY 2008, but could potentially reverse direction if we were to adopt an HSRVcc methodology for FY 2009). Again, we are interested in public comments on all of these issues before we make a final decision as to whether to proceed with the RTI's short-term recommendations in the final rule for FY 2008. Among its other short-term recommendations, RTI also suggested that we incorporate edits to reject or require more intensive review of cost reports from hospitals with extreme CCRs. This action would reduce the number of hospitals with excluded data in the national CCR computations, and would also improve the accuracy of all departmental CCRs within problem cost reports by forcing hospitals to review and correct the assignment of costs and charges before the cost report is filed. Although we do not have a substantive disagreement with the recommendation, we generally focus our audit resources on areas in which cost report information directly affects payments to individual providers. RTI further suggested revising cost report instructions to reduce cost and charge mismatching and program charge misalignment in its short-term recommendations. Although RTI suggests such an action could be immediately effective for correcting the reporting of costs and charges for medical supply items that are now distributed across multiple cost centers, we note that changes to improve cost reporting now will not become part of the relative weights for several years because of lags between the submission of hospital reports and our ability to use them in setting the relative weights. Currently, we expect there will continue to be a 3-year lag between a hospital's cost report fiscal year and the year it is used to set the relative weights. Thus, even if it were possible to issue instructions immediately beginning for FY 2008, revised reporting would not affect the relative weights until at least FY 2011. Nevertheless, we agree with this recommendation, and we welcome public input on potential changes to cost reporting instructions to improve consistency between how charges are reported on cost reports and in the Medicare claims. We will consider these changes to the cost reporting instructions as we consider further changes to the cost report described below. b. Medium-Term Recommendations RTI recommended that we expand the MedPAR file to include separate fields that disaggregate several existing charge departments. For compatibility with prior years' data, the new fields should partition the existing ones rather than recombine charges. RTI recommended including additional fields in the MedPAR file for the hospital departments that it statistically disaggregated in its report, as well as intermediate care, observation beds, other special nursing codes, therapeutic radiation and EEG, and possibly others. As with some of RTI's earlier recommendations with respect to cost reports, we will examine this suggestion in conjunction with other competing priorities CMS has been given for our information systems. We have limited information systems resources, and we will need to consider whether the time constraints we have to develop the IPPS final rule, in conjunction with the inconvenience of using the SAF and accounting for charge compression through regression, will justify the infrastructure cost to our information 
                        ( print page 24716)
                        systems of incorporating these variables into the MedPAR. Finally, RTI's medium-term recommendations include encouraging providers to use existing standard cost centers, particularly those for Blood and Blood Administration and for Therapeutic Radiology, in the current Medicare cost report. We believe this recommendation is closely related to the one for improved cost reporting instructions. Therefore, we will consider this recommendation as part of any further effort we may undertake to revise cost reporting instructions or change the cost report. c. Long-Term Recommendations RTI's long-term recommendations include adding new cost centers to the Medicare cost report and/or undertaking the following activities: Add “Devices, Implants and Prosthetics” under the line for “Medical Supplies Charged to Patients.” Consider also adding a similar line for IV Solutions as a subscripted line under the line for “Drugs Charged to Patients.”
                    Add CT Scanning and MRI as subscripted lines under the line for “Radiology-Diagnostic.” About one-third of hospitals that offer CT Scanning and/or MRI services are already reporting these services on nonstandard line numbers. More consistent reporting for both cost centers would eliminate the need for statistical estimation on the radiology CCRs.
                    In consultation with hospital industry representatives, determine the best way to separate cardiology cost centers and add a new standard cost center for cardiac catheterization and/or for all other cardiac diagnostic laboratory services. About 20 percent of hospitals already include a nonstandard line on their cost reports for catheterization. Creating a new standard cost center could improve consistency in reporting and substantially improve the program charge mismatching that now occurs.
                    In consultation with hospital industry representatives, consider establishing a new cost center to capture intermediate care units as distinct from routine or intensive care.
                    Establish expert study groups or other research vehicles to study options for improving patient-level charging within nursing units. Nursing accounts for one-fourth of IPPS charges and 41 percent of the computed costs from our claims analysis file. Historically, nursing charges and costs have been assigned to patients without relying on individual measures of service use. Consideration should be given to finding ways to improve precision in nursing cost-finding that will improve relative resource weights without adding substantial administrative costs to either the Medicare program or to hospitals. We agree with RTI that attention should be paid to these issues as we consider changes to the Medicare cost report. The cost report has not been revised in nearly 10 years. During this time, there have been significant changes to the Medicare statute and regulations that have affected the Medicare payment policies. Necessary incremental changes have been made to the Medicare cost report over the years to accommodate the Medicare wage index, disproportionate share payments, indirect and direct graduate medical education payments, reporting of uncompensated care costs, among others. The adoption of cost-based weights for the IPPS beginning in FY 2007 has brought further attention to the importance of the Medicare cost report and how hospitals report costs and charges. We recently began doing a comprehensive review of the Medicare cost report and plan to make updates that will consider its many uses. As we update the cost report, we will give strong consideration to RTI's recommendations and potential long-term improvements that could be made to the IPPS cost-based relative weighting methodology. F. Hospital-Acquired Conditions, Including Infections (If you choose to comment on issues in this section, please include the caption “DRGs: Hospital-Acquired Conditions” at the beginning of your comment.) 1. General Medicare's IPPS encourages hospitals to treat patients efficiently. Hospitals receive the same DRG payment for stays that vary in length. In many cases, complications acquired in the hospital do not generate higher payments than the hospital would otherwise receive for other cases in the same DRG. To this extent, the IPPS does encourage hospitals to manage their patients well and to avoid complications, when possible. However, complications, such as infections, acquired in the hospital can trigger higher payments in two ways. First, the treatment of complications can increase the cost of hospital stays enough to generate outlier payments. However, the outlier payment methodology requires that hospitals experience large losses on outlier cases (for example, in FY 2007, the fixed-loss amount was $24,485 before a case qualified for outlier payments, and the hospital then only received 80 percent of its costs above the fixed-loss cost threshold). Second, there are about 121 sets of DRGs that split based on the presence or absence of a complication or comorbidity (CC). The CC DRG in each pair would generate a higher Medicare payment. If a condition acquired during the beneficiary's hospital stay is one of the conditions on the CC list, the result may be a higher payment to the hospital under a CC DRG. Under the proposed MS-DRGs, there will be 258 sets of DRGs that are split into 2 or 3 subgroups based on the presence or absence of a major CC (MCC) or CC. If a condition acquired during the beneficiary's hospital stay is one of the conditions on the MCC or CC list, the result may be a higher payment to the hospital under the MS-DRGs. (See section II.C. of the FY 2007 IPPS final rule (71 FR 47881) for a detailed discussion of proposed DRG reforms.) 2. Legislative Requirement Section 5001(c) of Pub. L. 109-171 requires the Secretary to select, by October 1, 2007, at least two conditions that are (a) high cost or high volume or both, (b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case will be paid as though the secondary diagnosis was not present. Section 5001(c) provides that we can revise the list of conditions from time to time, as long as the list contains at least two conditions. Section 5001(c) also requires hospitals to submit the secondary diagnoses that are present at admission when reporting payment information for discharges on or after October 1, 2007. 3. Public Input In the FY 2007 IPPS proposed rule (71 FR 24100), we sought input from the public about which conditions and which evidence-based guidelines should be selected in order to implement section 5001(c) of Public Law 109-171. The comments that we received were summarized in the FY 2007 IPPS final rule (71 FR 48051 through 48053). In that final rule, we indicated that the next opportunity for formal public comment would be this FY 2008 proposed rule and encouraged the public to comment on our proposal at that time. 
                        ( print page 24717) In summary, the majority of the comments that we received in response to the FY 2007 IPPS proposed rule addressed conceptual issues concerning the selection, measurement, and prevention of hospital-acquired infections. Many commenters encouraged CMS to engage in a collaborative discussion with relevant experts in designing, evaluating, and implementing this section. The commenters urged CMS to include individuals with expertise in infection control and prevention, as well as representatives from the provider community, in the discussions. Many commenters supported the statutory requirement for hospitals to submit information regarding secondary diagnoses present on admission beginning in FY 2008, and suggested that it would better enable CMS and health care providers to more accurately differentiate between comorbidities and hospital-acquired complications. MedPAC, in particular, noted that this requirement was recommended in its March 2005 Report to Congress and indicated that this information is important to Medicare's value-based purchasing efforts. Other commenters cautioned us about potential problems with relying on secondary diagnosis codes to identify hospital-acquired complications, and indicated that secondary diagnosis codes may be an inaccurate method for identifying true hospital-acquired complications. A number of commenters expressed concerns about the data coding requirement for this payment change and asked for detailed guidance from CMS to help them identify and document hospital-acquired complications. Other commenters expressed concern that not all hospital-acquired infections are preventable and noted that sicker and more complex patients are at greater risk for hospital-acquired infections and complications. Commenters suggested that CMS include standardized infection-prevention process measures, in addition to outcome measures of hospital-acquired infections. Some commenters proposed that CMS expand the scope of the payment changes beyond the statutory minimum of two conditions. They noted that the death, injury, and cost of hospital-acquired infections are too high to limit this provision to only two conditions. Commenters also recommended that CMS annually select additional hospital-acquired complications for the payment change. Conversely, a number of commenters proposed that CMS initially begin with limited demonstrations to test CMS' methodology before nationwide implementation. One commenter recommended that CMS include appropriate consumer protections to prevent providers from billing patients for the nonreimbursed costs of the hospital-acquired complications and to prevent hospitals from selectively avoiding patients perceived at risk of complications. In addition to the broad conceptual suggestions, some commenters recommended specific conditions for possible inclusion in the payment changes, which we discuss in detail in section II.D.4. of this preamble. We also discuss throughout section II.D. of this preamble other comments that we have considered in developing hospital-acquired conditions that would be subject to reporting. 4. Collaborative Effort CMS worked with public health and infectious disease experts from the Centers for Disease Control and Prevention (CDC) to identify a list of hospital-acquired conditions, including infections, as required by section 5001(c) of Public Law 109-171. As previously stated, the selected conditions must meet the following three criteria: (a) High cost or high volume or both; (b) result in the assignment of the case to a DRG that has a higher payment when present as a secondary diagnosis; and (c) could reasonably have been prevented through the application of evidence-based guidelines. CMS and CDC staff also collaborated on developing a process for hospitals to submit a Present on Admission (POA) indicator with each secondary condition. The statute requires the Secretary to begin collecting this information as of October 1, 2007. The POA indicator is required in order for us to determine which of the selected conditions developed during a hospital stay. The current electronic format used by hospitals to obtain this information (ASC X12N 837, Version 4010) does not provide a field to obtain the POA information. We are in the process of issuing instructions to require acute care IPPS hospitals to submit the POA indicator for all diagnosis codes effective October 1, 2007. The instructions will specify how hospitals under the IPPS will submit this information in segment K3 in the 2300 loop, data element K301 on the ASC X12N 837, Version 4010 claim. Specific instructions on how to select the correct POA indicator for a diagnosis code are included in the ICD-9-CM Official Guidelines for Coding and Reporting. These guidelines can be found at the following Web site:   
                        *http://www.cdc.gov/​nchs/​datawh/​ftpserv/​ftpicd9/​ftpicd9.htm* CMS and CDC staff also received input from a number of groups and organizations on hospital-acquired conditions, including infections. Many of these groups and organizations recommended the selection of conditions mentioned in the FY 2007 IPPS final rule, including the following because of the high cost or high volume (frequency) of the condition, or both, and because in some cases preventable guidelines already exist: Surgical site infections. The groups and organizations stated that there were evidence-based measures to prevent the occurrence of these infections which are currently measured and reported as part of the Surgical Care Improvement Program (SCIP).
                    Ventilator-associated pneumonias. The groups and organizations pointed out that these conditions are currently measured and reported through SCIP. However, other organizations counseled against selecting these conditions because they believed it was difficult to obtain good definitions and that it was not always clear which ones are hospital-acquired.
                    Catheter associated bloodstream infections.
                    Pressure ulcers, as an alternative to hospital-acquired infections. The groups and organizations pointed out that the specific language in section 5001(c) ofPublic Law 109-171 mentions hospital-acquired conditions; therefore, the language does not restrict the Secretary to the selection of infections.
                    Hospital falls, as an alternative to hospital-acquired infections. The injury prevention groups included this condition among a group referred to as “serious preventable events,” also commonly referred to as “never events” or “serious reportable events.” A serious preventable event is defined as a condition which should not occur during an inpatient stay. In addition to the aforementioned conditions, we received other recommendations for the selection of hospital-acquired conditions. These recommendations were also based on the high cost and the high volume of the condition, or both, or the fact that preventable guidelines exist. The recommendations include— Bloodstream infections/septicemia. Some commenters suggested that we focus on one specific organism, such as staph aureus septicemia.
                    Pneumonia. Some commenters recommended the inclusion of a broader group of pneumonia patients, instead of restricting cases to ventilator-associated pneumonias. Some commenters( print page 24718)
                        mentioned that while prevention guidelines exist for pneumonia, it is not clear how effective these guidelines may be in preventing pneumonia.
                    Vascular catheter associated infections. Commenters pointed out that there are CDC guidelines for these infections. Other commenters pointed out that while this condition certainly deserves focused attention by health care providers, there is not a clear one unique ICD-9-CM code that identifies vascular catheter-associated infections. Therefore, these commenters suggested that there would be difficulty separately identifying these conditions.
                    Clostridium difficile-associated disease (CDAD). Several commenters identified this condition as a significant public health issue. Other commenters pointed out that while prevalence of this condition is emerging as a public health problem, there is not currently a strategy for reasonably preventing these infections.
                    Methicillin-resistant staphylococcus aureus (MRSA). Several commenters pointed out that MRSA has become a very common bacteria occurring both in and outside the hospital environment. However, other organizations pointed out that the code for MRSA (V09.0, Infection with microorganism resistant to penicillins Methicillin-resistant staphylococcus aureus) is not currently classified as a CC. Therefore, the commenters stated that MRSA does not lead to a higher reimbursement when the code is reported.
                    Serious preventable events. As stated earlier, some commenters representing injury prevention groups suggested including a broader group of conditions than hospital falls which should not be expected to occur during a hospital admission. Hey notes that these conditions are referred to as “serious preventable events,” and include events such as the following: (a) Leaving an object in during surgery; (b) operating on the wrong body part or patient, or performing the wrong surgery; (c) air embolism as a result of surgery; and (d) providing incompatible blood or blood products. Other commenters indicated that serious preventable events are so rare that they should not be selected as a hospital condition that cannot result in a case being assigned to a higher paying DRG. 5. Criteria for Selection of the Hospital-Acquired Conditions CMS and CDC staff greatly appreciate the many comments and suggestions offered by organizations and groups that were interested in providing input into the selection of the initial hospital-acquired conditions. CMS and CDC staff evaluated each recommended condition under the three criteria established by section 1886(d)(4)(D)(iv) of the Act. In order to meet the higher payment criterion, the condition selected must have an ICD-9-CM diagnosis code that clearly identifies the condition and is classified as a CC, or as an MCC as proposed for the MS-DRGs in this proposed rule. Some conditions recommended for inclusion among the initial hospital-acquired conditions did not have codes that clearly identified the conditions. Because there has not been national reporting of a POA indicator for each diagnosis, there is no Medicare data to determine the incidence of the reported secondary diagnoses occurring after admission. To the extent possible, we used information from the CDC on the incidence of these conditions. CDC's data reflect the incidence of hospital-acquired conditions in 2002. We also examined FY 2006 Medicare data on the frequency that these conditions were reported as secondary diagnoses. We developed the following criteria to assist in our analysis of the conditions. The conditions described were those recommended for inclusion in the initial hospital-acquired infection provision. Coding—Under section 1886(d)(4)(D)(ii)(I) of the Act, a discharge is subject to the payment adjustment if “the discharge includes a condition identified by a diagnosis code” selected by the Secretary under section 1886(d)(4)(D)(iv) of the Act. We only selected conditions that have (or could have) a unique ICD-9-CM code that clearly describes the condition. Some conditions recommended by the commenters would require the use of two or more ICD-9-CM codes to clearly identify the conditions. Although we did not exclude these conditions from further consideration, the need to utilize multiple ICD-9-CM codes to identify them may present operational issues. For instance, below we describe in detail the complexities associated with selecting septicemia as a hospital-acquired condition that would be subject to section 5001(c) of the DRA. In some cases, septicemia may be a reasonably preventable condition with proper hospital care. However, in other cases, clinicians may argue that the condition arose from further development of another infection the patient did have upon admission and the septicemia was not preventable. As we indicate in detail below, there could be a significant variety of clinical scenarios and potential coding vignettes to describe situations where septicemia occurs. Although we could select septicemia, we would also have to identify many exclusions for situations where the septicemia is not preventable. The vast number of clinical scenarios that we would have to account for could complicate implementation of the provision.
                    Burden (High Cost/High Volume)—Under section 1886(d)(4)(D)(iv)(I) of the act, we must select cases that have conditions that are high cost or high volume, or both.
                    Prevention guidelines—Under section 1886(d)(4)(D)(iv)(II) of the Act, we must select codes that describe conditions that could reasonably have been prevented through application of evidence-based guidelines. We evaluated whether there is information available for hospitals to follow to prevent the condition from occurring.
                    CC—Under section 1886(d)(4)(D)(iv)(III) of the Act, we must select codes that result in assignment of the case to a DRG that has a higher payment when the code it present as a secondary diagnosis. The condition must be an MCC or a CC that would, in the absence of this provision, result in assignment to a higher paying DRG.
                    Considerations—We evaluate each condition above according to how it meets the statutory criteria in light of the potential difficulties that we would face if the condition were selected. 6. Proposed Selection of Hospital-Acquired Conditions We discuss below our analysis of each of the conditions that were raised as possible candidates for selection under section 5001(c) of Pub. L. 109-171 according to the criteria described above in section II.D.5. of this preamble. We also discuss any considerations, which would include any administrative issues surrounding the selection of a proposed condition. For example, the condition may only be able to be identified by multiple codes, thereby requiring the development of special GROUPER logic to also exclude similar or related ICD-9-CM codes from being classified as a CC. Similarly, a condition acquired during a hospital stay may arise from another condition that the patient had prior to admission, making it difficult to determine whether the condition was reasonably preventable. Following a discussion of each condition, we provide a summary table that describes the extent to which each condition meets each of the above criteria. We present 13 conditions in rank order. In our view, the conditions listed at the top of the table best meet the statutory selection criteria, while the conditions 
                        ( print page 24719)
                        listed lower may meet the selection criteria but could present a particular challenge (that is, they may be preventable only in some circumstances but not in others). Therefore, we would submit that the first conditions listed should receive the highest consideration of selection among our initial group of hospital-acquired conditions. We encourage comments on whether or not we have ranked these conditions appropriately. We also encourage additional comments on clinical, coding, and prevention issues that may affect the conditions selected. While we have ranked these conditions, there may be compelling public health reasons for including conditions that are not at the top of our list. We ask commenters to recommend how many and which conditions should be selected for implementation on October 1, 2008, along with justifications for these selections. (a) Catheter-Associated Urinary Tract Infections Coding—ICD-9-CM code 996.64 (Infection and inflammatory reaction due to indwelling urinary catheter) clearly identifies this condition. The hospital would also report the code for the specific type of urinary infection. For instance, when a patient develops a catheter associated urinary tract infection during the inpatient stay, the hospital would report code 996.64 and 599.0 (Urinary tract infection, site not specified) to clearly identify the condition. There are also a number of other more specific urinary tract infection codes that could also be coded with code 996.64. These codes are classified as CCs. If we were to select catheter-associated urinary tract infections, we would implement the decision by not counting code 996.64 and any of the urinary tract infection codes listed below when both codes are present and the condition was acquired after admission. If only code 996.64 were coded on the claim as a secondary diagnosis, we would not count it as a CC. Burden (High Cost/High Volume)—CDC reports that there are 561,667 catheter-associated urinary tract infections per year. For FY 2006, there were 11,780 reported cases of Medicare patients who had a catheter associated urinary tract infection as a secondary diagnosis. The cases had average charges of $40,347 for the entire hospital stay. According to a study in the 
                        *American Journal of Medicine,*
                         catheter-associated urinary tract infection is the most common nosocomial infection, accounting for more than 1 million cases in hospitals and nursing homes nationwide.[12]
                        
                         Approximately 11.3 million women in the United States had at least one presumed acute community-acquired urinary tract infection resulting in antimicrobial therapy in 1995, with direct costs estimated at $659 million and indirect costs totaling $936 million. Nosocomial urinary tract infection necessitates one extra hospital day per patient, or nearly 1 million extra hospital days per year. It is estimated that each episode of symptomatic urinary tract infection adds $676 to a hospital bill. In total, according to the study, the estimated annual cost of nosocomial urinary tract infection in the United States ranges between $424 and $451 million. Prevention guidelines—There are widely recognized guidelines for the prevention of catheter-associated urinary tract infections. Guidelines can be found at the following Web site: 
                        *http://www.cdc.gov/​ncidod/​dhqp/​gl_​catheter_​assoc.html.* CC—Codes 996.64 and 599.0 are classified as CCs in the current CMS DRGs as well as in the proposed MS-DRGs. Considerations—The primary prevention intervention would be not using catheters or removing catheters as soon as possible, both of which are worthy goals because once catheters are in place for 3 to 4 days, most clinicians and infectious disease/infection control experts do not believe urinary tract infections are preventable. While there may be some concern about the selection of catheter associated urinary tract infections, it is an important public health goal to encourage practices that will reduce urinary tract infections. Approximately 40 percent of Medicare beneficiaries have a urinary catheter during hospitalization based on Medicare Patient Safety Monitoring System (MPSMS) data. As stated above in the Coding section, this condition is clearly identified through ICD-9-CM code 996.64. Code 996.64 is classified as a CC. The hospital would also report the code for the specific type of urinary infection. For instance, when a patient develops a catheter associated urinary tract infection during the inpatient stay, the hospital would report codes 996.64 and 599.0 or another more specific code that clearly identifies the condition. These codes are classified as CCs under the current CMS DRGs as well as the proposed MS-DRGs. To select catheter-associated urinary tract infections as one of the hospital-acquired conditions that would not be counted as a CC, we would not classify code 996.64 as a CC if the condition occurred after admission. Furthermore, we would also not classify any of the codes listed below as CCs if present on the claim with code 996.64 because these additional codes identify the same condition. The following codes represent specific types of urinary infections. We did not include codes for conditions that could be considered chronic urinary infections, such as code 590.00 (Chronic pyelonephritis, without lesion or renal medullary necrosis). Chronic conditions may indicate that the condition was not acquired during the current stay. We would not count code 996.64 or any of the following codes representing acute urinary infections if they developed after admission and were coded together on the same claim. 112.2 (Candidiasis of other urogenital sites)
                    590.10 (Acute pyelonephritis, without lesion of renal medullary necrosis)
                    590.11 (Acute pyelonephritis, with lesion of renal medullary necrosis)
                    590.2 (Renal and perinephric abscess)
                    590.3 (Pyeloureteritis cystica)
                    590.80 (Pyelonephritis, unspecified)
                    590.81 (Pyelitis or pyelonephritis in diseases classified elsewhere)
                    590.9 (Infection of kidney, unspecified)
                    595.0 (Acute cystitis)
                    595.3 (Trigonitis)
                    595.4 (Cystitis in diseases classified elsewhere)
                    595.81 (Cystitis cystica)
                    595.89 (Other specified type of cystitis, other)
                    595.9 (Cystitis, unspecified)
                    597.0 (Urethral abscess)
                    597.80 (Urethritis, unspecified)
                    599.0 (Urinary tract infection, site not specified) We believe the condition of catheter-associated urinary tract infection meets all of our criteria for selection as one of the initial hospital-acquired conditions. We can easily identify the cases with ICD-9-CM codes. The condition is a CC under both the current CMS DRGs and the proposed MS-DRGs that are discussed earlier in this proposed rule. The condition meets our burden criterion with its high cost and high frequency. There are prevention guidelines on which the medical community agrees. Of all 13 conditions discussed in this proposed rule, we believe this condition best meets the 
                        ( print page 24720)
                        criteria discussed. Therefore, we are proposing the selection of catheter-associated urinary tract infections as one of the initial hospital-acquired conditions. We encourage comments on both the selection of this condition and the related conditions that we are proposing to exclude from being counted as CCs. (b) Pressure Ulcers Coding—Pressure ulcers are also referred to as decubitus ulcers. The following codes clearly identify pressure ulcers. 707.00 (Decubitus ulcer, unspecified site)
                    707.01 (Decubitus ulcer, elbow)
                    707.02 (Decubitus ulcer, upper back)
                    707.03 (Decubitus ulcer, lower back)
                    707.04 (Decubitus ulcer, hip)
                    707.05 (Decubitus ulcer, buttock)
                    707.06 (Decubitus ulcer, ankle)
                    707.07 (Decubitus ulcer, heel)
                    707.09 (Decubitus ulcer, other site) Burden (High Cost/High Volume)—This is both a high-cost and high-volume condition. For FY 2006, there were 322,946 reported cases of Medicare patients who had a pressure ulcer as a secondary diagnosis. These cases had average charges for the hospital stay of $40,381. Prevention guidelines—Prevention guidelines can be found at the following Web sites: 
                        *http://www.npuap.org/​positn1.html. http://www.ncbi.nlm.nih.gov/​books/​bv.fcgi?​rid=​hstat2.chapter.4409* CC—Decubitus ulcer codes are classified as CCs under the current CMS DRGs. Codes 707.00, 707.01, and 707.09 are CCs under the proposed MS-DRGs. Codes 707.02 through 707.07 are considered MCCs under the proposed MS-DRGs. As discussed earlier, MCCs result in even larger payments than CCs. Considerations—Pressure ulcers are an important hospital-acquired complication. Prevention guidelines exist (non-CDC) and can be implemented by hospitals. Clinicians may state that some pressure ulcers present on admission cannot be identified (skin is not yet broken (Stage I) but damage to tissue is already done and skin will eventually break down. However, by selecting this condition, we would provide hospitals the incentive to perform careful examination of the skin of patients on admission to identify decubitus ulcers. If the condition is present on admission, the provision will not apply. We are proposing to include pressure ulcers as one of our initial hospital-acquired conditions. This condition can be clearly identified through ICD-9-CM codes. These codes are classified as a CC under the current CMS DRGs and as a CC or MCC under the proposed MS-DRGs. Pressure ulcers meet the burden criteria because they are both high cost and high frequency cases. There are clear prevention guidelines. While there is some question as to whether all cases with developing pressure ulcers can be identified on admission, we believe the selection of this condition will result in a closer examination of the patient's skin on admission. This will result in better quality of care. We welcome comments on the proposed inclusion of this condition. Serious Preventable Events Serious preventable events are events that should not occur in health care. The injury prevention community has developed information on serious preventable events. CMS reviewed the list of serious preventable events and identified those events for which there was an ICD-9-CM code that would assist in identifying them. We identified four types of serious preventable events to include in our evaluation. These include leaving an object in a patient; performing the wrong surgery (surgery on the wrong body part, wrong patient, or the wrong surgery); air embolism following surgery; and providing incompatible blood or blood products. Three of these serious preventable events have unique ICD-9-CM codes to identify them. There is not a clear and unique code for surgery performed on the wrong body part, wrong patient, or the wrong surgery. Each of these events is discussed separately. (c) Serious Preventable Event—Object Left in During Surgery Coding—Retention of a foreign object in a patient after surgery is identified through ICD-9-CM code 998.4 (Foreign body accidentally left during a procedure). Burden (High Cost/High Volume)—For FY 2006, there were 764 cases reported of Medicare patients who had an object left in during surgery reported as a secondary diagnosis. The average charges for the hospital stay were $61,962. This is a rare event. Therefore, it is not high volume. However, an individual case will likely have high costs, given that the patient will need additional surgery to remove the foreign body. Potential adverse events stemming from foreign body could further raise costs for an individual case. Prevention guidelines—There are widely accepted and clear guidelines for the prevention of this event. Prevention guidelines for avoiding leaving objects in during surgery are located at the following Web site: 
                        *http://www.qualityindicators.ahrq.gov/​psi_​download.htm.*
                         This event should not occur. CC—This code is a CC under the current CMS DRGs as well as under the proposed MS-DRGs. Considerations—There are no significant considerations for this condition. There is a unique ICD-9-CM code and wide agreement on the prevention guidelines. We are proposing to include this condition as one of our initial hospital-acquired conditions. The cases can be clearly identified through an ICD-9-CM. This code is a CC under both the current CMS DRGs and the proposed MS-DRGs. There are clear prevention guidelines. While the cases may not meet the high frequency criterion, they do meet the high-cost criterion. Individual cases can be high cost. We welcome comments on including this condition as one of our initial hospital-acquired conditions. (d) Serious Preventable Event—Air Embolism Coding—An air embolism is identified through ICD-9-CM code 999.1 (Complications of medical care, NOS, air embolism). Burden (High Cost/High Volume)—This event is rare. For FY 2006, there were 45 reported cases of air embolism for Medicare patients. The average charges for the hospital stay were $66,007. Prevention guidelines—There are clear prevention guidelines for air embolisms. This event should not occur. Serious preventable event guidelines can be found at the following Web site: 
                        *http://www.qualityindicators.ahrq.gov/​psi_​download.htm.* CC—This code is a CC under the current CMS DRGs and is an MCC under the proposed MS-DRGs. Considerations—There are no significant considerations for this condition. There is a unique ICD-9-CM code and wide agreement on the prevention guidelines. In addition, as stated earlier, the condition is a CC under the current CMS DRGs and an MCC under the proposed MS-DRGs. While the condition is rare, it does meet the cost burden criterion because individual cases can be expensive. Therefore, air embolism is a high-cost condition because average charges per case are high. We welcome comments on the proposal to include this condition. 
                        ( print page 24721) (e) Serious Preventable Event—Blood Incompatibility Coding—Delivering ABO-incompatible blood or blood products is identified by ICM-9-CM code 999.6 (Complications of medical care, NOS, ABO incompatibility reaction). Burden (High Cost/High Volume)—This event is rare. Therefore, it is not high volume. For FY 2006, there were 33 reported cases of blood incompatibility among Medicare patients, with average charges of $46,492 for the hospital stay. Therefore, individual cases have high costs. Prevention guidelines—There are prevention guidelines for avoiding the delivery of incompatible blood or blood products. The event should not occur. Serious preventable event guidelines can be found at the following Web site: 
                        *http://www.qualityindicators.ahrq.gov/​psi_​download.htm* CC—This code is a CC under the current CMS DRGs as well as the proposed MS-DRGs. Considerations—There are no significant considerations for this condition. There is a unique ICD-9-CM code which is classified as a CC under the CMS DRGs as well as the proposed MS-DRGs. There is wide agreement on the prevention guidelines. While this may not be a high-volume condition, average charges per case are high. Therefore, we believe this condition is a high-cost condition and, therefore, meets our burden criterion. We are proposing to include this condition as one of our initial hospital-acquired conditions. (f) Staphylococcus Aureus Bloodstream Infection/Septicemia Coding—ICD-9-CM Code 038.11 (Staphylococcus aureus septicemia) identifies this condition. However, the codes selected to identify septicemia are somewhat complex. The following ICD-9-CM codes may also be reported to identify septicemia: 995.91 (Sepsis) and 995.92 ( Severe sepsis). These codes are reported as secondary codes and further define cases with septicemia.
                    998.59 (Other postoperative infections). This code includes septicemia that develops postoperatively.
                    999.3 (Other infection). This code includes but is not limited to sepsis/septicemia resulting from infusion, injection, transfusion, vaccination (ventilator-associated pneumonia also included here). Burden (High Cost/High Volume)—CDC reports that there are 290,000 cases of staphylococcus aureus infection annually in hospitalized patients of which approximately 25 percent are bloodstream infections or sepsis. For FY 2006, there were 29,500 cases of Medicare patients who had staphylococcus aureus infection reported as a secondary diagnosis. The average charges for the hospital stay were $82,678. Inpatient staphylococcus aureus result in an estimated 2.7 million days in excess length of stay, $9.5 billion in excess charges, and approximately 12,000 inpatient deaths per year. Prevention guidelines—CDC guidelines are located at the following Web site: 
                        *http://www.cdc.gov/​ncidod/​dhqp/​gl_​intravascular.html.* CC—Codes 038.11, 995.91, 998.59, and 999.3 are classified as CCs under the current CMS DRGs and as MCCs under the proposed MS-DRGs. Considerations—Preventive health care associated bloodstream infections/septicemia that are preventable are primarily those that are related to a central venous/vascular catheter, a surgical procedure (postoperative sepsis) or those that are secondary to another preventable infection (for example, sepsis due to catheter-associated urinary tract infection). Otherwise, physicians and other public health experts may argue whether septicemia is reasonably preventable. The septicemia may not be simply a hospital-acquired infection. It may simply be a progression of an infection that occurred prior to admission. Furthermore, physicians cannot always tell whether the condition was hospital-acquired. We examined whether it might be better to limit the septicemia cases to a specific organism (for example, code 038.11 (Staphylococcus aureus septicemia)). CDC staff recommended that we focus on staphylococcus aureus septicemia because this condition is a significant public health issue. As stated earlier, there is a specific code for staphylococcus aureus septicemia, code 038.11. Therefore, the cases would be easy to identify. However, as stated earlier, while this type of septicemia is identified through code 038.11, coders may also provide sepsis code 995.91 or 995.92 to more fully describe the staphylococcus aureus septicemia. Codes 995.91 and 995.92 are reported as secondary codes and further define cases with septicemia. Codes 995.91 and 995.92 are CCs under the current CMS DRGs and MCCs under the proposed MS-DRGs. 998.59 (Other postoperative infections). This code includes septicemia that develops postoperatively.
                    999.3 (Other infection). This code includes but is not limited to sepsis/septicemia resulting from infusion, injection, transfusion, vaccination (ventilator-associated pneumonia also indexed here). To implement this condition as one of our initial ones, we would have to exclude the specific code for staphylococcus aureus septicemia, 038.11, and the additional septicemia codes, 995.91, 995.92, 998.59, and 999.3. We acknowledge that there are additional issues involved with the selection of this condition that may involve developing an exclusion list of conditions present on admission for which we would not apply a CC exclusion to staphylococcus aureus septicemia. For example, a patient may come into the hospital with a staphylococcus aureus infection such as pneumonia. The pneumonia might develop into staphylococcus aureus septicemia during the admission. It may be appropriate to consider excluding cases such as those of patients admitted with staphylococcus aureus pneumonia that subsequently develop staphylococcus aureus septicemia from the provision. In order to exclude cases that did not have a staphylococcus aureus infection prior to admission, we would have to develop a list of specific codes that identified all types of staphylococcus aureus infections such as code 482.41 (Pneumonia due to staphylococcus aureus). We likely would not apply the new provision to cases of staphylococcus aureus septicemia if a patient were admitted with staphylococcus aureus pneumonia. However, if the patient had other types of infections, not classified as being staphylococcus aureus, and then developed staphylococcus aureus septicemia during the admission, we would apply the provision and exclude the staphylococcus aureus septicemia as a CC. We were not able to identify any other specific ICD-9-CM codes that identify specific infections as being due to staphylococcus aureus. Other types of infections, such as urinary tract infections, would require the reporting of an additional code, 041.11 (Staphylococcus aureus), to identify the staphylococcus aureus infection. This additional coding presents administrative issues, because it will not always be clear which condition code 041.11 (Staphylococcus aureus) is describing. We do not believe it would be appropriate to make code 041.11, in combination with other codes, subject to the hospital-acquired conditions provision until we better understand how to address the 
                        ( print page 24722)
                        administrative issues that would be associated with their selection. Therefore, we would exclude staphylococcus aureus septicemia cases with code 482.41 reported as being subject to the hospital-acquired conditions provision. Stated conversely, we would allow staphylococcus aureus septicemia to count as a CC if the patient was admitted with staphylococcus aureus pneumonia. We recognize that there may be other conditions which we should consider for this type of exclusion. We are proposing to include staphylococcus aureus bloodstream infection/septicemia (code 038.11) as one of our initial hospital-acquired conditions. We would also exclude codes 995.91, 998.59, and 999.3 from counting as an MCC/CC when they are reported with code 038.11. The condition can be clearly identified through ICD-9-CM codes that are classified as CC under the current CMS DRGs and MCCs under the proposed MS-DRGs. The condition meets our burden criterion by being both high cost and high volume. There are prevention guidelines which we acknowledge are subject to some debate among the medical community. We also acknowledge that we would have to exclude this condition if a patient were admitted with a staphylococcus aureus infection of a more limited location, such as pneumonia. We encourage commenters to make suggestions on this issue and to recommend any other appropriate exclusion for staphylococcus aureus septicemia. We encourage comments on the appropriateness of selecting staphylococcus aureus septicemia as one of our proposed initial hospital-acquired conditions. (g) Ventilator Associated Pneumonia (VAP) and Other Types of Pneumonia Coding “ Pneumonia is identified through the following codes: 073.0 (Ornithosis with pneumonia)
                    112.4 (Candidiasis of lung)
                    136.3 (Pneumocystosis)
                    480.0 (Pneumonia due to adenovirus)
                    480.1 (Pneumonia due to respiratory syncytial virus)
                    480.2 (Pneumonia due to parainfluenza virus)
                    480.3 (Pneumonia due to SARS-associated coronavirus)
                    480.8 (Pneumonia due to other virus not elsewhere classified)
                    480.9 (Viral pneumonia, unspecified)
                    481 (Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia])
                    482.0 (Pneumonia due to Klebsiella pneumoniae)
                    482.1 (Pneumonia due to Pseudomonas)
                    482.2 (Pneumonia due to Hemophilus influenzae [H. influenzae])
                    482.30 (Pneumonia due to Streptococcus, unspecified)
                    482.31 (Pneumonia due to Streptococcus, Group A)
                    482.32 (Pneumonia due to Streptococcus, Group B)
                    482.39 (Pneumonia due to other Streptococcus)
                    482.40 (Pneumonia due to Staphylococcus, unspecified)
                    482.41 (Pneumonia due to Staphylococcus aureus)
                    482.49 (Other Staphylococcus pneumonia)
                    482.81 (Pneumonia due to Anaerobes)
                    482.82 (Pneumonia due to Escherichia coli [E. coli])
                    482.83 (Pneumonia due to other gram-negative bacteria)
                    482.84 (Pneumonia due to Legionnaires' disease)
                    482.89 (Pneumonia due to other specified bacteria)
                    482.9 (Bacterial pneumonia unspecified)
                    483.0 (Pneumonia due to Mycoplasma pneumoniae) There is not a unique code that identifies ventilator associated pneumonia. The creation of a code for ventilator associated pneumonia was discussed at the September 29, 2006 meeting of the ICD-9-CM Coordination and Maintenance Committee meeting. Many issues and concerns were raised at the meeting concerning the creation of this proposed new code. It has been difficult to define ventilator-associated pneumonia. We plan to continue working closely with the CDC to develop a code that can accurately describe this condition for implementation in FY 2009. CDC will address the creation of a unique code for this condition at the September 28-29, 2007 ICD-9-CM Coordination and Maintenance Committee meeting. While we list 27 pneumonia codes above, our clinical advisors do not believe that all of the codes mentioned could possibly be associated with ventilator-associated pneumonia. Our clinical advisors specifically question whether the following codes would ever represent cases of ventilator-associated pneumonia: 073.0, 480.0, 480.1, 480.2, 480.3, 480.8, 480.9, and 483.0. Therefore, we have a range of pneumonia codes, all of which may not represent cases that could involve ventilator-associated pneumonia. In addition, we do not have a specific code that uniquely identifies cases of ventilator-associated pneumonia. Burden (High Cost/High Volume)—CDC reports that there are 250,205 ventilator-associated pneumonias per year. Because there is not a unique ICD-9-CM code for ventilator-associated pneumonia, there is not accurate data for FY 2006 on the number of Medicare patients who had this condition as a secondary diagnosis. However, we did examine data for FY 2006 on the number of Medicare patients who listed pneumonia as a secondary diagnosis. There were 92,586 cases with a secondary diagnosis of pneumonia, with average charges of $88,781. According to the journal 
                        *Critical Care Medicine,*
                         patients with ventilator-associated pneumonia have statistically significantly longer intensive care lengths of stay (mean = 6.10 days) than those who do not (mean = 5.32-6.87 days). In addition, patients who develop ventilator-associated pneumonia incur, on average, greater than or equal to $10,019 in additional hospital costs compared to those who do not.[13]
                        
                         Therefore, we believe that this is a high-volume condition. Prevention guidelines—Prevention guidelines are located at the following Web site: 
                        *http://www.cdc.gov/​ncidod/​dhqp/​ gl_​hcpneumonia.html*. However, it is not clear how effective these guidelines are in preventing pneumonia. Ventilator-associated pneumonia may be particularly difficult to prevent. CC—All of the pneumonia codes listed above are CCs under the current CMS DRGs and under the proposed MS-DRGs, except for the following pneumonia codes which are non-CCs: 073.0, 480.0, 480.1, 480.2, 480.3, 480.8, 480.9, 483.0. However, as mentioned earlier, there is not a unique ICD-9-CM code for ventilator-associated pneumonia. Therefore, this condition does not currently meet the statutory criteria for being selected. Considerations—Hospital-acquired pneumonias, and specifically ventilator associated pneumonias, are an important problem. However, based on our work with the medical community to develop specific codes for this condition, we have learned that it is difficult to define what constitutes ventilator associated pneumonia. Although prevention guidelines exist, it is not clear how effective these are in preventing pneumonia. Clinicians cannot always tell which pneumonias are acquired in a hospital. In addition, 
                        ( print page 24723)
                        as mentioned above, there is not a unique code that identifies ventilator-associated pneumonia. There are a number of codes that capture a range of pneumonia cases. It is not possible to specifically identify if these pneumonia cases are ventilator-associated or arose from other sources. Because we cannot identify cases with ventilator-associated pneumonia and there are questions about its preventability, we are not proposing to select this condition as one of our initial hospital-acquired conditions. However, we welcome public comments on how to create an ICD-9-CM code that identifies ventilator-associated pneumonia, and we encourage participation in our September 28-29, 2007 ICD-9-CM Coordination and Maintenance Committee meeting where this issue will be discussed. We will reevaluate the selection of this condition in FY 2009. (h) Vascular Catheter-Associated Infections Coding—The code used to identify vascular catheter associated infections is ICD-9-CM code 996.62 (Infection due to other vascular device, implant, and graft). This code includes infections associated with all vascular devices, implants, and grafts. It does not uniquely identify a vascular catheter associated infections. Therefore, there is not a unique ICD-9-CM code for this infection. CDC and CMS staff requested that the ICD-9-CM Coordination and Maintenance Committee discuss the creation of a unique ICD-9-CM code for vascular catheter associated infections because the issue is important for public health. The proposal to create a new ICD-9-CM was discussed at the March 22-23, 2007 meeting of the ICD-9-CM Coordination and Maintenance Committee. A summary of this meeting can be found at: 
                        *http://www.cdc.gov/​nchs/​icd9.htm*. Coders would also assign an additional code for the infection such as septicemia. Therefore, a list of specific infection codes would have to be developed to go along with code 996.62. If the vascular catheter associated infection was hospital-acquired, the DRG logic would have to be modified so that neither the code for the vascular catheter associated infection along with the specific infection code would count as a CC. Burden (High Cost/High Volume)—CDC reports that there are 248,678 central line associated bloodstream infections per year. It appears to be both high cost and high volume. However, we were not able to identify Medicare data on these cases because there is no existing unique ICD-9-CM code. Prevention guidelines—CDC guidelines are located at the following Web site: 
                        *http://www.cdc.gov/​ncidod/​dhqp/​gl_​intravascular.html*. CC—Code 996.62 is a CC under the current CMS DRGs and the proposed MS-DRGs. However, as stated earlier, this code is broader than vascular catheter-associated infections. Therefore, there is not a unique ICD-9-CM code to identify the condition at this time, and it does not currently meet the statutory criteria to be selected. However, as indicated above, we will be creating a code(s) to identify this condition and may select it as a condition under the provision beginning in FY 2009. Considerations—There is not yet a unique ICD-9-CM code to capture this condition. If one is implemented on October 1, 2007, we would be able to specifically identify these cases. Some patients require long-term indwelling catheters, which are more prone to infections. Ideally catheters should be changed at certain time intervals. However, circumstances might prevent such practice (for example, the patient has a bleeding diathesis). In addition, a patient may acquire an infection from another source which can colonize the catheter. As mentioned earlier, coders would also assign an additional code for the infection, such as septicemia. Therefore, a list of specific infection codes would have to be developed to go along with code 996.62. If the vascular catheter-associated infection was hospital-acquired, the DRG logic would have to be modified so that neither the code for the vascular catheter-associated infection along with the specific infection code would count as a CC. Without a specific code for infections due to a catheter, it would be difficult to identify these patients. Given the current lack of an ICD-9-CM code for this condition, we are not proposing to include it as one of our initial hospital-acquired conditions at this time. However, we believe it shows merit for inclusion in future lists of hospital-acquired conditions once we have resolved the coding issues and are able to better identify the condition in the Medicare data. We will reevaluate the selection of this condition in FY 2009. We encourage comments on this condition which was identified as an important public health issue by several organizations that provided recommendations on hospital-acquired conditions. We are particularly interested in receiving comments on how we should handle additional associated infections that might develop along with the vascular catheter-associated infection. (i) Clostridium Difficile-Associated Disease (CDAD) Coding—This condition is identified by ICD-9-CM code 008.45 (Clostridium difficile). Burden (High Cost/High Volume)—CDC reports that there are 178,000 cases per year in U.S. hospitals. For FY 2006, there were 110,761 reported cases of Medicare patients with CDAD as a secondary diagnosis, with average charges for the hospital stay of $52,464. Therefore, this is a high-volume condition. Prevention guidelines—Prevention guidelines are not available. Therefore, we do not believe this condition can reasonably be prevented through the application of evidence-based guidelines. CC—Code 008.45 is a CC under the current CMS DRGs and the proposed MS-DRGs. Considerations—CDAD is an emerging problem with significant public health importance. If found early CDAD cases can easily be treated. However, cases not diagnosed early can be expensive and difficult to treat. CDAD occurs in patients on a variety of antibiotic regiments, many of which are unavoidable, and therefore preventability is an issue. We are not proposing to include CDAD as one of our initial hospital-acquired conditions at this time, given the lack of prevention guidelines. We welcome public comments on CDAD, specifically on its preventability and whether there is potential to develop guidelines to identify it early in the disease process and/or diminish its incidence. We will reevaluate the selection of this condition in FY 2009. (j) Methicillin-Resistant Staphylococcus Aureus (MRSA) Coding—MRSA is identified by ICD-9-CM code V09.0 (Infection with microorganisms resistant to penicillins). One would also assign a code(s) to describe the exact nature of the infection. Burden (High Cost/High Volume)—For FY 2006, there were 95,103 reported cases of Medicare patients who had MRSA as a secondary diagnosis. The average charges for these cases were $31,088. This condition is a high-cost and high-volume infection. MRSA has become a very common bacteria occurring both in and outside of the hospital environment. Prevention guidelines—CDC guidelines are located at the following Web site: 
                        *http://www.cdc.gov/​ncidod/​dhqp/​pdf/​ar/​mdroGuideline2006.pdf*. CC—Code V09.0 is not a CC under the current CMS DRGs and the proposed 
                        ( print page 24724)
                        MS-DRGs. The specific infection would be identified in a code describing the exact nature of the infection, which may be a CC. Considerations—As stated earlier, preventability may be hard to ascertain since the bacteria has become so common both inside and outside the hospital. There are also considerations in identifying MRSA infections because hospitals would report the code for MRSA along with additional codes that would describe the exact nature of the infection. We would have to develop a list of specific infections that could be the result of MRSA. We are not proposing to include MRSA as one of our initial hospital-acquired conditions because the condition is not a CC. We recognize that associated conditions may be a CC. We welcome comments on the proposal not to include this condition. Should there be support for including this condition, we request recommendations on what codes might be selected to identify the specific types of infections associated with MRSA. (k) Surgical Site Infections Coding—Surgical site infections are identified by ICD-9-CM code 998.59 (Other postoperative infection). The code does not tell the exact location or nature of the postoperative wound infection. The code includes wound infections and additional types of postoperative infections such as septicemia. The coding guidelines instruct the coder to add an additional code to identify the type of infection. To implement this condition we would have to remove both code 998.59 and the specific infection from counting as a CC if they occurred after the admission. We would have to develop an extensive list of possible infections that would be subject to the provision. We may also need to recommend the creation of a series of new ICD-9-CM codes to identify various types of surgical site infections, should this condition merit inclusion among those that are subject to the proposed hospital-acquired conditions provision. Burden (High Cost/High Volume)—CDC reports that there are 290,485 surgical sites infections each year. As stated earlier, there is not a unique code for surgical site infection. Therefore, we examined Medicare data on patients with any type of postoperative infection. For FY 2006, there were 38,763 reported cases of Medicare patients who had a postoperative infection. These patients had average charges for the hospital stay of $79,504. We are unable to determine how many of these patients had surgical site infections. Prevention guidelines—CDC guidelines are available at the following Web site: 
                        *http://www.cdc.gov/​ncidod/​dhqp/​gl_​surgicalsite.html* CC—Code 998.59 is a CC under the current CMS DRGs and the proposed MS-DRGs. Considerations—As mentioned earlier, code 998.59 is not exclusive to surgical site infections. It includes other types of postoperative infections. Therefore, code 998.59 does not currently meet the statutory criteria for being subject to the provision because it does not uniquely identify surgical site infections. To identify surgical site infections, we would need new codes that provide more detail about the type of postoperative infection as well as the site of the infection. In addition, one would report both code 998.59 as well a more specific code for the specific type of infection, making implementation difficult. While there are prevention guidelines, it is not always possible to identify the specific types of surgical infections that are preventable. Therefore, we are not proposing to select surgical site infections as one of our proposed hospital-acquired conditions at this time. However, we welcome public comments on whether we can develop criteria and codes to identify preventable surgical site infections that would assist us in reducing their incidence. We are exploring ways to identify surgical site infections and will reevaluate this condition in FY 2009. (l) Serious Preventable Event—Surgery on Wrong Body Part, Patient, or Wrong Surgery Coding—Surgery performed on the wrong body part, wrong patient, or the wrong surgery would be identified by ICD-9-CM code E876.5 (Performance of inappropriate operation). This diagnosis code does not specifically identify which of these events has occurred. Burden (High Cost/High Volume)—As stated earlier, there are not unique ICD-9-CM codes which capture surgery performed on the wrong body part or the wrong patient, or the wrong surgery. Therefore, we examined Medicare data on the code for performance of an inappropriate operation. For FY 2006, there was one Medicare case reported with this code, and the patient had average charges for the hospital stay of $24,962. This event is rare. Therefore, it is not high volume. Individual cases could have high costs. However, we were unable to determine the impact with our limited data. Prevention guidelines—There are prevention guidelines for performing the correct surgery on the correct patient or correct patient's body part. This event should not occur. CC—This code is not a CC under the current CMS DRGs and the proposed MS-DRGs. Therefore, it does not meet the criteria for selection under section 1886(d)(4)(D)(iv) of the Act. However, Medicare does not pay for performing surgery on the wrong body part or patient, or performing the wrong surgery. These services are not considered to be reasonable and necessary and are excluded from Medicare coverage. Considerations—There are significant considerations for the selection of this condition. There is not a unique ICD-9-CM code that would describe the nature of the inappropriate operation. All types of inappropriate operations are included in code E876.5. Unlike other conditions, performance of an inappropriate operation is not a complication of a prior medical event that was medically necessary. Rather, in this case, there was a needed intervention but it was done to either the wrong body part or the wrong patient, or was not the correct operation. Thus, a service was completed that was not reasonable and necessary and Medicare does not pay for any inpatient service associated with the wrong surgery. It is not necessary for us to select this condition because Medicare does not pay for it under any circumstances. (m) Falls Coding—There is no single code that shows that a patient has suffered a fall in the hospital. Codes would be assigned to identify the nature of any resulting injury from the fall such as a fracture, contusion, concussion, etc. There is a code to indicate that a patient fell from bed, code E884.4 (Fall from bed). One would then assign a code that identifies the external cause of the injury (the fall from the bed) and an additional code(s) for any resulting injury (a fractured bone). Burden (High Cost/High Volume)—As stated earlier, there is not a code to capture all types of falls. Therefore, we examined Medicare data on the number of Medicare beneficiaries who fell out of bed. For FY 2006, there were 2,591 cases reported of Medicare patients who fell out of bed. These patients had average charges of the hospital stay of $24,962. However, depending on the nature of the injury, costs may vary in specific cases. Prevention guidelines—Falls may or may not be preventable. Serious preventable event guidelines can be found at the following Web site: 
                        *http://www.qualityindicators.ahrq.gov/​psi_​download.htm*( print page 24725) CC—Code E884.4 is not a CC under the current CMS DRGs or the proposed MS-DRGs. Considerations—There are not clear codes that identify all types of falls. Hospitals would also have to use additional codes for fractures and other injuries that result from the fall. In addition, depending on the circumstances, the falls may or may not be preventable. We are not proposing the inclusion of falls as one of our initial hospital-acquired conditions at this time because we can only identify a limited number of these cases, and they are not classified as a CC. However, we welcome public comments on how to develop codes or coding logic that would allow us to identify injuries that result from falls in the hospital so that Medicare would not recognize the higher costs associated with treating patients who acquire these conditions in the hospital. We will reevaluate this condition in FY 2009. The following table summarizes whether or not the potential conditions meet our criteria and if there are significant considerations with selecting the particular condition. As mentioned earlier, we have listed these conditions in the priority order according to how well they meet the statutory criteria. As discussed earlier, we are proposing to select the first six conditions (catheter associated urinary tract infections through Staphylococcus aureus septicemia) as our initial hospital-acquired conditions. We would not include the last seven conditions (ventilator-associated pneumonia through falls) as initial hospital-acquired conditions. We welcome comments on how appropriately we have evaluated and proposed the selection of the first six conditions. We also encourage specific comments on any additional conditions we should select for October 1, 2008 implementation. We request commenters to include a rationale for selecting any suggested additional conditions, as well as an analysis of why each suggested additional condition meets the criteria under section 1886(d)(4)(D)(iv) of the Act and whether there would be coding issues or other considerations associated with selecting each condition. Proposed Hospital-Acquired Conditions and Criteria
Proposed hospital-acquired condition
Coding—unique code?
Burden—high cost and/or high volume?
Prevention guidelines?
CC?
Considerations?1. Catheter associated urinary tract infections
Yes
Yes
Yes
Yes
Minimal—additional infection codes.2. Pressure ulcers (Decubitus ulcers)
Yes
Yes
Yes
Yes
No.3. Serious preventable event—Object left in surgery
Yes
Yes—high cost in specific circumstances
Yes
Yes
No.4. Serious preventable event—air embolism
Yes
Yes—high cost in specific circumstances
Yes
Yes
No .5. Serious preventable event—Blood incompatibility
Yes
Yes—high cost in specific circumstances
Yes
Yes
No.6. Staphylococcus aureus septicemia
Yes—multiple codes reported
Yes
Yes
Yes
Multiple codes.7. Ventilator associated pneumonia (VAP)/Pneumonia/
No VAP code, multiple pneumonia codes
Yes
Yes
No—no unique codes
Preventability issues. VAPs—identification issues.8. Vascular catheter associated infections
No
Yes
Yes
Yes—but code is too broad
Preventability issues.9. Clostridium difficile-associated disease (CDAD)
Yes
Yes
No
Yes
Preventability issues.10. Methicillin-resistant staphylococcus aureus (MRSA)
Yes
Yes
Yes
No
Preventability issues.11. Surgical site infections
No
Yes
Yes
Yes—but code is too broad
Cannot identify.12. Serious preventable event—Wrong surgery
Yes
Yes—high cost in specific circumstances
Yes
No
Not a CC.13. Falls
No—not for all types of falls
Yes—high cost in specific circumstances
No—for all types of falls
No
Cannot identify.
 As stated earlier, we are soliciting comments on the six conditions we proposed to include among the initial hospital-acquired conditions. We welcome any comments on the clinical aspects of the conditions and on which conditions should be selected for implementation on October 1, 2008. We also solicit comments on any problematic issues for specific conditions that may support not selecting them as one of the initial conditions. We encourage comments on how some of the administrative problems can be overcome if there is support for a particular condition. 7. Other Issues Under section 1886(d)(4)(D)(vi) of the Act, “[a]ny change resulting from the application of this subparagraph shall not be taken into account in adjusting the weighting factors under subparagraph (C)(i) or in applying budget neutrality under subparagraph (C)(iii).” Subparagraph (C)(i) refers to DRG classifications and relative weights. Therefore, the statute requires the Secretary to continue counting the conditions selected under section 5001(c) of the DRA as MCCs or CCs when updating the relative weights annually. Thus, the higher costs 
                        ( print page 24726)
                        associated with a case with a hospital-acquired MCC or CC will continue to be assigned to the MCC or CC DRG when calculating the relative weight but payment will not be made to the hospital at one of these higher-paying DRGs. Further, subparagraph (C)(iii) refers to the budget neutrality calculations that are done so aggregate payments do not increase as a result of changes to DRG classifications and relative weights. Again, the higher costs associated with the cases that have a hospital-acquired MCC or CC will be included in the budget neutrality calculation but Medicare will make a lower payment to the hospital for the specific case that include an MCC or CC. Thus, to the extent that the provision applies and cases with an MCC or CC are assigned to a lower-paying DRG, section 5001(c) of the DRA will result in cost savings to the Medicare program. We note that the provision will only apply when the selected conditions are the only MCCs and CCs present on the claim. Therefore, if a nonselected MCC or CC is on the claim, the case will continue to be assigned to the higher paying MCC or CC DRG, and there will be no savings to Medicare from the case. We believe the provision will apply in a small minority of cases because it is rare that one of the selected conditions will be the only MCC or CC present on the claim. We provide our estimate of the savings associated with this provision in the impact section of this proposed rule. G. Proposed Changes to Specific DRG Classifications 1. Pre-MDC: Intestinal Transplantation (If you choose to comment on issues in this section, please include the caption “DRGs: Intestinal Transplantation” at the beginning of your comment.) In the FY 2005 IPPS final rule (69 FR 48976), we reassigned intestinal transplant cases from CMS DRG 148 (Major Small and Large Bowel Procedures with CC) and CMS DRG 149 (Major Small and Large Bowel Procedures without CC) to CMS DRG 480 (Liver Transplant and/or Intestinal Transplantation). In the FY 2006 IPPS final rule (70 FR 47286), we continued to evaluate these cases to see if a further DRG change was warranted. While we found that intestinal only transplants and combination liver-intestine transplants have higher average charges than other cases in CMS DRG 480, these cases are extremely rare (there were only 4 cases in FY 2004) and the insufficient number of cases does not warrant creating a separate DRG. For FY 2008, we examined the September 2006 update of the FY 2006 MedPAR file and found 1,208 cases assigned to CMS DRG 480. In the proposed MS-DRGs described in section II.C. of the preamble of this proposed rule, we are proposing to split CMS DRG 480 into two severity levels: proposed MS-DRG 005 (Liver Transplant and/or Intestinal Transplant with MCC) and proposed MS-DRG 006 (Liver Transplant and/or Intestinal Transplant without MCC). The following table displays our results: Proposed MS-DRG
Number of cases
Average length of stay
Average chargesMS-DRG 006—All cases
446
10.05
$129,519MS-DRG 006—Intestinal transplant cases only
3
34
354,793MS-DRG 005—All cases
762
22.25
243,271MS-DRG 005—Intestinal transplant cases only
9
40.22
460,089MS-DRG 005—Intestinal and liver transplant
1
56
1,179,425
 Under the proposed MS-DRGs, 10 of 13 intestinal transplant cases are assigned to proposed MS-DRG 005 based on the secondary diagnosis of the patient. The three remaining intestinal transplant cases do not have an MCC and would have been assigned to proposed MS-DRG 006, absent further changes to the DRG logic. These three intestinal transplants have average charges of approximately $354,793 and an average length of stay of 34 days. Average charges and length of stay for these three cases are more comparable to the average charges of approximately $243,271 and average length of stay of 40.22 days for all cases assigned to proposed MS-DRG 005. For this reason, we are proposing to move all intestinal transplant cases to proposed MS-DRG 005. As part of this proposal, we would redefine proposed MS-DRG 005 as “Liver Transplant with MCC or Intestinal Transplant.” The presence of a liver transplant with MCC or an intestinal transplant would assign a case to the higher severity level. Proposed MS-DRG would also be redefined as “Liver Transplant without MCC.” 2. MDC 1 (Diseases and Disorders of the Nervous System) a. Implantable Neurostimulators (If you choose to comment on issues in this section, please include the caption “DRGs: Neurostimulators” at the beginning of your comment.) We received a joint request from three manufacturers to review the DRG assignment for cases involving neurostimulators. The commenters are concerned that: Neurostimulator cases may be assigned to 30 different DRGs in 12 different MDCs depending upon the patient's principal diagnosis.
                    Neurostimulator cases represent a small proportion of the total cases in their assigned DRG and have higher costs.
                    The 11 new ICD-9-CM codes created beginning in FY 2007 that identify pain are assigned to MDC 23 (Factors Influencing Health Status and Other Contacts With Health Services) rather than MDC 1 (Diseases and Disorders of the Nervous System). The commenters are concerned that these pain codes will be a common principal diagnosis for patients who receive a neurostimulator and will be assigned to MDC 23, which contains a wide variety of dissimilar diagnoses. The new ICD-9-CM codes are: 338.0 (Central pain syndrome), 338.11 (Acute pain due to trauma), 338.12 (Acute post-thoracotomy pain), 338.18 (Other acute postoperative pain), 338.19 (Other acute pain), 338.21 (Chronic pain due to trauma), 338.22 (Chronic post-thoracotomy pain), 338.28 (Other chronic postoperative pain), 338.29 (Other chronic pain), 338.3 (Neoplasm related pain (acute)(chronic)), and 338.4 (Chronic pain syndrome) The commenters recommended that we: Reroute all spinal and peripheral neurostimulator cases into a common set of base DRGs.( print page 24727)
                    Reclassify ICD-9-CM pain codes 338.0 through 338.4 currently assigned to MDC 23 into MDC 1 when reported as principal diagnosis.
                    Revise surgical CMS DRGs in MDC 1 based on whether the patient received a major device.
                    Split the single surgical CMS DRG in MDC 19 (Mental Diseases and Disorders) and MDC 23 into two CMS DRGs: one CMS DRG for minor procedures as defined by CMS DRGs 477 (Non-Extensive O.R. Procedure Unrelated to Principal Diagnosis) and CMS DRG 468 (Extensive O.R. Procedure Unrelated to Principal Diagnosis) and one CMS DRG for major procedures.
                    Create a new CMS DRG in MDC 1 for major devices. The commenters recognize that implementing a re-routing feature in the CMS DRG system would be a major undertaking and, alternatively, suggested reassigning the pain codes to MDC 1 as an interim step. We agree with this suggestion as described further below. With respect to the suggestion to split the single surgical CMS DRG in MDCs 19 and 23 into two CMS DRGs and create a major device CMS DRG within MDC 1, we encourage the commenters to examine the assignment of neurostimulator cases under the MS-DRGs to determine whether the changes we are proposing to adopt to better recognize severity in the CMS DRG system would address these concerns. The implantation of a neurostimulator requires two types of procedures. First, the surgeons implant leads containing electrodes into the targeted section of the brain, spine, or peripheral nervous system. Second, a neurostimulator pulse generator is implanted into the pectoral region and extensions from the neurostimulator pulse generator are tunneled under the skin and connected with the proximal ends of the leads. Hospitals stage the two procedures required for a full system neurostimulator implant. There are separate ICD-9-CM procedure codes that identify the implant of the leads and the insertion of the pulse generator. The three codes for the leads insertion are: 02.93 (Implantation or replacement of intracranial neurostimulator lead(s)); 03.93 (Implantation or replacement of spinal neurostimulator lead(s)); and code 04.92 (Implantation or replacement of peripheral neurostimulator lead(s). The five codes for the insertion of the pulse generator are: 86.94 (Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable); 86.95 (Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable); 86.96 (Insertion or replacement of other neurostimulator pulse generator); 86.97 (Insertion or replacement of single array rechargeable neurostimulator pulse generator); and 86.98 (Insertion or replacement of dual array rechargeable neurostimulator pulse generator). The patient's principal diagnosis determines the MDC assignment. Implant of a cranial, spinal or peripheral neurostimulator will result in assignment of the case to a surgical DRG within that MDC. Although the commenters are correct that neurostimulator cases can potentially be assigned to many different CMS DRGs based on the patient's principal diagnosis, they also provided data that showed that nearly 90 percent are assigned to 6 different CMS DRGs that cross two MDCs. In MDC 1, neurostimulator cases are assigned to four CMS DRGs: CMS DRG 7 (Peripheral and Cranial Nerve and Other Nervous System Procedures With CC); CMS DRG 8 (Peripheral and Cranial Nerve and Other Nervous System Procedures Without CC); CMS DRG 531 (Spinal Procedures With CC); and CMS DRG 532 (Spinal Procedures Without CC). In MDC 8 (Disease and Disorders of the Musculoskeletal System and Connective Tissue), neurostimulator cases are assigned to two CMS DRGs: CMS DRG 499 (Back and Neck Procedures Except Spinal Fusion With CC); and CMS DRG 500 (Back and Neck Procedures Except Spinal Fusion Without CC). With very limited exceptions, such as tracheostomies and certain types of transplants, the principal diagnosis is fundamental to the assignment of a case to an MDC within the DRG system. By relying on the patient's principal diagnosis, the DRG system will group together patients who are clinically similar. For this reason, we are concerned about adopting the suggestion that all neurostimulator cases be rerouted to a common DRG irrespective of the patient's principal diagnosis. We believe such a step would be fundamentally inconsistent with the idea of creating common groups of patients who are clinically similar based on diagnosis and procedures. For this reason, we do not believe that a rerouting step should be adopted that would group together all neurostimulator cases. However, we do agree with the commenters' suggestion that the new ICD-9-CM codes created in FY 2007 for central and chronic pain syndrome and chronic pain (codes 338.0, 338.21 through 338.29, and 338.4) should be assigned to MDC 1 when present as the principal diagnosis. The commenters requested that we reclassify the pain codes (338.0 through 338.4) from MDC 23 to MDC 1. Our medical consultants advised that the acute pain codes (codes 338.11 through 338.19) should remain in MDC 23 because the acute pain is not a neurological condition. According to the commenters, the National Center for Health Statistics' (NCHS) choice in locating the pain codes within ICD-9-CM's Nervous System chapter has much clinical validity, particularly for chronic pain. The commenters further noted that acute pain is typically self-limited, a symptomatic response to an immediate insult that serves the body as a warning sign. However, chronic pain is unrelenting and serves no warning or protective function. It is a disease process of its own accord, according to the commenters. The commenters described pain as follows. Broadly, there are two main categories of pain: nociceptive and neuropathic. Nociceptive pain is caused by sensory neurons, called nociceptors, responding to tissue damage. This type of pain is the body's normal response to injury. The pain is usually localized and time-limited. That is, when the tissue damage heals, the pain typically resolves. Acute pain is typically nociceptive. In general, nociceptive pain is typically treated with anti-inflammatories and, in more severe cases, with opioids via a morphine pump for example. In contrast, neuropathic pain is caused by malfunctioning or pathologically altered nervous pathways stemming from injury to the nervous system, either as a direct result of trauma to a nerve (phantom limb syndrome, reflex sympathetic dystrophy/complex regional pain syndrome after injury) or due to other medical conditions that cause damage to the nerve such as herpes (postherpetic neuralgia), diabetes (diabetic neuropathy), and peripheral vascular disease (critical limb ischemia). Failed back surgery syndrome (FBSS) is another common source of neuropathic pain. Typically, neuropathic pain is chronic and may persist for months or years beyond the healing of damaged tissue. Because the nerves themselves have been damaged, neuropathic pain can be considered its own disease process. Neuropathic pain may be more difficult to treat than nociceptive pain and has been shown to be more responsive to neurostimulation. The pain codes, created effective October 1, 2006, are currently assigned to MDC 23. The neurostimulator cases with a principal diagnosis using the pain codes were assigned to CMS DRG 
                        ( print page 24728)
                        461 (O.R. Procedure With Diagnoses of Other Contact With Health Services) for the first time in FY 2007. As explained above, prior to our adoption of the new pain codes in FY 2007, these cases had historically been assigned to CMS DRGs 7 and 8 (Peripheral and Cranial Nerve and Other Nervous System Procedure With and Without CC, respectively) tin MDC 1. Adopting the commenters' recommendation would result in the neurostimulator cases being assigned to their historic CMS DRGs. Our medical officers agree that cases that use the new pain diagnosis codes for central and chronic pain syndrome and chronic pain (codes 338.0, 338.21 through 338.29, and 338.4) as a principal diagnosis should be assigned to MDC 1. For this reason, we are proposing to assign cases with a principal diagnosis of central pain syndrome (code 338.0), chronic pain due to trauma (code 338.21), chronic post-thoracotomy pain (code 338.22), other chronic postoperative pain (code 338.28), other chronic pain (code 338.29), or chronic pain syndrome (code 338.4) to MDC 1, although we plan to monitor their use and may reassign them if needed. b. Intracranial Stents (If you choose to comment on issues in this section, please include the caption “DRGs: Intracranial Stents” at the beginning of your comment.) Effective October 1, 2004, the ICD-9-CM Coordination and Maintenance Committee created procedure code 00.62 (Percutaneous angioplasty or atherectomy of intracranial vessel(s)). At the same time, we created code 00.65 (Percutaneous insertion of intracranial vascular stent(s)). It is our customary practice to assign new codes to the same DRG as their predecessor codes. Code 00.62 was removed from code 39.50 (Angioplasty or atherectomy of other noncoronary vessel(s)), which is assigned to CMS DRG 533 (Extracranial Procedures with CC) and CMS DRG 534 (Extracranial Procedures Without CC) (proposed MS-DRGs 37, 38, and 39 (Extracranial Procedures With MCC, With CC, and Without CC/MCC, respectively)) when the patient has principal diagnosis in MDC 1. Therefore, we assigned code 00.62 to CMS DRGs 533 and 534 in MDC 1 beginning in FY 2005. In addition, we made code 00.65 a non-O.R. procedure for DRG assignment. We also assigned code 00.62 to the Non-Covered Procedure edit of the MCE, as Medicare had a national noncoverage determination for intracranial angioplasty and atherectomy with stenting. Effective November 7, 2006, Medicare covers percutaneous transluminal angioplasty (PTA) and stenting of intracranial arteries for the treatment of cerebral artery stenosis in cases in which stenosis is 50 percent or greater in patients with intracranial atherosclerotic disease when furnished in accordance with FDA-approved protocols governing Category B Investigational Device Exemption (IDE) clinical trials. CMS determined that coverage of intracranial PTA and stenting is reasonable and necessary under these circumstances. All other indications for PTA without stenting to treat obstructive lesions of the vertebral and cerebral arteries remain noncovered. This decision can be found online in the CMS Coverage Manual: 
                        *http://www.cms.hhs.gov/​Manuals/​IOM/​itemdetail.asp*
                         at section 20.7.B.5. A manufacturer recently met with CMS to request that code 00.62 be reassigned to CMS DRGs 1 and 2 (Craniotomy Age > 17 With and Without CC, respectively) (proposed MS-DRGs 37 (Extracranial Procedures With MCC), 38 (Extracranial Procedures With CC), and 39 (Extracranial Procedures Without CC/MCC)) and CMS DRG 543 (Craniotomy with Major Device Implant or Acute Complex Central Nervous System Principal Diagnosis) (proposed MS-DRGs 23 and 24 (Craniotomy With Major Device Implant or Acute Complex Central Nervous System Principal Diagnosis With MCC and Without MCC, respectively). The manufacturer noted that other similar endovascular intracranial procedures that treat a cerebrovascular blockage are currently assigned to the craniotomy CMS DRGs. These endovascular-approach cases already assigned to the craniotomy CMS DRGs are identified by procedure codes 39.72 (Endovascular repair or occlusion of head and neck vessels), 39.74 (Endovascular removal of obstruction from head and neck vessel(s)), and 39.79 (Other endovascular repair (of aneurysm) of other vessels). Under the proposed MS-DRGs, we are proposing to assign procedure codes 39.72, 39.74, and 39.79 to MS-DRGs 011 through 013 and MS-DRG 543. Although we are concerned about the assignment of additional endovascular procedures to an open surgical DRG, we agree that there is clinical consistency between procedure codes 39.72, 39.74, and 39.79 and procedure code 00.62. For this reason, we agree that procedure code 00.62 should be assigned to CMS DRGs 1, 2, and 543 (proposed MS-DRGs 37, 38, and 39 and 243 and 24, respectively, that are divided by the presence or absence of specific CCs). For FY 2008, we are proposing to remove code 00.62 from CMS DRGs 533 and 534 and assign them to proposed MS-DRGs 37, 38, and 39, as well as to proposed MS-DRGs 23 and 24. In order to assure appropriate DRG assignment as described above, we are proposing to make conforming changes to the MCE by removing code 00.62 from the Non-Covered Procedure edit. However, as intracranial PTA is only covered when performed in conjunction with insertion of a stent, we are proposing to redefine the edit by specifying that code 00.62 must be accompanied by code 00.65 (Percutaneous insertion of intracranial vascular stent(s)). Should code 00.65 not be reported on the claim, the case would fail the MCE edit. For a full discussion of this proposed change, we refer readers to the MCE discussion in section II.F.6. of the preamble of this proposed rule. Although we are proposing to assign endovascular intracranial procedures to the same DRG as craniotomy, we remain concerned that endovascular intracranial procedures are clinically different than open craniotomy surgical procedures and may have very different resource requirements. At the current time, there are an insufficient number of cases to warrant creation of a separate base DRG for endovascular intracranial procedures. However, we intend to revisit the assignment of intracranial endovascular procedures at a later date when more data are available to analyze these cases. 3. MDC 3 (Diseases and Disorders of the Ear, Nose, Mouth, and Throat)—Cochlear Implants (If you choose to comment on issues in this section, please include the caption “DRGs: Cochlear Implants” at the beginning of your comment.) Cochlear implants were first covered by Medicare in 1986 and were assigned to CMS DRG 49 (Major Head and Neck Procedures) in MDC 3 (Diseases and Disorders of the Ear, Nose, Mouth, and Throat). CMS DRG 49 is the highest weighted DRG in that MDC. However, two manufacturers of cochlear implants contend that this DRG assignment is clinically and economically inappropriate and have requested that cochlear implant cases be reassigned from CMS DRG 49 to CMS DRG 543 (Craniotomy With Major Device Implant or Acute Complex Central Nervous System Principal Diagnosis). The manufacturers stated that procedures assigned to CMS DRG 49 are performed mostly for diseases such as head and neck cancers, while procedures in CMS DRG 543 include 
                        ( print page 24729)
                        operations on and inside the skull and implantation of complex devices, including intracranial neurostimulators. The manufacturers described the cochlear implant procedure as requiring incisions behind the ear to remove a section of the temporal bone, followed by microscopic neurotologic surgery under general anesthesia, and is typically completed in 2 to 4 hours to restore hearing to the profoundly deaf. For these reasons, these manufacturers believe cochlear implant procedures are similar to open craniotomies. Based on their analysis of the FY 2005 MedPAR data, the manufacturers identified a total of 139 cochlear implant cases using ICD-9-CM procedure codes 20.96 (Implantation or replacement of cochlear prosthetic device NOS), 20.97 (Implantation or replacement of cochlear prosthetic device, single channel), and 20.98 (Implantation or replacement of cochlear prosthetic device, multiple channel). The manufacturers reported 121 out of 139 cochlear implant cases were assigned to CMS DRG 49 with average standardized charges of approximately $58,078. When we reviewed the FY 2006 MedPAR data, we identified 104 cochlear implant cases assigned to CMS DRG 49. In the proposed MS-DRGs, CMS DRG 49 is subdivided into two severity levels: Proposed MS-DRG 129 (Major Head and Neck Procedures With CC or MCC) and proposed MS-DRG 130 (Major Head and Neck Procedures Without CC). The following table displays our results: Proposed MS-DRG
Number of cases
Average length of stay
Average chargesMS-DRG 130—All cases
1,095
3.04
$23,928MS-DRG 130—Code 20.96 cases only
38
1.63
51,740MS-DRG 130—Code 20.97 only
2
1.50
38,855MS-DRG 130—Code 20.98 only
45
1.24
50,219MS-DRG 129—All cases
1,244
5.35
34,169MS-DRG 129—Code 20.96 only
10
2.70
81,351MS-DRG 129—Code 20.97 only
1
5.00
95,441MS-DRG 129—Code 20.98 only
8
3.13
53.510
 Under the proposed MS-DRGs, 19 out of 104 cochlear implant cases are assigned to proposed MS-DRG 129 based on the secondary diagnosis of the patient. The 85 remaining cochlear implant cases do not have a CC or MCC and would be assigned to proposed MS-DRG 130, absent further changes to the DRG logic. The average charges of approximately $54,238 for cochlear implant cases are higher than the average charges of approximately $29,375 for the other cases in CMS DRG 49. However, the average charges are not as high as the average charges of approximately $78,118 for cases assigned to CMS DRG 543. Further, our medical advisors do not believe that surgery to implant a cochlear implant is clinically similar to an open craniotomy in MDC 1 because typically a craniotomy involves removing and then replacing a section of the skull in order to perform a procedure on or within the brain, whereas a cochlear implant involves drilling a hole in the mastoid bone in order to insert the implant into the inner ear. We have been unable to address this issue under the current DRGs because there are not enough inpatient cochlear implant cases to warrant creation of a separate DRG. Although these cases will continue to have higher charges than other cases in their assigned DRG, we are proposing to move the cochlear implant cases to the higher DRG severity level within CMS DRG 49. As part of this proposal, we would redefine proposed MS-DRG 129 as “Major Head and Neck Procedures With CC or MCC or Major Device”. The presence of a major head and neck procedure with a CC or MCC or major device would assign the case to the higher severity level within CMS DRG 49. 4. MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue) a. Hip and Knee Replacements (If you choose to comment on issues in this section, please include the caption “DRGs: Hip and Knee Replacements” at the beginning of your comment.) In the FY 2006 IPPS final rule (70 FR 47303), we deleted DRG 209 (Major Joint and Limb Reattachment Procedures of Lower Extremity) and created two new DRGs: 544 (Major Joint Replacement or Reattachment of Lower Extremity) and 545 (Revision of Hip or Knee Replacement). The two new DRGs were created to identify that revisions of joint replacement procedures are significantly more resource intensive than original hip and knee replacements procedures. DRG 544 includes the following procedure code assignments: 81.51, Total hip replacement
                    81.52, Partial hip replacement
                    81.54, Total knee replacement
                    81.56, Total ankle replacement
                    84.26, Foot reattachment
                    84.27, Lower leg or ankle reattachment
                    84.28, Thigh reattachment DRG 545 includes the following procedure code assignments: 00.70, Revision of hip replacement, both acetabular and femoral components
                    00.71, Revision of hip replacement, acetabular component
                    00.72, Revision of hip replacement, femoral component
                    00.73, Revision of hip replacement, acetabular liner and/or femoral head only
                    00.80, Revision of knee replacement, total (all components)
                    00.81, Revision of knee replacement, tibial component
                    00.82, Revision of knee replacement, femoral component
                    00.83, Revision of knee replacement, patellar component
                    00.84, Revision of knee replacement, tibial insert (liner)
                    81.53, Revision of hip replacement, not otherwise specified
                    81.55, Revision of knee replacement, not otherwise specified Further, we created a number of new ICD-9-CM procedure codes effective October 1, 2005, that better distinguish the many different types of joint replacement procedures that are currently being performed. In the FY 2006 IPPS final rule (70 FR 47305), we indicated that a commenter had requested that, once we receive claims data using the new procedure codes, we closely examine data from the use of the codes under the two new DRGs to determine if future additional DRG modifications are needed. Further, the American Association of Hip & Knee Surgeons (AAHKS) recommended that we make further 
                        ( print page 24730)
                        refinements to the DRGs for knee and hip arthroplasty procedures. AAHKS previously presented data to CMS on the important differences in clinical characteristics and resource utilization between primary and revision total joint arthroplasty procedures. AAHKS stated that CMS' decision to create a separate DRG for revision of total joint arthroplasty (TJA) in October 2005 resulted in more equitable reimbursement for hospitals that perform a disproportionate share of complex revision of TJA procedures, recognizing the higher resource utilization associated with these cases. AAHKS stated that this important payment policy change led to increased access to care for patients with failed total joint arthroplasties, and ensured that high volume TJA centers could continue to provide a high standard of care for these challenging patients. AAHKS further stated that the addition of new, more descriptive ICD-9-CM diagnosis and procedure codes for TJA in October 2005 gave it the opportunity to further analyze differences in clinical characteristics and resource intensity among TJA patients and procedures. Inclusive of the preparatory work to submit its recommendations, the AAHKS compiled, analyzed, and reviewed detailed clinical and resource utilization data from over 6,000 primary and revision TJA procedure codes from 4 high volume joint arthroplasty centers located within different geographic regions of the United States: University of California, San Francisco, CA; Mayo Clinic, Rochester, MN; Massachusetts General Hospital, Boston, MA; and the Hospital for Special Surgery, New York, NY. Based on its analysis, AAHKS recommended that CMS examine Medicare claims data and consider the creation of separate DRGs for total hip and total knee arthroplasty procedures. DRG 545 currently contains revisions of both hip and knee replacement procedures. AAHKS stated that based on the differences between patient characteristics, procedure characteristics, resource utilization, and procedure code payment rates between total hip and total knee replacements, separate DRGs were warranted. Furthermore, AAHKS recommended that CMS create separate base DRGs for routine versus complex joint revision or replacement procedures as shown below. Routine Hip Replacements 00.73, Revision of hip replacement, acetabular liner and/or femoral heal only
                    00.85, Resurfacing hip, total, acetabulum and femoral head
                    00.86, Resurfacing hip, partial, femoral head
                    00.87, Resurfacing hip, partial, acetabulum
                    81.51, Total hip replacement
                    81.52, Partial hip replacement
                    81.53, Revision of hip replacement, not otherwise specified Complex Hip Replacements 00.70, Revision of hip replacement, both acetabular and femoral components
                    00.71, Revision of hip replacement, acetabular component
                    00.72, Revision of hip replacement, femoral component Routine Knee Replacements and Ankle Procedures 00.83, Revision of knee replacement, patellar component
                    00.84, Revision of knee replacement, tibial insert (liner)
                    81.54, Revision of knee replacement, not otherwise specified
                    81.55, Revision of knee replacement, not otherwise specified
                    81.56, Total ankle replacement Complex Knee Replacements and other reattachments 00.80, Revision of knee replacement, total (all components)
                    00.81, Revision of knee replacement, tibial component
                    00.82, Revision of knee replacement, femoral component
                    84.26, Foot reattachment
                    84.27, Lower leg or ankle reattachment
                    84.28, Thigh reattachment AAHKS also recommended the continuation of DRG 471 (Bilateral or Multiple Major Joint Procedures of Lower Extremity) without modifications. DRG 471 includes any combination of two or more of the following procedure codes: 00.70, Revision of hip replacement, both acetabular and femoral components
                    00.80, Revision of knee replacement, total (all components)
                    00.85, Resurfacing hip, total, acetabulum and femoral head
                    00.86, Resurfacing hip, partial, femoral head
                    00.87, Resurfacing hip, partial, acetabulum
                    81.51, Total hip replacement
                    81.52, Partial hip replacement
                    81.54, Total knee replacement
                    81.56, Total ankle replacement As discussed in section II.C. of the preamble of this proposed rule, we are proposing to adopt MS-DRGs to better recognize severity of illness for FY 2008. The proposed MS-DRGs include two new severity of illness levels under the current base DRG 544. We are also proposing to add three new severity of illness levels to the base DRG for Revision of Hip or Knee Replacement (currently DRG 545). The new MS-DRGs are as follows: Proposed MS-DRG 466 (Revision of Hip or Knee Replacement with MCC)
                    Proposed MS-DRG 467 (Revision of Hip or Knee Replacement with CC)
                    Proposed MS-DRG 468 (Revision of Hip or Knee Replacement without CC)
                    Proposed MS-DRG 483 (Major Joint Replacement or Reattachment of Lower Extremity with CC/MCC)
                    Proposed MS-DRG 484 (Major Joint Replacement or Reattachment of Lower Extremity without CC/MCC) We found that the proposed MS-DRGs greatly improved our ability to identify joint procedures with higher resource costs. The following table indicates the average charges for each new proposed MS-DRG for the joint procedures. Proposed MS-DRGs That Replace DRGs 544 and 535 With New Severity Levels
Proposed MS-DRG
Number of cases
Average length of stay
Average  chargesMS-DRG 466
390,344
4.03
$33,465.85MS-DRG 467
28,211
8.46
53,676.09MS-DRG 468
26,718
4.06
38,720.28MS-DRG 483
10,078
6.06
48,575.01MS-DRG 484
3,886
9.55
69,649.08
 
 
 AAHKS analyzed Medicare data under the current DRG system and was unaware of how its analysis would change under the proposed MS-DRGs. Under the current DRGs, the AAHKS recommendation would replace 2 DRGs with 4 new ones. However, under the proposed MS-DRGs, the AAHKS recommendation would result in 5 DRGs becoming 12. Because AAHKS is recommending four new joint replacement DRGs (two for knees and two for hips), each would need to be subdivided into severity levels under our proposed MS-DRG system. Therefore, the four new joint DRGs could be subdivided into three levels each, leading to 12 new DRGs. At this time, we believe that the changes we are proposing to make to adopt the proposed MS-DRGs are sufficiently better for recognizing severity of illness among the hip and knee replacement cases. We do not believe that there would be significant improvements in the proposed MS-DRGs recognition of severity of illness from creating an additional 7 DRGs. However, we acknowledge the valuable assistance the AAHKS has provided to CMS in creating the new joint replacement procedure codes and modifying the joint replacement DRGs beginning in FY 2006. These efforts greatly improved our ability to categorize significantly different groups of patients according to severity of illness. We welcome comments from AAHKS on whether the proposed MS-DRGs recognize patient complexity and severity of illness in the hip and knee replacement DRGs consistent with the concerns it expressed to us in previous comments. We also welcome public comments from others as well on whether the proposed changes to the hip and knee replacement DRGs better recognize severity of illness and complexity of these operations in the Medicare patient population. b. Spinal Fusions (If you choose to comment on issues in this section, please include the caption “DRGs: Spinal Procedures” at the beginning of your comment.) In the FY 2007 final rule (71 FR 47947), we discussed a request that urged CMS to consider applying a severity concept to all of the back and spine surgical cases, similar to the approach that was used in the FY 2006 final rule in refining the cardiac DRGs with an MCV. Specifically, the commenter recommended that the use of spinal devices be uniquely identified within the spine DRGs. The commenter's suggestion involved the development of 10 new spine DRGs as well as additional modifications. One of these modifications included revising DRG 546 (Spinal Fusions Except Cervical with Curvature of the Spine or Malignancy). The commenter stated DRG 546 did not adequately recognize clinical severity or the resource differences among spinal fusion patients whose surgeries include fusing multiple levels of their spinal vertebrae. We agreed with the commenter that it was important to recognize severity when classifying groups of patients into specific DRGs. In addition, in response to recommendations from MedPAC's March 2005 Report to Congress, we stated that we were conducting a comprehensive analysis of the entire DRG system to determine if we could better identify severity of illness. We further stated that until results from our analysis were available, it would be premature to implement a severity concept for the spine DRGs. Therefore, we did not make any adjustments to those DRGs at that time. Under the proposed MS-DRGs described in section II.D. of the preamble of this proposed rule, we are proposing a number of refinements that would better recognize severity for FY 2008. The proposed MS-DRGs include several refinements to the spine DRGs. These refinements are described in detail below. In the FY 2006 IPPS final rule, we noted that there are numerous innovations occurring in spinal surgery such as artificial spinal disc prostheses, kyphoplasty, vertebroplasty and the use of spine decompression devices. As part of our analysis of the DRG system for this proposed rule, we did a comprehensive review of the DRGs for spinal fusion and other back and neck procedures to determine whether additional refinements beyond the proposed MS-DRGs were necessary. We studied data from the FY 2006 MedPAR file for the entire group of spine DRGs. This group included DRG 496 (Combined Anterior/Posterior Spinal Fusion), DRGs 497 and 498 (Spinal Fusion Except Cervical With and Without CC, respectively), DRGs 499 and 500 (Back and Neck Procedures Except Spinal Fusion With and Without CC, respectively), DRGs 519 and 520 (Cervical Spinal Fusion With and Without CC, respectively), and DRG 546 (Spinal Fusion Except Cervical with Curvature of the Spine or Malignancy). As indicated earlier, we are proposing a two or three-way split for each of these spine DRGs to better recognize severity of illness, complexity of service, and resource utilization. In addition, we examined the procedure codes that identify multiple fusion or refusion of the vertebrae (codes 81.62 through 81.64) to determine if the data supported further refinement when a greater number of vertebrae are fused. In applying the proposed MS-DRG logic, CMS DRG 497 and 498 were collapsed and the result is a split with two severity levels: proposed MS-DRG 459 (Spinal Fusion Except Cervical With MCC) and proposed MS-DRG 460 (Spinal Fusion Except Cervical Without MCC). There were a total of 51,667 cases in proposed MS-DRGs 459 and 460. We identified 288 cases where nine or more noncervical vertebrae were fused (code 81.64) that currently are assigned to proposed MS-DRGs 459 and 460. The average charges and length of stay for cases in these MS-DRGs are closer to the average charges and length of stay for cases in proposed MS-DRGs 456 through 458 (Spinal Fusion Except Cervical With Curvature of the Spine or Malignancy With MCC, With CC, and Without CC, respectively). For example, in proposed MS-DRG 460, there were 238 cases with an average length of stay of 6.20 days and average charges of $110,908 when nine or more noncervical vertebrae are fused. There are an additional 50 cases where nine or more vertebrae were fused in proposed MS-DRG 459 with average charges of $171,839. Without any further modification to the proposed MS-DRGs, these cases would be assigned to proposed MS-DRGs 459 and 460 that have average charges of $59,698, and $99,298, respectively. The average charges for these cases are more comparable to $142,871, $95,489, and $77,528, respectively, for proposed MS-DRGs 456 through 458. We believe these data support assigning cases where nine or more noncervical vertebrae are fused from proposed MS-DRG 459 and 460 into proposed MS-DRG 456 through 458. The table below represents our findings. Proposed MS-DRG
Number of cases
Average length of stay
Average chargesMS-DRG 459 (Spinal Fusion Except Cervical With MCC)—All Cases
3,186
10.10
$99,298( print page 24732)MS-DRG 459 (Spinal Fusion Except Cervical With MCC)—Cases with Procedure Code 81.64 (Fusion or refusion of 9 or more vertebrae)
50
13.00
171.839MS-DRG 460 (Spinal Fusion Except Cervical Without MCC)—All Cases
48,481
4.36
59,698MS-DRG 460 (Spinal Fusion Except Cervical Without MCC)—Cases with Procedure Code 81.64 (Fusion or refusion of 9 or more vertebrae)
238
6.20
110,908MS-DRG 456 (Spinal Fusion Except Cervical With Curvature of the Spine or Malignancy With MCC)—All Cases
548
14.79
142,871MS-DRG 456 (Spinal Fusion Except Cervical With Curvature of the Spine or Malignancy With MCC)—Cases With Procedure Code 81.64 (Fusion or refusion of 9 or more vertebrae)
61
13.34
170,655MS-DRG 457 (Spinal Fusion Except Cervical With Curvature of the Spine or Malignancy With CC)—All Cases
1,500
8.14
95,489MS-DRG 457 (Spinal Fusion Except Cervical With Curvature of the Spine or Malignancy With CC)—Cases With Procedure Code 81.64 (Fusion or refusion of 9 or more vertebrae)
146
8.88
125,722MS-DRG 458 (Spinal Fusion Except Cervical With Curvature of the Spine or Malignancy Without CC—All Cases
1,340
4.58
77,528MS-DRG 458 (Spinal Fusion Except Cervical With Curvature of the Spine or Malignancy Without CC)—Cases With Procedure Code 81.64 (Fusion or refusion of 9 or more vertebrae)
81
6.21
123,823
 Therefore, we are proposing to move those cases that include fusing or refusing nine or more vertebrae from proposed MS-DRGs 459 and 460 into proposed MS-DRGs 456 through 458. This proposed modification would include revising the MS-DRG title to reflect the fusion of nine or more vertebrae. The revised titles for proposed MS-DRGs 456 through 458 would be as follows: Proposed MS-DRG 456 (Spinal Fusion Except Cervical with Spinal Curvature or Malignancy or 9+ Fusions With MCC)
                    Proposed MS-DRG 457 (Spinal Fusion Except Cervical with Spinal Curvature or Malignancy or 9+ Fusions With CC)
                    Proposed MS-DRG 458 (Spinal Fusion Except Cervical with Spinal Curvature or Malignancy or 9+ Fusions Without CC/MCC) We invite public comment on this topic as well as on the additional changes we are proposing to the spine MS-DRGs discussed below. Further analysis demonstrates that spinal fusion cases with a principal diagnosis of tuberculosis or osteomyelitis also have higher average charges than other cases in CMS DRG 497 (proposed MS-DRGs 459 and 460) that are more similar to the cases assigned to CMS DRG 546 (proposed MS-DRGs 456 through 458). Although the volume of cases is relatively low, the data show very high average charges for these patients. The following tables display our results: Proposed MS-DRG
Number of cases
Average length of  stay
Average  chargesMS-DRG 459 (Spinal Fusion Except Cervical With MCC)
3,186
10.10
$99,298MS-DRG 460 (Spinal Fusion Except Cervical Without MCC)
48,481
4.36
59,698
 Proposed MS-DRG
Number of cases
Average length of stay
Average   chargesMS-DRG 456 (Spinal Fusion Except Cervical with Spinal Curvature or    Malignancy or 9+ Fusions With MCC)
548
14.79
$142,870MS-DRG 457 (Spinal Fusion Except Cervical with Spinal Curvature or    Malignancy or 9+ Fusions With CC)
1,500
8.14
95,489MS-DRG 458 (Spinal Fusion Except Cervical With Spinal Curvature or    Malignancy or 9+ Fusions Without CC/MCC)
1,340
4.58
77,528
 Tuberculosis and OsteomyelitisPrincipal diagnosis
Number of cases
Average  length of  stay
Average  chargesCodes 015.02, 015.04, 015.05, 730.08, 730.18 and 730.28
194
24.8
$128,073
 For this reason, we are proposing to add the following diagnoses to the principal diagnosis list for proposed MS-DRGs 456 through 458: 015.02, Tuberculosis of bones and joints, vertebral column, bacteriological or histological examination unknown (at present)
                    015.04, Tuberculosis of bones and joints, vertebral column, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture
                    015.05, Tuberculosis of bones and joints, vertebral column, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically
                    730.08, Acute osteomyelitis of other specified sites( print page 24733)
                    730.18, Chronic osteomyelitis of other specified sites
                    730.28, Unspecified osteomyelitis of other specified sites For the complete list of principal diagnosis codes that lead to assignment of CMS DRG 546 (proposed MS-DRGs 496 through 498), we refer readers to section II.D.4.b. of the preamble of the FY 2007 IPPS final rule (71 FR 47947). c. Spinal Disc Devices Over the past several years, manufacturers of spinal disc devices have requested reassignment of DRGs for their products and applied for new technology add-on payments. CHARITETM
                         is one of these devices. CHARITETM
                         is a prosthetic intervertebral disc. On October 26, 2004, the FDA approved the CHARITETM
                         Artificial Disc for single level spinal arthroplasty in skeletally mature patients with degenerative disc disease between L4 and S1. On October 1, 2004, we created new procedure codes for the insertion of spinal disc prostheses (codes 84.60 through 84.69). We provided the CMS DRG assignments for these new codes in Table 6B of the FY 2005 IPPS proposed rule (69 FR 28673). We received comments on the FY 2005 proposed rule recommending that we change the assignments for these codes from CMS DRG 499 (Back and Neck Procedures Except Spinal Fusion With CC) and CMS DRG 500 (Back and Neck Procedures Except Spinal Fusion Without CC) to the CMS DRGs for spinal fusion, CMS DRG 497 (Spinal Fusion Except Cervical With CC) and CMS DRG 498 (Spinal Fusion Except Cervical Without CC) for procedures on the lumbar spine and to CMS DRGs 519 and 520 for procedures on the cervical spine. In the FY 2005 IPPS final rule (69 FR 48938), we indicated that CMS DRGs 497 and 498 are limited to spinal fusion procedures. Because the surgery involving the CHARITETM
                         Artificial Disc is not a spinal fusion, we decided not to include this procedure in these CMS DRGs. However, we stated that we would continue to analyze this issue and solicited further public comments on the DRG assignment for spinal disc prostheses. In the FY 2006 final rule (70 FR 47353), we noted that, if a product meets all of the criteria for Medicare to pay for the product as a new technology under section 1886(d)(5)(K) of the Act, there is a clear preference expressed in the statute for us to assign the technology to a DRG based on similar clinical or anatomical characteristics or costs. However, for FY 2006, we did not find that the CHARITETM
                         Artificial Disc met the substantial clinical improvement criterion and, thus, did not qualify as a new technology. Consequently, we did not address the DRG classification request made under the authority of this provision of the Act. We did evaluate whether to reassign the CHARITETM
                         Artificial Disc to different CMS DRGs using the Secretary's authority under section 1886(d)(4) of the Act (70 FR 47308). We indicated that we did not have Medicare charge information to evaluate CMS DRG changes for cases involving an implant of a prosthetic intervertebral disc like the CHARITETM
                         and did not make a change in its CMS DRG assignments. We stated that we would consider whether changes to the CMS DRG assignments for the CHARITETM
                         Artificial Disc were warranted for FY 2007, once we had information from Medicare's data system that would assist us in evaluating the costs of these patients. As we discussed in the FY 2007 IPPS proposed rule (71 FR 24036), we received correspondence regarding the CMS DRG assignments for the CHARITETM
                         Artificial Disc, code 84.65 (Insertion of total spinal disc prosthesis, lumbosacral). The commenter had previously submitted an application for the CHARITETM
                         Artificial Disc for new technology add-on payments for FY 2006 and had requested a reassignment of cases involving CHARITETM
                         implantation to CMS DRGs 497 and 498. The commenter asked that we examine claims data for FY 2005 and reassign procedure code 84.65 from CMS DRGs 499 and 500 into CMS DRGs 497 and 498. The commenter again stated the view that cases with the CHARITETM
                         Artificial Disc reflect comparable resource use and similar clinical indications as do those in CMS DRGs 497 and 498. If CMS were to reject reassignment of the CHARITETM
                         Artificial Disc to CMS DRGs 497 and 498, the commenter suggested creating two separate DRGs for lumbar disc replacements. On February 15, 2006, we posted a proposed national coverage determination (NCD) on the CMS Web site seeking public comment on our proposed finding that the evidence is not adequate to conclude that lumbar artificial disc replacement with the CHARITETM
                         Artificial Disc is reasonable and necessary. The proposed NCD stated that lumbar artificial disc replacement with the CHARITETM
                         Artificial Disc is generally not indicated in patients over 60 years old. Further, it stated that there is insufficient evidence among either the aged or disabled Medicare population to make a reasonable and necessary determination for coverage. With an NCD pending to make spinal arthroplasty with the CHARITETM
                         Artificial Disc noncovered, we indicated in the FY 2007 IPPS proposed rule that we did not believe it was appropriate at that time to reassign procedure code 84.65 from CMS DRGs 499 and 500 to CMS DRGs 497 and 498. After considering the public comments and additional evidence received, we made a final NCD on May 16, 2006, that Medicare would not cover the CHARITETM
                         Artificial Disc for the Medicare population over 60 years of age. For Medicare beneficiaries 60 years of age and under, local Medicare contractors have the discretion to determine coverage for lumbar artificial disc replacement procedures involving the CHARITETM
                         Artificial Disc. The final NCD can be found on the CMS Web site at: 
                        *http://www.cms.hhs.gov/​mcd/​viewncd.asp:ncd-id 150.10&ncd_version1&basket=ncd%3A150%2E10%3A1%3ALumbar+Artificial+Disc+Replacement%280ADR%29.* We agreed with a commenter on the FY 2007 IPPS proposed rule that it was not appropriate to consider a DRG revision at that time for the CHARITETM
                         Artificial Disc, given the recent decision to limit coverage for surgical procedures involving this device. Although we had reviewed the Medicare charge data, we were concerned that there were a very small number of cases for patients under 60 years of age who had received the CHARITETM
                         Artificial Disc. We believed it appropriate to base the decision of a DRG change on charge data only on the population for which the procedure is covered. We had an extremely small number of cases for Medicare beneficiaries under 60 on which to base such a decision. For this reason, we did not believe it was appropriate to modify the CMS DRGs in FY 2007 for CHARITETM
                         cases. For FY 2008, we collapsed CMS DRGs 499 and 500 (Back and Neck Procedures Except Spinal Fusion With and Without CC, respectively) and identified a total of 74,989 cases. Under the proposed MS-DRGs, the result of the analysis of the data supports that these CMS DRGs split into two severity levels: proposed MS-DRG 490 (Back and Neck Procedures Except Spinal Fusion with CC or MCC) and proposed MS-DRG 491 (Back and Neck Procedures Except Spinal Fusion Without CC or MCC). We found a total of 53 cases that used the CHARITETM
                         Artificial Disc. Without any further modification to the proposed MS-DRGs, average charges are $26,481 for 6 cases with a CC or MCC and $37,324 for 47 CHARITETM
                         cases 
                        ( print page 24734)
                        without a CC or MCC. (We find it counterintuitive that average charges for cases in the higher severity level are lower but checked our data and found it to be correct). We also analyzed data for other spinal disc devices. Average charges for the X Stop Interspinous Process Decompression Device (code 84.58) are $31,400 for cases with a CC or MCC and $28,821 for cases without a CC or MCC. Average charges for other specified spinal devices described by code 84.59 (Coflex, Dynesys, M-Brace) are $34,002 for 18 cases with a CC or MCC and $33,873 for 65 cases without a CC or MCC. We compared these average charges to data in the proposed spinal fusion MS-DRGs 453 (Combined Anterior/Posterior Spinal Fusion With MCC), 454 (Combined Anterior/Posterior Spinal Fusion With CC), 455 (Combined Anterior/Posterior Spinal Fusion Without CC/MCC), 459 (Spinal Fusion Except Cervical With MCC), and 460 (Spinal Fusion Except Cervical Without MCC). These cases have lower average charges than the spinal fusion MS-DRGs. The following tables display the results: Proposed MS-DRGs 490 and 491
Number of cases
Average  length of stay
Average  chargesMS-DRG 490—All Cases
17,493
5.13
$29,656MS-DRG 490—Cases with Procedure Code   84.65 (CHARITETM)
6
3.33
26,481MS-DRG 491—All Cases
57,496
2.27
17,789MS-DRG 491—Cases with Procedure Code   84.65 (CHARITETM)
47
2.43
37,324MS-DRG 491—Cases without Procedure Code   84.65 (CHARITETM)
57,449
2.27
17,773
 Proposed MS-DRGs 490 and 491
Number of cases
Average  length of stay
Average  chargesMS-DRG 490—All Cases
17,493
5.13
$29,656MS-DRG 490—Cases with Procedure Code   84.58 (X Stop)
179
2.65
31,400MS-DRG 490—Cases without Procedure Code   84.58 (X Stop)
17,314
5.15
29,638MS-DRG 491—All Cases
57,496
2.27
17,789MS-DRG 491—Cases with Procedure Code   84.58 (X Stop)
1,174
1.34
28,821MS-DRG 491—Cases without Procedure Code   84.58 (X-Stop)
56,322
2.29
17,559
 Proposed MS-DRGs 490 and 491
Number of cases
Average  length of stay
Average  chargesMS-DRG 490—All Cases
17,493
5.13
$29,656MS-DRG 490—Cases with Procedure Code   84.59 (Coflex/Dynesys/M-Brace)
18
5.56
34,002MS-DRG 490—Cases without Procedure Code   84.59 (Coflex/Dynesys/M-Brace)
17,475
5.13
29,651MS-DRG 491—All Cases
57,496
2.27
17,789MS-DRG 491—Cases with Procedure Code   84.59 (Coflex/Dynesys/M-Brace)
65
2.35
33,873MS-DRG 491—Cases without Procedure Code   84.59 (Coflex/Dynesys/M-Brace)
57,431
2.27
17,770
 Proposed MS-DRGs   453, 454, 455, 459 and 460
Number of cases
Average length of stay
Average chargesMS-DRG 453—Combined Anterior/Posterior   Spinal Fusion With MCC
792
15.84
$180,658MS-DRG 454—Combined Anterior/Posterior   Spinal Fusion With CC
1,411
8.69
116,402MS-DRG 455—Combined Anterior/Posterior   Spinal Fusion Without CC/MCC
1,794
4.84
85,927MS-DRG 459—Spinal Fusion Except   Cervical with MCC
3,186
10.10
99,298MS-DRG 460—Spinal Fusion Except   Cervical Without MCC
48,481
4.36
59,698
 The data demonstrate that the average charges for CHARITETM
                         and the other devices are higher than other cases in proposed MS-DRGs 490 and 491 but lower than proposed MS-DRGs 453 through 55 and 459 and 460. For this reason, we do not believe that any of the cases that use these spine devices should be assigned to the spinal fusion MS-DRGs. However, we do believe that the average charges for cases using these spine devices are more similar to the higher severity level in MS-DRG 490. As such, we are proposing to move cases with procedure codes 84.58, 84.59, and 84.65 into proposed MS-DRG 490 and revise the title to reflect disc devices. The proposed modified MS-DRG title would be: MS-DRG 490 (Back and Neck Procedures Except Spinal Fusion with CC or MCC or Disc Devices). We believe these proposed changes to the spine DRGs are appropriate to recognize the similar utilization of resources, differences in levels of severity, and complexity of the services performed for various types of spinal procedures described above. We encourage commenters to provide input on this approach to better recognize the types of patients these procedures are being performed upon and their outcomes. d. Other Spinal DRGs We did not identify any data to support moving cases in or out of CMS DRGs 496 (Combined Anterior/Posterior Spinal Fusion), 519 (Cervical Spinal Fusion With CC), or 520 (Cervical Spinal Fusion Without CC)). Under the proposed MS-DRG system, CMS DRG 496 would be split into three severity levels: proposed MS-DRG 453 (Combined Anterior/Posterior Spinal Fusion With MCC), proposed MS-DRG 454 (Combined Anterior/Posterior Spinal Fusion With CC), and proposed MS-DRG 455 (Combined Anterior/Posterior Spinal Fusion Without CC). 
                        ( print page 24735)
                        CMS DRG 519 would also be split into three severity levels: proposed MS-DRG 471 (Cervical Fusion With MCC), proposed MS-DRG 472 (Cervical Fusion With CC), and proposed MS-DRG 473 (Cervical Fusion Without CC). We are not proposing changes to these DRGs at this time. 5. MDC 17 (Myeloproliferative Diseases and Disorders, Poorly Differentiated Neoplasm): Endoscopic Procedures (If you choose to comment on issues in this section, please include the caption “DRGs: Endoscopy” at the beginning of your comment.) We received a request from a manufacturer to review the DRG assignment of codes 33.71 (Endoscopic insertion or replacement of bronchial valve(s)), 33.78 (Endoscopic removal of bronchial device(s) or substances), and 33.79 (Endoscopic insertion of other bronchial device or substances) with the intent of moving these three codes out of CMS DRG 412 (History of Malignancy With Endoscopy) (proposed MS-DRGs 843, 844, and 845). The requestor has noted that CMS DRG 412 is titled to be a DRG for cases with a history of malignancy, and none of the three codes (33.71, 33.78, or 33.79) necessarily involve treatment for malignancies. In addition, the requestor believed the integrity of the DRG is compromised because the other endoscopy codes assigned to CMS DRG 412 are all diagnostic in nature, while codes 33.71, 33.78, and 33.79 represent therapeutic procedures. The requestor also stated that while the diagnostic endoscopies in CMS DRG 412 do not have significant costs for equipment or pharmaceutical agents beyond the basic endoscopy, the therapeutic procedures described by codes 33.71, 33.78, and 33.79 involve substantial costs for devices or substances in relation to the cost of the endoscopic procedure itself. The requestor was concerned that, if these three codes continue to be assigned to CMS DRG 412, payment will be so inadequate as to constitute a substantial barrier to Medicare beneficiaries for these treatments. ICD-9-CM procedure codes 33.71, 33.78, and 33.79 were all created for use beginning October 1, 2006. As these codes have been in use only for a few months, we have no data to make a different DRG assignment. We assigned these codes based on the advice of our medical officers to a DRG that includes similar clinical procedures. On the matter of codes 33.71, 33.78, and 33.79 being therapeutic in nature while all other endoscopies assigned to CMS DRG 412 are diagnostic, we disagree with the commenter. CMS DRG 412 includes procedure codes for therapeutic endoscopic destruction of lesions of the bronchus, lung, stomach, anus, and duodenum, as well as codes for polypectomy of the intestine and rectum. In addition, we note that there are codes for insertion of therapeutic devices currently located in this DRG. We believe it would be premature to assign these codes to another DRG without any supporting data. We will reconsider our decision for these codes if we have data suggesting that a DRG reassignment is warranted. Therefore, aside from the proposed changes to the MS-DRGs, we are not proposing to change the current DRG assignment for codes 33.71, 33.78, and 33.79 at this time. 6. Medicare Code Editor (MCE) Changes (If you choose to comment on issues in this section, please include the caption “Medicare Code Editor” at the beginning of your comment.) As explained under section II.B.1. of this preamble, the Medicare Code Editor (MCE) is a software program that detects and reports errors in the coding of Medicare claims data. Patient diagnoses, procedure(s), discharge status, and demographic information go into the Medicare claims processing systems and are subjected to a series of automated screens. The MCE screens are designed to identify cases that require further review before classification into a DRG. For FY 2008, we are proposing to make the following changes to the MCE edits. a. Non-Covered Procedure Edit: Code 00.62 (Percutaneous angioplasty or atherectomy of intracranial vessel(s)) As discussed in II.G.2. of the preamble of this proposed rule, under MDC 1, code 00.62 is a covered service when performed in conjunction with code 00.65 (Percutaneous insertion of intracranial vascular stent(s)). Effective November 6, 2006, Medicare covers PTA and stenting of intracranial arteries for the treatment of cerebral artery stenosis in cases in which stenosis is 50 percent or greater in patients with intracranial atherosclerotic disease when furnished in accordance with the FDA-approved protocols governing Category B Investigational Device Exemption (IDE) clinical trials. CMS determines that coverage of intracranial PTA and stenting is reasonable and necessary under these circumstances. Therefore, we are proposing to make a conforming change and to add the following language to this edit: Procedure code 00.62 (PTA of intracranial vessel(s)) is identified as a noncovered procedure except when it is accompanied by procedure code 00.65 (Intracranial stent). b. Non-Specific Principal Diagnosis Edit 7 and Non-Specific O.R. Procedures Edit 10 When MCE Non-Specific Principal Diagnosis Edit 7 and Non-Specific O.R. Procedures Edit 10 were created at the beginning of the IPPS, it was with the intent that they were to encourage hospitals to code as specifically as possible. While the codes on both edits are valid according to the ICD-9-CM coding scheme, more precise codes are preferable to give a more complete understanding of the services provided on the Medicare claims. When the MCE was created, we had intended that these specific edits would allow educational contact between the provider and the contractor. It was never the intention that these edits would be used to deny/reject or return-to-provider claims submitted with non-specific codes. However, we found these two edits to be misunderstood, and found that claims were erroneously being denied, rejected, or returned. On November 11, 2006, CMS issued a Joint Signature Memorandum which instructed all fiscal intermediaries and all Part A and Part B Medicare Administrative Contractors (A/B MACs) to deactivate the Fiscal Intermediary Shared System Edits W1436 through W1439 and W1489 through W1491 which edited for Non-Specific Diagnoses and the Non-Specific Procedures. Therefore, we are proposing to make a conforming change to the MCE by removing the following codes from Edit 7: 00320
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 c. Limited Coverage Edit 17 Edit 17 in the MCE contains ICD-9-CM procedure codes describing medically complex procedures, including lung volume reduction surgery, organ transplants, and implantable heart assist devices which are to be performed only in certain preapproved medical centers. CMS has established, through a regulation (CMS-3835-F: Medicare Conditions of Participation: Requirements for Approval and Reapproval of Transplant Centers to Perform Organ Transplants, published in the 
                        **Federal Register**
                         on March 30, 2007 (72 FR 15198)), a survey and certification process for organ transplant programs. The organs covered in this regulation are heart, heart and lung combined, intestine, kidney, liver, lung, pancreas, and multivisceral. Historically, kidney transplants have been regulated under the End-Stage Renal Disease (ESRD) conditions for coverage. Other types of organ transplant facilities have been regulated under various NCDs. The regulation becomes effective on June 28, 2007. Organ transplant programs will have 180 days from the June 28, 2007 effective date of the regulation to apply for participation in the Medicare program under the new survey and certification process. After these programs apply, we will survey and approve programs that meet the new Medicare conditions of participation. Until transplant facilities are surveyed and approved, kidney transplant facilities will continue to be regulated under the ESRD conditions for coverage, and other types of organ transplant facilities will continue to be regulated under the NCDs. In this proposed rule, we are proposing to add conforming Medicare Part A payment edits to the MCE, consistent with the requirements of the organ transplant regulation (CMS-3835-F), to ensure that Medicare covers only those organ transplants performed in Medicare-approved facilities. We are proposing to add the following procedure codes to the existing list of limited coverage procedures under Edit 17: 55.69, Other kidney transplantation
                    52.80, Pancreatic transplant, not otherwise specified
                    52.82, Homotransplant of pancreas 7. Surgical Hierarchies (If you choose to comment on issues in this section, please include the caption “Surgical Hierarchies” at the beginning of your comment.) Some inpatient stays entail multiple surgical procedures, each one of which, occurring by itself, could result in assignment of the case to a different DRG within the MDC to which the principal diagnosis is assigned. Therefore, it is necessary to have a decision rule within the GROUPER by which these cases are assigned to a single DRG. The surgical hierarchy, an ordering of surgical classes from most resource-intensive to least resource-intensive, performs that function. Application of this hierarchy ensures that cases involving multiple surgical procedures are assigned to the DRG associated with the most resource-intensive surgical class. Because the relative resource intensity of surgical classes can shift as a function of DRG reclassification and recalibrations, we reviewed the surgical hierarchy of each MDC, as we have for previous reclassifications and recalibrations, to determine if the ordering of classes coincides with the intensity of resource utilization. A surgical class can be composed of one or more DRGs. For example, in MDC 11, the surgical class “kidney transplant” consists of a single DRG (DRG 302) and the class “kidney, ureter and major bladder procedures” consists of three DRGs (DRGs 303, 304, and 305). Consequently, in many cases, the surgical hierarchy has an impact on more than one DRG. The methodology for determining the most resource-intensive surgical class involves weighting the average resources for each 
                        ( print page 24738)
                        DRG by frequency to determine the weighted average resources for each surgical class. For example, assume surgical class A includes DRGs 1 and 2 and surgical class B includes DRGs 3, 4, and 5. Assume also that the average charge of DRG 1 is higher than that of DRG 3, but the average charges of DRGs 4 and 5 are higher than the average charge of DRG 2. To determine whether surgical class A should be higher or lower than surgical class B in the surgical hierarchy, we would weight the average charge of each DRG in the class by frequency (that is, by the number of cases in the DRG) to determine average resource consumption for the surgical class. The surgical classes would then be ordered from the class with the highest average resource utilization to that with the lowest, with the exception of “other O.R. procedures” as discussed below. This methodology may occasionally result in assignment of a case involving multiple procedures to the lower-weighted DRG (in the highest, most resource-intensive surgical class) of the available alternatives. However, given that the logic underlying the surgical hierarchy provides that the GROUPER search for the procedure in the most resource-intensive surgical class, in cases involving multiple procedures, this result is sometimes unavoidable. We note that, notwithstanding the foregoing discussion, there are a few instances when a surgical class with a lower average charge is ordered above a surgical class with a higher average charge. For example, the “other O.R. procedures” surgical class is uniformly ordered last in the surgical hierarchy of each MDC in which it occurs, regardless of the fact that the average charge for the DRG or DRGs in that surgical class may be higher than that for other surgical classes in the MDC. The “other O.R. procedures” class is a group of procedures that are only infrequently related to the diagnoses in the MDC, but are still occasionally performed on patients in the MDC with these diagnoses. Therefore, assignment to these surgical classes should only occur if no other surgical class more closely related to the diagnoses in the MDC is appropriate. A second example occurs when the difference between the average charges for two surgical classes is very small. We have found that small differences generally do not warrant reordering of the hierarchy because, as a result of reassigning cases on the basis of the hierarchy change, the average charges are likely to shift such that the higher-ordered surgical class has a lower average charge than the class ordered below it. For FY 2008, we are not proposing any revisions of the surgical hierarchy for any MDC. In general, the MS-DRGs that are being proposed for use in FY 2008 and discussed in section II.D. of the preamble of this proposed rule follow the same hierarchical order as the CMS DRGs they are to replace, except for DRGs that were deleted and consolidated. 8. CC Exclusion List Proposed for FY 2008 (If you choose to comment on issues in this section, please include the caption “CC Exclusion List” at the beginning of your comment.) a. Background As indicated earlier in this preamble, under the IPPS DRG classification system, we have developed a standard list of diagnoses that are considered complications or comorbidities (CCs). Historically, we developed this list using physician panels that classified each diagnosis code based on whether the diagnosis, when present as a secondary condition, would be considered a substantial complication or comorbidity. A substantial complication or comorbidity was defined as a condition that, because of its presence with a specific principal diagnosis, would cause an increase in the length of stay by at least 1 day in at least 75 percent of the patients. We refer readers to section II.D.2. and 3. of the preamble of this proposed rule for a discussion of the refinement of CCs in relation to the MS-DRGs we are proposing to adopt for FY 2008. b. Proposed CC Exclusions List for FY 2008 In the September 1, 1987 final notice (52 FR 33143) concerning changes to the DRG classification system, we modified the GROUPER logic so that certain diagnoses included on the standard list of CCs would not be considered valid CCs in combination with a particular principal diagnosis. We created the CC Exclusions List for the following reasons: (1) To preclude coding of CCs for closely related conditions; (2) to preclude duplicative or inconsistent coding from being treated as CCs; and (3) to ensure that cases are appropriately classified between the complicated and uncomplicated DRGs in a pair. As we indicated above, we developed a list of diagnoses, using physician panels, to include those diagnoses that, when present as a secondary condition, would be considered a substantial complication or comorbidity. In previous years, we have made changes to the list of CCs, either by adding new CCs or deleting CCs already on the list. In the May 19, 1987 proposed notice (52 FR 18877) and the September 1, 1987 final notice (52 FR 33154), we explained that the excluded secondary diagnoses were established using the following five principles: Chronic and acute manifestations of the same condition should not be considered CCs for one another.
                    Specific and nonspecific (that is, not otherwise specified (NOS)) diagnosis codes for the same condition should not be considered CCs for one another.
                    Codes for the same condition that cannot coexist, such as partial/total, unilateral/bilateral, obstructed/unobstructed, and benign/malignant, should not be considered CCs for one another.
                    Codes for the same condition in anatomically proximal sites should not be considered CCs for one another.
                    Closely related conditions should not be considered CCs for one another. The creation of the CC Exclusions List was a major project involving hundreds of codes. We have continued to review the remaining CCs to identify additional exclusions and to remove diagnoses from the master list that have been shown not to meet the definition of a CC.[14] For FY 2008, we are proposing to make limited revisions to the CC Exclusions List to take into account the changes that will be made in the ICD-
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                        9-CM diagnosis coding system effective October 1, 2007. (See section II.G.10. of this preamble for a discussion of ICD-9-CM changes.) We are proposing to make these changes in accordance with the principles established when we created the CC Exclusions List in 1987. In addition, as discussed in section II.D.3. of the preamble of this proposed rule, we are proposing to indicate on the CC Exclusion List some updates to reflect the proposed exclusion of a few codes from being an MCC under the MS-DRG system that we are proposing to adopt for FY 2008. Table 6I (which is available through the Internet on the CMS Web site at: 
                        *http://www.cms.hhs.gov/​AcuteInpatientPPS*) contains the complete CC Exclusions List that will be effective for discharges occurring on or after October 1, 2007. Table 6I shows the principal diagnoses for which there is a CC exclusion. Each of these principal diagnoses is shown with an asterisk, and the conditions that will not count as a CC, are provided in an indented column immediately following the affected principal diagnosis. Tables 6G and 6H, Additions to and Deletions from the CC Exclusion List, respectively, are also available through the Internet on the CMS Web site at: 
                        *http://www.cms.hhs.gov/​AcuteInpatientPPS.*) Beginning with discharges on or after October 1, 2007, the indented diagnoses will not be recognized by the GROUPER as valid CCs for the asterisked principal diagnosis. Alternatively, the complete documentation of the GROUPER logic, including the current CC Exclusions List, is available from 3M/Health Information Systems (HIS), which, under contract with CMS, is responsible for updating and maintaining the GROUPER program. The current DRG Definitions Manual, Version 24.0, is available for $225.00, which includes $15.00 for shipping and handling. Version 25.0 of this manual, which will include the final FY 2008 DRG changes, will be available in hard copy for $250.00. Version 25.0 of the manual is also available on a CD for $200.00; a combination hard copy and CD is available for $400.00. These manuals may be obtained by writing 3M/HIS at the following address: 100 Barnes Road, Wallingford, CT 06492; or by calling (203) 949-0303. Please specify the revision or revisions requested. 9. Review of Procedure Codes in CMS DRGs 468, 476, and 477 Each year, we review cases assigned to CMS DRG 468 (Extensive O.R. Procedure Unrelated to Principal Diagnosis), CMS DRG 476 (Prostatic O.R. Procedure Unrelated to Principal Diagnosis), and CMS DRG 477 (Nonextensive O.R. Procedure Unrelated to Principal Diagnosis) to determine whether it would be appropriate to change the procedures assigned among these CMS DRGs. Under the MS-DRGs that we are proposing to adopt for FY 2008, discussed in section II.D. of the preamble of this proposed rule, CMS DRG 468 would have a three-way split and would become proposed MS-DRGs 981, 982, and 983 (Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC). CMS DRG 476 would become proposed MS-DRGs 984, 985, and 986 (Prostatic O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and Without CC/MCC). CMS DRG 477 would become proposed MS-DRGs 987, 988, and 989 (Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC). Proposed MS-DRGs 981 through 983, 984 through 986, and 987 through 989 (formerly CMS DRGs 468, 476, and 477, respectively) are reserved for those cases in which none of the O.R. procedures performed are related to the principal diagnosis. These CMS DRGs are intended to capture atypical cases, that is, those cases not occurring with sufficient frequency to represent a distinct, recognizable clinical group. Proposed MS-DRGs 984 through 986 (previously CMS DRG 476) are assigned to those discharges in which one or more of the following prostatic procedures are performed and are unrelated to the principal diagnosis: 60.0, Incision of prostate
                    60.12, Open biopsy of prostate
                    60.15, Biopsy of periprostatic tissue
                    60.18, Other diagnostic procedures on prostate and periprostatic tissue
                    60.21, Transurethral prostatectomy
                    60.29, Other transurethral prostatectomy
                    60.61, Local excision of lesion of prostate
                    60.69, Prostatectomy, not elsewhere classified
                    60.81, Incision of periprostatic tissue
                    60.82, Excision of periprostatic tissue
                    60.93, Repair of prostate
                    60.94, Control of (postoperative) hemorrhage of prostate
                    60.95, Transurethral balloon dilation of the prostatic urethra
                    60.96, Transurethral destruction of prostate tissue by microwave thermotherapy
                    60.97, Other transurethral destruction of prostate tissue by other thermotherapy
                    60.99, Other operations on prostate All remaining O.R. procedures are assigned to proposed MS-DRGs 981 through 983 and 987 through 989 (previously CMS DRGs 468 and 477), with proposed MS-DRGs 987 through 989 (previously CMS DRG 477) assigned to those discharges in which the only procedures performed are nonextensive procedures that are unrelated to the principal diagnosis.[15] For FY 2008, we are not proposing to change the procedures assigned among these CMS DRGs. a. Moving Procedure Codes From CMS DRG 468 (Proposed MS-DRGs 981 Through 983) or CMS DRG 477 (Proposed MS-DRGs 987 Through 989) to MDCs We annually conduct a review of procedures producing assignment to CMS DRG 468 (proposed MS-DRGs 981 through 983) or CMS DRG 477 (proposed MS-DRGs 987 through 989) on the basis of volume, by procedure, to see if it would be appropriate to move procedure codes out of these DRGs into one of the surgical DRGs for the MDC into which the principal diagnosis falls. The data are arrayed in two ways for comparison purposes. We look at a frequency count of each major operative procedure code. We also compare procedures across MDCs by volume of procedure codes within each MDC. We identify those procedures occurring in conjunction with certain principal diagnoses with sufficient frequency to justify adding them to one of the surgical DRGs for the MDC in which the diagnosis falls. Based on this 
                        ( print page 24740)
                        year's review, we are not proposing to remove any procedures from CMS DRG 477 or CMS DRG 468 with assignment to one of the surgical DRGs. b. Reassignment of Procedures Among CMS DRGs 468, 476, and 477 (Proposed MS-DRGs 981 Through 983, 984 Through 986, and 987 Through 989) We also annually review the list of ICD-9-CM procedures that, when in combination with their principal diagnosis code, result in assignment to CMS DRGs 468, 476, and 477 (proposed MS-DRGs 981 through 983, 984 through 986, and 987 through 989, respectively), to ascertain whether any of those procedures should be reassigned from one of these three DRGs to another of the three DRGs based on average charges and the length of stay. We look at the data for trends such as shifts in treatment practice or reporting practice that would make the resulting DRG assignment illogical. If we find these shifts, we would propose to move cases to keep the DRGs clinically similar or to provide payment for the cases in a similar manner. Generally, we move only those procedures for which we have an adequate number of discharges to analyze the data. We are not proposing to move any procedure codes from CMS DRG 476 (proposed MS-DRGs 984, 985, and 986) to CMS DRG 468 (proposed MS-DRGs 981, 982, and 983) or to CMS DRG 477 (proposed MS-DRGs 987, 988, and 989), or from CMS DRG 477 (proposed MS-DRGs 987, 988, and 989) to CMS DRGs 468 (proposed MS-DRGs 981, 982, and 983) or to CMS DRG 476 (proposed MS-DRGs 984, 985, and 986) for FY 2008. c. Adding Diagnosis or Procedure Codes to MDCs Based on our review this year, we are not proposing to add any diagnosis codes to MDCs for FY 2008. 10. Changes to the ICD-9-CM Coding System (If you choose to comment on issues in this section, please include the caption “ICD-9-CM Coding System” at the beginning of your comment.) As described in section II.B.1. of this preamble, the ICD-9-CM is a coding system used for the reporting of diagnoses and procedures performed on a patient. In September 1985, the ICD-9-CM Coordination and Maintenance Committee was formed. This is a Federal interdepartmental committee, co-chaired by the National Center for Health Statistics (NCHS), the Centers for Disease Control and Prevention, and CMS, charged with maintaining and updating the ICD-9-CM system. The Committee is jointly responsible for approving coding changes, and developing errata, addenda, and other modifications to the ICD-9-CM to reflect newly developed procedures and technologies and newly identified diseases. The Committee is also responsible for promoting the use of Federal and non-Federal educational programs and other communication techniques with a view toward standardizing coding applications and upgrading the quality of the classification system. The Official Version of the ICD-9-CM contains the list of valid diagnosis and procedure codes. (The Official Version of the ICD-9-CM is available from the Government Printing Office on CD-ROM for $25.00 by calling (202) 512-1800.) The Official Version of the ICD-9-CM is no longer available in printed manual form from the Federal Government; it is only available on CD-ROM. Users who need a paper version are referred to one of the many products available from publishing houses. The NCHS has lead responsibility for the ICD-9-CM diagnosis codes included in the 
                        *Tabular List*
                         and 
                        *Alphabetic Index for Diseases,*
                         while CMS has lead responsibility for the ICD-9-CM procedure codes included in the 
                        *Tabular List*
                         and 
                        *Alphabetic Index for Procedures*. The Committee encourages participation in the above process by health-related organizations. In this regard, the Committee holds public meetings for discussion of educational issues and proposed coding changes. These meetings provide an opportunity for representatives of recognized organizations in the coding field, such as the American Health Information Management Association (AHIMA), the American Hospital Association (AHA), and various physician specialty groups, as well as individual physicians, health information management professionals, and other members of the public, to contribute ideas on coding matters. After considering the opinions expressed at the public meetings and in writing, the Committee formulates recommendations, which then must be approved by the agencies. The Committee presented proposals for coding changes for implementation in FY 2008 at a public meeting held on September 28-29, 2006, and finalized the coding changes after consideration of comments received at the meetings and in writing by December 4, 2006. Those coding changes are announced in Tables 6A through 6F in the Addendum to this proposed rule. The Committee held its 2007 meeting on March 22-23, 2007. Proposed new codes for which there was a consensus of public support and for which complete tabular and indexing changes can be made by May 2007 will be included in the October 1, 2007 update to ICD-9-CM. Code revisions that were discussed at the March 22-23, 2007 Committee meeting could not be finalized in time to include them in the Addendum to this proposed rule. These additional codes will be included in Tables 6A through 6F of the final rule and are marked with an asterisk (*). Copies of the minutes of the procedure codes discussions at the Committee's September 28-29, 2006 meeting can be obtained from the CMS Web site at: 
                        *http://cms.hhs.gov/​ICD9ProviderDiagnosticCodes/​03_​meetings.asp*. The minutes of the diagnosis codes discussions at the September 28-29, 2006 meeting are found at: 
                        *http://www.cdc.gov/​nchs/​icd9.htm*. Paper copies of these minutes are no longer available and the mailing list has been discontinued. These Web sites also provide detailed information about the Committee, including information on requesting a new code, attending a Committee meeting, and timeline requirements and meeting dates. We encourage commenters to address suggestions on coding issues involving diagnosis codes to: Donna Pickett, Co-Chairperson, ICD-9-CM Coordination and Maintenance Committee, NCHS, Room 2402, 3311 Toledo Road, Hyattsville, MD 20782. Comments may be sent by E-mail to: 
                        *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.brooks2@cms.hhs.gov*. The ICD-9-CM code changes that have been approved will become effective October 1, 2007. The new ICD-9-CM codes are listed, along with their DRG classifications, in Tables 6A and 6B (New Diagnosis Codes and New Procedure Codes, respectively) in the Addendum to this proposed rule. As we stated above, the code numbers and their titles were presented for public comment at the ICD-9-CM Coordination and Maintenance Committee meetings. Both oral and written comments were considered before the codes were approved. In this proposed rule, we are only soliciting 
                        ( print page 24741)
                        comments on the proposed classification of these new codes. For codes that have been replaced by new or expanded codes, the corresponding new or expanded diagnosis codes are included in Table 6A. New procedure codes are shown in Table 6B. Diagnosis codes that have been replaced by expanded codes or other codes or have been deleted are in Table 6C (Invalid Diagnosis Codes). These invalid diagnosis codes will not be recognized by the GROUPER beginning with discharges occurring on or after October 1, 2007. Table 6D contains invalid procedure codes. These invalid procedure codes will not be recognized by the GROUPER beginning with discharges occurring on or after October 1, 2007. Revisions to diagnosis code titles are in Table 6E (Revised Diagnosis Code Titles), which also includes the DRG assignments for these revised codes. Table 6F includes revised procedure code titles for FY 2008. In the September 7, 2001 final rule implementing the IPPS new technology add-on payments (66 FR 46906), we indicated we would attempt to include proposals for procedure codes that would describe new technology discussed and approved at the Spring meeting as part of the code revisions effective the following October. As stated previously, ICD-9-CM codes discussed at the March 22-23, 2007 Committee meeting that received consensus and that were finalized by May 2007, will be included in Tables 6A through 6F of the Addendum to the final rule. Section 503(a) of Pub. L. 108-173 included a requirement for updating ICD-9-CM codes twice a year instead of a single update on October 1 of each year. This requirement was included as part of the amendments to the Act relating to recognition of new technology under the IPPS. Section 503(a) amended section 1886(d)(5)(K) of the Act by adding a clause (vii) which states that the “Secretary shall provide for the addition of new diagnosis and procedure codes on April 1 of each year, but the addition of such codes shall not require the Secretary to adjust the payment (or diagnosis-related group classification) * * * until the fiscal year that begins after such date.” This requirement improves the recognition of new technologies under the IPPS system by providing information on these new technologies at an earlier date. Data will be available 6 months earlier than would be possible with updates occurring only once a year on October 1. While section 1886(d)(5)(K)(vii) of the Act states that the addition of new diagnosis and procedure codes on April 1 of each year shall not require the Secretary to adjust the payment, or DRG classification, under section 1886(d) of the Act until the fiscal year that begins after such date, we have to update the DRG software and other systems in order to recognize and accept the new codes. We also publicize the code changes and the need for a mid-year systems update by providers to identify the new codes. Hospitals also have to obtain the new code books and encoder updates, and make other system changes in order to identify and report the new codes. The ICD-9-CM Coordination and Maintenance Committee holds its meetings in the spring and fall in order to update the codes and the applicable payment and reporting systems by October 1 of each year. Items are placed on the agenda for the ICD-9-CM Coordination and Maintenance Committee meeting if the request is received at least 2 months prior to the meeting. This requirement allows time for staff to review and research the coding issues and prepare material for discussion at the meeting. It also allows time for the topic to be publicized in meeting announcements in the 
                        **Federal Register**
                         as well as on the CMS Web site. The public decides whether or not to attend the meeting based on the topics listed on the agenda. Final decisions on code title revisions are currently made by March 1 so that these titles can be included in the IPPS proposed rule. A complete addendum describing details of all changes to ICD-9-CM, both tabular and index, is publicized on CMS and NCHS Web sites in May of each year. Publishers of coding books and software use this information to modify their products that are used by health care providers. This 5-month time period has proved to be necessary for hospitals and other providers to update their systems. A discussion of this timeline and the need for changes are included in the December 4-5, 2005 ICD-9-CM Coordination and Maintenance Committee minutes. The public agreed that there was a need to hold the fall meetings earlier, in September or October, in order to meet the new implementation dates. The public provided comment that additional time would be needed to update hospital systems and obtain new code books and coding software. There was considerable concern expressed about the impact this new April update would have on providers. In the FY 2005 IPPS final rule, we implemented section 1886(d)(5)(K)(vii) of the Act, as added by section 503(a) of Pub. L. 108-173, by developing a mechanism for approving, in time for the April update, diagnosis and procedure code revisions needed to describe new technologies and medical services for purposes of the new technology add-on payment process. We also established the following process for making these determinations. Topics considered during the Fall ICD-9-CM Coordination and Maintenance Committee meeting are considered for an April 1 update if a strong and convincing case is made by the requester at the Committee's public meeting. The request must identify the reason why a new code is needed in April for purposes of the new technology process. The participants at the meeting and those reviewing the Committee meeting summary report are provided the opportunity to comment on this expedited request. All other topics are considered for the October 1 update. Participants at the Committee meeting are encouraged to comment on all such requests. There were no requests for an expedited April l, 2007 implementation of an ICD-9-CM code at the September 28-29, 2006 Committee meeting. Therefore, there were no new ICD-9-CM codes implemented on April 1, 2007. We believe that this process captures the intent of section 1886(d)(5)(K)(vii) of the Act. This requirement was included in the provision revising the standards and process for recognizing new technology under the IPPS. In addition, the need for approval of new codes outside the existing cycle (October 1) arises most frequently and most acutely where the new codes will identify new technologies that are (or will be) under consideration for new technology add-on payments. Thus, we believe this provision was intended to expedite data collection through the assignment of new ICD-9-CM codes for new technologies seeking higher payments. Current addendum and code title information is published on the CMS Web site at: 
                        *http://www.cms.hhs.gov/​icd9ProviderDiagnosticCodes/​01_​overview.asp#TopofPage*. Information on ICD-9-CM diagnosis codes, along with the Official ICD-9-CM Coding Guidelines, can be found on the Web site at: 
                        *http://www.cdc.gov/​nchs/​icd9.htm*. Information on new, revised, and deleted ICD-9-CM codes is also provided to the AHA for publication in the 
                        *Coding Clinic for ICD-9-CM*. AHA also distributes information to publishers and software vendors. CMS also sends copies of all ICD-9-CM coding changes to its contractors for 
                        ( print page 24742)
                        use in updating their systems and providing education to providers. These same means of disseminating information on new, revised, and deleted ICD-9-CM codes will be used to notify providers, publishers, software vendors, contractors, and others of any changes to the ICD-9-CM codes that are implemented in April. The code titles are adopted as part of the ICD-9-CM Coordination and Maintenance Committee process. Thus, although we publish the code titles in the IPPS proposed and final rules, they are not subject to comment in the proposed or final rules. We will continue to publish the October code updates in this manner within the IPPS proposed and final rules. For codes that are implemented in April, we will assign the new procedure code to the same DRG in which its predecessor code was assigned so there will be no DRG impact as far as DRG assignment. This mapping was specified by section 1886(d)(5)(K)(vii) of the Act as added by section 503(a) of Pub. L. 108-173. Any midyear coding updates will be available through the Web sites indicated above and through the 
                        *Coding Clinic for ICD-9-CM*. Publishers and software vendors currently obtain code changes through these sources in order to update their code books and software systems. We will strive to have the April 1 updates available through these Web sites 5 months prior to implementation (that is, early November of the previous year), as is the case for the October 1 updates. 11. Other Issues (If you choose to comment on issues in this section, please include the caption “DRGs: Headaches and Seizures” at the beginning of your comment.) a. Seizures and Headaches After publication of the FY 2007 IPPS final rule (71 FR 47928), we received correspondence expressing concerns about the revisions we made to the seizure and headache DRGs effective on October 1, 2006. We created new DRGs 562 (Seizure Age >17 With CC), DRG 563 (Seizure Age >17 Without CC), and DRG 564 (Headaches Age >17) as an interim step to better recognize severity of illness among seizure and headache patients for FY 2007. Although national Medicare utilization data supported the revised DRGs, the commenter indicated that the change did not appropriately recognize hospital resources associated with the patients treated in the hospital's inpatient headache program. The commenter stated that patients who are admitted to the hospital's inpatient headache program suffer from chronic headache pain and require inpatient treatment that can last up to 12 days. The commenter noted that these patients are referred from around the country after several months of unsuccessful pain relief and treatment. The commenter indicated that the majority of patients treated at the hospital's inpatient headache program are drug dependent from being administered increasing dosages of pain relievers that have been unsuccessful in resolving chronic headache pain. Further, the commenter noted that the patients require detoxification before any headache treatment begins. The commenter urged CMS to subdivide the headache DRG to better recognize the higher level of severity associated with treating chronic headache patients in the hospital's program. Although we are sympathetic to the commenter, it is not feasible to design a DRG system that addresses concerns that may be unique to one facility. Other than this one commenter, we did not receive any concern about our decision to create separate DRGs for seizures and headaches. However, we agreed to review this issue as part of our effort to redesign the DRG system to better recognize severity of illness for FY 2008. As discussed in section II.C. of the preamble of this proposed rule, we are proposing to adopt MS-DRGs for FY 2008. While our current DRG structure did not support splitting the headache DRG based on the presence or absence of a CC, the proposed MS-DRGs support the creation of a split for the headache DRGs based on whether the patient has an MCC as shown below: Proposed MS-DRG
Number of cases
Average length  of stay
Average chargesMS-DRG 102 (Headaches with MCC)
1,268
5.04
19,077.33MS-DRG 103 (Headaches without MCC)
14,277
3.22
11,989.43
 (The criteria for determining whether to subdivide a DRG are described in detail earlier in section II.D. of the preamble of this proposed rule.) Thus, we are proposing to create two MS-DRGs for headaches under the MS-DRGs as shown below: Proposed MS-DRG 102 (Headaches With MCC)
                    Proposed MS-DRG 103 (Headaches Without MCC) We believe this proposed structure would better recognize those headaches patients who are severely ill and require more resources as described by the commenter. We refer the readers to section II.D. of the preamble of this proposed rule for a detailed discussion of the MS-DRG proposal. b. Devices That Are Replaced Without Cost or Where Credit for a Replaced Device Is Furnished to the Hospital (If you choose to comment on issues in this section, please include the caption “Replaced Devices” at the beginning of your comment.) (1) Background We addressed the topic of Medicare payment for devices that are replaced without costs or where credit for a replaced device is furnished to the hospital in the FY 2007 IPPS final rule (71 FR 47962). In that final rule, we included the following background information: In recent years, there have been several field actions and recalls with regard to failure of implantable cardiac defibrillators (ICDs) and pacemakers. In many of these cases, the manufacturers have offered replacement devices without cost to the hospital or credit for the device being replaced if the patient required a more expensive device. In some circumstances, manufacturers have also offered, through a warranty package, to pay specified amounts for unreimbursed expenses to persons who had replacement devices implanted. Nonetheless, we believe that incidental device failures that are covered by manufacturer warranties occur routinely. While we understand that some device malfunctions may be inevitable as medical technology grows increasingly sophisticated, we believe that early recognition of problems would reduce the number of people who would be potentially adversely affected by these device problems. The medical community needs heightened and early awareness of patterns of device failures, voluntary field actions, and recalls so that it can take appropriate corrective action to care for patients. Systematic efforts must be undertaken by all interested and involved parties, including manufacturers, insurers, and the medical community, to ensure that 
                        ( print page 24743)
                        device problems are recognized, and are addressed as early as possible so that patients' quality of health care is protected and high quality medical care, equipment, and technologies are provided. We are taking several steps to assist in the early recognition and analysis of patterns of device problems to minimize the potential for harm from device-related defects to Medicare beneficiaries and the public in general. In recent years, CMS has recognized the importance of data collection as a condition of Medicare coverage for selected services. In 2005, we issued an NCD that expanded coverage of ICDs and also required registry participation when the devices were implanted for certain clinical indications. The NCD included this requirement in order to ensure that the medical care received by Medicare beneficiaries was reasonable and necessary and, therefore, that the provider or supplier would be appropriately paid. Presently, the American College of Cardiology—National Cardiovascular Data Registry (ACC-NCDR) collects these data and maintains the registry. In addition to ensuring appropriate payment of claims, collection, and ongoing analysis of ICD implantation, registry data can facilitate public response to the quality of health care issues in the event of future device recalls. Analysis of registry data may uncover patterns of device malfunction, device-related infection, or early battery depletion that would trigger a more specific investigation. Patterns found in registry data may identify problems in patient outcomes earlier than the currently available mechanisms, which do not systematically collect detailed information about each patient who receives an ICD. We encourage the medical community to work to develop additional registries for implantable devices, so that timely and comprehensive information is available regarding devices, recipients of those devices, and patients' quality of health care status and medical outcomes. While participation in an ICD registry is required as a Medicare condition of coverage for ICD implantation for certain clinical conditions, we believe that the potential benefits of other data collection extend well beyond their application in Medicare's specific NCDs. As medical technology continues to advance swiftly, data collection regarding the short-term and long-term medical outcomes of new technologies, especially concerning implanted devices that may remain in the bodies of patients for their lifetimes, will be essential to the timely recognition of any specific device-related problems, patterns of complications, and health-related outcomes. This information will facilitate early interventions to mitigate any harm potentially imposed upon Medicare beneficiaries and the public, and to improve the quality and efficiency of health care services provided. Moreover, published data from registries may further help the development of high quality, evidence-based clinical practice guidelines for the care of patients who may receive device implants. In turn, widespread use of evidence-based guidelines may reduce variation in medical practice, leading to improved personal care and overall public health. Registry information may also contribute to the development of more comprehensive and refined quality metrics that may be used to systematically assess the collected data, and then improve the safety and quality of health care provided to Medicare beneficiaries. Such improvements in the quality of care that result in better personal health will require the sustained commitment of industry, payers, health care providers, and others to progressively work towards that goal, and to ensure excellent and open communication and rapid systemwide responses. One strategy for this data collection involves adding information to the claims forms. CMS has a long history of collecting hemoglobin or hematocrit data from ESRD patients on the claims form. Modification of claims forms was necessary to do that. CMS is exploring the use of claims data to collect other types of clinical or technical data such as device manufacturer and model number. The systematic recording of model numbers can enhance knowledge of device-related outcomes and complications. We look forward to further discussions with the public about new strategies to both recognize device-related problems early as well as recognize health-related outcomes of new technologies. In addition, we believe that the routine identification of Medicare claims for certain device implantation procedures in situations where a payment adjustment is appropriate may enhance the medical community's recognition of device-related problems, potentially leading to more timely improvements in medical device technologies. This systematic approach, which enables hospitals to identify and then appropriately report selected services when devices are replaced without cost to the hospital, or with full or partial credit to the hospital for the cost of the replaced device, should provide comprehensive information regarding the hospitals' experiences with Medicare beneficiaries who have specific medical devices that are being replaced. Because Medicare beneficiaries are common recipients of implanted devices, the claims information may be particularly helpful in identifying patterns of device-related problems early in their natural history, so that appropriate strategies to reduce future problems may be developed. One possible strategy would be for the Medicare program to use information obtained through the use of bar coding of medical devices. The FDA issued a final rule in the 
                        **Federal Register**
                         on February 26, 2004 (69 FR 9119), that required bar codes for human drugs and biological product labels effective April 26, 2006. In the final rule, FDA deferred action on requiring bar codes for medical devices, noting the difficulty in standardizing medical devices, as compared to drugs and biologicals, which have the unique NDC numbering system. This rule can be reviewed on the 
                        **Federal Register**
                        's Web site at: 
                        *http://www.docket.access.gpo.gov/​2004/​04-4249.htm*. We intend to monitor FDA's work in this area to determine how this technology could help CMS promote higher quality through better clinical decision making and, as discussed below, assist in improving the accuracy of the Medicare payment system. In addition to our concern for overall public health, we also have a fiduciary responsibility to the Medicare Trust Fund to ensure that Medicare pays only for covered services. Therefore, in the FY 2007 IPPS final rule, we indicated that we believe we need to consider whether it is appropriate to reduce the Medicare payment in cases in which an implanted device is replaced at reduced or no cost to the hospital or with partial or full credit for the removed device. Such consideration could cover certain devices for which credit for the replaced medical device is given, or medical devices that are replaced as a result of or pursuant to a warranty, field action, voluntary recall, or involuntary recall, and medical devices that are provided free of charge. We indicated that conveying this information to the Medicare beneficiary could provide for a reduction in the IPPS payment if we determine that the device is replaced without cost to the provider or beneficiary or when the provider receives full credit for the cost of a replaced device. In FY 2007 IPPS final rule, we indicated a need to develop a methodology to determine the amount of the reduction to the otherwise 
                        ( print page 24744)
                        payable IPPS payment for medical devices furnished to Medicare beneficiaries. We believe that this policy is appropriate because, in these cases, the full cost of the replaced device is not incurred and, therefore, an adjustment to the payment is necessary to remove the cost of the device. (2) Current and Proposed Policies In the CY 2007 OPPS final rule (71 FR 68071 through 68077), we adopted a policy that requires a reduced payment to a hospital or ambulatory surgical center when a device is provided to them at no cost. From our experience with the OPPS, we understand that a manufacturer will often provide a credit or partial credit for the recalled device rather than a free replacement. In other situations, a manufacturer will provide either a full or partial credit for a device that needs to be replaced only during the manufacturer's warranty period. In either of these situations, the original implantation of the device was paid for either by Medicare, another third party on behalf of the beneficiary by making payment directly to the hospital, or the implantation was paid for directly by the beneficiary. Therefore, we believe that Medicare should not pay the hospital for the full cost of the replacement if the hospital is receiving a partial or full credit, either due to a recall or service during the warranty period. The device was already paid for at the time of initial implantation, and Medicare should retain the credit that is being provided to the hospital for service to a Medicare beneficiary. Moreover, we also believe that a proposed adjustment is consistent with section 1862(a)(2) of the Act, which excludes from Medicare coverage an item or service for which neither the beneficiary, nor anyone on his or her behalf, has an obligation to pay. Payment of the full IPPS payment amount in cases in which the device was replaced under warranty or in which there was a full or partial credit for the price of the recalled or failed device effectively results in Medicare payment for a noncovered item. Therefore, we are proposing to adjust the IPPS payment amount in these circumstances under the authority of section 1886(d)(5)(I) of the Act, which permits the Secretary to make “exceptions and adjustments to such payment amounts * * * as the Secretary deems appropriate.” Under the OPPS, we currently only apply the reduced payment amount in situations where the hospital received a replacement device at no cost or at full credit for the replacement device. Unlike the current OPPS policy, we are proposing for purposes of the IPPS to apply the policy for partial as well as full credit for a replacement device. As we indicated above, our experience with the OPPS suggests that the policy should be applied beyond full replacement of a recalled device. We are proposing to reduce the amount of the Medicare IPPS payment when a full or partial credit towards a replacement device is made or the device is replaced without cost to the hospital or with full credit for the removed device. However, we do not believe that the IPPS policy should apply to all DRGs and all situations in which a device is replaced without cost to the hospital for the device or with full or partial credit for the removed device. We recognize that, in many cases, the cost of the device is a relatively modest part of the IPPS payment. In other situations, we believe the amount of the credit will also be nominal. In these cases, we believe that the averaging nature of payments under the IPPS would incorporate any significant savings from a warranty replacement, field action, or recall into the payment rate for the associated DRG, and that no specific adjustment would be necessary or appropriate. For this reason, we are proposing to apply the policy only to those DRGs under the IPPS where the implantation of the device determines the base DRG assignment and situations where the hospital received a credit equal to 20 percent or more of the cost of the device. We believe a credit that is equal to or more than this percentage is substantial, and Medicare should not pay for the full cost of these replacement devices because hospitals have received significant savings from the manufacturer for its replacement costs. We are seeking comment on the application of this percentage amount. We further believe that it is appropriate to limit application of the policy only to those DRGs where implantation of the device determines the DRG assignment. In making a decision to assign a case based on whether a device was implanted, we recognized that the device cost was a significant portion of the overall costs faced by the hospital that treats the case. Therefore, we believe that Medicare should not make full payment for those DRGs where the assignment of the case is made based on implantation of the device when the hospital is receiving either a full or significant partial credit for the device. We have listed the CMS DRGs that would be subject to this proposed policy below. We have also listed, in parentheses after the CMS DRG title, the proposed new MS-DRG title to which these cases would be assigned. CMS DRGs Subject to Proposed Policy
MDC
CMS DRG
Narrative Description of DRGPRE
103
Heart Transplant or Implant of Heart Assist System (Proposed MS-DRGs 1 and 2, Heart Transplant or Implant of Heart Assist System With and Without MCC, respectively).1
1
Craniotomy Age > 17 With CC (Proposed MS-DRG 25 and 26, Craniotomy and Endovascular Intracranial Procedure With MCC or Without CC, respectively).1
2
Craniotomy Age > 17 Without CC (Proposed MS-DRGs 26 and 27, Craniotomy and Endovascular Intracranial Procedure Without CC/MCC).1
7
Peripheral & Cranial Nerve & Other Nervous System Procedures With CC (Proposed MS-DRGs 40 and 41, Peripheral & Cranial Nerve & Other Nervous System Procedure With MCC or With CC, respectively).1
8
Peripheral & Cranial Nerve & Other Nervous System Procedures Without CC (Proposed MS-DRG 42, Peripheral & Cranial Nerve & Other Nervous System Procedure Without CC/MCC).1
543
Craniotomy With Major Device Implant or Acute Complex Central Nervous System Principal Diagnosis (Proposed MS-DRGs 23 and 24, Craniotomy with Major Device Implant or Acute Complex Central Nervous System Principal Diagnosis With and Without MCC, respectively).3
49
Major Head & Neck Procedures (Proposed MS-DRGs 129 and 130, Major Head & Neck Procedures With CC/MCC or Major Device or Without CC/MCC, respectively).5
104
Cardiac Valve & Other Major Cardiothoracic Procedures  with Cardiac Catheterization (Proposed MS-DRGs 216, 217, and 218, Cardiac Valve & Other Major Cardiothoracic Procedure With Cardiac Catheterization With MCC, or Without CC, or Without CC/MCC, respectively).( print page 24745)5
105
Cardiac Valve & Other Major Cardiothoracic Procedures Without Cardiac Catheterization (Proposed MS-DRGs 219, 220, and 221, Cardiac Valve & Other Major Cardiothoracic Procedure Without Cardiac Catheterization With MCC, or With CC, or Without CC/MCC, respectively).5
110
Major Cardiovascular Procedures With CC (Proposed MS-DRG 237, Major Cardiovascular Procedures With MCC).5
111
Major Cardiovascular Procedures Without CC (Proposed MS-DRG 238, Major Cardiovascular Procedures Without MCC).5
117
Cardiac Pacemaker Revision Except Device Replacement  (Proposed MS-DRGs 260, 261, and 262, Cardiac Pacemaker Revision Except Device Replacement With MCC, or With CC, or Without CC/MCC, respectively).5
118
Cardiac Pacemaker Device Replacement (Proposed MS-DRGs 258 and 259, Cardiac Pacemaker Device Replacement With MCC, and Without MCC, respectively).5
515
Cardiac Defibrillator Implant Without Cardiac Catheterization (Proposed MS-DRGs 226 and 227, Cardiac Defibrillator Implant Without Cardiac Catheterization With MCC and Without MCC, respectively).5
525
Other Heart Assist System Implant (Proposed MS-DRG 215, Other Heart Assist System Implant).5
535
Cardiac Defibrillator Implant With Cardiac Catheterization With Acute Myocardial Infarction/Heart Failure/Shock (Proposed MS-DRGs 222 and 223, Cardiac Defibrillator Implant With Cardiac Catheterization With Acute Myocardial Infarction/Heart Failure/Shock With MCC and Without MCC, respectively).5
536
Cardiac Defibrillator Implant With Cardiac Catheterization Without Acute Myocardial Infarction/Heart Failure/Shock (Proposed MS-DRGs 224 and 225, Cardiac Defibrillator Implant With Cardiac Catheterization Without Acute Myocardial Infarction/Heart Failure/Shock With MCC and Without MCC, respectively).5
551
Permanent Cardiac Pacemaker Implant With Major Cardiovascular Diagnosis or AICD Lead or Generator (Proposed MS-DRGs 242, 243, and 244, Permanent Cardiac Pacemaker Implant With MCC, With CC, and Without CC/MCC, respectively).5
552
Other Permanent Cardiac Pacemaker Implant Without Major Cardiovascular Diagnosis (Proposed MS-DRGs 242, 243, and 244, Permanent Cardiac Pacemaker Implant With MCC, With CC, and Without CC/MCC, respectively).8
471
Bilateral or Multiple Major Joint Procedures of Lower Extremity (Proposed MS-DRGs 461 and 462, Bilateral or Multiple Major Joint Procedures of Lower Extremity With MCC, or Without MCC, respectively).8
544
Major Joint Replacement or Reattachment of Lower Extremity (Proposed MS-DRGs 469 and 470, Major Joint Replacement or Reattachment of Lower Extremity With MCC or Without MCC, respectively).8
545
Revision of Hip or Knee Replacement (Proposed MS-DRGs 466, 467, and 468, Revision of Hip or Knee Replacement With MCC, With CC, or Without CC/MCC, respectively).
 CMS has requested and received new condition codes from the National Uniform Billing Committee to describe claims where a provider has received a device or product without cost. We will use these condition codes to reduce payment when the hospital used a device for which full or partial credit is given, or the item was replaced as a result of or under a warranty, field action, voluntary recall, involuntary recall, or otherwise provided free of charge. On November 4, 2005, we issued Change Request 4058, Transmittal 741, in the Medicare Claims Processing Manual. The effective date of this transmittal was April 1, 2006, and the implementation date was April 3, 2006. This transmittal specifies that the following two new condition codes have been created. They are defined below: Condition Code 49—Product Replacement within Product Lifecycle. Replacement of a product earlier than the anticipated lifecycle due to an indication that the product is not functioning properly.
                    Condition Code 50—Product Replacement for Known Recall of a Product. The manufacturer or the FDA has identified the product for recall and therefore replacement. Hospitals must report these codes on any claim for IPPS services that includes a replacement device or product for which they received full or partial credit. Hospital billing offices would report one of these condition codes in addition to the specific code for the type of procedure performed (for example, replacement of a defibrillator). When this code is received by Medicare and the discharge is assigned to a DRG that is subject to this policy, we are proposing to suspend the claim so that it does not automatically process and the fiscal intermediary (or, if applicable, the MAC) makes a manual payment determination. We are proposing to require the hospital to provide invoices or other information indicating its normal cost of the device and the amount of the credit it received. This transmittal can be accessed at the following Web site: 
                        *http://www.cms.hhs.gov/​Transmittals/​downloads/​R741CP.pdf*. Under our policy, the fiscal intermediary (or, if applicable, the MAC) would manually process claims involving DRGs that are subject to this policy that include a device that is replaced without cost to the hospital for the device or with full or partial credit for the removed device as identified by condition codes 49 or 50. For a device provided to the hospital without cost, the fiscal intermediary (or, if applicable, the MAC) would subtract the cost of the device from the DRG payment. For a device for which the hospital received a full or partial credit, the fiscal intermediary (or, if applicable, the MAC) would subtract the amount credited from the DRG payment. We are proposing to require the hospital to provide invoices or other information indicating the cost of the device and the amount of credit it received. We are seeking comment on the best approach to making this payment adjustment and what types of documentation hospitals should provide to the fiscal intermediary or MAC. We are proposing to invoke our special exceptions and adjustment authority under section 1886(d)(5)(I)(i) of the Act to make this adjustment. The special exceptions and adjustment authority authorizes us to provide “for such other exceptions and adjustments to [IPPS] payment amounts* * *as the Secretary deems appropriate.” We believe it would be appropriate to adjust payments for surgical procedures to replace certain devices by providing payments to hospitals only for the nondevice-related procedural costs when such a device is replaced without cost to the hospital for the device or with full credit for the removed device. To codify in regulations the proposed policies for the IPPS discussed above, we are proposing to add a new paragraph (g) to § 412.2 and a new 
                        ( print page 24746)
                        § 412.89 to 42 CFR Part 412, Subpart F. We are also proposing to make a technical, conforming change to the heading of Subpart F and to add an uncoded center heading before the proposed new § 412.89. H. Recalibration of DRG Weights (If you choose to comment on issues in this section, please include the caption “Recalibration of DRG Weights” at the beginning of your comment.) In section II.D.3. of the preamble of this proposed rule, we stated that we are proposing to continue to implement the cost-based DRG relative weights under a 3-year transition period such that, in FY 2008, year two of the transition, the relative weights would be recalibrated using a blend of 67 percent of the cost relative weight and 33 percent of the charge relative weight. By FY 2009, the relative weights will be 100 percent cost-based. We are proposing a few minor changes to the cost-weighting methodology that we adopted in the FY 2007 IPPS final rule (71 FR 47962 through 47971). However, in section II.E.2. of the preamble of this proposed rule, we request public comments about whether to adopt any of the short-term recommendations to the cost relative weighting methodology for FY 2008 made by RTI. Therefore, if we were to adopt any of the RTI recommendations based on public comment, our description of the cost-weighting methodology shown below would be modified accordingly in the IPPS final rule. In developing the FY 2008 proposed system of weights, we used two data sources: claims data and cost report data. As in previous years, the claims data source is the MedPAR file. This file is based on fully coded diagnostic and procedure data for all Medicare inpatient hospital bills. The FY 2006 MedPAR data used in this proposed rule include discharges occurring on October 1, 2005, through September 30, 2006, based on bills received by CMS through December 2006, from all hospitals subject to the IPPS and short-term acute care hospitals in Maryland (which are under a waiver from the IPPS under section 1814(b)(3) of the Act). The FY 2006 MedPAR file used in calculating the relative weights includes data for approximately 11,748,387 Medicare discharges from IPPS providers. Discharges for Medicare beneficiaries enrolled in a Medicare Advantage managed care plan are excluded from this analysis. The data exclude CAHs, including hospitals that subsequently became CAHs after the period from which the data were taken. The second data source used in the cost relative weight methodology is the FY 2005 Medicare cost report data files from HCRIS, which represents the most recent full set of cost report data available. We used the December 31, 2006 update of the HCRIS cost report files for FY 2005 in setting the proposed relative cost based weights. Because we are implementing the relative weights on a transitional basis, it is necessary to calculate both charge-based and cost-based relative weights. The charge-based methodology used to calculate the DRG relative weights from the MedPAR data is the same methodology that was in place for FY 2006 and FY 2007 and was applied as follows: To the extent possible, all the claims were regrouped using the MS-DRGs being proposed for FY 2008, as discussed in section II.D. of this preamble.
                    The transplant cases that were used to establish the relative weight for heart and heart-lung, liver and/or intestinal, and lung transplants (proposed MS-DRGs 001, 002, 005, 006, and 007, respectively; previously CMS DRGs 103, 480, and 495) were limited to those Medicare-approved transplant centers that have cases in the FY 2005 MedPAR file. (Medicare coverage for heart, heart-lung, liver and/or intestinal, and lung transplants is limited to those facilities that have received approval from CMS as transplant centers.)
                    Organ acquisition costs for kidney, heart, heart-lung, liver, lung, pancreas, and intestinal (or multivisceral organs) transplants continue to be paid on a reasonable cost basis. Because these acquisition costs are paid separately from the IPPS rates, it was necessary to subtract the acquisition charges from the total charges on each transplant bill that showed acquisition charges before computing the average charge for the DRG and before eliminating statistical outliers.
                    Total charges were standardized to remove the effects of differences in area wage levels, indirect medical education and disproportionate share payments, and, for hospitals in Alaska and Hawaii, the applicable cost-of-living adjustment.
                    Statistical outliers were eliminated by removing all cases that were beyond 3.0 standard deviations from the mean of the log distribution of both the standardized charges per case and the standardized charges per day for each DRG.
                    The average charge for each DRG was then recomputed (excluding the statistical outliers). To compute the average DRG charge, we sum the standardized charges by DRG and divide by the transfer adjusted case count. A transfer case is counted as a fraction of a case based on the ratio of its transfer payment under the per diem payment methodology to the full DRG payment for nontransfer cases. That is, a transfer case receiving payment under the transfer methodology equal to half of what the case would receive as a nontransfer would be counted as 0.5 of a total case. The average charge per DRG is then divided by the national average standardized charge per case to determine the relative weight. The new charge-based weights were then normalized by an adjustment factor of 1.50808 so that the average case weight after recalibration was equal to the average case weight before recalibration. This normalization adjustment is intended to ensure that recalibration by itself neither increases nor decreases total payments under the IPPS as required by section 1886(d)(4)(C)(iii) of the Act. The methodology we used to calculate the DRG cost-based weights from the FY 2006 MedPAR claims data and FY 2005 Medicare cost report data is as follows: To the extent possible, all the claims were regrouped using the FY 2008 proposed MS-DRG classifications discussed in section II.D. of this preamble.
                    The transplant cases that were used to establish the relative weight for heart and heart-lung, liver and/or intestinal, and lung transplants (proposed MS-DRGs 001, 002, 005, 006, and 007, respectively; previously CMS DRGs 103, 480, and 495) were limited to those Medicare-approved transplant centers that have cases in the FY 2006 MedPAR file. (Medicare coverage for heart, heart-lung, liver and/or intestinal, and lung transplants is limited to those facilities that have received approval from CMS as transplant centers.)
                    Organ acquisition costs for kidney, heart, heart-lung, liver, lung, pancreas, and intestinal (or multivisceral organs) transplants continue to be paid on a reasonable cost basis. Because these acquisition costs are paid separately from the prospective payment rate, it is necessary to subtract the acquisition charges from the total charges on each transplant bill that showed acquisition charges before computing the average cost for each DRG and before eliminating statistical outliers.
                    Claims with total charges or total length of stay less than or equal to zero were deleted. Claims that had an amount in the total charge field that differed by more than $10.00 from the sum of the routine day charges, intensive care charges, pharmacy charges, special equipment charges, therapy services charges, operating( print page 24747)
                        room charges, cardiology charges, laboratory charges, radiology charges, other service charges, labor and delivery charges, inhalation therapy charges and anesthesia charges were also deleted.
                    At least 94 percent of the providers in the MedPAR file had charges for 10 of the 13 cost centers. Claims for providers that did not have charges greater than zero for at least 10 of the 13 cost centers were deleted.
                    Statistical outliers were eliminated by removing all cases that were beyond 3.0 standard deviations from the mean of the log distribution of both the total charges per case and the total charges per day for each DRG. Once the MedPAR data were trimmed and the statistical outliers were removed, the charges for each of the 13 cost groups for each claim were standardized to remove the effects of differences in area wage levels, indirect medical education and disproportionate share payments, and for hospitals in Alaska and Hawaii, the applicable cost-of-living adjustment. Charges were then summed by DRG for each of the 13 cost groups such that each DRG had 13 standardized charge totals. These charges were then adjusted to cost by applying the national average CCRs developed from the FY 2005 cost report data. The 13 cost centers that we used in the relative weight calculation are shown in the following table. In addition, the table shows the lines on the cost report that we used to create the national cost center CCRs that we used to adjust the DRG charges to cost. For FY 2008, we are proposing to make minor revisions to the Cardiology, Laboratory, Radiology, and Other Services CCRs we are using to calculate the DRG relative weights, as follows: The costs for cases involving Electroencephalography (EEG), cost report line 54, are currently in the Cardiology cost center group. However, MedPAR categorizes the claims data for EEG under Laboratory Charges (revenue codes 0740 and 0749). In order to maintain consistency with matching costs on the cost report to charges on MedPAR claims, we are proposing to move cost report line 54 for EEG out of the Cardiology cost center group into the Laboratory cost center group.
                    In the FY 2007 IPPS proposed rule, we originally included the costs for Radioisotopes, cost report line 43, in the Radiology cost center group. However, in response to comments, we moved Radioisotopes to the Other Services cost center group. After researching this issue further over the past year, we believe that Radioisotopes is a radiology-related service that more appropriately belongs in the Radiology cost center group. Accordingly, for FY 2008, we are proposing to move the cost report line item for line 43, Radioisotopes, out of the Other Services cost center group and into the Radiology cost center group. The proposed version of the 13 cost center groupings are in the table below: 
 
  
 
  
 
  
 
  
 
  
 
  We developed the national average CCRs as follows: Taking the FY 2005 cost report data, we removed CAHs, Indian Health Service hospitals, all-inclusive rate hospitals, and cost reports that represented time periods of less than 1 year (365 days). We included hospitals located in Maryland as we are including their charges in our claims database. We then created CCRs for each provider for each cost center (see prior table for line items used in the calculations) and removed any CCRs that were greater than 10 or less than 0.01. We normalized the departmental CCRs by dividing the CCR for each department by the total CCR for the hospital for the purpose of trimming the data. We then took the logs of the normalized cost center CCRs and removed any cost center CCRs where the log of the cost center CCR was greater or less than the mean log plus/minus 3 times the standard deviation for the log of that cost center CCR. Once the cost report data were trimmed, we calculated a Medicare-specific CCR. The Medicare-specific CCR was determined by taking 
                        ( print page 24754)
                        the Medicare charges for each line item from Worksheet D, Part 4 and deriving the Medicare specific costs by applying the hospital-specific departmental CCRs to the Medicare-specific charges for each line item from Worksheet D, Part 4. Once each hospital's Medicare-specific costs were established, we summed the total Medicare-specific costs and divided by the sum of the total Medicare-specific charges to produce national average, charge-weighted CCRs. After we multiplied the total charges for each DRG in each of the 13 cost centers by the corresponding national average CCR, we summed the 13 “costs” across each DRG to produce a total standardized cost for the DRG. The average standardized cost for each DRG was then computed as the total standardized cost for the DRG divided by the transfer adjusted case count for the DRG. The average cost for each DRG was then divided by the national average standardized cost per case to determine the relative weight. The new cost-based weights were then normalized by an adjustment factor of 1.50988 so that the average case weight after recalibration was equal to the average case weight before recalibration. Since more trims were applied to the data under the cost-based weights methodology than under the charge-based methodology, a smaller universe of claims was used in the cost-based methodology. In this instance, the different universe of claims also resulted in a slightly higher cost-based normalization factor than the normalization factor derived for charge-based weights. The normalization adjustment is intended to ensure that recalibration by itself neither increases nor decreases total payments under the IPPS as required by section 1886(d)(4)(C)(iii) of the Act. The 13 proposed national average CCRs for FY 2008 are as follows: Group
CCRRoutine Days
0.52Intensive Days
0.48Drugs
0.21Supplies & Equipment
0.34Therapy Services
0.42Laboratory
0.17Operating Room
0.30Cardiology
0.19Radiology
0.18Other Services
0.37Labor & Delivery
0.47Inhalation Therapy
0.19Anesthesia
0.14
 When we recalibrated the DRG weights for previous years, we set a threshold of 10 cases as the minimum number of cases required to compute a reasonable weight. We used that same case threshold in recalibrating the DRG weights for FY 2008. Using the FY 2006 MedPAR data set, there are 7 proposed MS-DRGs that contain fewer than 10 cases. Under the proposed MS-DRGs, we have fewer low-volume DRGs than under the CMS DRGs because we no longer have separate DRGs for patients age 0 to 17 years. With the exception of newborns, we previously separated some DRGs based on whether the patient was age 0-17 or age 17 and older. Other than the age split, cases grouping to these DRGs are identical. The DRGs for patients age 0 to 17 years generally have very low volumes because children are typically ineligible for Medicare. In the past, we have found that the low volume of cases for the pediatric DRGs could lead to significant year-to-year instability in their relative weights. Although we have always encouraged non-Medicare payers to develop weights applicable to their own patient populations, we have heard frequent complaints from providers about the use of the Medicare relative weights in the pediatric population. We believe that eliminating this age split in the proposed MS-DRGs will provide more stable payment for pediatric cases by determining their payment using adult cases that are much higher in total volume. All of the low-volume DRGs listed below are for newborns. Newborns are unique and require separate DRGs that are not mirrored in the adult population. Therefore, it remains necessary to retain separate DRGs for newborns. In FY 2008, because we do not have sufficient MedPAR data to set accurate and stable cost weights for these low-volume DRGs, we are proposing to compute weights for the low-volume DRGs by adjusting their FY 2007 weights by the percentage change in the average weight of the cases in other DRGs. The crosswalk table we are proposing is shown below: Low-volume DRG
DRG title
Crosswalk to DRG789
Neonates, Died or Transferred to Another Acute Care Facility
FY 2007 FR weight (adjusted by percent change in average weight of the cases in other DRGs).790
Extreme Immaturity or Respiratory Distress Syndrome, Neonate
FY 2007 FR weight (adjusted by percent change in average weight of the cases in other DRGs).791
Prematurity With Major Problems
FY 2007 FR weight (adjusted by percent change in average weight of the cases in other DRGs).792
Prematurity Without Major Problems
FY 2007 FR weight (adjusted by percent change in average weight of the cases in other DRGs).793
Full-term Neonate With Major Problems
FY 2007 FR weight (adjusted by percent change in average weight of the cases in other DRGs).794
Neonate With Other Significant Problems
FY 2007 FR weight (adjusted by percent change in average weight of the cases in other DRGs).795
Normal Newborn
FY 2007 FR weight (adjusted by percent change in average weight of the cases in other DRGs).
 I. Proposed MS-LTC-DRG Reclassifications and Relative Weights for LTCHs for FY 2008 (If you choose to comment on issues in this section, please include the caption “MS-LTC-DRGs” at the beginning of your comment.) 1. Background In the June 6, 2003 LTCH PPS final rule (68 FR 34122), we changed the LTCH PPS annual payment rate update cycle to be effective July 1 through June 30 instead of October 1 through September 30. In addition, because the patient classification system utilized under the LTCH PPS uses the same CMS DRGs as those currently used under the IPPS for acute care hospitals, in that same final rule, we explained that the annual update of the long-term care diagnosis-related group (LTC-DRG) classifications and relative weights will continue to remain linked to the annual reclassification and recalibration of the CMS DRGs used under the IPPS. Therefore, we specified that we will continue to update the LTC-DRG 
                        ( print page 24755)
                        classifications and relative weights to be effective for discharges occurring on or after October 1 through September 30 each year. We further stated that we will publish the annual proposed and final update of the LTC-DRGs in same notice as the proposed and final update for the IPPS (69 FR 34125). In the past, the annual update to the IPPS CMS DRGs has been based on the annual revisions to the ICD-9-CM codes and was effective each October 1. As discussed in the FY 2007 IPPS final rule (71 FR 47971 through 47994) and in the Rate Year (RY) 2008 LTCH PPS proposed rule (72 FR 4783 through 4789), with the implementation of section 503(a) of Pub. L. 108-173, there is the possibility that one feature of the GROUPER software program may be updated twice during a Federal fiscal year (October 1 and April 1) as required by the statute for the IPPS. Section 503(a) of Pub. L. 108-173 amended section 1886(d)(5)(K) of the Act by adding a new clause (vii) which states that “the Secretary shall provide for the addition of new diagnosis and procedure codes in [sic] April 1 of each year, but the addition of such codes shall not require the Secretary to adjust the payment (or diagnosis-related group classification) * * *  until the fiscal year that begins after such date.” This requirement improves the recognition of new technologies under the IPPS by accounting for those ICD-9-CM codes in the MedPAR claims data earlier than the agency had accounted for new technology in the past. In implementing the statutory change, the agency has provided that ICD-9-CM diagnosis and procedure codes for new medical technology may be created and assigned to existing CMS DRGs in the middle of the Federal fiscal year, on April 1. However, this policy change will not impact the DRG relative weights in effect for that year, which will continue to be updated only once a year (October 1), nor will it have any impact on Medicare payments. The use of the ICD-9-CM code set is also compliant with the current requirements of the Transactions and Code Sets Standards regulations at 45 CFR Parts 160 and 162, promulgated in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub. L. 104-191. As noted above, the patient classification system used under the LTCH PPS (LTC-DRGs) is based on the patient classification system used under the IPPS (CMS DRGs). Therefore, the ICD-9-CM codes currently used under both the IPPS and LTCH PPS may be updated as often as twice a year. This requirement is included as part of the amendments to the Act relating to recognition of new medical technology under the IPPS. Because we do not publish a midyear IPPS rule, any April 1 ICD-9-CM coding update will not be published midyear. Rather, we will assign any new diagnosis or procedure codes to the same DRG in which its predecessor code was assigned, so that there will be no impact on the DRG assignments (as also discussed in section II.G.10. of this preamble). Any coding updates will be available through the Web sites provided in section II.G.10. of this preamble and through the 
                        *Coding Clinic for ICD-9-CM,*
                         a product of the American Hospital Association. Publishers and software vendors currently obtain code changes through these sources in order to update their code books and software system. If new codes are implemented on April 1, revised code books and software systems, including the GROUPER software program, will be necessary because we must use current ICD-9-CM codes. Therefore, for purposes of the LTCH PPS, because each ICD-9-CM code must be included in the GROUPER algorithm to classify each case into a LTC-DRG, the GROUPER software program used under the LTCH PPS would need to be revised to accommodate any new codes. In implementing section 503(a) of Pub. L. 108-173, there will only be an April 1 update if new technology codes are requested and approved. We note that any new codes created for April 1 implementation will be limited to those diagnosis and procedure code revisions primarily needed to describe new technologies and medical services. However, we reiterate that the process of discussing updates to the ICD-9-CM is an open process through the ICD-9-CM Coordination and Maintenance Committee. Requestors will be given the opportunity to present the merits for a new code and to make a clear and convincing case for the need to update ICD-9-CM codes for purposes of the IPPS new technology add-on payment process through an April 1 update (as also discussed in section II.G.10. of this preamble). As we discussed in the RY 2008 LTCH PPS proposed rule (72 FR 4783 through 4789), at the September 28, 2006 ICD-9-CM Coordination and Maintenance Committee meeting, there were no requests for an April 1, 2007 implementation of ICD-9-CM codes. Therefore, the next update to the ICD-9-CM coding system will not occur until October 1, 2007 (FY 2008). Because there were no coding changes suggested for an April 1, 2007 update, the ICD-9-CM coding set implemented on October 1, 2006, will continue through September 30, 2007 (FY 2008). The update to the ICD-9-CM coding system for FY 2008 is discussed above in section II.G.10. of this preamble. Accordingly, in this proposed rule, as discussed in greater detail below, we are proposing to modify and revise the LTC-DRG classifications and relative weights, to be effective October 1, 2007 through September 30, 2008 (FY 2008). In addition, we will notify LTCHs of any revisions to the GROUPER software used under the IPPS and the LTCH PPS that may be implemented on April 1, 2008. The proposed LTC-DRGs and proposed relative weights for FY 2008 in this proposed rule are based on the proposed IPPS MS-DRGs (GROUPER Version 25.0) discussed in section II.B. of the preamble to this proposed rule. 2. Proposed Changes in the LTC-DRG Classifications a. Background Section 123 of Pub. L. 106-113 specifically requires that the agency implement a PPS for LTCHs that is a per discharge system with a DRG-based patient classification system reflecting the differences in patient resources and costs in LTCHs while maintaining budget neutrality. Section 307(b)(1) of Pub. L. 106-554 modified the requirements of section 123 of Pub. L. 106-113 by specifically requiring that the Secretary examine “the feasibility and the impact of basing payment under such a system [the LTCH PPS] on the use of existing (or refined) hospital diagnosis-related groups (DRGs) that have been modified to account for different resource use of long-term care hospital patients as well as the use of the most recently available hospital discharge data.” In accordance with section 123 of Pub. L. 106-113 as amended by section 307(b)(1) of Pub. L. 106-554 and § 412.515 of our existing regulations, the LTCH PPS uses information from LTCH patient records to classify patient cases into distinct LTC-DRGs based on clinical characteristics and expected resource needs. As described in II.D. of the preamble of this proposed rule, we are proposing to adopt MS-DRGs under the IPPS because we believe that adopting this system will result in a significant improvement in the DRG system's recognition of severity of illness and resource usage. We believe these improvements in the DRG system would be equally applicable to the LTCH PPS. The changes we are currently proposing for the IPPS would be reflected in the FY 2008 GROUPER, 
                        ( print page 24756)
                        Version 25.0, to be effective for discharges occurring on or after October 1, 2007 through September 30, 2008. Currently, the LTC-DRGs used as the patient classification component of the LTCH PPS correspond to the current CMS DRGs applicable under the IPPS for acute care hospitals Consistent with our historical practice of having LTC-DRGs correspond to the DRGs applicable under the IPPS, under the broad authority of section 123(a) of Pub. L. 106-113, as modified by section 307(b) of Pub. L. 106-554, we are proposing to use MS-LTC-DRGs which correspond to the proposed MS-DRGs. In addition, as stated above, we are proposing to use the FY 2008 GOUPER Version 25.0, to be effective for discharges occurring on or after October 1, 2007 through September 30, 2008. The proposed changes to the current CMS DRG classification system used under the IPPS for FY 2008 (GROUPER Version 25.0) are discussed in section II.D. of the preamble to this proposed rule. As noted above, the patient classification system used under the LTCH PPS (LTC-DRGs) is based on the patient classification system used under the IPPS (CMS DRGs), which historically has been updated annually as authorized by section 1886(d)(4)(C) of the Act and is effective for discharges occurring on or after October 1 through September 30 of each year. As such, the proposed updates to the CMS DRG classification system used under the IPPS for FY 2008 (GROUPER Version 25.0), discussed in section II.D. of the preamble of this proposed rule, would be applicable to updates under the LTCH PPS. In conjunction with the proposed changes to the existing CMS DRGs for the IPPS by adoption of the proposed MS-DRGs, we are proposing to adopt the MS-DRGs for the LTCH PPS, as both sets of DRGs are based on the same DRG structure. However, we refer to the proposed DRGs under the LTCH PPS as MS-LTC-DRGs. This proposed conforming change, that is, to replicate the MS-LTC-DRG structure after the proposed MS-DRG structure is appropriate in order to maintain consistency and uniformity among a number of stakeholders, such as acute care hospitals, LTCHs, epidemiologists, ratesetting organizations, and payors, among others. Under the LTCH PPS, as described in greater detail below, we determine relative weights for each of the DRGs to account for the difference in resource use by patients exhibiting the case complexity and multiple medical problems characteristic of LTCH patients. (Unless otherwise noted in this proposed rule, our MS-LTC-DRG analysis is based on LTCH data from the December 2006 update of the FY 2006 MedPAR file, which contains hospital bills received through December 31, 2006, for discharges occurring in FY 2006.) LTCHs do not typically treat the full range of diagnoses as do acute care hospitals. Therefore, as we discussed in the August 30, 2002 LTCH PPS final rule (67 FR 55985), which implemented the LTCH PPS, and the FY 2006 IPPS final rule (70 FR 47324), we use low-volume quintiles in determining the LTC-DRG relative weights for LTC-DRGs with less than 25 LTCH cases (low-volume LTC-DRGs). Specifically, we group those low-volume LTC-DRGs into 5 quintiles based on average charges per discharge. (A listing of the composition of low-volume quintiles for the FY 2007 LTC-DRGs (based on FY 2005 MedPAR data) appears in section II.I.2.d. of the FY 2007 IPPS final rule (71 FR 47975 through 47978).) We also adjust for cases in which the stay at the LTCH is less than or equal to five-sixths of the geometric average length of stay; that is, short-stay outlier cases (§ 412.529), as discussed below in section II.I.4. of this preamble. b. Patient Classifications into DRGs Generally, under the LTCH PPS, Medicare payment is made at a predetermined specific rate for each discharge; that is, payment varies by the LTC-DRG to which a beneficiary's stay is assigned. Just as cases have been classified into the proposed MS-DRGs for acute care hospitals under the IPPS (section II. of the preamble of this proposed rule), cases have been classified into proposed MS-LTC-DRGs for payment under the LTCH PPS based on the principal diagnosis, up to eight additional diagnoses, and up to six procedures performed during the stay, as well as age, sex, and discharge status of the patient. The diagnosis and procedure information is reported by the hospital using the ICD-9-CM codes. Under the proposed MS-DRGs for the IPPS and the proposed MS-LTC-DRGs for the LTCH PPS, these factors will not change. Section II.B. of the preamble of this proposed rule discusses the organization of the existing CMS DRGs, which we are proposing to maintain under the proposed MS-DRG and MS-LTC-DRG systems. As noted above, the patient classification system for the LTCH PPS is derived from the CMS DRGs and is similarly organized into 25 major diagnostic categories (MDCs). Most of these MDCs are based on a particular organ system of the body and the remainder involves multiple organ systems (such as MDC 22, Burns). Accordingly, the principal diagnosis determines MDC assignment. Within most MDCs, cases are then divided into surgical DRGs and medical DRGs. Under the present CMS DRGs, some surgical and medical DRGs are further differentiated based on the presence or absence of CCs. The existing LTC-DRGs are similarly categorized. (See section II.B. of the preamble of this proposed rule for further discussion of surgical DRGs and medical DRGs.) The proposed MS-DRGs and the proposed MS-LTC-DRGs contain base DRGs that have been subdivided into one, two, or three severity levels. The most severe level has at least one code that is a major CC, referred to as “with MCC”. The next lower severity level contains cases with at least one CC, referred to as “with CC”. Those DRGs without an MCC or a CC are referred to as “without CC/MCC”. When data did not support the creation of three severity levels, the base DRG was divided into either two levels or the base was not subdivided. The proposed two-level subdivisions consist of one of the following subdivisions: With CC/MCC
                    Without CC/MCC In this type of subdivision, cases with at least one code that is on the CC or MCC list are assigned to the “with CC/MCC” DRG. Cases without a CC or an MCC are assigned to the “without CC/MCC” DRG. The other type of proposed two-level subdivision is as follows: With MCC
                    Without MCC In this type of subdivision, cases with at least one code that is on the MCC list are assigned to the “with MCC” DRG. Cases that do not have an MCC are assigned to the “without MCC” DRG. This type of subdivision could include cases with a CC code, but no MCC. As under the present LTC-DRG system, we are proposing that the assignment of a case to a particular MS-LTC-DRG will determine the amount that is paid for the case. Therefore, it is important that the coding is accurate. Classifications and terminology used under the LTCH PPS are consistent with the ICD-9-CM and the Uniform Hospital Discharge Data Set (UHDDS), as recommended to the Secretary by the National Committee on Vital and Health Statistics (“Uniform Hospital Discharge Data: Minimum Data Set, National Center for Health Statistics, April 1980”) and as revised in 1984 by the Health Information Policy Council (HIPC) of the U.S. Department of Health and Human Services. Again, we point 
                        ( print page 24757)
                        out that the ICD-9-CM coding terminology and the definitions of principal and other diagnoses of the UHDDS are consistent with the requirements of the Transactions and Code Sets Standards under HIPAA (45 CFR Parts 160 and 162). The emphasis on the need for proper coding cannot be overstated. As under the present LTC-DRG system, inappropriate coding of cases under the proposed MS-LTC-DRG system could adversely affect the uniformity of cases in each proposed MS-LTC-DRG and produce inappropriate weighting factors at recalibration and result in inappropriate payments under the LTCH PPS. LTCHs are required to follow the same coding guidelines established under the IPPS, described in section II.G.10 of the preamble of this proposed rule established under the IPPS. It is mandatory that the coders continue to report the same principal diagnosis on all claims and include all diagnosis codes for conditions that coexist at the time of admission, for conditions that are subsequently developed, or for conditions that affect the treatment received. Similarly, all procedures performed in a LTCH, or paid for under arrangements by a LTCH (§ 412.509), during that stay are to be reported on each claim. Consistent with current practice, there will be only one proposed MS-LTC-DRG assigned to each discharge of the patient from a LTCH. Under the proposed MS-LTC-DRG classification system, as is required under existing policy, upon the discharge of the patient from a LTCH, the LTCH must assign appropriate diagnosis and procedure codes from the ICD-9-CM. Completed claim forms are to be submitted electronically to the LTCH's fiscal intermediary (or, if applicable, MAC). The fiscal intermediary or MAC enters the clinical and demographic information into their claims processing systems and subject this information to a series of automated screening processes called the MCE. These screens are designed to identify cases that require further review before assignment into a LTC-DRG can be made. After screening through the MCE, each LTCH claim will be classified into the appropriate LTC-DRG by the Medicare LTCH GROUPER. The LTCH GROUPER is specialized computer software and is the same GROUPER used under the IPPS. After the LTC-DRG is assigned, the fiscal intermediary or MAC determines the prospective payment by using the Medicare LTCH PPS PRICER program, which accounts for LTCH hospital-specific adjustments and payment rates. As provided for under the IPPS, we provide an opportunity for the LTCH to review the LTC-DRG assignments made by the fiscal intermediary or MAC and to submit additional information, if necessary, within a specified timeframe (§ 412.513(c)). Under the proposed adoption of the MS-LTC-DRG, there would be no changes in this procedure. The LTCH GROUPER is used both to classify past cases in order to measure relative hospital resource consumption to establish the proposed MS-LTC-DRG weights and to classify current cases for purposes of determining payment. The records for all Medicare hospital inpatient discharges are maintained in the MedPAR file. The data in this file are used to evaluate possible DRG classification changes and to recalibrate the DRG weights during our annual update (as discussed in section II.H. of the preamble of this proposed rule). The proposed MS-LTC-DRG relative weights are based on data for the population of LTCH discharges. 3. Development of the Proposed FY 2008 MS-LTC-DRG Relative Weights a. General Overview of Development of the Proposed MS-LTC-DRG Relative Weights As we stated in the August 30, 2002 LTCH PPS final rule (67 FR 55981), one of the primary goals for the implementation of the LTCH PPS is to pay each LTCH an appropriate amount for the efficient delivery of medical care to Medicare patients. The system must be able to account adequately for each LTCH's case-mix in order to ensure both fair distribution of Medicare payments and access to adequate care for those Medicare patients whose care is more costly. To accomplish these goals, we have annually adjusted the LTCH PPS standard Federal prospective payment system rate by the applicable LTC-DRG relative weight in determining payment to LTCHs for each case. (As we have noted above, we are proposing to adopt the MS-LTC-DRGs for the LTCH PPS for FY 2008. However, this proposed change in the patient classification system does not affect the basic principles of the development of relative weights under a DRG-based prospective payment system. For purposes of clarity, in the general discussion below in which we describe the basic methodology of the patient classification system, in use since the start of the LTCH PPS, we use “MS-LTC-DRG” to specify the proposed DRG system to be used by the LTCH prospective payment system in FY 2008.) Although the proposed adoption of the MS-LTC-DRGs will result in some modifications of existing procedures for assigning weights in cases of zero volume and/or nonmonotonicity, discussed in detail in the following sections, the basic methodology for developing the proposed FY 2008 MS-LTC-DRG relative weights in this proposed rule continue to be determined in accordance with the general methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55989 through 55991). (Therefore, as noted above, in this preamble, “LTC-DRGs” will be used in descriptions of the basic methodology established at the beginning of the LTCH PPS that will remain unchanged if we adopt the proposed MS-LTC-DRGs. Use of “MS-LTC-DRGs” will indicate a discussion of specifics aspects of our proposed adoption of the severity-weighted patient classification system for FY 2008.) Under the LTCH PPS, relative weights for each proposed MS-LTC-DRG are a primary element used to account for the variations in cost per discharge and resource utilization among the payment groups (§ 412.515). To ensure that Medicare patients classified to each proposed MS-LTC-DRG have access to an appropriate level of services and to encourage efficiency, we calculate a relative weight for each proposed MS-LTC-DRG that represents the resources needed by an average inpatient LTCH case in that proposed MS-LTC-DRG. For example, cases in a proposed MS-LTC-DRG with a relative weight of 2 will, on average, cost twice as much to treat as cases in a proposed MS-LTC-DRG with a weight of 1. b. Data To calculate the proposed MS-LTC-DRG relative weights for FY 2008 in his proposed rule, we obtained total Medicare allowable charges from FY 2006 Medicare LTCH bill data from the December 2006 update of the MedPAR file, which are the best available data at this time, and we used the proposed Version 25.0 of the CMS GROUPER used under the IPPS (as discussed in section II.B. of the preamble of this proposed rule) to classify cases. To calculate the final MS-LTC-DRG relative weights for FY 2008, we are proposing that, if more recent data are available (that is, data from the March 2007 update of the MedPAR file), we would use those data and the finalized Version 25.0 of the CMS GROUPER used under the IPPS. As we discussed in the FY 2007 IPPS final rule (71 FR 47974), we have excluded the data from LTCHs that are 
                        ( print page 24758)
                        all-inclusive rate providers and LTCHs that are reimbursed in accordance with demonstration projects authorized under section 402(a) of Pub. L. 90-248. Data from demonstration projects authorized under section 222(a) of Pub. L. 92-603 are also excluded. Therefore, in the development of the proposed FY 2008 MS-LTC-DRG relative weights in this proposed rule, we have excluded the data of the 19 all-inclusive rate providers and the 3 LTCHs that are paid in accordance with demonstration projects that had claims in the FY 2006 MedPAR file. c. Hospital-Specific Relative Value Methodology By nature, LTCHs often specialize in certain areas, such as ventilator-dependent patients and rehabilitation and wound care. Some case types (DRGs) may be treated, to a large extent, in hospitals that have, from a perspective of charges, relatively high (or low) charges. This nonarbitrary distribution of cases with relatively high (or low) charges in specific proposed MS-LTC-DRGs has the potential to inappropriately distort the measure of average charges. To account for the fact that cases may not be randomly distributed across LTCHs, we use a hospital-specific relative value (HSRV) method to calculate the proposed MS-LTC-DRG relative weights instead of the methodology used to determine the proposed CMS DRG relative weights under the IPPS described in section II.H. of the preamble this proposed rule. We believe this method will remove this hospital-specific source of bias in measuring LTCH average charges. Specifically, we reduce the impact of the variation in charges across providers on any particular LTC-DRG relative weight by converting each LTCH's charge for a case to a relative value based on that LTCH's average charge. Under the HSRV method, we standardize charges for each LTCH by converting its charges for each case to hospital-specific relative charge values and then adjusting those values for the LTCH's case-mix. The adjustment for case-mix is needed to rescale the hospital-specific relative charge values (which, by definition, average 1.0 for each LTCH). The average relative weight for a LTCH is its case-mix, so it is reasonable to scale each LTCH's average relative charge value by its case-mix. In this way, each LTCH's relative charge value is adjusted by its case-mix to an average that reflects the complexity of the cases it treats relative to the complexity of the cases treated by all other LTCHs (the average case-mix of all LTCHs). In accordance with the methodology established under § 412.523, as implemented in the August 30, 2002 LTCH PPS final rule (67 FR 55989 through 55991), we continue to standardize charges for each case by first dividing the adjusted charge for the case (adjusted for short-stay outliers under § 412.529 as described in section II.I.4. (step 3) of the preamble of this proposed rule) by the average adjusted charge for all cases at the LTCH in which the case was treated. Short-stay outliers under § 412.529 are cases with a length of stay that is less than or equal to five-sixths the average length of stay of the proposed MS-LTC-DRG. The average adjusted charge reflects the average intensity of the health care services delivered by a particular LTCH and the average cost level of that LTCH. The resulting ratio is multiplied by that LTCH's case-mix index to determine the standardized charge for the case. Multiplying by the LTCH's case-mix index accounts for the fact that the same relative charges are given greater weight at a LTCH with higher average costs than they would at a LTCH with low average costs, which is needed to adjust each LTCH's relative charge value to reflect its case-mix relative to the average case-mix for all LTCHs. Because we standardize charges in this manner, we count charges for a Medicare patient at a LTCH with high average charges as less resource intensive than they would be at a LTCH with low average charges. For example, a $10,000 charge for a case at a LTCH with an average adjusted charge of $17,500 reflects a higher level of relative resource use than a $10,000 charge for a case at a LTCH with the same case-mix, but an average adjusted charge of $35,000. We believe that the adjusted charge of an individual case more accurately reflects actual resource use for an individual LTCH because the variation in charges due to systematic differences in the markup of charges among LTCHs is taken into account. d. Proposed Treatment of Severity Levels in Developing Relative Weights With the implementation of the LTCH PPS for FY 2003, we established a procedure to address setting relative weights for LTC-DRG “pairs” that were differentiated on the presence or absence of CCs (71 FR 47979). For FY 2008, we are proposing to adopt a severity-based patient classification system for the LTCH PPS, the MS-LTC-DRGs described above, which requires us to adapt our existing procedures for dealing with setting relative weights for the severity levels within a specific base DRG. We are also proposing to modify our existing methodology for maintaining monotonicity when setting relative weights for the proposed MS-LTC-DRGs. As under the existing procedure, under the proposed MS-LTC-DRGs, for purposes of the annual setting of the relative weights, there continue to be three different categories of DRGs based on volume of cases within specific LTC-DRGs. DRGs with at least 25 cases are each assigned a relative weight; low-volume proposed MS-LTC-DRGs (that is, proposed MS-LTC-DRGs that contain between one and 24 cases annually) are grouped into quintiles (described below) and assigned the weight of the quintile. Cases with no-volume proposed MS-LTC-DRGs (that is, no cases in the databases were assigned to those proposed MS-LTC-DRGs) are crosswalked to other proposed MS-LTC-DRGs based on the clinical similarities and assigned the weight of the quintile that is closest to the relative weight of the crosswalked proposed MS-LTC-DRG. (We provide in-depth discussions of our proposals regarding weightsetting for low-volume MS-LTC-DRGs in section II.I.3.e. of the preamble of this proposed rule and for no-volume MS-LTC-DRGs, under Step 4 in section II.I.4. of the preamble of this proposed rule.) As described above, in response to the need to account for severity and pay appropriately for cases, we have developed a severity-adjusted patient classification system which we are proposing for both the IPPS and the LTCH PPS. As described in greater detail above, the proposed MS-LTC-DRG system can accommodate three severity levels: MCC (most severe); without CC/MCC (the least severe), and with CC, with each level assigned an individual MS-LTC-DRG number. In cases with two subdivisions, the levels are either with CC/MCC and without CC/MCC or with MCC and without MCC. Two parallel numbering systems have been developed, based on the MS-DRG patient classification system proposed under the IPPS, to describe proposed MS-LTC-DRGs. That is, while each severity level in each DRG category gets a unique MS-LTC-DRG number, in conjunction, each of the severity levels in a single DRG category are also assigned the same “base-DRG” number. We are proposing that the term “base DRG” is actually the MS-LTC-DRG number of the highest severity level and would be used when we refer to the MS-LTC-DRG category that encompasses all the levels of severity for that DRG. Therefore, under the proposed system, multiple sclerosis and cerebellar ataxia with MCC is MS-LTC-DRG 58; multiple sclerosis and 
                        ( print page 24759)
                        cerebellar ataxia with CC is MS-LTC-DRG 59; and multiple sclerosis and cerebellar ataxia without CC/MCC is MS-LTC-DRG 59, and the base MS-LTC-DRG for each is 58. As noted above, for FY 2008, we are proposing to adopt the MS-DRGs for use in both the LTCH PPS and the IPPS. While the LTCH PPS and the IPPS use the same patient classification system, the methodology that is used to set the DRG weights for use in each payment system differs because the overall volume of cases in the LTCH PPS is much less than in the IPPS. As a general rule, we are proposing to set the weights for the MS-LTC-DRGs using the following steps: (1) If an MS-LTC-DRG has at least 25 cases, it is assigned its own relative weight; (2) if an MS-LTC-DRGs has between 1 and 24 cases, it is assigned to a quintile to which we will assign a relative weight; and (3) if an MS-LTC-DRG has no cases, it is crosswalked to another DRG based upon clinical similarities and assigned the appropriate relative weight (as described in detail in Step 5, below). Theoretically, as with the existing LTC-DRG system, cases under the proposed MS-LTC-DRG system that are more severe require greater expenditure of medical care resources and will result in higher average charges. Therefore, in the three severity levels, weights should increase with severity, from lowest to highest. If the weights do not increase (that is, if based on the weight calculation, a proposed MS-LTC-DRG with MCC would have a lower relative weight than one with CC, or the DRG without CC/MCC would have a higher relative weight than either of the others), there is a problem with monotonicity. Since the start of the LTCH PPS for FY 2003 (67 FR 55990), we have adjusted the setting of the LTC-DRG relative weight in order to maintain monotonicity by grouping both sets of cases together and establishing a new relative weight that is assigned to both LTC-DRGs. Similarly, we are proposing a procedure for dealing with nonmonotonicity under the proposed MS-LTC-DRG classification system that we describe in detail in our explanation of our methodology for setting the proposed FY 2008 relative weights for the LTCH PPS, which is discussed in section II.F.4 of the preamble of this proposed rule. e. Low-Volume Proposed MS-LTC-DRGs In order to account for LTC-DRGs with low volume (that is, with fewer than 25 LTCH cases), under current policy, in accordance with the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55984), we group those “low-volume LTC-DRGs” (that is, DRGs that contained between 1 and 24 cases annually) into one of five categories (quintiles) based on average charges, for the purposes of determining relative weights. For this FY 2008 IPPS proposed rule, we are proposing to continue to employ this treatment of low-volume proposed MS-LTC-DRGs with a modification to combine proposed MS-LTC-DRGs for the purpose of computing a relative weight in cases where necessary to maintain monotonicity in determining the proposed FY 2008 MS-LTC-DRG relative weights using the best available LTCH data. In this proposed rule, using LTCH cases from the December 2006 update of the FY 2006 MedPAR file, we identified 307 proposed MS-LTC-DRGs that contained between 1 and 24 cases. This list of proposed MS-LTC-DRGs was then divided into one of the 5 low-volume quintiles, each containing a minimum of 61 proposed MS-LTC-DRGs (307/5 = 61, with a remainder of 2 proposed MS-LTC-DRGs). Consistent with our current methodology, we are proposing to make an assignment to a specific low-volume quintile by sorting the low-volume proposed MS-LTC-DRGs in ascending order by average charge. For this proposed rule, this results in a proposed assignment to a specific low-volume quintile of the sorted 307 low-volume proposed MS-LTC-DRGs by ascending order by average charge. Because the number of low-volume proposed MS-LTC-DRGs for FY 2008 is not evenly divisible by five, to determine the composition of the low-volume quintiles in accordance with our established methodology, the average charge of the low-volume proposed MS-LTC-DRG was used to determine which low-volume quintile received the additional proposed MS-LTC-DRGs. After sorting the 307 low-volume proposed MS-LTC-DRGs in ascending order, we grouped the first fifth (1st through 61st) of low-volume proposed MS-LTC-DRGs (with the lowest average charge) into Quintile 1. Because the average charge of the 62nd proposed MS-LTC-DRG in the sorted list is closer to the 61st proposed MS-LTC-DRGs average charge (assigned to Quintile 1) than to the average charge of the 63rd proposed MS-LTC-DRG in the sorted list (to be assigned to Quintile 2), we placed the 62nd proposed MS-LTC-DRG into Quintile 1. This process was repeated through the remaining low-volume proposed MS-LTC-DRGs so that 2 low-volume quintiles contain 62 proposed MS-LTC-DRGs and 3 low-volume quintiles contain 61 proposed MS-LTC-DRGs. The highest average charge cases were grouped into Quintile 5. In order to determine the proposed relative weights for the proposed MS-LTC-DRGs with low-volume for FY 2008, based on the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55984), we are proposing to use the five low-volume quintiles described above. In addition, in cases where the initial assignment of the low-volume proposed MS-LTC-DRGs to quintiles results in nonmonotonicity within a base DRG, we are proposing to combine those proposed MS-LTC-DRGs for the purpose of computing a relative weight and set the same relative weight to each of the proposed MS-LTC-DRGs within the base DRG that required combining. The treatment of low-volume proposed MS-LTC-DRGs to preserve monotonicity is further discussed in detail in section II.I.4 (Step 6 of the methodology for determining the proposed FY 2008 MS-LTC-DRG relative weights). The composition of each of the proposed five low-volume quintiles shown in the chart below was used in determining the proposed MS-LTC-DRG relative weights for FY 2008. We would determine a proposed relative weight and (geometric) average length of stay for each of the proposed five low-volume quintiles using the methodology that we apply to the regular proposed MS-LTC-DRGs (25 or more cases), as described below in section II.I.4. of the preamble of this proposed rule. We are proposing to assign the same relative weight and average length of stay to each of the proposed MS-LTC-DRGs that make up an individual proposed low-volume quintile. We note that, as this system is dynamic, it is possible that the number and specific type of MS-LTC-DRGs with a low volume of LTCH cases will vary in the future. We use the best available claims data in the MedPAR file to identify low-volume MS-LTC-DRGs and to calculate the relative weights based on our methodology. Therefore, we are proposing that, if we have updated data for the final rule, we will use that data to determine the finalized FY 2008 relative weights. 
                        ( print page 24760) Proposed Composition of Low-Volume Quintiles for FY 2008
Proposed MS-LTC-DRG
Proposed MS-LTC-DRG description**QUINTILE 1**30
Spinal procedures w/o CC/MCC.32
Ventricular shunt procedures w CC.33
Ventricular shunt procedures w/o CC/MCC.58
Multiple sclerosis & cerebellar ataxia w MCC*.60
Multiple sclerosis & cerebellar ataxia w/o CC/MCC*.66
Intracranial hemorrhage or cerebral infarction w/o  CC/MCC.67
Nonspecific CVA & precerebral occlusion w/o infarct w MCC.68
Nonspecific CVA & precerebral occlusion w/o infarct w/o MCC.69
Transient ischemia.72
Nonspecific cerebrovascular disorders w/o CC/MCC.76
Viral meningitis w/o CC/MCC.79
Hypertensive encephalopathy w/o CC/MCC.88
Concussion w MCC***.133
Other ear, nose, mouth & throat O.R. procedures w  CC/MCC***.122
Acute major eye infections w/o CC/MCC.123
Neurological eye disorders.149
Dysequilibrium.153
Otitis media & URI w/o MCC.182
Respiratory neoplasms w/o CC/MCC.183
Major chest trauma w MCC.184
Major chest trauma w CC**.201
Pneumothorax w/o CC/MCC.261
Cardiac pacemaker revision except device replacement w CC.262
Cardiac pacemaker revision except device replacement w/o CC/MCC.313
Chest pain.328
Stomach, esophageal & duodenal proc w/o CC/MCC.331
Major small & large bowel procedures w/o CC/MCC.349
Anal & stomal procedures w/o CC/MCC.376
Digestive malignancy w/o CC/MCC.434
Cirrhosis & alcoholic hepatitis w/o CC/MCC*.446
Disorders of the biliary tract w/o CC/MCC.505
Foot procedures w/o CC/MCC.512
Shoulder, elbow or forearm proc, exc major joint  proc w/o CC/MCC.544
Pathological fractures & musculoskelet & conn tiss malig w/o CC/MCC.547
Connective tissue disorders w/o CC/MCC.563
Fx, sprn, strn & disl except femur, hip, pelvis & thigh w/o MCC.598
Malignant breast disorders w CC***.630
Other endocrine, nutrit & metab O.R. proc w/o  CC/MCC.645
Endocrine disorders w/o CC/MCC.661
Kidney & ureter procedures for non-neoplasm w/o  CC/MCC.688
Kidney & urinary tract neoplasms w/o CC/MCC.696
Kidney & urinary tract signs & symptoms w/o MCC.714
Transurethral prostatectomy w/o CC/MCC.718
Other male reproductive system O.R. proc exc malignancy w/o CC/MCC.724
Malignancy, male reproductive system w/o CC/MCC.726
Benign prostatic hypertrophy w/o MCC.756
Malignancy, female reproductive system w/o CC/MCC.759
Infections, female reproductive system w/o CC/MCC.761
Menstrual & other female reproductive system disorders w/o CC/MCC.825
Lymphoma & non-acute leukemia w other O.R. proc w/o CC/MCC.836
Acute leukemia w/o major O.R. procedure w/o CC/MCC.869
Other infectious & parasitic diseases diagnoses w/o CC/MCC.876
O.R. procedure w principal diagnoses of mental illness.881
Depressive neuroses.882
Neuroses except depressive.883
Disorders of personality & impulse control.886
Behavioral & developmental disorders.894
Alcohol/drug abuse or dependence, left ama.895
Alcohol/drug abuse or dependence w rehabilitation therapy.906
Hand procedures for injuries.916
Allergic reactions w/o MCC.922
Other injury, poisoning & toxic effect diag w MCC.923
Other injury, poisoning & toxic effect diag w/o  MCC.**QUINTILE 2**75
Viral meningitis w  CC/MCC.77
Hypertensive  encephalopathy w MCC.( print page 24761)78
Hypertensive  encephalopathy w CC**.83
Traumatic stupor & coma, coma >1 hr w CC.84
Traumatic stupor & coma, coma >1 hr w/o  CC/MCC.99
Non-bacterial infect  of nervous sys exc viral meningitis w/o  CC/MCC.102
Headaches w MCC***.113
Orbital procedures w  CC/MCC.121
Acute major eye infections w CC/MCC.125
Other disorders of the eye w/o MCC.148
Ear, nose, mouth & throat malignancy w/o  CC/MCC.152
Otitis media & URI w  MCC.156
Nasal trauma & deformity w/o CC/MCC.157
Dental & Oral Diseases w MCC***.158
Dental & Oral Diseases w CC***.184
Major chest trauma w  CC***.188
Pleural effusion w/o  CC/MCC*.200
Pneumothorax w CC.245
AICD lead & generator  procedures.282
Circulatory disorders w AMI, discharged  alive w/o CC/MCC.285
Circulatory disorders w AMI, expired w/o  CC/MCC*.304
Hypertension w MCC.311
Angina pectoris.336
Peritoneal  adhesiolysis w CC.382
Complicated peptic ulcer w/o CC/MCC.384
Uncomplicated peptic ulcer w/o MCC.390
G.I. obstruction w/o  CC/MCC.433
Cirrhosis & alcoholic hepatitis w CC*.437
Malignancy of hepatobiliary system  or pancreas w/o CC/MCC.443
Disorders of liver  except malig, cirr, alc hepa w/o CC/MCC.499
Local excision & removal int fix devices of hip & femur w/o CC/MCC.514
Hand or wrist proc,  except major thumb or joint proc w/o CC/MCC.534
Fractures of femur w/o  MCC.535
Fractures of hip &  pelvis w MCC.553
Bone diseases &  arthropathies w MCC.555
Signs & symptoms of musculoskeletal system  & conn tissue w MCC.556
Signs & symptoms of musculoskeletal system  & conn tissue w/o MCC.578
Skin graft &/or debrid  exc for skin ulcer or cellulitis w/o CC/MCC.598
Malignant breast disorders w CC**.599
Malignant breast disorders w/o CC/MCC**.600
Non-malignant breast disorders w CC/MCC.601
Non-malignant breast disorders w/o CC/MCC.642
Inborn errors of metabolism.660
Kidney & ureter  procedures for non-neoplasm w CC.687
Kidney & urinary tract  neoplasms w CC.693
Urinary stones w/o ESW lithotripsy w MCC.694
Urinary stones w/o ESW lithotripsy w/o MCC**.723
Malignancy, male reproductive system w  CC.730
Other male reproductive system diagnoses w/o CC/MCC.744
D&C, conization, laparoscopy & tubal interruption w CC/MC769
Postpartum & post abortion diagnoses w   O.R. procedure.803
Other O.R. proc of the blood & blood forming organs w CC.815
Reticuloendothelial & immunity disorders w  CC.816
Reticuloendothelial & immunity disorders w/o  CC/MCC**.842
Lymphoma & non-acute leukemia w/o CC/MCC.848
Chemotherapy w/o acute leukemia as secondary diagnosis w/o CC/MCC.864
Fever of unknown  origin.897
Alcohol/drug abuse or dependence w/o rehabilitation therapy w/o MCC.903
Wound debridements for injuries w/o CC/MCC.905
Skin grafts for injuries w/o CC/MCC.917
Poisoning & toxic  effects of drugs w MCC.918
Poisoning & toxic  effects of drugs w/o  MCC.929
Full thickness burn w skin graft or inhal inj w/o CC/MCC.956
Limb reattachment, hip  & femur proc for multiple significant trauma.964
Other multiple significant trauma w  CC.965
Other multiple significant trauma w/o  CC/MCC.977
HIV w or w/o other related condition.**QUINTILE 3**42
Periph & cranial nerve & other nerv syst proc w/o  CC/MCC.53
Spinal disorders & injuries w/o CC/MCC.( print page 24762)78
Hypertensive encephalopathy w CC***.102
Headaches w MCC**.103
Headaches w/o MCC.133
Other ear, nose, mouth & throat O.R. procedures w  CC/MCC**.134
Other ear, nose, mouth & throat O.R. procedures w/o  CC/MCC**.157
Dental & Oral Diseases w MCC**.158
Dental & Oral Diseases w CC**.159
Dental & Oral Diseases w/o CC/MCC**.238
Major cardiovascular procedures w/o MCC.246
Percutaneous cardiovascular proc w drug-eluting stent w MCC.250
Perc cardiovasc proc w/o coronary artery stent or AMI w MCC.263
Vein ligation & stripping.284
Circulatory disorders w AMI, expired w CC*.287
Circulatory disorders except AMI, w card cath w/o MCC.294
Deep vein thrombophlebitis w CC/MCC.347
Anal & stomal procedures w MCC.348
Anal & stomal procedures w CC.352
Inguinal & femoral hernia procedures w/o CC/MCC.354
Hernia procedures except inguinal & femoral w CC.358
Other digestive system O.R. procedures w/o CC/MCC.380
Complicated peptic ulcer w MCC.381
Complicated peptic ulcer w CC.383
Uncomplicated peptic ulcer w MCC.387
Inflammatory bowel disease w/o CC/MCC*.420
Hepatobiliary diagnostic procedures w MCC.421
Hepatobiliary diagnostic procedures w CC.424
Other hepatobiliary or pancreas O.R. procedures w CC.425
Other hepatobiliary or pancreas O.R. procedures w/o  CC/MCC.494
Lower extrem & humer proc except hip, foot, femur w/o  CC/MCC.502
Soft tissue procedures w/o CC/MCC.504
Foot procedures w CC.507
Major shoulder or elbow joint procedures w CC/MCC.517
Other musculoskelet sys & conn tiss O.R. proc w/o  CC/MCC.533
Fractures of femur w MCC.597
Malignant breast disorders w MCC.599
Malignant breast disorders w/o CC/MCC***.604
Trauma to the skin, subcut tiss & breast w MCC.618
Amputat of lower limb for endocrine, nutrit, & metabol dis w/o CC/MCC.619
O.R. procedures for obesity w MCC.620
O.R. procedures for obesity w CC**.624
Skin grafts & wound debrid for endoc, nutrit & metab dis w/o CC/MCC.644
Endocrine disorders w CC.657
Kidney & ureter procedures for neoplasm w CC.662
Minor bladder procedures w MCC.665
Prostatectomy w MCC.667
Prostatectomy w/o CC/MCC.694
Urinary stones w/o ESW lithotripsy w/o MCC***.695
Kidney & urinary tract signs & symptoms w MCC.711
Testes procedures w CC/MCC***.722
Malignancy, male reproductive system w MCC.746
Vagina, cervix & vulva procedures w CC/MCC.749
Other female reproductive system O.R. procedures w  CC/MCC.755
Malignancy, female reproductive system w CC.809
Major hematol/immune diag exc sickle cell crisis & coagul w CC.810
Major hematol/immune diag exc sickle cell crisis & coagul w/o CC/MCC.816
Reticuloendothelial & immunity disorders w/o CC/MCC***.821
Lymphoma & leukemia w major O.R. procedure w CC.826
Myeloprolif disord or poorly diff neopl w maj O.R.  proc w MCC.834
Acute leukemia w/o major O.R. procedure w MCC.835
Acute leukemia w/o major O.R. procedure w CC.838
Chemo w acute leukemia as sdx or w high dose chemo  agent w CC.843
Other myeloprolif dis or poorly diff neopl diag w  MCC***.844
Other myeloprolif dis or poorly diff neopl diag w  CC***.855
Infectious & parasitic diseases w O.R. procedure w/o  CC/MCC.896
Alcohol/drug abuse or dependence w/o rehabilitation therapy w MCC.963
Other multiple significant trauma w MCC.989
Non-extensive O.R. proc unrelated to principal diagnosis w/o CC/MCC.**QUINTILE 4**28
Spinal procedures w MCC.( print page 24763)29
Spinal procedures w CC.38
Extracranial procedures w CC.39
Extracranial procedures w/o   CC/MCC.88
Concussion w MCC**.89
Concussion w CC.124
Other disorders of the eye w MCC.168
Other resp system  O.R. procedures w/o CC/MCC.241
Amputation for circ sys disorders  exc upper limb & toe w/o CC/MCC242
Permanent cardiac  pacemaker implant w MCC***.244
Permanent cardiac  pacemaker implant w/o CC/MCC.254
Other vascular  procedures w/o  CC/MCC.257
Upper limb & toe  amputation for circ system disorders w/o  CC/MCC*.286
Circulatory disorders except  AMI, w card cath w  MCC.351
Inguinal & femoral hernia procedures w CC.368
Major esophageal disorders w MCC.369
Major esophageal disorders w CC.370
Major esophageal disorders w/o  CC/MCC**.408
Biliary tract proc  except only cholecyst w or w/o c.d.e. w MCC***.407
Pancreas, liver & shunt procedures w/o CC/MCC.412
Cholecystectomy w c.d.e. w CC.414
Cholecystectomy  except by laparoscope w/o c.d.e. w MCC.415
Cholecystectomy  except by laparoscope w/o c.d.e. w CC.418
Laparoscopic cholecystectomy w/o c.d.e. w CC.423
Other hepatobiliary or  pancreas O.R.  procedures w MCC.472
Cervical spinal fusion w CC.476
Amputation for musculoskeletal sys & conn tissue dis w/o CC/MCC*.478
Biopsies of musculoskeletal system & connective tissue w CC.479
Biopsies of musculoskeletal system & connective tissue w/o CC/MCC.482
Hip & femur  procedures except major joint w/o  CC/MCC.486
Knee procedures w  pdx of infection w  CC.487
Knee procedures w  pdx of infection w/o CC/MCC.490
Back & neck  procedures except spinal fusion w  CC/MCC or disc devices.493
Lower extrem & humer proc except hip, foot, femur w  CC.497
Local excision & removal int fix devices exc hip & femur w/o CC/MCC.503
Foot procedures w  MCC.511
Shoulder, elbow or forearm proc, exc major joint proc w  CC.516
Other musculoskelet sys  & conn tiss O.R.  proc w CC.562
Fx, sprn, strn & disl except femur, hip, pelvis & thigh w MCC.576
Skin graft &/or debrid exc for skin ulcer or cellulitis w MCC.577
Skin graft &/or debrid exc for skin ulcer or cellulitis w CC.584
Breast biopsy, local excision &  other breast  procedures w  CC/MCC.620
O.R. procedures for obesity w  CC***.659
Kidney & ureter  procedures for non-neoplasm w MCC.675
Other kidney & urinary tract  procedures w/o  CC/MCC.709
Penis procedures w  CC/MCC.711
Testes procedures w CC/MCC**.712
Testes procedures w/o CC/MCC**.717
Other male reproductive system O.R. proc  exc malignancy w  CC/MCC.725
Benign prostatic hypertrophy w MCC.754
Malignancy, female reproductive system w MCC.760
Menstrual & other female reproductive system disorders w  CC/MCC.776
Postpartum & post  abortion diagnoses w/o O.R. procedure.781
Other antepartum diagnoses w medical complications.823
Lymphoma & non-acute leukemia w  other O.R. proc w  MCC.824
Lymphoma & non-acute leukemia w  other O.R. proc w  CC.843
Other myeloprolif dis or poorly diff  neopl diag w MCC**.844
Other myeloprolif dis or poorly diff  neopl diag w CC**.845
Other myeloprolif dis or poorly diff  neopl diag w/o  CC/MCC**.880
Acute adjustment reaction &  psychosocial dysfunction.909
Other O.R.  procedures for injuries w/o  CC/MCC.928
Full thickness burn w skin graft  or inhal inj w  CC/MCC.933
Extensive burns or full thickness burns w MV 96+ hrs w/o skin graft.958
Other O.R.  procedures for multiple significant trauma w CC.983
Extensive O.R.  procedure unrelated to principal diagnosis w/o  CC/MCC.985
Prostatic O.R.  procedure unrelated to principal diagnosis w CC.986
Prostatic O.R. procedure unrelated to principal diagnosis w/o   CC/MCC.**QUINTILE 5**12
Tracheostomy for face, mouth & neck diagnoses w CC.( print page 24764)26
Craniotomy & endovascular intracranial procedures w CC.31
Ventricular shunt procedures w MCC.37
Extracranial procedures w MCC.131
Cranial/facial procedures w CC/MCC.134
Other ear, nose, mouth & throat O.R. procedures w/o CC/MCC***.137
Mouth procedures w CC/MCC.139
Salivary gland procedures.159
Dental & Oral Diseases w/o CC/MCC***.164
Major chest procedures w CC.226
Cardiac defibrillator implant w/o cardiac cath w MCC.227
Cardiac defibrillator implant w/o cardiac cath w/o MCC.237
Major cardiovascular procedures w MCC.242
Permanent cardiac pacemaker implant w MCC**.243
Permanent cardiac pacemaker implant w CC.248
Percutaneous cardiovasc proc w non-drug-eluting stent w MCC.258
Cardiac pacemaker device replacement w MCC.260
Cardiac pacemaker revision except device replacement w MCC.327
Stomach, esophageal & duodenal proc w CC.329
Major small & large bowel procedures w MCC.330
Major small & large bowel procedures w CC.335
Peritoneal adhesiolysis w MCC.350
Inguinal & femoral hernia procedures w MCC.370
Major esophageal disorders w/o CC/MCC***.405
Pancreas, liver & shunt procedures w MCC.406
Pancreas, liver & shunt procedures w CC.408
Biliary tract proc except only cholecyst w or w/o c.d.e. w MCC**.409
Biliary tract proc except only cholecyst w or w/o c.d.e. w CC.417
Laparoscopic cholecystectomy w/o c.d.e. w MCC.454
Combined anterior/posterior spinal fusion w CC.456
Spinal fusion exc cerv w spinal curv, malig or 9+ fusions w MCC.459
Spinal fusion except cervical w MCC.460
Spinal fusion except cervical w/o MCC.466
Revision of hip or knee replacement w MCC.467
Revision of hip or knee replacement w CC.469
Major joint replacement or reattachment of lower extremity w MCC.470
Major joint replacement or reattachment of lower extremity w/o MCC.471
Cervical spinal fusion w MCC.477
Biopsies of musculoskeletal system & connective tissue w MCC.480
Hip & femur procedures except major joint w MCC.481
Hip & femur procedures except major joint w CC.485
Knee procedures w pdx of infection w MCC.488
Knee procedures w/o pdx of infection w CC/MCC.492
Lower extrem & humer proc except hip, foot, femur w MCC.498
Local excision & removal int fix devices of hip & femur w CC/MCC.513
Hand or wrist proc, except major thumb or joint proc w CC/MCC.582
Mastectomy for malignancy w CC/MCC.664
Minor bladder procedures w/o CC/MCC.668
Transurethral procedures w MCC.669
Transurethral procedures w CC.670
Transurethral procedures w/o CC/MCC.691
Urinary stones w esw lithotripsy w CC/MCC.712
Testes procedures w/o CC/MCC***.713
Transurethral prostatectomy w CC/MCC.715
Other male reproductive system O.R. proc for malignancy w CC/MCC.802
Other O.R. proc of the blood & blood forming organs w MCC.829
Myeloprolif disord or poorly diff neopl w other O.R. proc w CC/MCC.837
Chemo w acute leukemia as sdx or w high dose chemo agent w MCC.845
Other myeloprolif dis or poorly diff neopl diag w/o CC/MCC***.957
Other O.R. procedures for multiple significant trauma w MCC.969
HIV w extensive O.R. procedure w MCC.970
HIV w extensive O.R. procedure w/o MCC.984
Prostatic O.R. procedure unrelated to principal diagnosis w MCC* One of the original 307 low-volume proposed MS-LTC-DRGs initially assigned to this proposed low-volume quintile; removed from this proposed low-volume quintile in addressing nonmonotonicity (see step 6 below).** One of the original 307 low-volume proposed MS-LTC-DRGs initially assigned to a different proposed low-volume quintile but moved to this proposed low-volume quintile in addressing nonmonotonicity (see step 6 below).*** One of the original 307 low-volume proposed MS-LTC-DRGs initially assigned to this proposed low-volume quintile but moved to a different proposed low-volume quintile in addressing nonmonotonicity (see step 6 below).
 
 
 We note that we will continue to monitor the volume (that is, the number of LTCH cases) in these low-volume quintiles to ensure that our proposed quintile assignment results in appropriate payment for such cases and does not result in an unintended financial incentive for LTCHs to inappropriately admit these types of cases. 4. Steps for Determining the Proposed FY 2008 MS-LTC-DRG Relative Weights As we noted previously, although the proposed adoption of the MS-LTC-DRGs will result in some modifications of existing procedures for assigning weights in cases of zero volume and/or nonmonotonicity, described in detail elsewhere in this section, the proposed FY 2008 MS-LTC-DRG relative weights in this proposed rule are based on the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55989 through 55991). In summary, for FY 2008, LTCH cases would be grouped to the appropriate MS-LTC-DRG, while taking into account the low-volume proposed MS-LTC-DRGs as described above, before the proposed FY 2008 MS-LTC-DRG relative weights can be determined. After grouping the cases to the appropriate proposed MS-LTC-DRG, we are proposing to calculate the proposed relative weights for FY 2008 by first removing statistical outliers and cases with a length of stay of 7 days or less, as discussed in greater detail below. Next, we are proposing to adjust the number of cases in each proposed MS-LTC-DRG for the effect of short-stay outlier cases under § 412.529, as also discussed in greater detail below. The short-stay adjusted discharges and corresponding charges are used to calculate “relative adjusted weights” in each proposed MS-LTC-DRG using the HSRV method described above. Below we discuss in detail the steps for calculating the proposed FY 2008 MS-LTC-DRG relative weights. We note that, as we stated above in section II.I.3.b. of the preamble of this proposed rule, we have excluded the data of all-inclusive rate LTCHs and LTCHs that are paid in accordance with demonstration projects that had claims in the FY 2006 MedPAR file. *Step 1*
                        —Remove statistical outliers. The first step in the calculation of the proposed FY 2008 MS-LTC-DRG relative weights is to remove statistical outlier cases. We define statistical outliers as cases that are outside of 3.0 standard deviations from the mean of the log distribution of both charges per case and the charges per day for each proposed MS-LTC-DRG. These statistical outliers are removed prior to calculating the proposed relative weights. As noted above, we believe that they may represent aberrations in the data that distort the measure of average resource use. Including those LTCH cases in the calculation of the proposed relative weights could result in an inaccurate relative weight that does not truly reflect relative resource use among the proposed MS-LTC-DRGs. *Step 2*
                        —Remove cases with a length of stay of 7 days or less. The proposed FY 2008 MS-LTC-DRG relative weights reflect the average of resources used on representative cases of a specific type. Generally, cases with a length of stay of 7 days or less do not belong in a LTCH because these stays do not fully receive or benefit from treatment that is typical in a LTCH stay, and full resources are often not used in the earlier stages of admission to a LTCH. As explained above, if we were to include stays of 7 days or less in the computation of the proposed FY 2008 MS-LTC-DRG relative weights, the value of many relative weights would decrease and, therefore, payments would decrease to a level that may no longer be appropriate. We do not believe that it would be appropriate to compromise the integrity of the payment determination for those LTCH cases that actually benefit from and receive a full course of treatment at a LTCH, by including data from these very short-stays. Thus, as explained above, in determining the proposed FY 2008 MS-LTC-DRG relative weights, we remove LTCH cases with a length of stay of 7 days or less. *Step 3*
                        —Adjust charges for the effects of short-stay outliers. After removing cases with a length of stay of 7 days or less, we are left with cases that have a length of stay of greater than or equal to 8 days. The next step in the calculation of the proposed FY 2008 MS-LTC-DRG relative weights is to adjust each LTCH's charges per discharge for those remaining cases for the effects of short-stay outliers as defined in § 412.529(a). (We note that even if a case was removed in Step 2 (that is, cases with a length of stay of 7 days or less), it was paid as a short-stay outlier if its length of stay was less than or equal to five-sixths of the average length of stay of the MS-LTC-DRG, in accordance with § 412.529.) We make this adjustment by counting a short-stay outlier as a fraction of a discharge based on the ratio of the length of stay of the case to the average length of stay for the proposed MS-LTC-DRG for non-short-stay outlier cases. This has the effect of proportionately reducing the impact of the lower charges for the short-stay outlier cases in calculating the average charge for the proposed MS-LTC-DRG. This process produces the same result as if the actual charges per discharge of a short-stay outlier case were adjusted to what they would have been had the patient's length of stay been equal to the average length of stay of the proposed MS-LTC-DRG. As we explained in the FY 2007 IPPS final (71 FR 47979), counting short-stay outlier cases as full discharges with no adjustment in determining the proposed MS-LTC-DRG relative weights would lower the proposed LTC-DRG relative weight for affected proposed MS-LTC-DRGs because the relatively lower charges of the short-stay outlier cases would bring down the average charge for all cases within a proposed MS-LTC-DRG. This would result in an “underpayment” for nonshort-stay outlier cases and an “overpayment” for short-stay outlier cases. Therefore, we adjust for short-stay outlier cases under § 412.529 in this manner because it results in more appropriate payments for all LTCH cases. *Step 4*
                        —Calculate the proposed FY 2008 MS-LTC-DRG relative weights on an iterative basis. The process of calculating the proposed MS-LTC-DRG relative weights using the HSRV methodology is iterative. First, for each LTCH case, we calculate a hospital-specific relative charge value by dividing the short-stay outlier adjusted charge per discharge (see step 3) of the LTCH case (after removing the statistical outliers (see step 1)) and LTCH cases with a length of stay of 7 days or less (see step 2) by the average charge per discharge for the LTCH in which the case occurred. The resulting ratio is then multiplied by the LTCH's case-mix index to produce an adjusted hospital-specific relative charge value for the case. An initial case-mix index value of 1.0 is used for each LTCH. For each proposed DRG, the proposed FY 2008 MS-LTC-DRG relative weight is calculated by dividing the average of the adjusted hospital-specific relative charge values (from above) for the proposed MS-LTC-DRG by the overall average hospital-specific relative charge value across all cases for all LTCHs. Using these proposed recalculated MS-LTC-DRG relative weights, each LTCH's average relative weight for all of its cases (case-mix) is calculated by dividing the sum of all the LTCH's proposed MS-LTC-DRG relative weights by its total number of cases. The LTCHs' hospital-specific relative charge values above are multiplied by these hospital-specific case-mix indexes. These hospital-specific case-mix 
                        ( print page 24766)
                        adjusted relative charge values are then used to calculate a new set of proposed MS-LTC-DRG relative weights across all LTCHs. In this proposed rule, this iterative process is continued until there is convergence between the weights produced at adjacent steps, for example, when the maximum difference is less than 0.0001. *Step 5*
                        —Determine a proposed FY 2007 MS-LTC-DRG relative weight for proposed MS-LTC-DRGs with no LTCH cases. As we stated above, we determine the proposed relative weight for each proposed MS-LTC-DRG using total Medicare allowable charges reported in the December 2006 update of the FY 2006 MedPAR file. Of the 745 proposed MS-LTC-DRGs for FY 2008, we identified 124 proposed MS-LTC-DRGs for which there were no LTCH cases in the database. That is, based on data from the FY 2006 MedPAR file used in this proposed rule, no patients who would have been classified to those proposed MS-LTC-DRGs were treated in LTCHs during FY 2006 and, therefore, no charge data were reported for those proposed MS-LTC-DRGs. Thus, in the process of determining the proposed MS-LTC-DRG relative weights, we are unable to determine weights for these 124 proposed MS-LTC-DRGs using the methodology described in Steps 1 through 4 above. However, because patients with a number of the diagnoses under these proposed MS-LTC-DRGs may be treated at LTCHs beginning in FY 2008, for this proposed rule, we are proposing to assign relative weights to each of the 124 no-volume proposed MS-LTC-DRGs based on clinical similarity and relative costliness to one of the remaining 621 (745−124 = 621) proposed MS-LTC-DRGs for which we are able to determine proposed relative weights, based on FY 2006 LTCH claims data. In general, we determined proposed relative weights for the 124 proposed MS-LTC-DRGs with no LTCH cases in the FY 2006 MedPAR file used in this proposed rule by crosswalking these proposed MS-LTC-DRGs to other proposed MS-LTC-DRGs and then grouping them to the appropriate proposed low-volume quintile. This methodology is consistent with our methodology used in determining relative weights to account for the low-volume proposed MS-LTC-DRGs described above. Our proposed methodology for determining the relative weights for the no-volume MS-LTC-DRGs is as follows: We crosswalk the no-volume proposed MS-LTC-DRG to a proposed MS-LTC-DRG for which there are LTCH cases in the FY 2006 MedPAR file and to which it is similar clinically and in intensity of use of resources as determined by care provided during the period of time surrounding surgery, surgical approach (if applicable), length of time of surgical procedure, postoperative care, and length of stay. If the proposed MS-LTC-DRG to which it is crosswalked is grouped to one of the proposed low-volume quintiles, we assign the relative weight for the applicable low-volume quintile to the no volume proposed MS-LTC-DRG. However, if the proposed MS-LTC-DRG to which the no-volume proposed MS-LTC-DRG is crosswalked is not one of the proposed MS-LTC-DRGs in a low-volume quintile, we do the following: (1) compare the relative weight of the proposed MS-LTC-DRG to which the no-volume proposed MS-LTC-DRG is crosswalked to the relative weights of each of the five quintiles; (2) assign the no volume proposed MS-LTC-DRG the relative weight of the low-volume quintile with the relative weight that is closest to the proposed MS-LTC-DRG to which the no volume proposed MS-LTC-DRG is crosswalked. (We note that in the infrequent case where nonmonotonicity involving a no volume proposed MS-LTC-DRG results, additional measures as described in Step 6 are required in order to maintain monotonically increasing relative weights.) or this proposed rule, a list of the no-volume proposed FY 2008 MS-LTC-DRGs and the proposed FY 2008 MS-LTC-DRG to which it is crosswalked is shown in the chart below. No-Volume Proposed MS-LTC-DRG Crosswalk for FY 2008
Proposed MS-LTC-DRG
Proposed MS-LTC-DRG  description
Proposed crosswalked MS-LTC-DRG9
Bone marrow transplant
82320
Intracranial vascular procedures w PDX hemorrhage w MCC
3121
Intracranial vascular procedures w PDX hemorrhage w CC
3222
Intracranial vascular procedures w PDX hemorrhage w/o CC/MCC
3323
Craniotomy w major device implant or acute complex CNS PDX w MCC
3124
Craniotomy w major device implant or acute complex CNS PDX w/o MCC
3334
Carotid artery stent procedure w MCC
3735
Carotid artery stent procedure w CC
3836
Carotid artery stent procedure w/o CC/MCC
3961
Acute ischemic stroke w use of thrombolytic agent w MCC
7062
Acute ischemic stroke w use of thrombolytic agent w CC
7163
Acute ischemic stroke w use of thrombolytic agent w/o CC/MCC
72115
Extraocular procedures except orbit
125116
Intraocular procedures w CC/MCC
125117
Intraocular procedures w/o CC/MCC
125129
Major head & neck procedures w CC/MCC or major device
146130
Major head & neck procedures w/o CC/MCC
148135
Sinus & mastoid procedures w CC/MCC
133136
Sinus & mastoid procedures w/o CC/MCC
133150
Epistaxis w MCC
152151
Epistaxis w/o MCC
153215
Other heart assist system implant
238216
Cardiac valve & oth maj cardiothoracic proc w card cath w MCC
237217
Cardiac valve & oth maj cardiothoracic proc w card cath w CC
238218
Cardiac valve & oth maj cardiothoracic proc w card cath w/o CC/MCC
250219
Cardiac valve & oth maj cardiothoracic proc w/o card cath w MCC
237220
Cardiac valve & oth maj cardiothoracic proc w/o card cath w CC
238221
Cardiac valve & oth maj cardiothoracic proc w/o card cath w/o CC/MCC
250( print page 24767)222
Cardiac defib implant w cardiac cath w AMI/HF/shock w MCC
242223
Cardiac defib implant w cardiac cath w AMI/HF/shock w/o MCC
243224
Cardiac defib implant w cardiac cath w/o AMI/HF/shock w MCC
242225
Cardiac defib implant w cardiac cath w/oAMI/HF/shock w/o MCC
243228
Other cardiothoracic procedures w MCC
252229
Other cardiothoracic procedures w CC
253230
Other cardiothoracic procedures w/o CC/MCC
254231
Coronary bypass w PTCA w MCC
237232
Coronary bypass w PTCA w/o MCC
238233
Coronary bypass w cardiac cath w MCC
237234
Coronary bypass w cardiac cath w/o MCC
238235
Coronary bypass w/o cardiac cath w MCC
237236
Coronary bypass w/o cardiac cath w/o MCC
238296
Cardiac arrest, unexplained w MCC
283297
Cardiac arrest, unexplained w CC
284298
Cardiac arrest, unexplained w/o CC/MCC
285332
Rectal resection w MCC
356333
Rectal resection w CC
357334
Rectal resection w/o CC/MCC
358338
Appendectomy w complicated principal diag w MCC
371339
Appendectomy w complicated principal diag w CC
372340
Appendectomy w complicated principal diag w/o CC/MCC
373341
Appendectomy w/o complicated principal diag w MCC
371342
Appendectomy w/o complicated principal diag w CC
372343
Appendectomy w/o complicated principal diag w/o CC/MCC
373344
Minor small & large bowel procedures w MCC
371345
Minor small & large bowel procedures w CC
372346
Minor small & large bowel procedures w/o CC/MCC
373457
Spinal fusion exc cerv w spinal curv, malig or 9+ fusions w CC
456461
Bilateral or multiple major joint procs of lower extremity w MCC
480462
Bilateral or multiple major joint procs of lower extremity w/o MCC
482483
Major joint & limb reattachment proc of upper extremity w CC/MCC
480484
Major joint & limb reattachment proc of upper extremity w/o CC/MCC
482506
Major thumb or joint procedures
514509
Arthroscopy
505537
Sprains, strains, & dislocations of hip, pelvis & thigh w CC/MCC
505538
Sprains, strains, & dislocations of hip, pelvis & thigh w/o CC/MCC
505614
Adrenal & pituitary procedures w CC/MCC
629615
Adrenal & pituitary procedures w/o CC/MCC
630625
Thyroid, parathyroid & thyroglossal procedures w MCC
628626
Thyroid, parathyroid & thyroglossal procedures w CC
629627
Thyroid, parathyroid & thyroglossal procedures w/o CC/MCC
630653
Major bladder procedures w MCC
659654
Major bladder procedures w CC
660655
Major bladder procedures w/o CC/MCC
661666
Prostatectomy w CC
665671
Urethral procedures w CC/MCC
687672
Urethral procedures w/o CC/MCC
688697
Urethral stricture
688707
Major male pelvic procedures w CC/MCC
660708
Major male pelvic procedures w/o CC/MCC
661734
Pelvic evisceration, rad hysterectomy & rad vulvectomy w CC/MCC
717735
Pelvic evisceration, rad hysterectomy & rad vulvectomy w/o CC/MCC
718736
Uterine & adnexa proc for ovarian or adnexal malignancy w MCC
754737
Uterine & adnexa proc for ovarian or adnexal malignancy w CC
755738
Uterine & adnexa proc for ovarian or adnexal malignancy w/o CC/MCC
756739
Uterine,adnexa proc for non-ovarian/adnexal malig w MCC
754740
Uterine,adnexa proc for non-ovarian/adnexal malig w CC
755741
Uterine,adnexa proc for non-ovarian/adnexal malig w/o CC/MCC
756742
Uterine & adnexa proc for non-malignancy w CC/MCC
755743
Uterine & adnexa proc for non-malignancy w/o CC/MCC
756748
Female reproductive system reconstructive procedures
749765
Cesarean section w CC/MCC
744766
Cesarean section w/o CC/MCC
769767
Vaginal delivery w sterilization &/or D&C
769768
Vaginal delivery w O.R. proc except steril &/or D&C
769770
Abortion w D&C, aspiration curettage or hysterotomy
769774
Vaginal delivery w complicating diagnoses
769775
Vaginal delivery w/o complicating diagnoses
769777
Ectopic pregnancy
769( print page 24768)778
Threatened abortion
759779
Abortion w/o D&C
759780
False labor
759782
Other antepartum diagnoses w/o medical complications
759789
Neonates, died or transferred to another acute care facility
761790
Extreme immaturity or respiratory distress syndrome, neonate
761791
Prematurity w major problems
760792
Prematurity w/o major problems
761793
Full term neonate w major problems
760794
Neonate w other significant problems
760795
Normal newborn
761799
Splenectomy w MCC
423800
Splenectomy w CC
424801
Splenectomy w/o CC/MCC
425827
Myeloprolif disord or poorly diff neopl w maj O.R. proc w CC
823887
Other mental disorder diagnoses
881927
Extensive burns or full thickness burns w MV 96+ hrs w skin graft
933955
Craniotomy for multiple significant trauma
26
 To illustrate this methodology for determining the proposed relative weights for the 124 proposed MS-LTC-DRGs with no LTCH cases, we are providing the following example, which refers to the no volume proposed MS-LTC-DRGs crosswalk information for FY 2008 provided in the chart above. *Example 1:* There were no cases in the FY 2006 MedPAR file used for this proposed rule for proposed MS-LTC-DRG 22 (Intracranial vascular procedures w PDX hemorrhage w/o CC/MCC). We determined that proposed MS-LTC-DRG 33 (Ventricular shunt procedures w/o CC/MCC), which is assigned to low-volume Quintile 1 for the purpose of determining the proposed FY 2008 relative weights, is similar clinically and based on resource use to proposed MS-LTC-DRG 22. Therefore, we are proposing to assign the same relative weight of proposed MS-LTC-DRG 33 of 0.48011 (Quintile 1) for FY 2008 (Table 11 in the Addendum to this proposed rule) to proposed MS-LTC-DRG 22. Furthermore, for FY 2008 we are proposing to establish proposed MS-LTC-DRG relative weights of 0.0000 for the following transplant proposed MS-LTC-DRGs: Heart transplant or implant of heart assist system w MCC (proposed LTC-DRG 1); Heart transplant or implant of heart assist system w/o MCC (proposed LTC-DRG 2); Liver transplant w MCC or intestinal transplant (proposed LTC-DRG 5); Liver transplant w/o MCC (proposed LTC-DRG 6); Lung transplant (proposed LTC-DRG 7); Simultaneous pancreas/kidney transplant (proposed LTC-DRG 8); and Pancreas transplant (proposed LTC-DRG 10). This is because Medicare will only cover these procedures if they are performed at a hospital that has been certified for the specific procedures by Medicare and presently no LTCH has been so certified. Based on our research, we found that most LTCHs only perform minor surgeries, such as minor small and large bowel procedures, to the extent any surgeries are performed at all. Given the extensive criteria that must be met to become certified as a transplant center for Medicare, we believe it is unlikely that any LTCHs will become certified as a transplant center. In fact, in the nearly 20 years since the implementation of the IPPS, there has never been a LTCH that even expressed an interest in becoming a transplant center. If in the future a LTCH applies for certification as a Medicare-approved transplant center, we believe that the application and approval procedure would allow sufficient time for us to determine appropriate weights for the proposed MS-LTC-DRGs affected. At the present time, we would only include these seven proposed transplant MS-LTC-DRGs in the GROUPER program for administrative purposes only. Because we use the same GROUPER program for LTCHs as is used under the IPPS, removing these proposed MS-LTC-DRGs would be administratively burdensome. Again, we note that, as this system is dynamic, it is entirely possible that the number of proposed MS-LTC-DRGs with no volume of LTCH cases based on the system will vary in the future. We used the most recent available claims data in the MedPAR file to identify no volume proposed MS-LTC-DRGs and to determine the proposed relative weights in this proposed rule. Table 11 in the Addendum to this proposed rule lists the proposed MS-LTC-DRGs and their respective proposed relative weights, geometric mean length of stay, and five-sixths of the geometric mean length of stay (to assist in the determination of short-stay outlier payments under § 412.529) for FY 2008. *Step 6*
                        —Adjust the proposed FY 2008 MS-LTC-DRG relative weights to account for nonmonotonically increasing relative weights. As explained in section II.B. of this preamble, the IPPS proposed FY 2008 MS-DRGs, on which the proposed FY 2008 MS-LTC-DRGs are based, provide a significant improvement in the DRG system's recognition of severity of illness and resource usage. The proposed MS-DRGs contain base DRGs that have been subdivided into one, two, or three severity levels. Where there are three severity levels, the most severe level has at least one code that is referred to as an MCC. The next lower severity level contains cases with at least one code that is a CC. Those cases without a MCC or a CC are referred to as without CC/MCC. When data did not support the creation of three severity levels, the base was divided into either two levels or the base was not subdivided. The two-level subdivisions could consist of the CC/MCC and the without CC/MCC. Alternatively, the other type of two level subdivision could consist of the MCC and without MCC. In base DRGs with two levels, cases classified into a “without CC/MCC” proposed MS-LTC-DRG are expected to have lower resource use 
                        ( print page 24769)
                        (and lower costs) than the “with CC/MM” and “with MCC.” That is, theoretically, cases that are more severe typically require greater expenditure of medical care resources and will result in higher average charges. Therefore, in the three severity levels, relative weights should increase by severity, from lowest to highest. If the weights do not increase (that is, if within a base MS-LTC-DRG, a proposed MS-LTC-DRG with MCC has a lower relative weight than one with CC, or the proposed MS-LTC-DRG without CC/MCC has a higher relative weight than either of the others, they are nonmonotonic. We continue to believe that utilizing nonmonotonic relative weights to adjust Medicare payments would result in inappropriate payments. Consequently, we are proposing that, in general, we would combine proposed MS-LTC-DRG severity levels within a proposed base MS-LTC-DRG for the purpose of computing a relative weight when necessary to ensure that monotonicity is maintained. Specifically, under each of the example scenarios provided below, we would combine severity levels within a proposed base MS-LTC-DRG as follows: The first example of nonmonotonically increasing relative weights for MS-LTC-DRG pertains to base DRGs with a three-level split and each of the three levels has 25 or more LTCH cases and, therefore, did not fall into one of the proposed five low-volume quintiles. If nonmonotonicity is detected in the relative weights of proposed MS-LTC-DRGs in adjacent severity levels (for example, the relative weight of the “with MCC” (the highest severity level) is less than the “with CC” (the middle level), or the “with CC” is less than the “without CC/MCC”), we are proposing to combine the adjacent proposed MS-LTC-DRGs and determine one relative weight based on the case-weighted average of the combined LTCH cases of the nonmonotonic proposed MS-LTC-DRG. The case-weighted average charge is determined by dividing the total charges for all LTCH cases in both severity levels by the total number of LTCH cases for the combined proposed MS-LTC-DRGs. We are proposing to apply this relative weight to both affected levels of the proposed base MS-LTC-DRG. If nonmonotonicity remains an issue because the above process results in a relative weight that is still nonmonotonic to the remaining proposed MS-LTC-DRG, we are proposing to combine all three of the severity levels to determine one relative weight which is assigned to each of the proposed MS-LTC-DRG in that proposed base MS-LTC-DRG. A second scenario of nonmonotonically increasing relative weights for an MS-LTC-DRG pertains to the situation where one or more of the severity levels within a base DRG has less than 25 LTCH cases (that is, low volume). If nonmonotonicity occurs in the case where either the highest or lowest severity level (with MCC” or “without CC/MCC”) has 25 LTCH cases or more and the other two severity levels are low volume (and therefore the other two severity levels would otherwise be assigned to quintiles), we are proposing to combine the data for the cases in the two adjacent low-volume proposed MS-LTC-DRGs for the purpose of determining a relative weight. If the combination results in at least 25 cases, we are proposing to calculate one relative weight and assign it to both of the proposed severity levels. If the combination results in less than 25 cases, based on the case-weighted average charge of the combined low-volume MS-LTC-DRGs, both MS-LTC-DRGs, are assigned the relative weight of the quintile that has the closest relative weight to the case weighted average change of the combined low volume case. If nonmonotonicity persists, we are proposing to combine all three severity levels and one relative weight would be assigned to all three levels based on the case weighted average of the combined severity level. Similarly, in nonmonotonic cases where the middle level has 25 cases or more but either or both the lowest or highest severity level has less than 25 cases (that is, low volume), we are proposing to combine the nonmonotonic low-volume proposed MS-LTC-DRG with the middle level proposed MS-LTC-DRG of the base DRG. We are proposing to calculate one relative weight and apply it to both of the affected proposed MS-LTC-DRGs. If the nonmonotonicity persists, we are proposing to combine all three levels for the purpose of determining a relative weight, and apply that relative weight to all three levels. A third scenario addresses nonmonotonicity in a base DRG where at least one of the severity levels has no cases. As discussed in greater detail in Step 5, based on clinical similarity, we would cross-walk the proposed MS-LTC-DRG to a proposed MS-LTC-DRG to which it is similar clinically and in intensity of resource use and then assign it to a quintile with the relative weight closest to that of the MS-LTC-DRG to which the no-volume MS-LTC-DRG had been cross-walked. If this results in nonmonotonicity, in the case where the no-volume proposed MS-LTC-DRG is either the lowest or highest severity level, we are proposing to assign to the no-volume proposed MS-LTC-DRG the same relative weight that is assigned to the middle level of the MS-LTC-DRG in that base DRG. If nonmonotonicity persists, we are proposing that all three severity levels be combined for the purpose of calculating one relative weight which is applied to each of the three levels. We note that this is a departure from our current treatment of no-volume LTC-DRGs which results in an ultimate assignment to a quintile. However, we propose that in the infrequent case where nonmonotonicity involves a no-volume proposed MS-LTC-DRG, we believe it is appropriate to resolve the nonmonotonicity by assigning the no-volume proposed MS-LTC-DRG the relative weight of the proposed MS-LTC-DRG(s) in the base DRG, regardless of whether the other proposed MS-LTC-DRG(s) is low volume (therefore assigned a relative weight of a quintile) or high volume (assigned its own relative weight). We believe this treatment achieves monotonically increasing relative weights while providing appropriate payment for the no-volume proposed MS-LTC-DRG because the relative weight assigned to the no-volume proposed MS-LTC-DRG is based on the average charges of services rendered within the same proposed base MS-LTC-DRG, rather than a quintile which contains proposed MS-LTC-DRGs from different proposed base MS-LTC-DRGs. We are proposing to apply the same process where the proposed base MS-LTC-DRG contains a two-level split. For example, if nonmonotonicity occurs in a proposed base MS-LTC-DRG with two severity levels (that is, the higher severity level relative weight is less than the lower severity level), where both of the MS-LTC-DRGs have at least 25 cases or where one or both of the proposed MS-LTC-DRGs is low volume, we are proposing to combine the two proposed MS-LTC-DRGs of that proposed base MS-LTC-DRG for the purpose of determining a case-weighted relative weight. If the combination still results in at least 25 cases, we are proposing to calculate one relative weight and assign it to both of the proposed MS-LTC-DRGs. If the combination results in less than 25 cases, we determine the quintile assignment for both MS-LTC-DRGs based on the case-weighted average charge and assign both MS-LTC-DRGs the same relative weight of the appropriate quintile. *Step 7*
                        —Calculate the proposed FY 2008 budget neutrality factor. 
                        ( print page 24770) As we stated in the FY 2008 LTCH PPS proposed rule (72 FR 4784 through 4786), under the broad authority conferred upon the Secretary under section 123 of Pub. L. 106-113 as amended by section 307(b) of Pub. L. 106-554 to develop the LTCH PPS, we proposed that, beginning with the MS-LTC-DRG update for FY 2008, the annual update to the proposed MS-LTC-DRG classifications and relative weights would be done in a budget neutral manner such that estimated aggregate LTCH PPS payments would be unaffected, that is, would be neither greater than nor less than the estimated aggregate LTCH PPS payments that would have been made without the proposed MS-LTC-DRG classification and relative weight changes. Currently under § 412.517, the LTC-DRG classifications and relative weights are adjusted annually to reflect changes in factors affecting the relative use of LTCH resources, such as treatment patterns, technology and number of discharges. In addition, there are currently no statutory or regulatory requirements that the annual update to the LTC-DRG classifications and relative weights be done in a budget neutral manner. Since the initial implementation of the LTCH PPS in FY 2003, we have updated the LTC-DRG relative weights each year without a budget neutrality adjustment based on the most recent available LTCH claims data, which reflect current LTCH patient mix and coding practices, and appropriately reflected more or less resource use than the previous year's LTC-DRG relative weights (71 FR 47991). Historically, we have not updated the LTC-DRGs in a budget neutral manner because we believed that past fluctuations in the LTC-DRG relative weights were primarily due to changes in LTCH coding practices. We believe that changes in the LTCH PPS payment rates, including the LTC-DRG relative weights, should accurately reflect changes in LTCHs' true cost of treating patients (real CMI increase), and should not be influenced by changes in coding practices (apparent CMI increase). Because LTCH 2006 claims data does not appear to significantly reflect changes in LTCH coding practices in response to the implementation of the LTCH PPS, we believe that it may be appropriate to update the LTC-DRGs so that estimated aggregate LTCH PPS payments would neither increase nor decrease. Thus, in the FY 2008 LTCH PPS proposed rule (72 FR 4784), we proposed that the annual update to the LTC-DRG classifications and relative weights be done in a budget neutral manner. (For a detailed discussion on updating the LTC-DRG classifications and relative weights in a budget neutral manner, refer to the FY 2008 LTCH PPS proposed rule (72 FR 4784 through 4786). Updating the LTC-DRGs in a budget neutral manner would result in an annual update to the individual LTC-DRG classifications and relative weights based on the most recent available data to reflect changes in relative LTCH resource use, and the LTC-DRG relative weights would be uniformly adjusted to ensure that estimated aggregate payments under the LTCH PPS would not be affected (that is, decreased or increased). Consistent with that proposal, we are proposing to update the proposed MS-LTC-DRG classifications and relative weights for FY 2008 based on the most recent available data and include a budget neutrality adjustment. To ensure budget neutrality in updating the MS-LTC-DRG classifications and relative weights under the proposed change to § 412.517, we are proposing to use a method that is similar to the methodology used under the IPPS. (A discussion of the IPPS DRG budget neutrality adjustment can be found in the FY 2007 IPPS final rule (71 FR 47970).) Specifically, we are proposing that, after recalibrating the proposed MS-LTC-DRG relative weights, as we do under the methodology as described in detail in Steps 1 through 6 above, we would calculate and apply a normalization factor to the proposed MS-LTC-DRG relative weights to ensure that estimated payments are not influenced by changes in the composition of case types or changes made to the classification system. That is, the normalization adjustment is intended to ensure that the recalibration of the proposed MS-LTC-DRG relative weights (that is, the process itself) neither increases nor decreases total estimated payments. To calculate the normalization factor, we are proposing to use the most recent available claims data (FY 2006) and apply the proposed GROUPER (Version 25.0) to calculate the proposed relative weights. Furthermore, we are proposing to use the most recent available claims data in the analysis for the final rule. These weights are determined such that the average CMI value is 1.0. Then, we are proposing to group the same claims data (FY 2006) using the current GROUPER (Version 24.0) and current relative weights. The average CMI is calculated for the claims data using the current GROUPER and relative weights. Finally, the ratio of the average CMI of the claims data set under the current GROUPER and the proposed GROUPER is calculated as the proposed normalization factor. For FY 2008, based on the latest available data, the proposed normalization factor is estimated as 1.020302, which is applied to each proposed MS-LTC-DRG relative weight. (However, if more current data become available prior to publication of the final rule, we will use those data to determine the normalization factor.) That is, each proposed MS-LTC-DRG relative weight is multiplied by 1.020302 in the first step of the budget neutrality process. We are also proposing to ensure that estimated aggregate LTCH PPS payments (based on the most recent available LTCH claims data) after recalibration (the proposed relative weights) would be equal to estimated aggregate LTCH PPS payments (for the same most recent available LTCH claims data) before recalibration (the existing relative weights). Therefore, we are proposing to calculate the budget neutrality adjustment factor by simulating estimated payments under both sets of GROUPERs and relative weights. We are proposing to simulate total estimated payments under the current payment policies (RY 2007) using the most recent available claims data (FY 2006) and using the proposed GROUPER (Version 25.0), and normalized relative weights. Then, we are proposing to simulate estimated payments using the most recent available claims data (FY 2006) and apply the proposed GROUPER (Version 25.0). We next calculate payments using the same claims data (FY 2006) with the current GROUPER (Version 24.0). The ratio of the estimated average payment under the current GROUPER and the proposed GROUPER is calculated as the proposed budget neutrality factor. Then each of the proposed normalized relative weights is multiplied by the budget neutrality factor to determine the proposed budget neutral relative weight for each proposed MS-LTC-DRG. Accordingly, based on the most recent available data, we are proposing a budget neutrality factor of 1.003924 that is applied to the relative weights after normalizing. If more current data become available prior to publication of the final rule, we will use those data to determine the budget neutrality factor. The relative weights in Table 11 in the Addendum of this proposed rule reflect those budget neutral weights. If, as a result of comments, we decide not to finalize the proposed budget neutrality policy, the proposed weights in Table 11 of the Addendum to this proposed 
                        ( print page 24771)
                        rule change by the two factors discussed herein. *Step 8*
                        —Apply the proposed case-mix budget neutrality factor to the proposed MS-LTC-DRG relative weight. As discussed under section II.D.6. of the preamble of this proposed rule, we are proposing a budget neutral adjustment for FY 2008 and FY 2009 to eliminate the effect of changes in coding or classification of discharges that do not reflect real change in case-mix because we believe that adoption of the proposed MS-LTC-DRGs would create a risk of increased aggregate levels of payment as a result of increased documentation and coding. The additional step 8 would be necessary for FY 2008 and FY 2009 to ensure that estimated aggregate LTCH PPS payments would be neither greater than nor less than the estimated aggregate LTCH PPS payments that would have been made without the adoption of the proposed MS-LTC-DRG patient classification system. Accordingly, each of the relative weights in Table 11 of the Addendum to this proposed rule reflects this proposed adjustment. That is, each proposed MS-LTC-DRG relative weight is multiplied by a factor of 0.976 to account for changes in coding or classification of discharges resulting from the adoption of the new patient classification system. J. Proposed Add-On Payments for New Services and Technologies (If you choose to comment on issues in this section, please include the caption “New Technology” at the beginning of your comment.) 1. Background Sections 1886(d)(5)(K) and (L) of the Act establish a process of identifying and ensuring adequate payment for new medical services and technologies (sometimes collectively referred to in this section as “new technologies”) under the IPPS. Section 1886(d)(5)(K)(vi) of the Act specifies that a medical service or technology will be considered new if it meets criteria established by the Secretary after notice and opportunity for public comment. Section 1886(d)(5)(K)(ii)(I) of the Act specifies that the process must apply to a new medical service or technology if, “based on the estimated costs incurred with respect to discharges involving such service or technology, the DRG prospective payment rate otherwise applicable to such discharges under this subsection is inadequate.” The regulations implementing this provision establish three criteria for new medical services and technologies to receive an additional payment. First, § 412.87(b)(2) defines when a specific medical service or technology will be considered new for purposes of new medical service or technology add-on payments. The statutory provision contemplated the special payment treatment for new medical services or technologies until such time as data are available to reflect the cost of the technology in the DRG weights through recalibration. There is a lag of 2 to 3 years from the point a new medical service or technology is first introduced on the market and when data reflecting the use of the medical service or technology are used to calculate the DRG weights. For example, data from discharges occurring during FY 2006 are used to calculate the proposed FY 2008 DRG weights in this proposed rule. Section 412.87(b)(2) provides that, “a medical service or technology may be considered new within 2 or 3 years after the point at which data begin to become available reflecting the ICD-9-CM code assigned to the new medical service or technology (depending on when a new code is assigned and data on the new medical service or technology become available for DRG recalibration). After CMS has recalibrated the DRGs based on available data to reflect the costs of an otherwise new medical service or technology, the medical service or technology will no longer be considered ‘new’ under the criterion for this section.” The 2-year to 3-year period during which a medical service or technology can be considered new would ordinarily begin with FDA approval, unless there was some documented delay in bringing the product onto the market after that approval (for instance, component production or drug production has been postponed until FDA approval due to shelf life concerns or manufacturing issues). After the DRGs have been recalibrated to reflect the costs of an otherwise new medical service or technology, the special add-on payment for new medical services or technologies ceases (§ 412.87(b)(2)). For example, an approved new technology that received FDA approval in October 2006 and entered the market at that time may be eligible to receive add-on payments as a new technology until FY 2010 (discharges occurring before October 1, 2009), when data reflecting the costs of the technology could be used to recalibrate the DRG weights. Because the FY 2009 DRG weights would be calculated using FY 2007 MedPAR data, the costs of such a new technology would be reflected in the FY 2009 DRG weights. Section 412.87(b)(3) further provides that new medical services or technologies must be inadequately paid otherwise under the DRG system to receive the add-on payment. To assess whether technologies would be inadequately paid under the DRGs, we establish thresholds to evaluate applicants for new technology add-on payments. In the FY 2004 IPPS final rule (68 FR 45385), we established the threshold at the geometric mean standardized charge for all cases in the DRG plus 75 percent of 1 standard deviation above the geometric mean standardized charge (based on the logarithmic values of the charges and transformed back to charges) for all cases in the DRG to which the new medical service or technology is assigned (or the case-weighted average of all relevant DRGs, if the new medical service or technology occurs in many different DRGs). However, section 503(b)(1) of Pub. L. 108-173 amended section 1886(d)(5)(K)(ii)(I) of the Act to provide for “applying a threshold * * * that is the lesser of 75 percent of the standardized amount (increased to reflect the difference between cost and charges), or 75 percent of 1 standard deviation for the diagnosis-related group involved.” The provisions of section 503(b)(1) apply to classification for fiscal years beginning with FY 2005. (Refer to section IV.D. of the preamble to the FY 2005 IPPS final rule (69 FR 49084) for a discussion of the revision of the regulations to incorporate the change made by section 503(b)(1) of Pub. L. 108-173.) Table 10 of the Addendum to the FY 2007 IPPS final rule (71 FR 48319) contained the final thresholds that are being used to evaluate applications for new technology add-on payments for FY 2008. An applicant must demonstrate that the cost threshold is met using information from inpatient hospital claims. We were recently asked to revisit the issue of whether the HIPAA Privacy Rule at 45 CFR Parts 160 and 164 applies to claims information that providers submit with applications for new technology add-on payments. We previously addressed this issue in the September 7, 2001 final rule (66 FR 46917) that established the new technology add-on payment regulations. In the preamble to that final rule, we explained that health plans, including Medicare, and providers that conduct certain transactions electronically, including the hospitals that would be receiving payment under the FY 2001 IPPS final rule, are required to comply with the HIPAA Privacy Rule. We further explained how such entities could meet the applicable HIPAA 
                        ( print page 24772)
                        requirements by discussing how the HIPAA Privacy Rule permitted providers to share with health plans information needed to ensure correct payment, if they have obtained consent from the patient to use that patient's data for treatment, payment, or health care operations. We also explained that because the information to be provided within applications for new technology add-on payment would be needed to ensure correct payment, no additional consent would be required. The HHS Office of Civil Rights has since amended the HIPAA Privacy Rule, but the results remain. The HIPAA Privacy Rule no longer requires covered entities to obtain consent from patients to use or disclose individually identifiable health information for treatment, payment, or health care operations, and expressly permits such entities to use or to disclose individually identifiable health information to covered entities for any of these purposes (45 CFR §§ 164.502(a)(1)(ii), and 506(c)(1) and (c)(3); and the Standards for Privacy of Individually Identifiable Health Information published in the 
                        **Federal Register**
                         on August 14, 2002 for a full discussion of changes in consent requirements). Section 412.87(b)(1) of our existing regulations provides that a new technology is an appropriate candidate for an additional payment when it represents “an advance that substantially improves, relative to technologies previously available, the diagnosis or treatment of Medicare beneficiaries.” For example, a new technology represents a substantial clinical improvement when it reduces mortality, decreases the number of hospitalizations or physician visits, or reduces recovery time compared to the technologies previously available. (Refer to the September 7, 2001 final rule (66 FR 46902) for a complete discussion of this criterion.) The new medical service or technology add-on payment policy provides additional payments for cases with high costs involving eligible new medical services or technologies while preserving some of the incentives under the average-based payment system. The payment mechanism is based on the cost to hospitals for the new medical service or technology. Under § 412.88, Medicare pays a marginal cost factor of 50 percent for the costs of a new medical service or technology in excess of the full DRG payment. If the actual costs of a new medical service or technology case exceed the DRG payment by more than the 50-percent marginal cost factor of the new medical service or technology, Medicare payment is limited to the DRG payment plus 50 percent of the estimated costs of the new technology. The Congressional report language accompanying section 533 of Pub. L. 106-554 indicated Congress' intent to require the Secretary to implement the new mechanism on a budget neutral basis (H.R. Conf. Rep. No. 106-1033, 106th Cong., 2nd Sess. at 897 (2000)). Section 1886(d)(4)(C)(iii) of the Act requires that the adjustments to annual DRG classifications and relative weights must be made in a manner that ensures that aggregate payments to hospitals are not affected. Therefore, in the past, we accounted for projected payments under the new medical service and technology provision during the upcoming fiscal year at the same time we estimated the payment effect of changes to the DRG classifications and recalibration. The impact of additional payments under this provision was then included in the budget neutrality factor, which was applied to the standardized amounts and the hospital-specific amounts. Section 1886(d)(5)(K)(ii)(III) of the Act, as amended by section 503(d)(2) of Pub. L. 108-173, provides that there shall be no reduction or adjustment in aggregate payments under the IPPS due to add-on payments for new medical services and technologies. Therefore, add-on payments for new medical services or technologies for FY 2005 and later years have not been budget neutral. Applicants for add-on payments for new medical services or technologies for FY 2009 must submit a formal request, including a full description of the clinical applications of the medical service or technology and the results of any clinical evaluations demonstrating that the new medical service or technology represents a substantial clinical improvement, along with a significant sample of data to demonstrate the medical service or technology meets the high-cost threshold. Complete application information, along with final deadlines for submitting a full application, will be available on our web site after publication of the IPPS FY 2008 final rule at: 
                        *http://www.cms.hhs.gov/​AcuteInpatientPPS/​08_​newtech.asp*. To allow interested parties to identify the new medical services or technologies under review before the publication of the proposed rule for FY 2009, the web site will also list the tracking forms completed by each applicant. 2. Public Input Before Publication of a Notice of Proposed Rulemaking on Add-On Payments Section 1886(d)(5)(K)(viii) of the Act, as amended by section 503(b)(2) of Pub. L. 108-173, provides for a mechanism for public input before publication of a notice of proposed rulemaking regarding whether a medical service or technology represents a substantial clinical improvement or advancement. The process for evaluating new medical service and technology applications requires the Secretary to— Provide, before publication of a proposed rule, for public input regarding whether a new service or technology represents an advance in medical technology that substantially improves the diagnosis or treatment of Medicare beneficiaries.
                    Make public and periodically update a list of the services and technologies for which applications for add-on payments are pending.
                    Accept comments, recommendations, and data from the public regarding whether a service or technology represents a substantial clinical improvement.
                    Provide, before publication of a proposed rule, for a meeting at which organizations representing hospitals, physicians, manufacturers, and any other interested party may present comments, recommendations, and data regarding whether a new medical service or technology represents a substantial clinical improvement to the clinical staff of CMS. In order to provide an opportunity for public input regarding add-on payments for new medical services and technologies for FY 2008 before publication of the FY 2008 IPPS proposed rule, we published a notice in the 
                        **Federal Register**
                         on December 22, 2006 (71 FR 77031), and held a town hall meeting at the CMS Headquarters Office in Baltimore, MD, on February 22, 2007. In the announcement notice for the meeting, we stated that the opinions and alternatives provided during the meeting would assist us in our evaluations of applications by allowing public discussion of the substantial clinical improvement criterion for each of the FY 2008 new medical service and technology add-on payment applications before the publication of the FY 2008 IPPS proposed rule. Approximately 70 individuals attended the town hall meeting in person, while additional participants listened over an open telephone line. Boston Scientific presented data on how its product (Wingspan® Stent System with GatewayTM
                         PTA Balloon Catheter) meets the substantial clinical improvement criterion, as well as the need for additional payments to ensure its access to Medicare beneficiaries. No other attendees at the town hall meeting 
                        ( print page 24773)
                        made a presentation with regard to the Wingspan® new technology add-on payment application. We considered Boston Scientific's presentation made at the town hall meeting, as well as written comments submitted with their application, in our evaluation of the Wingspan® new technology application for FY 2008 in this proposed rule. We have summarized these comments under section I.4. of this preamble. We did not receive any other comments regarding substantial clinical improvement of Wingspan®. However, there were a number of public comments made at the town hall meeting suggesting that CMS provide more specific detail about how it would apply the substantial clinical improvement criterion. For example, the public commenters at the town hall meeting suggested that CMS provide clear guidance with respect to the type of data that applicants should submit to support an application for add-on payments for new medical services and technologies. We were asked to work with stakeholders, including researchers, clinicians, representatives of patients, and manufacturers, to develop specific criteria and data quality standards that would make determinations of “substantial clinical improvement” more predictable and transparent. We welcome public comment on this issue. In particular, we are interested in any “specific criteria or data quality standards” that the commenters believe we should adopt to improve the new technology add-on application process, or any concerns or challenges that commenters believe we may encounter in undertaking this effort. Again, as we stated at the new technology town hall meeting, we are always interested in working with our stakeholders to improve the inpatient new technology add-on payment process. We are interested in ensuring that the latest medical technology that improves care for the Medicare patient population continues to be available to our beneficiaries. 3. FY 2008 Status of Technologies Approved for FY 2007 Add-On Payments a. Endovascular Graft Repair of the Thoracic Aorta W. L. Gore & Associates, Inc. submitted an application for consideration of its Endovascular Graft Repair of the Thoracic Aorta (GORE TAG) for new technology add-on payments for FY 2006. The manufacturer argued that endovascular stent-grafting of the descending thoracic aorta provides a less invasive alternative to the traditional open surgical approach required for the management of descending thoracic aortic aneurysms. The GORE TAG device is a tubular stent-graft mounted on a catheter-based delivery system, and it replaces the synthetic graft normally sutured in place during open surgery. The device was initially identified using ICD-9-CM procedure code 39.79 (Other endovascular repair (of aneurysm) of other vessels). The applicant also requested a unique ICD-9-CM procedure code. As noted in Table 6B of the FY 2006 IPPS final rule (70 FR 47637), new procedure code 39.73 (Endovascular implantation of graft in thoracic aorta) was assigned to this technology. In the FY 2006 IPPS final rule (70 FR 47356), we approved the GORE TAG device for new technology add-on payment for FY 2006. FDA approved GORE TAG on March 23, 2005. Because the technology remained within the 2-to 3-year period during which it could be considered new for FY 2007, we continued add-on payments for the endovascular graft repair of the thoracic aorta in the FY 2007 IPPS final rule (71 FR 47999). GORE TAG will have been on the market for more than 3 years as of March 23, 2008, or less than 6 months of FY 2008. Our practice has been to begin and end new technology add-on payments on the basis of a fiscal year. In general, we extend add-on payments for an additional year only if the 3-year anniversary date of the product's entry on the market occurs in the latter half of the fiscal year (70 FR 47362). Because the 3-year anniversary date of GORE TAG's entry onto the market was in the first half of the fiscal year, we are proposing to discontinue its new technology add-on payment for FY 2008. b. Restore® Rechargeable Implantable Neurostimulator Medtronic Neurological submitted an application for new technology add-on payments for its Restore® Rechargeable Implantable Neurostimulator for FY 2006. The Restore® 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® 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 2006 and FY 2007. Cases involving these devices, made by any manufacturer, are identified by the presence of newly created ICD-9-CM code 86.98 (Insertion or replacement of dual array rechargeable neurostimulator pulse generator). The FDA approved the Restore® Rechargeable Implantable Neurostimulator in 2005. However, as noted in the FY 2006 IPPS final rule (70 FR 47358), at least one similar product was approved by the FDA as early as April 2004. Because the Restore” Rechargeable Implantable Neurostimulator will be beyond the 2- to 3-year period during which it can be considered new for FY 2008, we are proposing to discontinue add-on payments for the technology in FY 2008. c. X STOP Interspinous Process Decompression System St. Francis Medical Technologies submitted an application for new technology add-on payments for the X STOP Interspinous Process Decompression System (X STOP) for FY 2007. Lumbar spinal stenosis describes a condition that occurs when the spaces between bones in the spine become narrowed due to arthritis and other age-related conditions. This narrowing, or stenosis, causes nerves coming from the spinal cord to be compressed, thereby causing symptoms including pain, numbness, and weakness. It particularly causes symptoms when the spine is in extension, when a patient stands fully upright or leans back. The X STOP device is inserted between the spinous processes of adjacent vertebrae in order to provide a minimally invasive alternative to conservative treatment (exercise and physical therapy) and invasive surgery (spinal fusion). It works by limiting the spine's extension that compresses the nerve's roots while still preserving as much motion as possible. The device is inserted in a relatively simple, primarily outpatient procedure using local anesthesia. However, in some circumstances, the physician may prefer to admit the 
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                        patient for an inpatient stay. The manufacturer described the device as providing “a new minimally invasive, stand-alone alternative treatment for lumbar spinal stenosis.” The X STOP Interspinous Process Decompression system received pre-market approval from the FDA on November 21, 2005. The device is currently described by ICD-9-CM code 84.58 (Implantation of Interspinous process decompression device) (excluding: Fusion of spine (codes 81.00 through 81.08, and 81.30 through 81.39)). This ICD-9-CM code went into effect on October 1, 2005. In the FY 2007 final rule, with respect to substantial clinical improvement, we noted our concern that, during the FDA approval process, the Center for Devices and Radiological Health Advisory Panel voted against pre-market approval of X STOP because of concerns about proper patient selection, as well as the lack of objective endpoints. The applicant addressed our concerns by demonstrating that the mechanism of effect on the spine in cadavers with in vivo clinical radiographic data. That is, the applicant was able to show that the X STOP device limits spine extension that compresses the nerve. Thus, we indicated that we believed the technology has promise for providing a less invasive alternative to procedures such as laminectomy or fusion for patients that have failed conservative treatment (exercise, physical therapy and medication). The X STOP system represents a new level of treatment on the continuum of care for patients with lumbar spinal stenosis that previously did not exist. Accordingly, after consideration of the comments received, we approved the X STOP Interspinous Process Decompression System for new technology add-on payment for FY 2007. Cases involving X STOP are identified by ICD-9-CM code 84.58 (Implantation of interspinous process decompression device). These cases are generally included in CMS-DRG 499 (Back and Neck Procedures Except Spinal Fusion with CC) and CMS-DRG 500 (Back and Neck Procedures Except Spinal Fusion without CC) for FY 2007. The X STOP Interspinous Process Decompression System is still within the 2- to 3-year period during which it can be considered new for FY 2008. However, we are concerned that it may no longer meet the cost-threshold criterion. In section II.D. of the preamble of this proposed rule, we are proposing to adopt MS-DRGs for FY 2008 and assign cases with procedure codes 84.58 into proposed MS-DRG 490 (Back and Neck Procedures Except Spinal Fusion with CC or MCC or Disc Devices). Proposed MS-DRG 490 includes back and neck procedures except spinal fusion with a CC or MCC. As indicated earlier, we did a comprehensive review of the spinal fusion and nonspinal fusion DRGs. Based on this review, we are proposing to further modify MS-DRG 490 to also include the higher cost of cases where the patient receives a spinal disc device such as an artificial spinal disc prosthesis, or an interspinous process decompression system. Our earlier analysis of the spinal and nonspinal fusion DRGs showed that the average charge per case for cases involving X STOP is $29,162. The average charge per case for MS-DRG 490 is $29,656. Therefore, cases that use X STOP have a lower average charge per case than all cases in MS-DRG 490. The data show that the technology is not inadequately paid under the revised MS-DRGs, and it no longer meets the cost threshold for new technology add-on payment. For this reason, we are proposing to discontinue new technology add-on payments for X STOP in FY 2008 and correlate the payments under MS-DRG 490. The high costs for cases using X STOP that necessitated an add-on payment under the CMS DRGs will no longer be necessary because of the higher payment that would be made under the proposed MS-DRG 490. 4. FY 2008 Application for New Technology Add-On Payments Boston Scientific submitted an application for the Wingspan® Stent System with Gateway PTA Balloon Catheter (Wingspan®) for new technology add-on payments for FY 2008. The device is designed for the treatment of patients with significant intracranial arterial stenosis who are refractory to medical management. The device consists of the following: a self-expanding nitinol stent; a multilumen over wire delivery catheter; and a GatewayTM
                         PTA Balloon Catheter. The device is used to treat stenoses that occur in the intracranial vessels. Prior to stent placement, the GatewayTM
                         PTA Balloon is inflated to dilate the target lesion, and then the stent is deployed across the lesion to restore and maintain luminal patency. Effective October 1, 2004, two new ICD-9-CM procedure codes were created to code intracranial angioplasty and intracranial stenting procedures: procedure codes 00.62 (Percutaneous angioplasty or atherectomy of intracranial vessels) and 00.65 (Percutaneous insertion of intracranial vascular stents). On August 3, 2005, the Wingspan® was approved by the FDA as a Humanitarian Device Exemption (HDE). We note that the applicant submitted an application for new technology add-on payments in FY 2006 but was not approved for add-on payments because it had not yet received FDA approval. In November 2006, we issued a national coverage determination (NCD) on intracranial stents. The NCD stated that the treatment of cerebral artery stenosis in patients with intracranial atherosclerotic disease with intracranial percutaneous transluminal angioplasty (PTA) and stenting is reasonable and necessary when furnished in accordance with the FDA-approved protocols governing Category B Investigational Device Exemption (IDE) clinical trials. Currently, there are no clinical trials in place for the Wingspan®. However, because the technology is covered by Medicare, if it is used in the setting of a clinical trial, we will evaluate whether the Wingspan® meets the criteria for an inpatient new technology add-on payment. The Wingspan® has been available on the market since August 3, 2005. Therefore, we believe that the technology meets the newness criterion. The applicant noted in its application that cases of intracranial angioplasty and stenting cases are currently grouped to CMS DRGs 533 (Extracranial Procedure with CC) and 534 (Extracranial Procedure Without CC). However, the applicant believes these cases should be assigned to CMS DRGs 1 (Craniotomy Age > 17 With CC), 2 (Craniotomy Age > 17 Without CC), and 543 (Craniotomy With Major Device Implant or Acute Complex Central Nervous System Principal Diagnosis) based on resource use and for clinical consistency with other endovascular intracranial procedures assigned to these DRGs. As discussed in section II.D. of the preamble of this proposed rule, we are proposing to move procedure code 00.62 to proposed MS-DRGs 25, 26, and 27 (Craniotomy & Endovascular Intracranial Procedures With MCC, With CC, and Without CC/MCC, respectively) and proposed MS-DRGs 23 and 24 (Craniotomy With Major Device Implant or Acute Complex Central Nervous System Principal Diagnosis With MCC or Without MCC, respectively) under the proposed MS-DRG system, which are comparable to DRGs 1, 2, and 543 under the current CMS-DRG system. To demonstrate that the Wingspan® meets the cost threshold, the manufacturer submitted data from MedPAR and non-MedPAR databases. Using the FY 2005 MedPAR data, the applicant identified cases of intracranial angioplasty that had a procedure code of 39.50 (Angioplasty or atherectomy of 
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                        other noncoronary vessels) in combination with one of the following principal diagnosis codes: Any principal diagnosis code that begins with the prefix of 433 (Occlusion and stenosis of precerebral arteries), excluding 433.10 (Cartoid artery without mention of cerebral infarction) and 433.11 (Cartoid artery with cerebral infarction); any principal diagnosis code that begins with the prefix of 434 (Occlusion of cerebral arteries), 437.0 (Cerebral atherosclerosis), 437.1 (Other generalized ischemic cerebrovascular disease), or 437.9 (Unspecified). The applicant noted that procedure code 39.50 is the predecessor code for identifying cases of intracranial angioplasty. The applicant explained that, given the newness of procedure codes 00.62 and 00.65 that were implemented beginning October 1, 2005, it believes there are still cases being coded with the predecessor procedure codes. Using this methodology, the applicant found 577 cases in DRG 533 and 179 cases in DRG 534. The applicant noted that charges in the MedPAR file do not include the total costs of devices, drugs, and medical supplies associated with the Wingspan®, so the applicant conducted an estimate of the charges associated with the Wingspan®. The applicant determined that costs associated with the Wingspan® are approximately $10,073. Because we use charges to determine if a technology meets the threshold, it is necessary to inflate the costs to charges. Using the national average CCR of 0.47, the applicant inflated the costs associated with the Wingspan® to $21,432 in charges. After adding the charges associated with the Wingspan®, the average standardized charge per case was $76,416 and $51,277 for DRGs 533 and 534, respectively. We are concerned regarding whether the cases identified by the applicant are a useful proxy to identify cases of intracranial angioplasty. Procedure code 39.50 describes cases of angioplasty in any artery of the body except the heart. Intracranial angioplasty with stenting was not covered by Medicare in any circumstance prior to October 2006. Therefore, the Medicare cases submitted by the applicant under procedure code 39.50 should not involve intracranial angioplasty because they are neither described by the code nor covered by Medicare. Furthermore, procedure code 00.62 is assigned to the Non-Covered Procedure edit of the MCE. The applicant supplied Medicare data from FY 2005 for claims coded with procedure code 00.62. It is unclear to us how these claims were processed despite the Non-Covered Procedure edit. Because these data appear to be based on claims that may not have been coded or processed correctly, we question the reliability and validity of these data. We are concerned that it may not be appropriate to rely on these data for purposes of determining whether the technology meets the cost threshold. As stated above, the applicant also submitted non-Medicare data. The applicant used the 2005 patient discharge data from California's Office of Statewide Health Planning and Development database for hospitals in California and the 2005 patient data from Florida's Agency for Health Care Administration for hospitals in Florida. Similar to the analysis above, the applicant identified cases of intracranial angioplasty using procedure code 39.50 in combination with the diagnosis codes listed above. The applicant identified 43 cases in DRG 533, and 21 cases in DRG 534. Because these cases already include charges associated with Wingspan®, it was not necessary to include the $21,432 in charges associated with Wingspan®. The average standardized charge per case was $89,697 and $40,475 for DRGs 533 and 534, respectively. As discussed above, we are concerned about whether these cases actually represent cases of intracranial angioplasty. We also note that we are unable to validate these data because they are non-Medicare data. In addition, similar to the analysis described above, the applicant also identified cases of intracranial angioplasty using procedure code 00.62. The applicant found 30 cases in DRG 533, and 23 cases in DRG 534. The average standardized charge per case was $93,215 and $31,479 for DRGs 533 and 534, respectively. Based on these data, the applicant maintains that the technology meets the cost threshold. As noted above, the applicant has requested that cases of the Wingspan® be reassigned to CMS DRGs 1, 2 and 543. In section II.G.2. of the preamble of this proposed rule, we are proposing to assign procedure code 00.62 to proposed MS-DRGs 23, 24, 25, 26 and 27, which replace DRGs 1, 2, and 543 of the current CMS DRGs. The thresholds in Table 10 of the Addendum of the FY 2007 IPPS final rule (as corrected at 71 FR 60040) for DRGs 1, 2 and 543 are $53,969, $37,116 and $64,397, respectively. Analyzing the same Medicare and non-Medicare data that the applicant used to demonstrate that the Wingspan® exceeds the cost threshold for DRGs 533 and 534, the applicant compared the average standardized charge per case to the thresholds for DRGs 1, 2, and 543. The applicant maintains that the Wingspan® would still exceed the cost threshold even if it were reassigned to DRGs 1, 2, and 543. However, for the reasons described above, it is not clear whether Wingspan® meets the cost threshold for new technology add-on payment. We welcome public comments on this issue. The applicant also maintains that the technology meets the substantial clinical improvement criterion. In the past there has been no surgical or medical treatment available for recurrent strokes that occur despite optimal medical management. The applicant asserts that the Wingspan® provides a new treatment option for these patients. The applicant submitted three studies to support this position. First, the applicant cites data derived from a series of cases of 45 patients who received the Wingspan® that demonstrate 4.4 percent composite ipsilateral stroke or death at 30 days, 7.0 percent composite ipsilateral stroke or death at 6 months, and 9.3 percent ipsilateral stroke or death at 13 months. The applicant then used patients in the well known Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial as a historical control against which to compare patients who received Wingspan®. The WASID trial compared the warfarin vs. aspirin therapy in treating symptomatic intracranial arterial stenosis, and it demonstrated a 23 percent stroke/death rate at one year in patients with severe (70 percent or greater) stenosis, and a 21 percent stroke/death rate at 2 years in patients with 50 percent or greater stenosis. The applicant also submitted data from an ongoing Wingspan® registry of patients that demonstrate a 4.8 percent stroke/death rate at 30 days, and a 9.7 percent stroke/death rate at 3 to 6 month follow up in 72 patients. In addition, the applicant submitted data from a multicenter NIH registry of 131 patients with 70 percent or greater stenosis that demonstrate an 8.4 percent rate of stroke, intracerebral hemorrhage or death at 30 days and a 9.9 percent rate of stroke and death at the mean 3.2 months followup. While we recognize that Wingspan® may represent a promising technology in patients with significant intracranial arterial stenosis who are refractory to medical management, we are concerned that, to date, there has been no controlled, randomized trial to demonstrate its clinical efficacy. We are also concerned that the Wingspan® data did not compare patients over the same followup periods as WASID. In addition, we are concerned over the use 
                        ( print page 24776)
                        of WASID patients as a control group against which to compare Wingspan® patients. The current FDA Humanitarian Device Exemption, in combination with the current CMS NCD, while providing access to this technology for very ill patients with generally poor prognoses who have few other options, also effectively designates the technology as investigational, and in need of further studies to prove its effectiveness. We would prefer that the product's effectiveness be demonstrated before we judge whether the product represents a substantial clinical improvement. For these reasons, we are concerned that there may not be sufficient evidence that Wingspan® represents an advance that substantially improves the diagnosis or treatment of Medicare beneficiaries. However, we welcome public comments that may pertain to this matter. 5. Technical Correction Section 1886(d)(5)(K)(i) of the Act requires that the Secretary establish a mechanism to recognize the costs of new medical services and technologies under subsection (d) of section 1886 of the Act. As made clear under section 1886(d)(1)(A) of the Act, subsection (d) provides the methodology for payment with respect to the operating costs of inpatient hospital services. Section 1886(g) of the Act provides for payment of capital costs of inpatient hospital services. Although it has always been our policy that new technology add-on payment is available only with respect to operating costs, § 412.88(a)(2) of our regulations does not specifically refer to operating costs or the operating CCR. Therefore, we are proposing to revise § 412.88(a)(2) to clarify that the new technology add-on payment is available only for operating costs, and that we estimate the costs of a case by applying the hospital's operating CCR to the billed charges. This proposed correction would not have an impact on new technology add-on payments because, to the best of our knowledge, MACs already correctly apply only the operating CCR to calculate new technology add-on payments. III. Proposed Changes to the Hospital Wage Index A. Background Section 1886(d)(3)(E) of the Act requires that, as part of the methodology for determining prospective payments to hospitals, the Secretary must adjust the standardized amounts “for area differences in hospital wage levels by a factor (established by the Secretary) reflecting the relative hospital wage level in the geographic area of the hospital compared to the national average hospital wage level.” In accordance with the broad discretion conferred under the Act, we currently define hospital labor market areas based on the definitions of statistical areas established by the Office of Management and Budget (OMB). A discussion of the proposed FY 2008 hospital wage index based on the statistical areas, including OMB's revised definitions of Metropolitan Areas, appears under section III.B. of this preamble. Beginning October 1, 1993, section 1886(d)(3)(E) of the Act requires that we update the wage index annually. Furthermore, this section provides that the Secretary base the update on a survey of wages and wage-related costs of short-term, acute care hospitals. The survey must exclude the wages and wage-related costs incurred in furnishing skilled nursing services. This provision also requires us to make any updates or adjustments to the wage index in a manner that ensures that aggregate payments to hospitals are not affected by the change in the wage index. The proposed adjustment for FY 2008 is discussed in section II.B. of the Addendum to this proposed rule. As discussed below in section III.I. of this preamble, we also take into account the geographic reclassification of hospitals in accordance with sections 1886(d)(8)(B) and 1886(d)(10) of the Act when calculating IPPS payment amounts. Under section 1886(d)(8)(D) of the Act, the Secretary is required to adjust the standardized amounts so as to ensure that aggregate payments under the IPPS after implementation of the provisions of sections 1886(d)(8)(B) and (C) and 1886(d)(10) of the Act are equal to the aggregate prospective payments that would have been made absent these provisions. The proposed budget neutrality adjustment for FY 2008 is discussed in section II.A.4.b. of the Addendum to this proposed rule. Section 1886(d)(3)(E) of the Act also provides for the collection of data every 3 years on the occupational mix of employees for short-term, acute care hospitals participating in the Medicare program, in order to construct an occupational mix adjustment to the wage index. A discussion of the occupational mix adjustment that we are proposing to apply beginning October 1, 2007 (the FY 2008 wage index) appears under section III.C. of this preamble. B. Core-Based Statistical Areas for the Hospital Wage Index (If you choose to comment on issues in this section, please include the caption “CBSAs” at the beginning of your comments.) The wage index is calculated and assigned to hospitals on the basis of the labor market area in which the hospital is located. In accordance with the broad discretion under section 1886(d)(3)(E) of the Act, beginning with FY 2005, we define hospital labor market areas based on the Core-Based Statistical Areas (CBSAs) established by OMB and announced in December 2003 (69 FR 49027). For a discussion of OMB's revised definitions of CBSAs and our implementation of the CBSA definitions, we refer readers to the preamble of the FY 2005 IPPS final rule (69 FR 49026 through 49032). The revised area designations established by OMB resulted in a higher wage index for some areas and a lower wage index for others. Further, some hospitals that were previously classified as urban became classified as rural. Given the significant payment impacts upon some hospitals because of these changes, we provided a transition period to the new labor market areas in the FY 2005 IPPS final rule. As part of that transition, we allowed urban hospitals that became rural under the new definitions to maintain their assignment to the MSA where they were previously located for the 3-year period of FY 2005, FY 2006, and FY 2007. For a discussion of the transition, we refer readers to the FY 2005 IPPS final rule (69 FR 49032 through 49034). FY 2007 was the last year of the transition period for urban hospitals that became classified as rural. Therefore, for discharges on or after October 1, 2007 (FY 2008), these hospitals will receive their statewide rural wage index or their FY 2008 MGCRB reclassified age index. (These hospitals were and are eligible to apply for reclassification by the MGCRB both during the transition period and in subsequent years. These hospitals are considered rural for reclassification purposes.) Consistent with the FY 2005, FY 2006, and FY 2007 IPPS final rules, for FY 2008 we are proposing to provide that hospitals receive 100 percent of their wage index based upon the CBSA configurations. Specifically, for each hospital, we will determine a wage index for FY 2008 employing wage index data from FY 2004 hospital cost reports and using the CBSA labor market definitions. We consider CBSAs that are MSAs to be urban, and CBSAs that are Micropolitan Statistical Areas as well as areas outside of CBSAs to be rural. In addition, where an MSA has been divided into Metropolitan Divisions, we consider the Metropolitan 
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                        Division to comprise the labor market areas for purposes of calculating the wage index (69 FR 49029). On December 18, 2006, OMB announced the inclusion of two new CBSAs and the revision of designations for six areas (OMB Bulletin No. 07-01). The new CBSAs are as follows: Lake Havasu-Kingman, Arizona (CBSA 29420). This CBSA comes from Mohave County, Arizona;
                    Palm Coast, Florida (CBSA 37380). This CBSA comes from Flager County, Florida; The revised CBSA designations are as follows: Mauldin, South Carolina and Easley, South Carolina qualify as new principal cities of the Greenville-Mauldin-Easley, South Carolina CBSA;
                    Conway, Arkansas qualifies as a new principal city of the Little Rock-North Little Rock-Conway, Arkansas CBSA;
                    Goleta, California qualifies as a new principal city of the Santa Barbara-Santa Maria-Goleta, California CBSA;
                    Franklin, Tennessee qualifies as a new principal city of the Nashville-Davidson-Murfreesboro-Franklin, Tennessee CBSA;
                    Fort Pierce, Florida no longer qualifies as a principal city of the Port St. Lucie-Fort Pierce, Florida CBSA; the new designation is Port St. Lucie, Florida CBSA. (We note also that OMB renamed the Essex County, Massachusetts Metropolitan Division as the Peabody, Massachusetts Metropolitan Division. OMB also changed the CBSA code from 21604 to 37764.) The OMB bulletin is available on the OMB Web site at 
                        *http://www.whitehouse.gov/​OMB—*
                        go to “Bulletins” or “Statistical Programs and Standards.” CMS will apply these changes to the IPPS beginning October 1, 2007. C. Proposed Occupational Mix Adjustment to the Proposed FY 2008 Wage Index (If you choose to comment on issues in this section, please include the caption “Occupational Mix Adjustment” at the beginning of your comment.) As stated earlier, section 1886(d)(3)(E) of the Act provides for the collection of data every 3 years on the occupational mix of employees for each short-term, acute care hospital participating in the Medicare program, in order to construct an occupational mix adjustment to the wage index, for application beginning October 1, 2004 (the FY 2005 wage index). The purpose of the occupational mix adjustment is to control for the effect of hospitals' employment choices on the wage index. For example, hospitals may choose to employ different combinations of registered nurses, licensed practical nurses, nursing aides, and medical assistants for the purpose of providing nursing care to their patients. The varying labor costs associated with these choices reflect hospital management decisions rather than geographic differences in the costs of labor. 1. Development of Data for the Proposed FY 2008 Occupational Mix Adjustment On October 14, 2005, we published a notice in the 
                        **Federal Register**
                         (70 FR 60092) proposing to use a new survey, the 2006 Medicare Wage Index Occupational Mix Survey (the 2006 survey) to apply an occupational mix adjustment to the FY 2008 wage index. In the proposed 2006 survey, we included several modifications based on the comments and recommendations we received on the 2003 survey, including (1) allowing hospitals to report their own average hourly wage rather than using BLS data; (2) extending the prospective survey period; and (3) reducing the number of occupational categories but refining the subcategories for registered nurses. We made the changes to the occupational categories in response to MedPAC comments to the FY 2005 IPPS final rule (69 FR 49036). Specifically, MedPAC recommended that CMS assess whether including subcategories of registered nurses would result in a more accurate occupational mix adjustment. MedPAC believed that including all registered nurses in a single category may obscure significant wage differences among the subcategories of registered nurses, for example, the wages of surgical registered nurses and floor registered nurses may differ. Also, to offset additional reporting burden for hospitals, MedPAC recommended that CMS should combine the general service categories that account for only a small percentage of a hospital's total hours with the “all other occupations” category because most of the occupational mix adjustment is correlated with the nursing general service category. In addition, in response to the public comments on the October 14, 2005 notice, we modified the 2006 survey. On February 10, 2006, we published a 
                        **Federal Register**
                         notice (71 FR 7047) that solicited comments and announced our intent to seek OMB approval on the revised occupational mix survey (Form CMS-10079 (2006)). OMB approved the survey on April 25, 2006. The 2006 survey provides for the collection of hospital-specific wages and hours data, a 6-month prospective reporting period (that is, January 1, 2006, through June 30, 2006), the transfer of each general service category that comprised less than 4 percent of total hospital employees in the 2003 survey to the “all other occupations” category (the revised survey focuses only on the mix of nursing occupations), additional clarification of the definitions for the occupational categories, an expansion of the registered nurse category to include functional subcategories, and the exclusion of average hourly rate data associated with advance practice nurses. The 2006 survey included only two general occupational categories: nursing and “all other occupations.” The nursing category has four subcategories: registered nurses, licensed practical nurses, aides, orderlies, attendants, and medical assistants. The registered nurse subcategory includes two functional subcategories: Management personnel and staff nurses or clinicians. As indicated above, the 2006 survey provided for a 6-month data collection period, from January 1, 2006 through June 30, 2006. However, we allowed flexibility for the reporting period begin and end dates to accommodate some hospitals' bi-weekly payroll and reporting systems. That is, the 6-month reporting period had to begin on or after December 25, 2005, and end before July 9, 2006. We are proposing to use the 6-month 2006 survey data to calculate the occupational mix adjustment for the FY 2008 wage index. We used the 1st quarter of 2006 survey data in the FY 2007 wage index to comply with a court decision in 
                        *Bellevue Hosp. Center*
                         v. 
                        *Leavitt*, 443 F.3d 163 (2nd Cir. 2006). For a discussion of our use of the 2006 survey data in the FY 2007 wage index, in compliance with the Bellevue decision, we refer readers to the FY 2007 IPPS final rule (71 FR 48007) as well as the FY 2007 IPPS final notice (71 FR 90886). However, as stated above, we are proposing to use the entire 6-month 2006 survey data (that is, from the period January 1, 2006 through June 30, 2006) to calculate the occupational mix adjustment for the FY 2008 wage index. 2. Timeline for the Collection, Review, and Correction of the Occupational Mix Data In a Joint-Signature Memorandum that we issued on April 21, 2006 (JSM-06412), and in the FY 2007 IPPS final rule (71 FR 48008), we discussed the schedule for the 1st quarter 2006 
                        ( print page 24778)
                        occupational mix survey data that would be used in the FY 2007 wage index. The schedule included deadlines for— Hospitals to submit 1st quarter occupational mix data. The deadline was June 1, 2006.
                    MAC review of the submitted 1st quarter data. The deadline was June 22, 2006.
                    Availability of the submitted first quarter data on the CMS Web site. The deadline was June 29, 2006.
                    Hospitals to submit requests to their MACs for corrections to their 1st quarter occupational mix data. The deadline was July 13, 2006.
                    MACs to submit corrected 1st quarter occupational mix survey data to CMS. The deadline was July 27, 2006. In the Joint-Signature Memorandum, we also indicated that hospitals were to submit their 2nd quarter 2006 occupational mix survey data to their intermediaries (MACs) by August 31, 2006. On October 6, we published on our web site both the audited 1st quarter and unaudited 2nd quarter 2006 occupational survey data and Worksheet S-3 wage data to be used in calculating the FY 2008 wage index. In addition, we sent a letter to hospitals through their MACs (dated October 6, 2006) that discussed the timeframe for reviewing and correcting Worksheet S-3 wage data and the 2nd quarter 2006 survey data, and an opportunity for hospitals to request additional adjustments to their 1st quarter 2006 survey data for the FY 2008 wage index. The revision and correction process for all of the data to be used for computing the FY 2008 wage index is discussed in detail in section III.K. of this preamble. 3. Calculation of the Proposed Occupational Mix Adjustment for FY 2008 For FY 2008 (as we did for FY 2007), we are proposing to calculate the occupational mix adjustment factor using the following steps: *Step 1*
                        —For each hospital, determine the percentage of the total nursing category attributable to a nursing subcategory by dividing the nursing subcategory hours by the total nursing category's hours (registered nurse management personnel and registered nurse staff nurses or clinicians are treated as separate nursing subcategories). Repeat this computation for each of the five nursing subcategories: registered nurse management personnel, registered nurse staff nurses or clinicians, licensed practical nurses; nursing aides, orderlies, and attendants; and medical assistants. *Step 2*
                        —Determine a national average hourly rate for each nursing subcategory by dividing a subcategory's total salaries for all hospitals in the occupational mix survey database by the subcategory's total hours for all hospitals in the occupational mix survey database. *Step 3*
                        —For each hospital, determine an adjusted average hourly rate for each nursing subcategory by multiplying the percentage of the total nursing category (from Step 1) by the national average hourly rate for that nursing subcategory (from Step 2). Repeat this calculation for each of the five nursing subcategories. *Step 4*
                        —For each hospital, determine the adjusted average hourly rate for the total nursing category by summing the adjusted average hourly rate (from Step 3) for each of the nursing subcategories. *Step 5*
                        —Determine the national average hourly rate for the total nursing category by dividing total nursing category salaries for all hospitals in the occupational mix survey database by total nursing category hours for all hospitals in the occupational mix survey database. *Step 6*
                        —For each hospital, compute the occupational mix adjustment factor for the total nursing category by dividing the national average hourly rate for the total nursing category (from Step 5) by the hospital's adjusted average hourly rate for the total nursing category (from Step 4). If the hospital's adjusted average hourly rate is less than the national average hourly rate (indicating the hospital employs a less costly mix of nursing employees), the occupational mix adjustment factor would be greater than 1.0000. If the hospital's adjusted average hourly rate is greater than the national average hourly rate, the occupational mix adjustment factor would be less than 1.0000. *Step 7*
                        —For each hospital, calculate the occupational mix adjusted salaries and wage-related costs for the total nursing category by multiplying the hospital's total salaries and wage-related costs (from Step 5 of the unadjusted wage index calculation in section III.F. of this preamble) by the percentage of the hospital's total workers attributable to the total nursing category (using the occupational mix survey data, this percentage is determined by dividing the hospital's total nursing category salaries by the hospital's total salaries for “nursing and all other”) and by the total nursing category's occupational mix adjustment factor (from Step 6 above). The remaining portion of the hospital's total salaries and wage-related costs that is attributable to all other employees of the hospital is not adjusted by the occupational mix. A hospital's all other portion is determined by subtracting the hospital's nursing category percentage from 100 percent. *Step 8*
                        —For each hospital, calculate the total occupational mix adjusted salaries and wage-related costs for a hospital by summing the occupational mix adjusted salaries and wage-related costs for the total nursing category (from Step 7) and the portion of the hospital's salaries and wage-related costs for all other employees (from Step 7). To compute a hospital's occupational mix adjusted average hourly wage, divide the hospital's total occupational mix adjusted salaries and wage-related costs by the hospital's total hours (from Step 4 of the unadjusted wage index calculation in section III.F. of this preamble). *Step 9*
                        —To compute the occupational mix adjusted average hourly wage for an urban or rural area, sum the total occupational mix adjusted salaries and wage-related costs for all hospitals in the area, then sum the total hours for all hospitals in the area. Next, divide the area's occupational mix adjusted salaries and wage-related costs by the area's hours. *Step 10*
                        —To compute the national occupational mix adjusted average hourly wage, sum the total occupational mix adjusted salaries and wage-related costs for all hospitals in the Nation, then sum the total hours for all hospitals in the Nation. Next, divide the national occupational mix adjusted salaries and wage-related costs by the national hours. *Step 11*
                        —To compute the occupational mix adjusted wage index, divide each area's occupational mix adjusted average hourly wage (Step 9) by the national occupational mix adjusted average hourly wage (Step 10). *Step 12*
                        —To compute the Puerto Rico specific occupational mix adjusted wage index, follow Steps 1 through 11 above. The table below is an illustrative example of the proposed occupational mix adjustment. 
 
  
 
  Because the occupational mix adjustment is required by statute, all hospitals that are subject to payments under the IPPS, or any hospital that 
                        ( print page 24781)
                        would be subject to the IPPS if not granted a waiver, must complete the occupational mix survey, unless the hospital has no associated cost report wage data that are included in the proposed FY 2008 wage index. For the FY 2007 wage index, if a hospital did not respond to the occupational mix survey, or if we determined that a hospital's submitted data were too erroneous to include in the wage index, we assigned the hospital the average occupational mix adjustment for the labor market area (71 FR 48013). We believed this method had the least impact on the wage index for other hospitals in the area. For areas where no hospital submitted data for purposes of calculating the occupational mix adjustment, we applied the national occupational mix factor of 1.0000 in calculating the area's FY 2007 occupational mix adjusted wage index. We indicated in the FY 2007 IPPS final rule that we reserve the right to apply a different approach in future years, including potentially penalizing nonresponsive hospitals. For the FY 2008 wage index, we are proposing to handle the data for hospitals that did not respond to the occupational mix survey (neither the 1st quarter nor 2nd quarter data) in the same manner as discussed above for the FY 2007 wage index. In addition, if a hospital submitted survey data for either the 1st quarter or 2nd quarter, but not for both quarters, we are proposing to use the data the hospital submitted for one quarter to calculate the hospital's FY 2008 occupational mix adjustment factor. Lastly, if a hospital submitted a survey(s), but that survey data could not be used because we determined it to be aberrant, we also assigned the hospital the average occupational mix adjustment for its labor market area. For example, if a hospital's individual nurse category average hourly wages were out of range (that is, unusually high or low), and the hospital did not provide sufficient documentation to explain the aberrancy, or the hospital did not submit any registered nurse staff salaries or hours data, we assigned the hospital the average occupational mix adjustment for the labor market area in which it is located. In calculating the average occupational mix adjustment factor for a labor market area, we replicated Steps 1 through 6 of the calculation for the occupational mix adjustment. However, instead of performing these steps at the hospital level, we aggregated the data at the labor market area level. In following these steps, for example, for CBSAs that contain providers that did not submit occupational mix survey data, the occupational mix adjustment factor ranged from a low of 0.8972 (CBSA 39820, Redding, CA), to a high of 1.0728 (CBSA 19, Rural Louisiana). Also, in computing a hospital's occupational mix adjusted salaries and wage-related costs for nursing employees (Step 7 of the calculation), in the absence of occupational mix survey data, we multiplied the hospital's total salaries and wage-related costs by the percentage of the area's total workers attributable to the area's total nursing category. For FY 2008, there is one CBSA in which none of the providers submitted the occupational mix survey (CBSA 49740, Yuma, AZ). In the absence of any data in this labor market area, we applied an occupational mix adjustment factor of 1.0 to all provider(s). In the FY 2007 IPPS final rule, we also indicated that we would give serious consideration to applying a hospital-specific penalty if a hospital does not comply with regulations requiring submission of occupational mix survey data in future years. We stated that we believe that section 1886(d)(5)(I)(i) of the Act provides us with the authority to penalize hospitals that do not submit occupational mix survey data. That section authorizes us to provide for exceptions and adjustments to the payment amounts under IPPS as the Secretary deems appropriate. We also indicated that we would address this issue in the FY 2008 IPPS proposed rule. We are soliciting comments and suggestions for a hospital-specific penalty for hospitals that do not submit occupational mix survey. In response to the FY 2007 IPPS proposed rule, some commenters suggested a 1-percent to 2-percent reduction in the hospital's wage index value or a set percentage of the standardized amount. Any penalty that we would determine for nonresponsive hospitals would apply to a future wage index, not the FY 2008 wage index. 4. Proposed 2007-2008 Occupational Mix Survey for the FY 2010 Wage Index As stated earlier, section 304(c) of Pub. L. 106-554 amended section 1886(d)(3)(E) of the Act to require CMS to collect data every 3 years on the occupational mix of employees for each short-term, acute care hospital participating in the Medicare program. We are currently using occupational mix survey data collected in 2006 in the FY 2007 IPPS. Since we implemented the 2006 survey, we received several public comments suggesting further improvements to the occupational mix survey instructions and definitions. Specifically, some commenters recommended that we include certain employees, such as surgical technicians and paramedics in the occupational mix adjustment. The commenters indicated that these occupations perform similar functions, and in some cases, are used as substitutes for nursing staff. Therefore, they recommended that CMS include these occupations with the nursing categories on the survey. (On the 2003 and 2006 surveys, these categories were included in the “All Other Occupations” category.) The commenters also recommended that CMS expand the list of cost centers for the survey to include additional cost centers that contain a significant number of nursing personnel. Some commenters suggested that CMS not collect occupational mix data for the “Registered Nurse” subcategories (that is, Management Personnel and Staff Nurse/Clinician). The commenters expressed concern that requiring the subcategories led to errors and inconsistencies in reporting, and added to the hospitals' collection burden. The commenters did not believe that this level of specificity significantly affects the adjustment. Therefore they recommended that CMS eliminate the RN subcategories. In addition, commenters recommended that CMS provide for a 1-year data collection period rather than a 6-month data collection period for the next survey collection. The commenters suggested that a 1-year data collection period would provide a better representation of a hospital's employment mix, which can vary during different times of the year. The commenters also indicated that a 1-year data collection period would allow hospitals to verify their wages and hours to year-end payroll reports and contractor invoices. In response to these suggestions we have modified the occupational mix survey. The revised 2007-2008 occupational mix survey will provide for the collection of hospital-specific wages and hours data for a 1-year prospective reporting period from July 1, 2007, through June 30, 2008, additional clarifications to the survey instructions, the elimination of the registered nurse subcategories, some refinements to the definitions of the occupational categories, and the inclusion of additional cost centers that typically provide nursing services. The revised 2007-2008 Medicare occupational mix survey will be applied beginning with the FY 2010 wage index. On February 2, 2007, we published a notice soliciting comments on the proposed revisions to the occupational mix survey (Form CMS-10079 (2006)) 
                        ( print page 24782)
                        (72 FR 5055). The comment period for the proposed survey ended on April 3, 2007. A final notice is expected to be published in the 
                        **Federal Register**
                         by July 1, 2007. D. Worksheet S-3 Wage Data for the Proposed FY 2008 Wage Index (If you choose to comment on issues in this section, please include the caption “Wage Data” at the beginning of your comment.) The proposed FY 2008 wage index values (to be effective for hospital discharges occurring on or after October 1, 2007, and before October 1, 2008) in section II.B. of the Addendum to this proposed rule are based on the data collected from the Medicare cost reports submitted by hospitals for cost reporting periods beginning in FY 2004 (the FY 2007 wage index was based on FY 2003 wage data). 1. Included Categories of Costs The proposed FY 2008 wage index includes the following categories of data associated with costs paid under the IPPS (as well as outpatient costs): Salaries and hours from short-term, acute care hospitals (including paid lunch hours and hours associated with military leave and jury duty).
                    Home office costs and hours.
                    Certain contract labor costs and hours (which includes direct patient care, certain top management, pharmacy, laboratory, and nonteaching physician Part A services).
                    Wage-related costs, including pensions and other deferred compensation costs. 2. Contract Labor for Indirect Patient Care Services In the FY 2003 IPPS final rule (67 FR 50022), we discussed the inclusion of contract labor cost in calculating the wage index. Our policy has evolved over the years with the increasing role of contract labor in meeting special personnel needs of hospitals. In response to suggestions that we further expand our definition of contract labor for the wage index, we indicated our intent to begin collecting data in future Medicare cost reports on the following overhead services: administrative and general (A&G); housekeeping; and dietary. We selected these three overhead services for consideration because they are provided at all hospitals, either directly or through contracts, and together they comprise about 60 percent of a hospital's overhead hours. Consistent with our consideration of contract A&G services, we also stated that we would begin collecting costs and hours data associated with other contract management services that would not be included on the cost report as overhead A&G and are not top management contracts (that is, the chief executive officer, chief financial officer, chief operating officer, and nurse administrator) that are included on Line 9 of Worksheet S-3, Part II. We revised the cost report, beginning October 1, 2003 (the FY 2004 cost report), to provide for the collection of cost and hours data for the four identified contract indirect patient care services. We added four new line items to Worksheet S-3, Part II: Line 9.03 (Contract management and administrative services); Line 22.01 (Contract A & G services); Line 26.01 (Contract housekeeping services); and Line 27.01 (Contract dietary services). We stated in the FY 2003 final rule that our decision on whether to include these costs in calculating the wage index would depend on our analyses of the data and public comments. The FY 2008 wage index, which is based on FY 2004 cost report data, is the first year that we can assess the impact of including these costs in the wage index. As part of the FY 2008 wage index desk review program, we required the fiscal intermediaries (or, if applicable, the MAC) to verify the accuracy of the data reported on the new Lines 9.03, 22.01, 26.01, and 27.01. After the completion of these reviews, some hospitals continued to fail our edits for reasonableness: 12 hospitals (0.3 percent) failed edits for Line 9.03; 130 hospitals (3.6 percent) failed edits for Line 22.01; 56 hospitals (1.6 percent) failed edits for Line 26.01; and 99 hospitals (2.8 percent) failed edits for Line 27.01. Many of these edit failures are for wage data that are not to be included in the wage index and will be excluded through the wage index calculation. That is, as specified in the cost reporting instructions in the Provider Reimbursement Manual, Part II, section 3605.2, if a hospital's ratio of excluded area hours (Lines 8 and 8.0) on Worksheet S-3, Part II to total adjusted hours is less than 15 percent, Lines 21 through 35 of Part II should not be completed by hospitals. In addition, some of the aberrant data will be resolved by the final rule through the correction process described in section III.K. of the preamble of this proposed rule. Nevertheless, we believe that the amount of aberrant data on these new line items is minimal and will have little impact on area wage index values. In addition, we have simulated the effect of including these wage data for contract indirect patient care services on the wage index. Under this simulation, we found that the resulting average hourly wage would not affect 3,231 hospitals (90.2 percent), would decrease for 121 hospitals (3.4 percent), and would increase for 229 hospitals (6.4 percent). Only one hospital would experience a decrease of greater than 1 percent (3 percent), and 19 hospitals would experience an increase of greater than 1 percent (the largest being 7.8 percent). At the labor market area level, we found that the resulting average hourly wage would not affect 316 areas (72.6 percent), would decrease for 28 areas (6.4 percent), and would increase for 91 areas (20.9 percent). No area, rural or urban, would experience an increase or decrease of greater than 0.6 percent in its wage index. We believe that the combined effect of including these costs in the wage index is negligible because the higher labor costs associated with contract management and A&G services are offset by the lower labor costs associated with contract housekeeping and dietary services. Public commenters have expressed interest in including in the wage index the costs and hours for contract management, A&G, housekeeping, and dietary services. We also believe that including a more comprehensive measure of area differences in the cost of labor will improve the accuracy of the wage index. For these reasons, we are proposing to include these contract services in the wage index, beginning with FY 2008. Although we invite public comment on whether we should revise a future cost report to collect contract labor data for the remaining indirect patient care cost centers on Worksheet S-3, Part II for possible inclusion in the wage index, we will consider these comments in the context of potential reforms of the IPPS wage index for FY 2009 and subsequent years. As indicated in section III.M. of the preamble of this proposed rule, section 106(b) of the MIEA-TRHCA (Pub. L. 109-432) requires the Secretary to consider a MedPAC study and nine specific aspects of the wage index in making one or more proposals for revisions in FY 2009. 3. Excluded Categories of Costs Consistent with the wage index methodology for FY 2007, the proposed wage index for FY 2008 also excludes the direct and overhead salaries and hours for services not subject to IPPS payment, such as SNF services, home health services, costs related to GME (teaching physicians and residents) and certified registered nurse anesthetists (CRNAs), and other subprovider components that are not paid under the IPPS. The proposed FY 2008 wage index 
                        ( print page 24783)
                        also excludes the salaries, hours, and wage-related costs of hospital-based rural health clinics (RHCs), and Federally qualified health centers (FQHCs) because Medicare pays for these costs outside of the IPPS (68 FR 45395). In addition, salaries, hours, and wage-related costs of CAHs are excluded from the wage index, for the reasons explained in the FY 2004 IPPS final rule (68 FR 45397). 4. Use of Wage Index Data by Providers Other Than Acute Care Hospitals under the IPPS Data collected for the IPPS wage index are also currently used to calculate wage indices applicable to other providers, such as SNFs, home health agencies, and hospices. In addition, they are used for prospective payments to IRFs, IPFs, and LTCHs, and for hospital outpatient services. We note that, in the IPPS rules, we do not address comments pertaining to the wage indices for non-IPPS providers. Such comments should be made in response to separate proposed rules for those providers. E. Verification of Worksheet S-3 Wage Data (If you choose to comment on this section, please include the caption “Wage Data” at the beginning of your comment.) The wage data for the proposed FY 2008 wage index were obtained from Worksheet S-3, Parts II and III of the FY 2004 Medicare cost reports. Instructions for completing the Worksheet S-3, Parts II and III are in the Provider Reimbursement Manual, Part I, sections 3605.2 and 3605.3. The data file used to construct the proposed wage index includes FY 2004 data submitted to us as of February 26, 2007 As in past years, we will perform an intensive review of the wage data, mostly through the use of edits designed to identify aberrant data. We asked our fiscal intermediaries/MACs to revise or verify data elements that resulted in specific edit failures. We identified and excluded 23 hospitals with data that was too aberrant to include in the proposed wage index, although if these data elements are corrected, we may include some of these providers in the FY 2008 final wage index. However, some unresolved data elements are included in the calculation of the proposed FY 2008 wage index. We instructed fiscal intermediaries/MACs to complete their data verification of questionable data elements and to transmit any changes to the wage data no later than April 13, 2007. We believe all unresolved data elements will be resolved by the date the final rule is issued. The revised data will be reflected in the final rule. In constructing the proposed FY 2008 wage index, we include the wage data for facilities that were IPPS hospitals in FY 2004, even for those facilities that have since terminated their participation in the program as hospitals, as long as those data do not fail any of our edits for reasonableness. We believe that including the wage data for these hospitals is, in general, appropriate to reflect the economic conditions in the various labor market areas during the relevant past period. However, we exclude the wage data for CAHs as discussed in 68 FR 45397. For this proposed rule, we removed 18 hospitals that converted to CAH status between February 17, 2006, the cut-off date for CAH exclusion from the FY 2007 wage index, and February 16, 2007, the cut-off date for CAH exclusion from the FY 2008 wage index. After removing hospitals with aberrant data and hospitals that converted to CAH status, the proposed FY 2008 wage index is calculated based on 3,581 hospitals. F. Wage Index for Multicampus Hospitals (If you choose to comment on issues in this section, please include the caption “Multicampus Hospitals” at the beginning of your comment.) As discussed earlier under section III.B. of this preamble, effective October 1, 2004, for the IPPS, CMS implemented new labor market areas based on the CBSA definitions of MSAs. As a result of the new labor market areas, there are multicampus hospitals previously located in a single MSA that are now located in more than one CBSA. A multicampus hospital is a single integrated institution. For this reason, the multicampus hospital has one provider number and submits a single cost report that combines the total wages and hours of each of its campuses. When campuses of a multicampus hospital are located in the same CBSA, the wages and hours for the entire institution are included in the calculation of the wage index for that labor market area and there is no need to separate the data by campus. However, when a multicampus hospital has campuses located in different labor market areas, wages and hours are reported in a single CBSA even though the hospital's staff is working at campuses in more than one labor market area. The wage data are reported in the labor market area of the hospital campus associated with the provider number. Wages and hours are not reported separately for each campus and no data from the multicampus hospital are used in determining the wage index for the labor market area(s) where the other campus(es) are located. Under § 412.64(b)(5) of our regulations, the wage-adjusted standardized amount is based on geographic location of the hospital facility at which the discharge occurred. Therefore, the wage index for each hospital campus used to make the IPPS payment is based on its geographic location, while the wage data from all of the campuses, including those that may be located in a different geographic area, are applied to one area only. We have received inquiries from several hospitals suggesting that we should adopt a policy that results in an allocation of a multicampus hospital's wages and hours across the different labor market areas where its campuses are located. The wage index was developed to adjust the IPPS standardized amount to reflect area differences in hospital wage levels in the hospital's geographic area compared to the national hospital wage level as required under section 1886(d)(3)(E) of the Act. Although we acknowledge that reporting the wage data into a single labor market area when individual campuses of a multicampus hospital are located in different labor market areas may not allocate wage data with exact precision, the Medicare cost report, in its current form, does not enable a multicampus hospital to separately report its costs by location. The fact that a multicampus hospital submits a single cost report reflects that it is an integrated institution with one accounting structure. Nevertheless, we agree with the comments brought to our attention that we should consider a policy that allocates a multicampus hospital's wages and hours among the different labor market areas where it is located. That is, rather than giving 100 percent of the hospital's wage data to the labor market area associated with its provider number, we believe that an allocation of its wage data should be made to each campus. We considered three alternative methods of apportionment: beds, discharges, or FTE staff. A hospital's number of discharges can fluctuate from year to year and may be an unstable data source to use in allocating a hospital's wages and hours among the different campuses. Alternatively, while a hospital's number of beds is a more static number, it likely does not correlate well with how a hospital incurs its wage costs. Furthermore, neither of these numbers is available on a campus-specific basis in Medicare's data systems. (While an individual 
                        ( print page 24784)
                        campus of a multicampus hospital located in a different labor market area than the remainder of the institution is required to indicate a suffix on its provider number when submitting a claim in order to receive payment using the wage index for its geographic location, the suffix is only used by the fiscal intermediary (or, if applicable, the MAC) and is not retained in Medicare's historical data files that we use to determine IPPS rates). Given the unavailability of beds and discharges and their respective drawbacks for allocating wages and hours across multiple campuses, we are proposing to apportion wages and hours for each campus of a multicampus hospital based on FTE staff. For example, a multicampus hospital may have three campuses located in two different labor market areas. Campuses A and B are located in labor market area 1 and have 50 and 25 FTEs, respectively. Campus C is located in labor market area 2 and has an additional 25 FTEs. Therefore, 75 percent of the hospital's FTEs work in labor market 1 and 25 percent in labor market area 2. Under the proposed policy, we would apportion 75 percent of the hospital's occupational mix adjusted total salaries, wage-related costs and hours to labor market 1 and 25 percent to labor market 2. We believe that the number of FTEs will provide the best method of apportioning wages and hours among the different campuses, thereby allowing the apportioned wage data to be included in each geographic area where the hospital has employees working. This proposed policy requires the identification of all multicampus hospitals located in more than one CBSA, the county, State, and zip code of each campus, and the campus-specific number of FTEs. Based on our comprehensive interactions with our fiscal intermediaries since adopting the revised labor market areas beginning in FY 2005, we are only aware of three multicampus hospitals that are located in more than one labor market area. We are beginning the process to make updates and refinements to the cost report for the future. We are currently planning to add additional lines to Worksheet S-2 of the cost report that will allow a multicampus hospital to report the locations of its different campuses (county, State, and zip code) and number of FTE staff by location so this information would become part of the cost report submission process. The effective date of the revised cost report is not expected until FY 2009. Therefore, we would not have data from multicampus hospitals under our normal wage data collection process to be able to allocate wages to each labor market area by FTEs until at least the FY 2013 wage index. In the interim, we will collect this information from multicampus hospitals on a small survey form through our fiscal intermediaries/MACs as part of the wage index desk review process beginning with the FY 2009 wage index. We will not be able to apply this policy to the FY 2008 wage index unless we have this information from multicampus hospitals prior to the close of the comment period on this proposed rule. Therefore, for the FY 2008 wage index, multicampus hospitals with campuses located in more than one geographic area should submit the information during the comment period on this proposed rule for the county, State, and zip code of its campuses, and the FTE number, including contract labor, per campus along with supporting documentation to: Centers for Medicare & Medicaid Services, Wage Index Team, C4-08-06, 7500 Security Boulevard, Baltimore, Maryland 21244, Attn: Kathy Ellingson. The hospitals should submit data from their FY 2004 cost reporting period to match the same data that will be used for the FY 2008 wage index. However, if unavailable, the hospital may submit the data for a subsequent cost reporting period that is closest to the FY 2004 reporting period that provides the information in order to apportion the hospital's wage data among its campuses. These data will enable CMS to apportion the wages and hours of the multicampus hospital among its different campuses for use in the FY 2008 wage index calculations should this proposal become final. As stated earlier, we are only aware of three hospitals that would be affected by this proposed information collection request. As stipulated under 5 CFR 1320.3(c)(4), the proposed information collection request is exempt from the Paperwork Reduction Act (PRA) as it does not affect 10 or more persons within a 12-month period. However, if during the IPPS rule comment period, we determine the number of affected persons surpasses the threshold of 10 as specified in 5 CFR 1320.3(c)(4), we will not adopt the policy until FY 2009 in order for us to seek the requisite approval from OMB under the PRA. G. Computation of the Proposed FY 2008 Unadjusted Wage Index (If you choose to comment on issues in this section, please include the caption “Wage Index” at the beginning of your comment.) 1. Method for Computing the Proposed FY 2008 Unadjusted Wage Index The method used to compute the proposed FY 2008 wage index without an occupational mix adjustment follows: *Step 1*
                        —As noted above, we based the proposed FY 2008 wage index on wage data reported on the FY 2004 Medicare cost reports. We gathered data from each of the non-Federal, short-term, acute care hospitals for which data were reported on the Worksheet S-3, Parts II and III of the Medicare cost report for the hospital's cost reporting period beginning on or after October 1, 2003, and before October 1, 2004. In addition, we include data from some hospitals that had cost reporting periods beginning before October 2003 and reported a cost reporting period covering all of FY 2004. These data are included because no other data from these hospitals would be available for the cost reporting period described above, and because particular labor market areas might be affected due to the omission of these hospitals. However, we generally describe these wage data as FY 2004 data. We note that, if a hospital had more than one cost reporting period beginning during FY 2004 (for example, a hospital had two short cost reporting periods beginning on or after October 1, 2003, and before October 1, 2004), we include wage data from only one of the cost reporting periods, the longer, in the wage index calculation. If there was more than one cost reporting period and the periods were equal in length, we include the wage data from the later period in the wage index calculation. *Step 2*
                        —Salaries—The method used to compute a hospital's average hourly wage excludes certain costs that are not paid under the IPPS. In calculating a hospital's average salaries plus wage-related costs, we subtract from Line 1 (total salaries) the GME and CRNA costs reported on Lines 2, 4.01, 6, and 6.01, the Part B salaries reported on Lines 3, 5 and 5.01, home office salaries reported on Line 7, and exclude salaries reported on Lines 8 and 8.01 (that is, direct salaries attributable to SNF services, home health services, and other subprovider components not subject to the IPPS). We also subtract from Line 1 the salaries for which no hours were reported. To determine total salaries plus wage-related costs, we add to the net hospital salaries the costs of contract labor for direct patient care, certain top management, pharmacy, laboratory, and nonteaching physician Part A services (Lines 9 and 10), home office salaries and wage-related costs reported by the 
                        ( print page 24785)
                        hospital on Lines 11 and 12, and nonexcluded area wage-related costs (Lines 13, 14, and 18). We note that contract labor and home office salaries for which no corresponding hours are reported are not included. In addition, wage-related costs for nonteaching physician Part A employees (Line 18) are excluded if no corresponding salaries are reported for those employees on Line 4. *Step 3*
                        —Hours—With the exception of wage-related costs, for which there are no associated hours, we compute total hours using the same methods as described for salaries in Step 2. *Step 4*
                        —For each hospital reporting both total overhead salaries and total overhead hours greater than zero, we then allocate overhead costs to areas of the hospital excluded from the wage index calculation. First, we determine the ratio of excluded area hours (sum of Lines 8 and 8.01 of Worksheet S-3, Part II) to revised total hours (Line 1 minus the sum of Part II, Lines 2, 3, 4.01, 5, 5.01, 6, 6.01, 7, and Part III, Line 13 of Worksheet S-3). We then compute the amounts of overhead salaries and hours to be allocated to excluded areas by multiplying the above ratio by the total overhead salaries and hours reported on Line 13 of Worksheet S-3, Part III. Next, we compute the amounts of overhead wage-related costs to be allocated to excluded areas using three steps: (1) we determine the ratio of overhead hours (Part III, Line 13) to revised hours (Line 1 minus the sum of Lines 2, 3, 4.01, 5, 5.01, 6, 6.01, 7, 8, and 8.01); (2) we compute overhead wage-related costs by multiplying the overhead hours ratio by wage-related costs reported on Part II, Lines 13, 14, and 18; and (3) we multiply the computed overhead wage-related costs by the above excluded area hours ratio. Finally, we subtract the computed overhead salaries, wage-related costs, and hours associated with excluded areas from the total salaries (plus wage-related costs) and hours derived in Steps 2 and 3. *Step 5*
                        —For each hospital, we adjust the total salaries plus wage-related costs to a common period to determine total adjusted salaries plus wage-related costs. To make the wage adjustment, we estimate the percentage change in the employment cost index (ECI) for compensation for each 30-day increment from October 14, 2003, through April 15, 2005, for private industry hospital workers from the BLS' 
                        *Compensation and Working Conditions*. We use the ECI because it reflects the price increase associated with total compensation (salaries plus fringes) rather than just the increase in salaries. In addition, the ECI includes managers as well as other hospital workers. This methodology to compute the monthly update factors uses actual quarterly ECI data and assures that the update factors match the actual quarterly and annual percent changes. We also note that, since April 2006 with the publication of March 2006 data, the BLS' ECI uses a different classification system, the North American Industrial Classification System (NAICS), instead of the Standard Industrial Codes (SICs), which no longer exist. We have consistently used the ECI as the data source for our wages and salaries and other price proxies in the IPPS market basket and are not proposing to make any changes to the usage at this time. However, we are soliciting comments on our continued use of the BLS ECI data in light of the BLS change in system usage to the NAICS-based ECI. The factors used to adjust the hospital's data were based on the midpoint of the cost reporting period, as indicated below. Midpoint of Cost Reporting Period
After
Before
Adjustment Factor10/14/2003
11/15/2003
1.0574311/14/2003
12/15/2003
1.0535512/14/2003
01/15/2004
1.0496401/14/2004
02/15/2004
1.0457802/14/2004
03/15/2004
1.0419803/14/2004
04/15/2004
1.0383004/14/2004
05/15/2004
1.0348205/14/2004
06/15/2004
1.0315306/14/2004
07/15/2004
1.0282107/14/2004
08/15/2004
1.0246608/14/2004
09/15/2004
1.0208609/14/2004
10/15/2004
1.0170510/14/2004
11/15/2004
1.0134411/14/2004
12/15/2004
1.0100312/14/2004
01/15/2005
1.0067101/14/2005
02/15/2005
1.0033602/14/2005
03/15/2005
1.0000003/14/2005
04/15/2005
0.99663
 For example, the midpoint of a cost reporting period beginning January 1, 2004, and ending December 31, 2004, is June 30, 2004. An adjustment factor of 1.02821 would be applied to the wages of a hospital with such a cost reporting period. In addition, for the data for any cost reporting period that began in FY 2004 and covered a period of less than 360 days or more than 370 days, we annualize the data to reflect a 1-year cost report. Dividing the data by the number of days in the cost report and then multiplying the results by 365 accomplishes annualization. *Step 6*
                        —Each hospital is assigned to its appropriate urban or rural labor market area before any reclassifications under section 1886(d)(8)(B), section 1886(d)(8)(E), or section 1886(d)(10) of the Act. Within each urban or rural labor market area, we add the total adjusted salaries plus wage-related costs obtained in Step 5 for all hospitals in that area to determine the total adjusted salaries plus wage-related costs for the labor market area. *Step 7*
                        —We divide the total adjusted salaries plus wage-related costs obtained under both methods in Step 6 by the sum of the corresponding total hours (from Step 4) for all hospitals in each labor market area to determine an average hourly wage for the area. *Step 8*
                        —We add the total adjusted salaries plus wage-related costs obtained in Step 5 for all hospitals in the Nation and then divide the sum by the national 
                        ( print page 24786)
                        sum of total hours from Step 4 to arrive at a national average hourly wage. Using the data as described above, the proposed national average hourly wage is $30.9298. *Step 9*
                        —For each urban or rural labor market area, we calculate the hospital wage index value, unadjusted for occupational mix, by dividing the area average hourly wage obtained in Step 7 by the national average hourly wage computed in Step 8. *Step 10*
                        —Following the process set forth above, we develop a separate Puerto Rico-specific wage index for purposes of adjusting the Puerto Rico standardized amounts. (The national Puerto Rico standardized amount is adjusted by a wage index calculated for all Puerto Rico labor market areas based on the national average hourly wage as described above.) We add the total adjusted salaries plus wage-related costs (as calculated in Step 5) for all hospitals in Puerto Rico and divide the sum by the total hours for Puerto Rico (as calculated in Step 4) to arrive at an overall proposed average hourly wage of $13.4729 for Puerto Rico. For each labor market area in Puerto Rico, we calculate the Puerto Rico-specific wage index value by dividing the area average hourly wage (as calculated in Step 7) by the overall Puerto Rico average hourly wage. *Step 11*
                        —Section 4410 of Pub. L. 105-33 provides that, for discharges on or after October 1, 1997, the area wage index applicable to any hospital that is located in an urban area of a State may not be less than the area wage index applicable to hospitals located in rural areas in that State. For FY 2008, this change affects 239 hospitals in 65 urban areas. The areas affected by this provision are identified by a footnote in Table 4A in the Addendum of this proposed rule. 2. Expiration of the Imputed Floor (If you choose to comment on issues in this section, please include the caption “Imputed Floor” at the beginning of your comment.) Section 4410 of Pub. L. 105-33 provides that the area wage index applicable to any hospital that is located in an urban area of a State may not be less than the area wage index applicable to hospitals located in rural areas of that State (“the rural floor”). There are two States that have no rural areas (New Jersey and Rhode Island) and one State that has rural areas but no IPPS hospitals located in the rural areas of the State (Massachusetts). In the FY 2005 IPPS final rule (69 FR 49109), we adopted an “imputed” floor measure to address the concern that hospitals in all-urban States were disadvantaged by the absence of rural areas, because there is no floor within the State. We limited application of the policy to FYs 2005, 2006, and 2007 and indicated our intent to make additional changes to the policy or eliminate it for fiscal years after FY 2007. In FY 2008, the rural floor will apply to 239 hospitals in 25 States. If the imputed rural floor were to continue into FY 2008, it would apply to an additional 28 hospitals in New Jersey. In FY 2007, 40 hospitals in 10 urban areas received higher wage indices due to the imputed floor policy: Massachusetts (10 hospitals in 2 areas); New Jersey (30 hospitals in 8 areas); Rhode Island (no areas and no hospitals). In Massachusetts, the imputed rural floor will no longer apply even if it were to continue because one hospital acquired rural status under § 412.103. We note that if a State has a hospital reclassified as rural under § 412.103, the State will be considered to have IPPS hospitals located in rural areas because, in this case, the reclassified hospital is treated as being located in a rural area in accordance with section 1886(d)(8)(E) of the Act. This policy also accords with how we defined an “all-urban State” under § 412.64(h)(5) of the regulations, which specifies that “A State with rural areas and with hospitals reclassified as rural under § 412.103 is not an all-urban State.” Therefore, in the case where a State has no hospitals that are geographically located in its rural areas, and one or more hospitals in the State are reclassified as rural under § 412.103, the data for the reclassified rural hospitals will be used to set the rural floor for the State until a new geographically located rural hospital opens and data are available from that hospital (as noted above, 4 years later) to compute the rural floor. We are proposing to discontinue the imputed floor policy after the FY 2007 wage index. After further considering the issue, we do not believe that it is necessary to have an “imputed” rural floor in States that have no rural areas or no rural hospitals. As discussed above, the imputed floor would not apply to two of the three States: it is not necessary for Rhode Island and is no longer necessary for Massachusetts. In addition, the imputed rural floor methodology creates a disadvantage in the application of the wage index to hospitals in States with rural hospitals but no urban hospitals receiving the rural floor. Because the application of a rural floor requires a transfer of payments from hospitals in States with rural hospitals but where the rural floor is not applied to hospitals in States where either a rural or imputed floor is applied, we believe the policy should apply only when required by statute. Thus, only States with both rural areas and hospitals located in such areas (including any hospital reclassified under § 412.103) would benefit from the rural floor, as required by Congress. For all of the reasons stated above, we are not proposing to continue the imputed rural floor. Nevertheless, we recognize that we would still need a policy for determining the rural wage index when a new IPPS hospital opens in a State that has rural areas, but no IPPS hospitals. There is a lag between the time a hospital opens or becomes an IPPS provider and when the hospital's cost report wage data are available to include in calculating the area wage index. For example, if a hospital files its first Medicare cost report as an IPPS provider with a beginning date of January 1, 2007, and an ending date of December 31, 2007, the hospital's FY 2007 wage data would not be included in the wage index until the FY 2011 IPPS update. Therefore, when a rural IPPS hospital opens in a State that has rural areas, but no wage data are available to calculate a rural wage index, we are proposing to apply a wage index to that hospital using the same methodology that we currently use for home health and other post-acute care providers in rural Massachusetts (71 FR 65906). That is, we would use the unweighted average of the wage indices from all CBSAs that are contiguous to the rural counties of the State. (We define contiguous as sharing a border.) We would apply the wage index calculated above until the new IPPS hospital files a cost report for the base year that is used in calculating the wage index. (In the above example, the rural hospital's wage index would be calculated for FYs 2008, 2009, and 2010 using urban area data.) Further, under section 4410 of Pub. L. 105-33, the wage index for this rural hospital would become the State's rural floor. As stated above, however, if a State has rural areas, and a hospital is reclassified as rural under § 412.103, then there would be no need to apply the above policy. The reclassified hospital would set the rural floor, and the wage data of the newly opened rural hospitals would be included in the calculation of the wage index of the rural area only once their wage data correlated with the survey year used to establish the wage index (4 years after wage data are reported). 3. CAHs Reverting Back to IPPS Hospitals and Raising the Rural Floor (If you choose to comment on issues in this section, please include the 
                        ( print page 24787)
                        caption “Rural Floor” at the beginning of your comment.) Medicare payments to CAHs are based on 101 percent of reasonable costs and are generally greater than the payments Medicare would make if the same hospitals were paid under the IPPS, which pays hospitals a fixed rate per discharge. Also, as a CAH, a hospital is guaranteed to recover is costs, while under the IPPS, it is not. We are aware of a situation where two rural hospitals in a State are considering converting from CAH status back to IPPS even though they continue to be CAH eligible. The CAHs would convert back to IPPS even though it would not directly benefit them. As IPPS providers, the hospitals' wage data would eventually set the rural floor for the State (that is, in 4 years when the hospitals' first IPPS cost reports would be included in a base year used in calculating the State's rural wage index). In this case, we are concerned that these hospitals are converting solely in order to take advantage of the rural floor provisions for the other hospitals in the State, but not for any reasons that are intrinsic to the two specific hospitals. Because the hospitals' wage levels are higher than most, if not all, of the urban IPPS hospitals in the State, including one hospital in the State that acquired rural status under § 412.103, the wage indices for most, if not all, of the State's urban hospitals would increase as a result of the rural floor provision if the CAHs convert to IPPS status. Such an arrangement would increase payments to the hospitals in the State at the expense of every other IPPS hospital in the nation. The two rural hospitals that are currently CAHs were last paid under the IPPS in FY 2003. We simulated the effect of allowing these two hospitals to set the State's rural floor with the same data used to calculate the FY 2003 wage index as would occur in FY 2011 if these hospitals were to convert to IPPS status in FY 2007 and no other hospitals were to open in the rural area of the State. Based on this simulation, all hospitals except two would be paid using the rural floor, increasing payments in excess of $220 million for a single year. If the average hourly wage for these two hospitals increased faster than the national average, the increase in payments would be even higher. It seems likely that over 5 years, Medicare payments to hospitals in this State would increase by more than $1 billion. Again, these increased payments would be budget neutralized at the expense of all other IPPS hospitals nationwide. Given that the hospitals continue to be eligible for the higher paying CAH status, we are concerned that hospitals are converting to IPPS status solely in order to raise the State's rural floor. We are concerned about the propriety of such an arrangement if the intent is to manipulate the State's area wage index values to receive higher Medicare reimbursement. Section 1886(d)(5)(I)(i) of the Act allows the Secretary the authority to “provide by regulation for such other exceptions and adjustments * * * as the Secretary deems appropriate.” We are soliciting comments regarding whether it would be appropriate for CMS to establish a policy under this authority to preclude the arrangement described above and, if so, how such a policy would be applied. We believe that any policy should only apply to a CAH that continues to meet the CAH certification requirements and should not apply if a CAH no longer met those requirements and converted to an IPPS provider. 4. Application of Rural Floor Budget Neutrality Section 4410 of the Balanced Budget Act of 1997 (BBA) established the rural floor by requiring that the wage index for a hospital in any urban area cannot be less than the area wage index determined for the State's rural area. Since FY 1998, we have implemented the budget neutrality requirement of this provision by adjusting the standardized amounts. A discussion and illustration of the calculation of the standardized amounts is shown in the Addendum of every year's IPPS rule.[16] In this proposed rule, we are proposing a prospective change to how budget neutrality is applied to implement the rural floor for FY 2008 and subsequent years. Section 4410(a) of the BBA indicates that “the area wage index applicable * * * to any hospital which is not located in a rural area'may not be less than the area wage index applicable * * * to hospitals located in rural areas in the State in which the hospital is located.” Section 4410(b) of the BBA imposes the budget neutrality requirement and states that the Secretary shall “adjust the area wage index referred to in subsection (a) for hospitals not described in such subsection.” One possible interpretation of section 4410(b) of the BBA is that the budget neutrality adjustment would be applied only to those hospitals that do not receive the rural floor. In other words, the wage index of an urban hospital subject to the rural floor would be increased to the level of the rural wage index in the same State, but would not be adjusted for budget neutrality. Thus, urban hospitals receiving the rural floor would receive a higher wage index than the rural hospitals within the same State (because rural floor hospitals would not be subject to budget neutrality, whereas rural hospitals would be). We believe such a reading would not be in accordance with Congressional intent, which was to set a floor for urban hospitals, not to pay urban hospitals a wage index higher than the wage index applicable to rural hospitals. In order to avoid the apparent contradiction between raising an urban hospital's wage index to the rural floor and not applying budget neutrality to its wage index, we also believe the statute could be read to allow an iterative calculation of budget neutrality and wage indices. Under such iterative calculations (consistent with section 4410(a) of the BBA), we would raise the wage index for urban hospitals to the level of the pre-budget neutrality rural wage index. Consistent with section 4410(b) of the BBA, we would adjust the wage index for all nonrural floor hospitals to achieve budget neutrality. However, such an adjustment would result in an urban hospital that would receive the rural floor having a higher wage index than a rural hospital in the same State. Therefore, we would then decrease wage indices for the rural floor hospitals so they are equal to the adjusted rural wage index in the same State. At this point, payments would be less in the aggregate than they were prior to applying the rural floor. Accordingly, a new budget neutrality adjustment would have to be calculated to raise the wage indices and total payments for rural hospitals and nonrural floor urban hospitals. The rural wage index would now be higher than the wage index for the rural floor hospitals in the same State. Therefore, the wage index for rural floor hospitals would then be increased again to the level of the State's rural wage index, leading to budget neutrality being recalculated again, the wage index reduced for rural floor hospitals, and so forth until the wage index and the budget neutrality adjustment stabilize. We have determined that the iterative method is substantively equivalent to 
                        ( print page 24788)
                        simply adjusting all area wage indices by a uniform percentage. We have performed the iterative calculation using provider-level data based on FY 2007 MedPAR data and the first half of FY 2007 wage index data. Using such data, we determined that the iterative method results in the same final wage indices through four decimal places that would result if a uniform budget neutrality factor were applied to all hospitals' wage indices. Furthermore, an iterative method, which requires adjusting only the wage index values of nonrural floor providers, reassigning the lowered rural floor value to rural floor providers, and reiterating the budget neutrality factor applied to the nonrural floor providers would require an excessive number of iterations and computer processing, which is not necessary if we simply apply a uniform budget neutrality adjustment to all wage index values. The latter method is accomplished more quickly, is less complex, and arrives at the same final wage index values. Because the IPPS schedule is relatively condensed, with a proposed rule issued in April, a 60-day comment period until June, and then only 2 months to analyze comments, respond to them, determine final policies and calculate final rates prior to the August 1 publication, we believe it would not be practical to require such multiple layers of calculations, when a uniform adjustment would produce substantively identical results. Therefore, we are proposing to implement the rural floor budget neutrality requirement by applying a uniform budget neutrality adjustment to all hospital wage indices rather than the more complicated iterative process illustrated below. The following hypothetical example, which includes a series of nine iterations, illustrates how the iterative process works. The example assumes three IPPS hospitals in one State. Hospital A is rural and Hospitals B and C are urban. Pre-Floor Wage Index
Hospital A
Hospital B
Hospital C
TotalWage Index
0.9500
1.1700
0.8600Relative Weights
100
200
150Location
Rural
Urban
UrbanStandardized Amounts
$1,000
$1,000
$1,000Payments
$95,000
$234,000
$129,000
$458,000**Note:**
                             Hospital C is urban and has a lower wage index than Hospital A which is rural.
 Post-Floor Wage Index; Pre-Budget Neutrality Hospital A
Hospital B
Hospital C
TotalWage Index
0.9500
1.1700
0.9500Relative Weights
100
200
150Location
Rural
Urban
UrbanStandardized Amounts
$1,000
$1,000
$1,000Payments
$95,000
$234,000
$142,500
$471,500**Note:**
                             Hospital C's wage index is raised to the same level as Hospital A.
 Post Floor—Budget Neutrality Process *Iteration 1:* *Step 1:*
                         Apply budget neutrality to Hospital A and Hospital B. Hospital A
Hospital B
Hospital C
TotalWage Index
0.9110
1.1220
0.9500
BN Factor.Relative Weights
100
200
150
0.95897.Location
Rural
Urban
Urban
Target.Standardized Amounts
$1,000
$1,000
$1,000
$458,000.Payments
$91,102
$224,398
$142,500
$458,000.
 *Step 2:*
                         Reduce Hospital C's wage index to Hospital A's level. Hospital A
Hospital B
Hospital C
TotalWage Index
0.9110
1.1220
0.9110
BN Factor.Relative Weights
100
200
150
0.95897.Location
Rural
Urban
Urban
Target.Standardized Amounts
$1,000
$1,000
$1,000
$458,000.Payments
$91,102
$224,398
$136,653
$452,153.
 
 
 *Iteration 2:* *Step 1:*
                         Apply budget neutrality to Hospital A and Hospital B. Hospital A
Hospital B
Hospital C
TotalWage Index
0.9279
1.1428
0.9110
BN Factor.Relative Weights
100
200
150
1.01853.Location
Rural
Urban
Urban
Target.Standardized Amounts
$1,000
$1,000
$1,000
$458,000.Payments
$92,790
$228,557
$136,653
$458,000.
 *Step 2:*
                         Increase Hospital C's wage index to Hospital A's level. Hospital A
Hospital B
Hospital C
TotalWage Index
0.9279
1.1428
0.9279
BN Factor.Relative Weights
100
200
150
1.01854.Location
Rural
Urban
Urban
Target.Standardized Amounts
$1,000
$1,000
$1,000
$458,000.Payments
$92,790
$228,557
$139,185
$460,532.
 *Iteration 3:* *Step 1:*
                         Apply budget neutrality to Hospital A and Hospital B. Hospital A
Hospital B
Hospital C
TotalWage Index
0.9206
1.1338
0.9279
BN Factor.Relative Weights
100
200
150
0.99212.Location
Rural
Urban
Urban
Target.Standardized Amounts
$1,000
$1,000
$1,000
$458,000.Payments
$92,059
$226,756
$139,185
$458,000.
 *Step 2:*
                         Reduce Hospital C's wage index to Hospital A's level. Hospital A
Hospital B
Hospital C
TotalWage Index
0.9206
1.1338
0.9206
BN Factor.Relative Weights
100
200
150
0.99212.Location
Rural
Urban
Urban
Target.Standardized Amounts
$1,000
$1,000
$1,000
$458,000.Payments
$92,059
$226,756
$138,088
$456,903.
 *Iteration 4:* *Step 1:*
                         Apply budget neutrality to Hospital A and Hospital B. Hospital A
Hospital B
Hospital C
TotalWage Index
0.9238
1.1377
0.9206
BN Factor.Relative Weights
100
200
150
1.00344.Location
Rural
Urban
Urban
Target.Standardized Amounts
$1,000
$1,000
$1,000
$458,000.Payments
$92,376
$227,536
$138,088
$458,000.
 *Step 2:*
                         Increase Hospital C's wage index to Hospital A's level. Hospital A
Hospital B
Hospital C
TotalWage Index
0.9238
1.1377
0.9238
BN Factor.Relative Weights
100
200
150
1.00344.Location
Rural
Urban
Urban
Target.Standardized Amounts
$1,000
$1,000
$1,000
$458,000.Payments
$92,376
$227,536
$138,563
$458,475.
 
 
 *Iteration 5:* *Step 1:*
                         Apply budget neutrality to Hospital A and Hospital B. Hospital A
Hospital B
Hospital C
TotalWage Index
0.9224
1.1360
0.9238
BN Factor.Relative Weights
100
200
150
0.99852.Location
Rural
Urban
Urban
Target.Standardized Amounts
$1,000
$1,000
$1,000
$458,000.Payments
$92,238
$227,198
$138,563
$458,000.
 *Step 2:*
                         Reduce Hospital C's wage index to Hospital A's level. Hospital A
Hospital B
Hospital C
TotalWage Index
0.9224
1.1360
0.9224
BN Factor.Relative Weights
100
200
150
0.99852.Location
Rural
Urban
Urban
Target.Standardized Amounts
$1,000
$1,000
$1,000
$458,000.Payments
$92,238
$227,198
$138,358
$457,794.
 *Iteration 6:* *Step 1:*
                         Apply budget neutrality to Hospital A and Hospital B. Hospital A
Hospital B
Hospital C
TotalWage Index
0.9230
1.1367
0.9224
BN Factor.Relative Weights
100
200
150
1.00064.Location
Rural
Urban
Urban
Target.Standardized Amounts
$1,000
$1,000
$1,000
$458,000.Payments
$92,298
$227,344
$138,358
$458,000.
 *Step 2:*
                         Increase Hospital C's wage index to Hospital A's level. Hospital A
Hospital B
Hospital C
TotalWage Index
0.9230
1.1367
0.9230
BN Factor.Relative Weights
100
200
150
1.00064.Location
Rural
Urban
Urban
Target.Standardized Amounts
$1,000
$1,000
$1,000
$458,000.Payments
$92,298
$227,344
$138,447
$458,089.
 *Iteration 7:* *Step 1:*
                         Apply budget neutrality to Hospital A and Hospital B. Hospital A
Hospital B
Hospital C
TotalWage Index
0.9227
1.1364
0.9230
BN Factor.Relative Weights
100
200
150
0.99972.Location
Rural
Urban
Urban
Target.Standardized Amounts
$1,000
$1,000
$1,000
$458,000.Payments
$92,272
$227,281
$138,447
$458,000.
 Step 2: Reduce Hospital C's wage index to Hospital A's level. Hospital A
Hospital B
Hospital C
TotalWage Index
0.9227
1.1364
0.9227
BN Factor.Relative Weights
100
200
150
0.99972.Location
Rural
Urban
Urban
Target.Standardized Amounts
$1,000
$1,000
$1,000
$458,000.Payments
$92,272
$227,281
$138,408
$457,961.
 
 
 *Iteration 8:* *Step 1:*
                         Apply budget neutrality to Hospital A and Hospital B. Hospital A
Hospital B
Hospital C
TotalWage Index
0.9228
1.1365
0.9227
BN Factor.Relative Weights
100
200
150
1.00012.Location
Rural
Urban
Urban
Target.Standardized Amounts
$1,000
$1,000
$1,000
$458,000.Payments
$92,283
$227,308
$138,408
$458,000.
 *Step 2:*
                         Increase Hospital C's wage index to Hospital A's level. Hospital A
Hospital B
Hospital C
TotalWage Index
0.9228
1.1365
0.9228
BN Factor.Relative Weights
100
200
150
1.00012.Location
Rural
Urban
Urban
Target.Standardized Amounts
$1,000
$1,000
$1,000
$458,000.Payments
$92,283
$227,308
$138,425
$458,016.
 *Iteration 9:* *Step 1:*
                         Apply budget neutrality to Hospital A and Hospital B. Hospital A
Hospital B
Hospital C
TotalWage Index
0.9228
1.1365
0.9228
BN Factor.Relative Weights
100
200
150
0.99995.Location
Rural
Urban
Urban
Target.Standardized Amounts
$1,000
$1,000
$1,000
$458,000.Payments
$92,279
$227,297
$138,425
$458,000.
 In the example above, the wage indices are shown only to the 4th decimal place even though they are not rounded. However, the actual wage indices that we calculate for the IPPS are rounded to 4 decimal places. In the 9th and final iteration of the budget neutrality adjustment shown above, there was no change to the wage indices through the 4th decimal place relative to the 8th iteration. Therefore, because the wage indices stopped changing, we could not obtain further precision in the budget neutrality and wage index calculations in the example shown above with further iterations. We note that the example above produces the same result as simply applying a uniform adjustment to hospital wage indices. Using the same data as the above hypothetical example, we show this result below: Pre-Floor Wage Index
Hospital A
Hospital B
Hospital C
TotalWage Index
0.9500
1.1700
0.8600Relative Weights
100
200
150Location
Rural
Urban
UrbanStandardized Amounts
$1,000
$1,000
$1,000Payments
$95,000
$234,000
$129,000
$458,000**Note:**
                             Hospital C is urban and has a lower wage index than Hospital A which is rural.
 Post-Floor Wage Index; Pre-Budget Neutrality Hospital A
Hospital B
Hospital C
TotalWage Index
0.9500
1.1700
0.9500Relative Weights
100
200
150Location
Rural
Urban
UrbanStandardized Amounts
$1,000
$1,000
$1,000Payments
$95,000
$234,000
$142,500
$471,500**Note:**
                             Hospital C's wage index is raised to the same level as Hospital A.
 
 
 Post Floor—Budget Neutrality Hospital A
Hospital B
Hospital C
TotalWage Index
0.9228
1.1365
0.9228
BN FactorRelative Weights
100
200
150
0.971368Location
Rural
Urban
Urban
TargetStandardized Amounts
$1,000
$1,000
$1,000
$458,000Payments
$92,280
$227,300
$138,420
$458,000
 We note that our proposed change would apply the budget neutrality adjustment to the wage index, and not to the standardized amount. In previous years, we applied a budget neutrality adjustment to the standardized amount to ensure that payments remained constant to payments that would have occurred in the absence of the rural floor requirement in section 4410 of the BBA. We believe such an adjustment is in keeping with the statute, which requires that the rural floor will not result in aggregate payments that are greater or less than those that would have been made in the absence of a rural floor. We believe that an adjustment to the wage index would result in a substantially similar payment as an adjustment to the standardized amount, as both involve multipliers to the standardized amount, and both would be based upon the same modeling parameters. We do note that because hospitals have different labor-related shares (62 percent for hospitals with wage indices less than or equal to 1; 69.7 percent for hospitals with wage indices greater than 1), an adjustment to the wage index would have slightly different effects from an adjustment to the standardized amount, as each wage index would be adjusted by a uniform percentage. For FY 2008, we are proposing to use FY 2006 discharge data and FY 2008 wage indices to simulate IPPS payments without the rural floor. We would compare these simulated payments to simulated payments using the same data with a rural floor. We believe that the statute supports either an adjustment to the standardized amount or the wage indices because under either methodology, the rural floor would not result in aggregate payments that were greater or less than those that would have been made in the absence of a rural floor. H. Analysis and Implementation of the Proposed Occupational Mix Adjustment and the Proposed FY 2008 Occupational Mix Adjusted Wage Index (If you choose to comment on issues in this section, please include the caption “Occupational Mix Adjusted Wage Index” at the beginning of your comment.) As discussed in section III.C. of this preamble, for FY 2008, we are proposing to apply the occupational mix adjustment to 100 percent of the FY 2008 wage index. We calculated the occupational mix adjustment using data from the 2006 occupational mix survey data, using the methodology described in section III.C.3. of this preamble. Using the first and second quarter occupational mix survey data and applying the occupational mix adjustment to 100 percent of the FY 2008 wage index results in a proposed national average hourly wage of $30.9074 and a proposed Puerto Rico-specific average hourly wage of $13.4678. After excluding data of hospitals that either submitted aberrant data that failed critical edits, or that do not have FY 2004 Worksheet S-3 cost report data for use in calculating the proposed FY 2008 wage index, we calculated the proposed FY 2008 wage index using the occupational mix survey data from 3,368 hospitals. Using the Worksheet S-3 cost report data of 3,581 hospitals and occupational mix first and/or second quarter survey data from 3,368 hospitals represents a 94.1 percent survey response rate. The proposed FY 2008 national average hourly wages for each occupational mix nursing subcategory as calculated in Step 2 of the occupational mix calculation are as follows: Occupational mix nursing subcategory
Average hourly wageNational RN Management
$38.6214National RN Staff
33.4800National LPN
19.2485National Nurse Aides, Orderlies, and Attendants
13.7267National Medical Assistants
15.7936National Nurse Category
28.7439
 The proposed national average hourly wage for the entire nurse category as computed in Step 5 of the occupational mix calculation is $28.7439. Hospitals with a nurse category average hourly wage (as calculated in Step 4) of greater than the national nurse category average hourly wage receive an occupational mix adjustment factor (as calculated in Step 6) of less than 1.0. Hospitals with a nurse category average hourly wage (as calculated in Step 4) of less than the national nurse category average hourly wage receive an occupational mix adjustment factor (as calculated in Step 6) of greater than 1.0. Based on the January through June 2006 occupational mix survey data, we determined (in Step 7 of the occupational mix calculation) that the proposed national percentage of hospital employees in the Nurse category is 42.9 percent, and the proposed national percentage of hospital employees in the All Other Occupations category is 57.1 percent. At the CBSA level, the percentage of hospital employees in the Nurse category ranged from a low of 27.3 percent in one CBSA, to a high of 85.3 percent in another CBSA. We compared the final FY 2007 occupational mix adjusted wage indices for each CBSA to the proposed FY 2008 wage indices adjusted for occupational mix. In proposing to implement an occupational mix adjusted wage index based on the above calculation using 6 months of survey data for FY 2008 as opposed to 3 months of survey data used for FY 2007, the final wage index values for 17 rural areas (36.2 percent) and 189 urban areas (48.7 percent) would decrease as a result of the adjustment. Nine rural areas (19.1 percent) and 127 urban areas (32.7 percent) would experience a decrease of 1 percent or greater in their wage index values. The largest negative impacts would be 3.40 percent and 14.82 percent for a rural and urban area, respectively. In addition, 30 rural areas (63.8 percent) and 197 urban areas (50.8 percent) would experience an increase in their wage index values. Twelve rural areas (25.5 percent) and 131 urban areas (33.8 percent) would experience an increase of 1 percent or greater in their wage index values. The largest increase for a rural area would be 10.75 percent and the largest increase for an urban area would be 16.87 percent. Two urban areas would be unaffected. These results indicate that a larger percentage of rural areas benefit from an occupational mix adjustment than do urban areas. However, as was the case with the FY 2007 occupational mix data, approximately a third of rural CBSAs (36.2 percent) continue to experience a decrease in their wage indices as a result of the occupational mix adjustment. 
                        ( print page 24793) The proposed wage index values for FY 2008 (except those for hospitals receiving wage index adjustments under section 1886(d)(13) of the Act) are shown in Tables 4A, 4B, 4C, and 4F in the Addendum to this proposed rule. Tables 3A and 3B in the Addendum to this proposed rule list the 3-year average hourly wage for each labor market area before the redesignation of hospitals based on FYs 2006, 2007, and 2008 cost reporting periods. Table 3A lists these data for urban areas and Table 3B lists these data for rural areas. In addition, Table 2 in the Addendum to this proposed rule includes the adjusted average hourly wage for each hospital from the FY 2002 and FY 2003 cost reporting periods, as well as the FY 2004 period used to calculate the proposed FY 2008 wage index. The 3-year averages are calculated by dividing the sum of the dollars (adjusted to a common reporting period using the method described previously) across all 3 years, by the sum of the hours. If a hospital is missing data for any of the previous years, its average hourly wage for the 3-year period is calculated based on the data available during that period. The proposed wage index values in Tables 4A, 4B, 4C, and 4F and the average hourly wages in Tables 2, 3A, and 3B in the Addendum to this proposed rule include the proposed occupational mix adjustment as well as the budget neutrality adjustment for the rural floor. I. Revisions to the Proposed Wage Index Based on Hospital Redesignations (If you choose to comment on issues in this section, please include the caption “Hospital Reclassifications and Redesignations” at the beginning of your comment.) 1. General Under section 1886(d)(10) of the Act, the Medicare Geographic Classification Review Board (MGCRB) considers applications by hospitals for geographic reclassification for purposes of payment under the IPPS. Hospitals must apply to the MGCRB to reclassify by September 1 of the year preceding the year during which reclassification is sought. Generally, hospitals must be proximate to the labor market area to which they are seeking reclassification and must demonstrate characteristics similar to hospitals located in that area. The MGCRB issues its decisions by the end of February for reclassifications that become effective for the following fiscal year (beginning October 1). The regulations applicable to reclassifications by the MGCRB are located in §§ 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 § 412.235. Section 1886(d)(8)(B) of the Act requires the Secretary to treat a hospital located in a rural county adjacent to one or more urban areas as being located in the MSA to which the greatest number of workers in the county commute, if the rural county would otherwise be considered part of an urban area under the standards for designating MSAs and if the commuting rates used in determining outlying counties were determined on the basis of the aggregate number of resident workers who commute to (and, if applicable under the standards, from) the central county or counties of 
                        *all*
                         contiguous MSAs. In light of the new CBSA definitions and the Census 2000 data that we implemented for FY 2005 (69 FR 49027), we undertook to identify those counties meeting these criteria. The eligible counties are identified under section III.I.8. of this preamble. 2. Effects of Reclassification/Redesignation Section 1886(d)(8)(C) of the Act provides that the application of the wage index to redesignated hospitals is dependent on the hypothetical impact that the wage data from these hospitals would have on the wage index value for the area to which they have been redesignated. These requirements for determining the wage index values for redesignated hospitals is applicable both to the hospitals located in rural counties deemed urban under section 1886(d)(8)(B) of the Act and hospitals that were reclassified as a result of the MGCRB decisions under section 1886(d)(10) of the Act. Therefore, as provided in section 1886(d)(8)(C) of the Act, the wage index values were determined by considering the following: If including the wage data for the redesignated hospitals would reduce the wage index value for the area to which the hospitals are redesignated by 1 percentage point or less, the area wage index value determined exclusive of the wage data for the redesignated hospitals applies to the redesignated hospitals.
                    If including the wage data for the redesignated hospitals reduces the wage index value for the area to which the hospitals are redesignated by more than 1 percentage point, the area wage index determined inclusive of the wage data for the redesignated hospitals (the combined wage index value) applies to the redesignated hospitals.
                    If including the wage data for the redesignated hospitals increases the wage index value for the urban area to which the hospitals are redesignated, both the area and the redesignated hospitals receive the combined wage index value. Otherwise, the hospitals located in the urban area receive a wage index excluding the wage data of hospitals redesignated into the area. Rural areas whose wage index values would be reduced by excluding the wage data for hospitals that have been redesignated to another area continue to have their wage index values calculated as if no redesignation had occurred (otherwise, redesignated rural hospitals are excluded from the calculation of the rural wage index). The wage index value for a redesignated rural hospital cannot be reduced below the wage index value for the rural areas of the State in which the hospital is located. CMS has also adopted the following policies by regulation: The wage data for a reclassified urban hospital is included in both the wage index calculation of the area to which the hospital is reclassified (subject to the rules described above) and the wage index calculation of the urban area where the hospital is physically located.
                    In cases where urban hospitals have reclassified to rural areas under42 CFR 412.103, the urban hospital wage data are: (a) Included in the rural wage index calculation, unless doing so would reduce the rural wage index; and (b) included in the urban area where the hospital is physically located. 3. FY 2008 MGCRB Reclassifications (If you choose to comment on issues in this section, please include the caption “MGCRB” at the beginning of your comment.) Under section 1886(d)(10) of the Act, the MGCRB considers applications by hospitals for geographic reclassification 
                        ( print page 24794)
                        for purposes of payment under the IPPS. The specific procedures and rules that apply to the geographic reclassification process are outlined in § 412.230 through § 412.280. At the time this proposed rule was constructed, the MGCRB had completed its review of FY 2008 reclassification requests. There were 365 hospitals approved for wage index reclassifications by the MGCRB for FY 2008. Because MGCRB wage index reclassifications are effective for 3 years, hospitals reclassified during FY 2006 or FY 2007 are eligible to continue to be reclassified based on prior reclassifications to current MSAs during FY 2008. There were 299 hospitals reclassified for wage index in FY 2006 and 214 hospitals reclassified for wage index in FY 2007. Some of the hospitals that reclassified for FY 2006 and FY 2007 have elected not to continue their reclassifications in FY 2008 because, under the revised labor market area definitions, they are now physically located in the areas to which they previously reclassified. Of all of the hospitals approved for reclassification for FY 2006, FY 2007, and FY 2008, 866 hospitals are in a reclassification status for FY 2008. Prior to FY 2004, hospitals had been able to apply to be reclassified for purposes of either the wage index or the standardized amount. Section 401 of Pub. L. 108-173 established that all hospitals will be paid on the basis of the large urban standardized amount, beginning with FY 2004. Consequently, all hospitals are paid on the basis of the same standardized amount, which made such reclassifications moot. Although there could still be some benefit in terms of payments for some hospitals under the DSH payment adjustment for operating IPPS, section 402 of Pub. L. 108-173 equalized DSH payment adjustments for rural and urban hospitals, with the exception that the rural DSH adjustment is capped at 12 percent (except that rural referral centers and, effective for discharges occurring on or after October 1, 2006, MDHs have no cap). (A detailed discussion of this application appears in section IV.I. of the preamble of the FY 2005 IPPS final rule (69 FR 49085). The exclusion of MDHs from the 12 percent DSH cap under Pub. L. 109-171 was discussed under section IV.F.4. of the preamble of the FY 2007 IPPS final rule (71 FR 48066.) Under § 412.273, hospitals that have been reclassified by the MGCRB are permitted to withdraw their applications within 45 days of the publication of a proposed rule. The request for withdrawal of an application for reclassification or termination of an existing 3-year reclassification that would be effective in FY 2008 must be received by the MGCRB within 45 days of the publication of this proposed rule. If a hospital elects to withdraw its wage index application after the MGCRB has issued its decision, but prior to the above date, it may later cancel its withdrawal in a subsequent year and request the MGCRB to reinstate its wage index reclassification for the remaining fiscal year(s) of the 3-year period (§ 412.273(b)(2)(i)). The request to cancel a prior withdrawal or termination must be in writing to the MGCRB no later than the deadline for submitting reclassification applications for the following fiscal year (§ 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 § 412.273, as well as the August 1, 2002, IPPS final rule (67 FR 50065) and the August 1, 2001 IPPS final rule (66 FR 39887). Changes to the wage index that result from withdrawals of requests for reclassification, wage index corrections, appeals, and the Administrator's review process will be incorporated into the wage index values published in the final rule. These changes may affect not only the wage index value for specific geographic areas, but also the wage index value redesignated hospitals receive; that is, whether they receive the wage index that includes the data for both the hospitals already in the area and the redesignated hospitals. Further, the wage index value for the area from which the hospitals are redesignated may be affected. Applications for FY 2009 reclassifications are due to the MGCRB by September 4, 2007 (the first working day of September 2007). We note that this is also the deadline for canceling a previous wage index reclassification withdrawal or termination under § 412.273(d). Applications and other information about MGCRB reclassifications may be obtained, beginning in mid-July 2007, via the CMS Internet Web site at: 
                        *http://cms.hhs.gov/​providers/​prrb/​mgcinfo.asp,*
                         or by calling the MGCRB at (410) 786-1174. The mailing address of the MGCRB is: 2520 Lord Baltimore Drive, Suite L, Baltimore, MD 21244-2670. 4. Hospitals That Applied for Reclassification Effective in FY 2008 and Reinstating Reclassifications in FY 2008 Applications for FY 2008 reclassifications were due to the MGCRB by September 1, 2006. We note that this deadline also applied for canceling a previous wage index reclassification withdrawal or termination under § 412.273(d). The MGCRB, in evaluating a hospital's request for reclassification for FY 2008 for the wage index, utilized the official data used to develop the FY 2007 wage index. The wage data used to support the hospital's wage comparisons were from the CMS hospital wage survey. Generally, the source for these data is the IPPS final rule to be published on or before August 1, 2006. However, the wage tables identifying the 3-year average hourly wage of hospitals were not available in time to include them in the FY 2007 IPPS final rule. Therefore, we made the data available subsequent to the publication of the FY 2007 IPPS final rule. Section 1886(d)(10)(C)(ii) of the Act indicates that a hospital requesting a change in geographic classification for a fiscal year must submit its application to the MGCRB not later than the first day of the 13-month period ending on September 30 of the preceding fiscal year. Thus, the statute requires that FY 2008 reclassification applications were to be submitted to the MGCRB by no later than September 1, 2006. For this reason, we required hospitals to file an FY 2008 reclassification application by the September 1, 2006 deadline even though the average hourly wage data used to develop the final FY 2007 wage indices were not yet available. However, as outlined in § 412.256(c)(2), we also allowed hospitals with incomplete applications submitted by the deadline to request an extension beyond September 1, 2006, to complete their applications. We also allowed hospitals 30 days from the date the final wage data were posted on the CMS Web site to request to cancel a withdrawal or termination in order to reinstate a reclassification for FY 2008 or FY 2009, or both fiscal years. For a more detailed discussion of the procedures used for the FY 2008 MGCRB applications we refer readers to the FY 2007 IPPS final rule (71 FR 48022-48023). 5. Clarification of Policy on Reinstating Reclassifications Under § 412.273(a) of our regulations, a hospital or group of hospitals may withdraw its application for reclassification at any time before the 
                        ( print page 24795)
                        MGCRB issues its decision or, if after the MGCRB issues its decision, within 45 days after publication of CMS's annual notice of proposed rulemaking for the upcoming fiscal year. In addition, a hospital may terminate a reclassification that is already in effect within 45 days after publication of the notice of proposed rulemaking for the upcoming fiscal year. Once a withdrawal or termination has been made, the hospital or group of hospitals will not be reclassified for purposes of the wage index to the same area for that year. The hospital also will not be reclassified to the withdrawn or terminated reclassification area in subsequent fiscal years unless the hospital subsequently cancels its withdrawal or termination. The procedures for making a withdrawal or termination, as well as for canceling a withdrawal or termination are specified at § 412.273. In the FY 2003 IPPS final rule (67 FR 50065-50066), we clarified our existing policy stating that a previous 3-year reclassification may not be reinstated after a subsequent 3-year reclassification to another area takes effect. Therefore, a hospital can only have one active 3-year reclassification at a time. We have been asked whether a hospital (or group of hospitals) can reinstate the two remaining years of a previously approved 3-year reclassification to one area, while at the same time the individual hospital (or group) request a new 3-year reclassification from the MGCRB to a different area and be approved for both at the same time. In this case, the hospital or group of hospitals is permitted to apply to a different area than the previously approved reclassification but, as stated in § 412.273(b)(2), once they accept a newly approved reclassification, a previously terminated and reinstated 3-year reclassification would be permanently terminated. Following the policy set forth at § 412.273(d), a hospital may cancel a previous withdrawal or termination by submitting written notice of its intent to the MGCRB no later than September 1 for reclassifications effective at the start of the second following fiscal year 13 months later. At the same time (because the deadline for geographic reclassification applications for the second following fiscal year 13 months later is also September 1), a hospital or group of hospitals could apply for reclassification to a different area. If the application is denied, the hospital or group of hospitals can select between the reinstated geographic reclassification and the home area wage index for the following fiscal year. The hospital or group of hospitals must file a written request to the MGCRB within 45 days after publication of the notice of proposed rulemaking to terminate the reinstated reclassification and receive the home area wage index. If the hospital or group of hospitals takes no action, the pending geographic reclassification will go into effect. If the new geographic reclassification application is approved, the hospital or group of hospitals will have 45 days from publication of the notice of proposed rulemaking to accept either of the two pending geographic reclassifications or revert to the home area wage index. If the hospital or group of hospitals takes no action, the most recent approved geographic reclassification will go into effect and the prior reclassification will be permanently terminated. Alternatively, the hospital or group of hospitals can withdraw the most recent approved reclassification and accept the previously approved and reinstated reclassification within 45 days of publication of the notice of proposed rulemaking. Such an action will permanently terminate the most recently approved geographic reclassification. Finally, the hospital or group hospitals can write to the MGCRB within 45 days of publication of the notice of proposed rulemaking to withdraw both geographic reclassifications in order to receive the home area wage index. In this case, the hospital or group of hospitals can only reinstate one of the two geographic reclassifications. The other geographic reclassification is permanently terminated. Once a hospital or group of hospitals makes a decision for the following fiscal year within 45 days of publication of the notice of proposed rulemaking, the hospital or group of hospitals cannot change the decision for that fiscal year. It is also important to note that the reinstatement of a reclassification only applies to those withdrawals which were made after the MGCRB issued an approved 3-year decision, not a withdrawal made prior to the MGCRB issuing an approval decision. For example, a hospital has been reclassified to area “A” for FYs 2007 through 2009. The hospital accepts this geographic reclassification for FY 2007. The hospital also applies for reclassification to a different area “B” for FYs 2008 through 2010 by September 1, 2006. If reclassification to area “B” is denied, the hospital can either withdraw or terminate its reclassification to area “A” within 45 days of publication of the proposed rule for FY 2008 and receive the home area wage index for FY 2008 or receive the reclassification to area “A” for FY 2008. If the hospital does nothing, it will receive the area “A” reclassification. If the hospital's reclassification application to area “B” is approved by the MGCRB, the hospital can (1) do nothing (and, therefore, receives the reclassification to area “B” for FY 2008, permanently terminating the reclassification to area “A”); (2) within 45 days of publication of the notice of proposed rulemaking, withdraw the reclassification to area “B” and receive the reclassification to area “A” for FY 2008 (permanently terminating the reclassification to area “B”); or (3) withdraw or terminate both the reclassifications to both areas “A” and “B” and receive the home area wage index for FY 2008). If the latter option is selected, the hospital can only reinstate one of the withdrawn/terminated reclassifications by September 1, 2007 (to take effect for FY 2009). Upon the sunset of the 45-day window, the reclassification selection is final and the hospital will receive that wage index for the fiscal year, in this case for FY 2008. 6. “Fallback” Reclassifications As indicated in section III.I.3. of this preamble, the regulations at § 412.273 provide the process that a hospital wishing to withdraw or terminate a reclassification must follow. If a hospital has an existing reclassification and then applies to the MGCRB to a second area and is approved, it has a choice between two reclassifications and its home area wage index for the following fiscal year. We have been asked a procedural question about how the hospital accepts its previously approved reclassification (its “fall back” reclassification) or how it can “fall back” to its home area wage index. As the example provided in the section III.I.5. of this preamble illustrates, a hospital will automatically be given its most recently approved reclassification (thereby permanently terminating any previously approved reclassifications) unless it provides written notice to the MGCRB within 45 days of publication of the notice of proposed rulemaking that it wishes to withdraw its most recently approved reclassification and “fall back” to either its prior reclassification or its home area wage index for the following fiscal year. If the hospital wishes to accept its home area wage index in preference to its previous “fall back” reclassification, the hospital must also state in its request to the MGCRB that it is not only withdrawing its most 
                        ( print page 24796)
                        recently approved reclassification but also terminating its previously approved reclassification. 7. Geographic Reclassification Issues for Multicampus Hospitals (If you choose to comments on issues in this section, please include the caption “Multicampus Hospitals” at the beginning of your comment.] In FY 2005, we modified the reclassification rules at § 412.230(d)(2)(iii) to allow campuses of multicampus hospitals located in separate wage index areas to support a reclassification application to the geographic area in which another campus is located using the average hourly wage data submitted on the cost report for the entire hospital. This special rule applies for applications for reclassifications effective in FYs 2006 through FY 2008. In the FY 2007 IPPS final rule, we decided not to extend this special rule for multicampus hospitals. However, we believe that the proposed change to how we allocate a multicampus hospital's wage data has implications for multicampus hospitals' reclassification requests. As stated above, we are proposing to allocate the multicampus hospital's wage data across the different labor market areas where the campuses are located based upon FTEs. For this reason, an individual campus located in a geographic area distinct from the geographic area associated with the provider number of the multicampus hospital will now have published, hospital-specific wage data that it may use to support a request for individual reclassification. The campus's wage data will be included in the wage data public use file and also provided to the MGCRB. These data will be considered appropriate wage data under § 412.230, because it will be part of the CMS hospital wage survey used to construct the wage index. We note, that where a multicampus hospital spanning two or more geographic areas does not provide us with appropriate FTE data, its campus-specific data will not be included in the public use files we use to construct the wage index. For this reason, unless a multicampus hospital has provided us with FTE data, we will not have appropriate campus-specific wage data that could be used to support an individual reclassification under § 412.230, and the reclassification request for the individual campus would be denied. In this sense, our policy allowing the allocation of wage data using FTEs is somewhat different from our prior policy on multicampus hospitals. We note that when a multicampus hospital's wage data are divided by FTEs, the ratio of wages to hours remains constant. Thus, the effect of our policy, in some sense, is that the individual campus of a multicampus hospital effectively uses the average hourly wage of the entire multicampus institution to support its individual reclassification request. However, as stated in the paragraph above, appropriate wage data will exist, only if the hospital has provided FTE data that can be used to allocate institution-wide wages and hours. Under current policy, an individual campus of a multicampus hospital located in a different area than the one associated with the provider number does not have to provide any official wage index data to join a group reclassification. However, given that we are allocating a portion of the average hourly wage of the hospital's data to the labor market area that includes this campus, we are also proposing that this same data be used as part of a group reclassification application. Again, these data will be published in a public use file and will be considered appropriate wage data under §§ 412.232 and 412.234. If a multicampus hospital spanning more than one geographic area has not provided us with FTE data, then, in accordance with our current policies for treating hospitals without official wage data, the individual campus would still be permitted to join the group application (and indeed would be required to join the application since all hospitals in a group must join in the application). In this case, the group application would omit the wage data from the individual campus of a multicampus hospital. 8. Redesignations of Hospitals Under Section 1886(d)(8)(B) of the Act Beginning October 1, 1988, section 1886 (d)(8)(B) of the Act required us to treat a hospital located in a rural county adjacent to one or more urban areas as being located in the MSA if certain criteria were met. Prior to FY 2005, the rule was that a rural county adjacent to one or more urban areas would be treated as being located in the MSA to which the greatest number of workers in the county commute, if the rural county would otherwise be considered part of an urban area under the standards published in the 
                        **Federal Register**
                         on January 3, 1980 (45 FR 956) for designating MSAs (and New England County Metropolitan Areas (NECMAs)), and if the commuting rates used in determining outlying counties (or, for New England, similar recognized areas) were determined on the basis of the aggregate number of resident workers who commute to (and, if applicable under the standards, from) the central county or counties of all contiguous MSAs (or NECMAs). Hospitals that met the criteria using the January 3, 1980 version of these OMB standards were deemed urban for purposes of the standardized amounts and for purposes of assigning the wage data index. Effective beginning FY 2005, we use OMB's 2000 CBSA standards and the Census 2000 data to identify counties qualifying for redesignation under section 1886(d)(8)(B) for the purpose of assigning the wage index to the urban area. Hospitals located in these counties have been known as “Lugar” hospitals and the counties themselves are often referred to as “Lugar” counties. We provide the chart below with the listing of the rural counties designated as urban under section 1886(d)(8)(B) of the Act that we are proposing to use for FY 2008. For discharges occurring on or after October 1, 2007, hospitals located in the first column of this chart will be redesignated for purposes of using the wage index of the urban area listed in the second column. Rural Counties Redesignated as Urban Under Section 1886(d)(8)(B) of the Act
[Based on CBSAs and Census 2000 Data]
Rural county
CBSACherokee, AL
Rome, GA.Macon, AL
Auburn-Opelika, AL.Talladega, AL
Anniston-Oxford, AL.Hot Springs, AR
Hot Springs, AR.Windham, CT
Hartford-West Hartford-East Hartford, CT.Bradford, FL
Gainesville, FL.Flagler, FL
Deltona-Daytona Beach-Ormond Beach, FL.Hendry, FL
West Palm Beach-Boca Raton-Boynton, FL.Levy, FL
Gainesville, FL.Walton, FL
Fort Walton Beach-Crestview-Destin, FL.Banks, GA
Gainesville, GA.Chattooga, GA
Chattanooga, TN-GA.Jackson, GA
Atlanta-Sandy Springs-Marietta, GA.Lumpkin, GA
Atlanta-Sandy Springs-Marietta, GA.Morgan, GA
Atlanta-Sandy Springs-Marietta, GA.Peach, GA
Macon, GA.Polk, GA
Atlanta-Sandy Springs-Marietta, GA.Talbot, GA
Columbus, GA-AL.Bingham, ID
Idaho Falls, ID.Christian, IL
Springfield, IL.DeWitt, IL
Bloomington-Normal, IL.Iroquois, IL
Kankakee-Bradley, IL.Logan, IL
Springfield, IL.Mason, IL
Peoria, IL.Ogle, IL
Rockford, IL.( print page 24797)Clinton, IN
Lafayette, IN.Henry, IN
Indianapolis-Carmel, IN.Spencer, IN
Evansville, IN-KY.Starke, IN
Gary, IN.Warren, IN
Lafayette, IN.Boone, IA
Ames, IA.Buchanan, IA
Waterloo-Cedar Falls, IA.Cedar, IA
Iowa City, IA.Allen, KY
Bowling Green, KY.Assumption Parish, LA
Baton Rouge, LA.St. James Parish, LA
Baton Rouge, LA.Allegan, MI
Holland-Grand Haven, MI.Montcalm, MI
Grand Rapids-Wyoming, MI.Oceana, MI
Muskegon-Norton Shores, MI.Shiawassee, MI
Lansing-East Lansing, MI.Tuscola, MI
Saginaw-Saginaw Township North, MI.Fillmore, MN
Rochester, MN.Dade, MO
Springfield, MO.Pearl River, MS
Gulfport-Biloxi, MS.Caswell, NC
Burlington, NC.Granville, NC
Durham, NC.Harnett, NC
Raleigh-Cary, NC.Lincoln, NC
Charlotte-Gastonia-Concord, NC-SC.Polk, NC
Spartanburg, NC.Los Alamos, NM
Santa Fe, NM.Lyon, NV
Carson City, NV.Cayuga, NY
Syracuse, NY.Columbia, NY
Albany-Schenectady-Troy, NY.Genesee, NY
Rochester, NY.Greene, NY
Albany-Schenectady-Troy, NY.Schuyler, NY
Ithaca, NY.Sullivan, NY
Poughkeepsie-Newburgh-Middletown, NY.Wyoming, NY
Buffalo-Niagara Falls, NY.Ashtabula, OH
Cleveland-Elyria-Mentor, OH.Champaign, OH
Springfield, OH.Columbiana, OH
Youngstown-Warren-Boardman, OH-PA.Cotton, OK
Lawton, OK.Linn, OR
Corvallis, OR.Adams, PA
York-Hanover, PA.Clinton, PA
Williamsport, PA.Greene, PA
Pittsburgh, PA.Monroe, PA
Allentown-Bethlehem-Easton, PA-NJ.Schuylkill, PA
Reading, PA.Susquehanna, PA
Binghamton, NY.Clarendon, SC
Sumter, SC.Lee, SC
Sumter, SC.Oconee, SC
Greenville, SC.Union, SC
Spartanburg, SC.Meigs, TN
Cleveland, TN.Bosque, TX
Waco, TX.Falls, TX
Waco, TX.Fannin, TX
Dallas-Plano-Irving, TX.Grimes, TX
College Station-Bryan, TX.Harrison, TX
Longview, TX.Henderson, TX
Dallas-Plano-Irving, TX.Milam, TX
Austin-Round Rock, TX.Van Zandt, TX
Dallas-Plano-Irving, TX.Willacy, TX
Brownsville-Harlingen, TX.Buckingham, VA
Charlottesville, VA.Floyd, VA
Blacksburg-Christiansburg-Radford, VA.Middlesex, VA
Virginia Beach-Norfolk-Newport News, VA.Page, VA
Harrisonburg, VA.Shenandoah, VA
Winchester, VA-WV.Island, WA
Seattle-Bellevue-Everett, WA.Mason, WA
Olympia, WA.Wahkiakum, WA
Longview, WA.Jackson, WV
Charleston, WV.Roane, WV
Charleston, WV.Green, WI
Madison, WI.Green Lake, WI
Fond du Lac, WI.Jefferson, WI
Milwaukee-Waukesha-West Allis, WI.Walworth, WI
Milwaukee-Waukesha-West Allis, WI.
 As in the past, hospitals redesignated under section 1886(d)(8)(B) of the Act are also eligible to be reclassified to a different area by the MGCRB. Affected hospitals are permitted to compare the reclassified wage index for the labor market area in Table 4C in the Addendum to this proposed rule into which they have been reclassified by the MGCRB to the wage index for the area to which they are redesignated under section 1886(d)(8)(B) of the Act. Hospitals may withdraw from an MCGRB reclassification within 45 days of the publication of this proposed rule. 9. Reclassifications Under Section 1886(d)(8)(B) of the Act We have been asked whether Lugar hospitals and counties (discussed above in section III.H.8. of this preamble) are considered urban or rural for MGCRB reclassification purposes. As stated in the regulations at 42 CFR 412.64(b)(3), as well as in section 1886(d)(8)(C) of the Act, Lugar hospitals and counties are deemed to be located in an urban area. Therefore, because they are physically located in a rural area and are deemed urban, they receive the reclassified wage index (Table 4C in the Addendum to this proposed rule) for the urban area to which they have been redesignated. Because Lugar hospitals are treated like reclassified hospitals, when they are seeking reclassification by the MCGRB, they are subject to the rural reclassification rules set forth at § 412.230. The procedural rules set forth at § 412.230 list the criteria which a hospital must meet in order to reclassify as a rural hospital. Lugar hospitals would be subject to the proximity criteria and payment thresholds that apply to rural hospitals. Specifically, the hospital would have to be no more than 35 miles from the area to which it seeks reclassification (§ 412.230(b)(1)); the hospital would have to show that its average hourly wage is at least 106 percent of the average hourly wage of all other hospitals in the area in which the hospital is located (§ 412.230(d)(1)(iii)(C)); and the hospital would have to demonstrate that its average hourly wage is equal to at least 82 percent of the average hourly wage of hospitals in the area to which it seeks redesignation (§ 412.230(d)(1)(iv)(C)). Hospitals not located in a Lugar county seeking reclassification to the urban area where the Lugar hospitals have been redesignated are not permitted to measure to the Lugar county to demonstrate proximity (no more than 15 miles for an urban hospital, and no more than 35 miles for a rural hospital or the closest urban or rural area for RRCs or SCHs) in order to be reclassified to such urban area. These hospitals must measure to the urban area exclusive of the Lugar County to meet the proximity or nearest urban or rural area requirement. 10. New England Deemed Counties Our regulations at 42 CFR 412.64(b)(1)(ii)(B) list New England counties that are deemed to be parts of urban areas under section 601(g) of the Social Security Amendments of 1983 (Pub. L. 98-21, 42 U.S.C. 1395ww(note)). These counties include Litchfield County, Connecticut; York County, Maine; Sagadahoc County, Maine; Merrimack County, New Hampshire; and Newport County, Rhode Island. OMB standards designate and define two categories of CBSAs: Metropolitan Statistical Areas (MSAs) and Micropolitan Statistical Areas (65 FR 82235). For our labor market area definitions, we treat micropolitan areas as rural. Of these five counties, three (York County, Sagadahoc County, and Newport County) are also included in metropolitan areas by OMB, whereas the remaining two, Litchfield County and Merrimack County, are located in micropolitan statistical areas and would 
                        ( print page 24798)
                        be treated as rural under our labor market area definitions were they not deemed urban under § 412.64(b)(1)(ii)(B) of the regulations. Litchfield County and Merrimack County have been listed as being part of urban CBSA 25540 Hartford-West Hartford-East Hartford, CT, and urban CBSA 31700 Manchester-Nashua, NH, respectively. Even though hospitals located in Litchfield County and Merrimack County are in micropolitan statistical areas, they have been treated as urban for reclassification purposes. Under our regulations, we have deemed both of these two New England counties and the hospitals within them as urban. Because the counties themselves were deemed urban, the hospitals within them have also been treated as urban for reclassification purposes, even though Litchfield and Merrimack counties are in micropolitan statistical areas. However, upon further consideration of this issue, we believe the hospitals located within these New England counties should be treated the same as Lugar hospitals. That is, the area would be considered rural but the hospitals within them would be deemed to be urban. Therefore, we are proposing to change our policy and consider Litchfield County and Merrimack County as rural but would continue to consider the hospitals within them as being redesignated to urban CBSA 25540 Hartford-West Hartford-East Hartford, CT, and urban CBSA 31700 Manchester-Nashua, NH, respectively. Under our proposal, hospitals located in these counties—like the Lugar hospitals described in section III.I.8. of this preamble—must meet the rural requirements set forth at § 412.230 for individual reclassifications and § 412.232 for group reclassifications. We are proposing to revise § 412.64(b)(1)(ii)(B) accordingly. Hospitals not located inside one of these deemed New England counties are not permitted to measure to these counties to demonstrate close proximity in order to be reclassified to the CBSA(s) to which the hospitals in Litchfield and Merrimack counties are redesignated. We note that Tables 2, 3A, 3B, 4A, and 4B in the Addendum to this proposed rule do not reflect this proposed change; rather, they reflect the wage index based on the current policy. 11. Reclassifications Under Section 508 of Pub. L. 108-173 (If you choose to comment on issues in this section, please include the caption “508 Reclassifications” at the beginning of your comment.) Under section 508 of Pub. L. 108-173, a qualifying hospital could appeal the wage index classification otherwise applicable to the hospital and apply for reclassification to another area of the State in which the hospital is located (or, at the discretion of the Secretary, to an area within a contiguous State). We implemented this process through notices published in the 
                        **Federal Register**
                         on January 6, 2004 (69 FR 661), and February 13, 2004 (69 FR 7340). Such reclassifications were applicable to discharges occurring during the 3-year period beginning April 1, 2004, and ending March 31, 2007. Section 106(a) of the MIEA-TRHCA (Pub. L. 109-432), extended any geographic reclassifications of hospitals that were made under section 508 and that would expire on March 31, 2007, by 6 months until September 30, 2007. On March 23, 2007, we published a notice in the 
                        **Federal Register**
                         (72 FR 13799) that indicated how we are implementing section 106(a) of the MIEA-TRHCA through September 30, 2007. Because the section 508 provision will expire on September 30, 2007, and will not be applicable in FY 2008, in this proposed rule, we are not making any proposals related to the provision. 12. Other Issues We have been advised of a reclassification scenario of concern to a particular hospital. In this scenario, two hospitals were approved by the Medicare Geographic Classification Review Board (MGCRB) for a 3-year group reclassification. Prior to the second year of the 3-year reclassification, one of the hospitals reclassified individually to another area. Consistent with our policy, the second hospital retained its group geographic reclassification for the two remaining years (see 66 FR 39888, August 1, 2001). However, once the group reclassification expires, the second hospital does not qualify to reclassify individually to another area. We have been asked to consider potential regulatory options that would allow this hospital to either reclassify or receive a declining blend of its home area and reclassified wage index as a transition to its post-reclassified wage index. There are no options under our current regulations that would allow this hospital to reclassify individually or as a group. The hospital does not meet the well established wage data comparison criteria to reclassify as an individual hospital. In order for a group reclassification to be approved, all hospitals in the county must apply as a group. We have been informed that one hospital will not join the group reclassification because it qualifies individually to reclassify to a different area with a higher wage index than where the group applied. We considered whether to change our regulations for this type of situation. However, we decided not to propose a change to our regulations given the need to gather additional information and better understand the policy issues in such a case. In this regard, we would be interested in receiving comments on whether such a situation is consistent with the purpose of reclassification. In particular, we would like to receive comments on how a hospital that is applying to reclassify would demonstrate similarity to hospitals in the neighboring area when the hospital would qualify to be part of a group reclassification if all other hospitals in the county the hospital is located agreed to apply. In addition, we would be interested in comments on how we could make a determination that a hospitals own area wage index is inappropriate when the hospital does not meet the current criteria for reclassification on its own, but would meet the criteria for a group reclassification in the event all hospitals in the county in which the hospital is located would agree to submit a group application. Finally, given that reclassifications are in effect for three years, we request comments on whether or how we could address this situation while simultaneously maintaining the distinction between group and individual reclassifications—particularly the rule that all members of a group must apply for a group reclassification. For all the above reasons, we decided, as noted, not to propose changes to the regulations to address the situation brought to our attention. Rather, we think it is appropriate to gather additional information and seek comment on this or similar situations. If commenters wish to raise issues with the points described in this section or comment on other issues we did not consider in the questions raised above, we welcome such public comments. J. Proposed FY 2008 Wage Index Adjustment Based on Commuting Patterns of Hospital Employees (If you choose to comment on issues in this section, please include the caption “Out-Migration Adjustment” at the beginning of your comment.) In accordance with the broad discretion under section 1886(d)(13) of the Act, as added by section 505 of Pub. L. 108-173, beginning with FY 2005, we established a process to make adjustments to the hospital wage index based on commuting patterns of hospital employees. The process, 
                        ( print page 24799)
                        outlined in the FY 2005 IPPS final rule (69 FR 49061), provides for an increase in the wage index for hospitals located in certain counties that have a relatively high percentage of hospital employees who reside in the county but work in a different county (or counties) with a higher wage index. Such adjustments to the wage index are effective for 3 years, unless a hospital requests to waive the application of the adjustment. A county will not lose its status as a qualifying county due to wage index changes during the 3-year period, and counties will receive the same wage index increase for those 3 years. However, a county that qualifies in any given year may no longer qualify after the 3-year period, or it may qualify but receive a different adjustment to the wage index level. Hospitals that receive this adjustment to their wage index are not eligible for reclassification under section 1886(d)(8) or section 1886(d)(10) of the Act. Adjustments under this provision are not subject to the budget neutrality requirements under section 1886(d)(3)(E) of the Act. Hospitals located in counties that qualify for the wage index adjustment are to receive an increase in the wage index that is equal to the average of the differences between the wage indices of the labor market area(s) with higher wage indices and the wage index of the resident county, weighted by the overall percentage of hospital workers residing in the qualifying county who are employed in any labor market area with a higher wage index. To date, we have used pre-reclassified wage indices when determining the out-migration adjustment. In the FY 2005 IPPS final rule (69 FR 49061 through 49063), we stated that it was reasonable to interpret the term “wage index” in section 1886(d)(13)(D) of the Act to mean the pre-reclassified, pre-adjusted wage index. At the time, we stated that it was unclear whether to use the pre- or post-reclassified wage index as the basis for comparison to determine the out-migration adjustment. We also cited complicating factors such as the use of blended wage indices as a result of the labor market area transition as another reason to base the out-migration adjustment on the pre-reclassified wage index. However, we indicated that we will continue to examine the possibility of employing post-reclassification wage indexes as we refine our policy for future adjustments. We have reconsidered our policy in this proposed rule and are proposing to calculate the out-migration adjustment using the post-reclassified wage index. First, the labor-market area transition has ended and the use of blended wage indexes is no longer a complicating factor in determining whether to use pre- or post-reclassified wage indexes to determine the out-migration adjustment. Second, we are proposing to apply budget neutrality for application of the rural floor to area wage indices rather than to the standardized amount beginning in FY 2008. The budget neutrality adjustment for the rural floor is being applied to the post-reclassification wage indices and is a component of the wage index that is being used to adjust for area differences in wages. Therefore, we believe the out-migration adjustment should be determined using post-reclassified wage index that reflects the budget neutrality adjustment for application of the rural floor. We are proposing to use the same formula described in the FY 2005 final rule (69 FR 49064), with the addition of now using the post-reclassified wage indices, to calculate the out-migration adjustment. This adjustment is calculated as follows: *Step 1.*
                         Subtract the wage index for the qualifying county from the wage index of each of the higher wage area(s) to which hospital workers commute. *Step 2.*
                         Divide the number of hospital employees residing in the qualifying county who are employed in such higher wage index area by the total number of hospital employees residing in the qualifying county who are employed in any higher wage index area. For each of the higher wage areas, multiply this result by the result obtaining in Step 1. *Step 3.*
                         Sum the products resulting from Step 2 (if the qualifying county has workers commuting to more than one higher wage area). *Step 4.*
                         Multiply the result from Step 3 by the percentage of hospital employees who are residing in the qualifying county and who are employed in any higher wage index area. These adjustments will be effective for each county for a period of 3 fiscal years. Hospitals that received the adjustment in FY 2007 will be eligible to retain that same adjustment for FY 2008. For hospitals in newly qualified counties, adjustments to the wage index are effective for 3 years, beginning with discharges occurring on or after October 1, 2007. Hospitals receiving the wage index adjustment under section 1886(d)(13)(F) of the Act are not eligible for reclassification under sections 1886(d)(8) or (d)(10) of the Act unless they waive the out-migration adjustment. Consistent with our FY 2005, 2006, and 2007 final rules, we are proposing that hospitals redesignated under section 1886(d)(8) of the Act or reclassified under section 1886(d)(10) of the Act will be deemed to have chosen to retain their redesignation or reclassification. Section 1886(d)(10) hospitals that wish to receive the out-migration adjustment, rather than their reclassification, should follow the termination/withdrawal procedures specified in 42 CFR 412.273 and section III.I.3. of the preamble of this proposed rule. Otherwise, they will be deemed to have waived the out-migration adjustment. Hospitals redesignated under section 1886(d)(8) of the Act will be deemed to have waived the out-migration adjustment, unless they explicitly notify CMS that they elect to receive the out-migration adjustment instead within 45 days from the publication of this proposed rule. These notifications should be sent to the following address: Centers for Medicare and Medicaid Services, Center for Medicare Management, Attention: Wage Index Adjustment Waivers, Division of Acute Care, Room C4-08-06, 7500 Security Boulevard, Baltimore, MD 21244-1850. Table 4J in the Addendum to this proposed rule lists the proposed out-migration wage index adjustments for FY 2008. Hospitals that are not otherwise reclassified or redesignated under section 1886(d)(8) or section 1886(d)(10) of the Act will automatically receive the listed adjustment. In accordance with the procedures discussed above, redesignated/reclassified hospitals will be deemed to have waived the out-migration adjustment unless CMS is otherwise notified. Hospitals that are eligible to receive the out-migration wage index adjustment and that withdraw their application for reclassification automatically receive the wage index adjustment listed in Table 4J in the Addendum to this proposed rule. Hospitals should carefully review the wage index adjustment that they would receive under this provision (as listed in Table 4J) and the area wage index value as listed in Table 4A (both included in the Addendum to this proposed rule) in comparison to the wage index value that they would receive under the MGCRB reclassification (Table 4C in the Addendum to this proposed rule). K. Process for Requests for Wage Index Data Corrections (If you choose to comment on issues in this section, please include the caption “Wage Index Data Corrections” at the beginning of your comment.) 
                        ( print page 24800) The preliminary Worksheet S-3 wage data and occupational mix survey data files (1st and 2nd quarter 2006) for the FY 2008 wage index were made available on October 6, 2006, through the Internet on the CMS Web site at: 
                        *http://cms.hhs.gov/​AcuteInpatientPPS/​.*
                         In a memorandum dated October 6, 2006, we instructed all fiscal intermediaries to inform the IPPS hospitals they service of the availability of the wage index data files and the process and timeframe for requesting revisions (including the specific deadlines listed below). We also instructed the fiscal intermediaries to advise hospitals that these data are also made available directly through their representative hospital organizations. If a hospital wished to request a change to its data as shown in the October 6, 2006 wage and occupational mix data files, the hospital was to submit corrections along with complete, detailed supporting documentation to its fiscal intermediary by December 4, 2006. Hospitals were notified of this deadline and of all other possible deadlines and requirements, including the requirement to review and verify their data as posted on the preliminary wage index data file on the Internet, through the October 6, 2006 memorandum referenced above. In the October 6, 2006 memorandum, we also specified that a hospital could request revisions to 1st and/or 2nd quarter occupational mix survey data if they missed the previous deadlines (June 1, 2006, for the 1st quarter data collection and August 31, 2006, for the 2nd quarter collection) for submitting occupational mix survey data to their fiscal intermediaries. A hospital requesting revisions to its 1st and/or 2nd quarter occupational mix survey data was to copy its record(s) from the CY 2006 occupational mix preliminary files posted to our website in October, highlight the revised cells on its spreadsheet, and submit its spreadsheet(s) and complete documentation to its fiscal intermediary no later than December 4, 2006. The fiscal intermediaries (or, if applicable, the MAC) notified the hospitals by mid-February 2007 of any changes to the wage index data as a result of the desk reviews and the resolution of the hospitals' early-December revision requests. The fiscal intermediaries or MAC also submitted the revised data to CMS by mid-February 2007. CMS published the proposed wage index public use files that included hospitals' revised wage data on February 23, 2007. In a memorandum also dated February 23, 2007, we instructed fiscal intermediaries and the MAC to notify all hospitals regarding the availability of the proposed wage index public use files and the criteria and process for requesting corrections and revisions to the wage index data. Hospitals had until March 12, 2007 to submit requests to the fiscal intermediaries or the MAC for reconsideration of adjustments made by the fiscal intermediaries or the MAC as a result of the desk review, and to correct errors due to CMS's or the fiscal intermediary's (or, if applicable, the MAC's) mishandling of the wage index data. Hospitals were also required to submit sufficient documentation to support their requests. After reviewing requested changes submitted by hospitals, fiscal intermediaries or the MAC are to transmit any additional revisions resulting from the hospitals' reconsideration requests by April 13, 2007. The deadline for a hospital to request CMS intervention in cases where the hospital disagreed with the fiscal intermediary's (or, if applicable, the MAC's) policy interpretations is April 20, 2007. Hospitals should also examine Table 2 in the Addendum to this proposed rule. Table 2 of this proposed rule contained each hospital's adjusted average hourly wage used to construct the wage index values for the past 3 years, including the FY 2004 data used to construct the proposed FY 2008 wage index. We note that the hospital average hourly wages shown in Table 2 only reflect changes made to a hospital's data and transmitted to CMS by February 21, 2007. We will release the final wage index data public use files in early May 2007 on the Internet at 
                        *http:/www.cms.hhs.gov/​AcuteInpatientPPS/​.*
                         The May 2007 public use files will be made available solely for the limited purpose of identifying any potential errors made by CMS or the fiscal intermediary or MAC in the entry of the final wage index data that result from the correction process described above (revisions submitted to CMS by the fiscal intermediaries or the MAC by April 13, 2007). If, after reviewing the May 2007 final files, a hospital believes that its wage or occupational mix data are incorrect due to a fiscal intermediary or MAC or CMS error in the entry or tabulation of the final data, the hospital should send a letter to both its fiscal intermediary or MAC and CMS that outlines why the hospital believes an error exists and to provide all supporting information, including relevant dates (for example, when it first became aware of the error). CMS and the fiscal intermediaries (or, if applicable, the MAC) must receive these requests no later than June 08, 2007. Requests mailed to CMS should be sent to: Centers for Medicare & Medicaid Services, Center for Medicare Management, Attention: Wage Index Team, Division of Acute Care, C4-08-06, 7500 Security Boulevard, Baltimore, MD 21244-1850. Each request also must be sent to the fiscal intermediary or the MAC. The fiscal intermediary or the MAC will review requests upon receipt and contact CMS immediately to discuss its findings. At this point in the process, that is, after the release of the May 2007 wage index data files, changes to the wage and occupational mix data will only made in those very limited situations involving an error by the fiscal intermediary or the MAC or CMS that the hospital could not have known about before its review of the final wage index data files. Specifically, neither the fiscal intermediary or the MAC nor CMS will approve the following types of requests: Requests for wage index data corrections that were submitted too late to be included in the data transmitted to CMS by fiscal intermediaries or the MAC on or before April 13, 2007.
                    Requests for correction of errors that were not, but could have been, identified during the hospital's review of the February 23, 2007 wage index public use files.
                    Requests to revisit factual determinations or policy interpretations made by the fiscal intermediary or the MAC or CMS during the wage index data correction process. Verified corrections to the wage index data received timely by CMS and the fiscal intermediaries or the MAC (that is, by June 08, 2007) will be incorporated into the final wage index to be published by August 1, 2007, to be effective October 1, 2007. We created the processes described above to resolve all substantive wage index data correction disputes before we finalize the wage and occupational mix data for the FY 2008 payment rates. Accordingly, hospitals that do not meet the procedural deadlines set forth above will not be afforded a later opportunity to submit wage index data corrections or to dispute the fiscal intermediary's (or, if applicable the MAC's) decision with respect to requested changes. Specifically, our policy is that hospitals that do not meet the procedural deadlines set forth above will not be permitted to challenge later, before the Provider Reimbursement Review Board, the failure of CMS to make a requested data revision. (See 
                        *W.A. Foote Memorial 
                            ( print page 24801)
                            Hospital*
                         v. 
                        *Shalala*, No. 99-CV-75202-DT (E.D. Mich. 2001) and 
                        *Palisades General Hospital*
                         v. 
                        *Thompson*, No. 99-1230 (D.D.C. 2003.) We refer the reader also to the FY 2000 final rule (64 FR 41513) for a discussion of the parameters for appealing to the PRRB for wage index data corrections. Again, we believe the wage index data correction process described above provides hospitals with sufficient opportunity to bring errors in their wage and occupational mix data to the fiscal intermediary's (or, if applicable, the MAC's) attention. Moreover, because hospitals will have access to the final wage index data by early May 2007, they have the opportunity to detect any data entry or tabulation errors made by the fiscal intermediary or the MAC or CMS before the development and publication of the final FY 2008 wage index by August 1, 2007, and the implementation of the FY 2008 wage index on October 1, 2007. If hospitals avail themselves of the opportunities afforded to provide and make corrections to the wage and occupational mix data, the wage index implemented on October 1 should be accurate. Nevertheless, in the event that errors are identified by hospitals and brought to our attention after June 08, 2007, we retain the right to make midyear changes to the wage index under very limited circumstances. Specifically, in accordance with § 412.64(k)(1) of our existing regulations, we make midyear corrections to the wage index for an area only if a hospital can show that: (1) The fiscal intermediary or the MAC or CMS made an error in tabulating its data; and (2) the requesting hospital could not have known about the error or did not have an opportunity to correct the error, before the beginning of the fiscal year. For purposes of this provision, “before the beginning of the fiscal year” means by the June deadline for making corrections to the wage data for the following fiscal year's wage index. This provision is not available to a hospital seeking to revise another hospital's data that may be affecting the requesting hospital's wage index for the labor market area. As indicated earlier, since CMS makes the wage index data available to hospitals on the CMS Web site prior to publishing both the proposed and final IPPS rules, and the fiscal intermediaries or the MAC notify hospitals directly of any wage index data changes after completing their desk reviews, we do not expect that midyear corrections will be necessary. However, under our current policy, if the correction of a data error changes the wage index value for an area, the revised wage index value will be effective prospectively from the date the correction is made. In the FY 2006 IPPS final rule (70 FR 47385), we revised § 412.64(k)(2) to specify that, effective on October 1, 2005, that is beginning with the FY 2006 wage index, a change to the wage index can be made retroactive to the beginning of the Federal fiscal year only when: (1) the fiscal intermediary (or, if applicable, the MAC) or CMS made an error in tabulating data used for the wage index calculation; (2) the hospital knew about the error and requested that the fiscal intermediary (or if applicable the MAC) and CMS correct the error using the established process and within the established schedule for requesting corrections to the wage index data, before the beginning of the fiscal year for the applicable IPPS update (that is, by the June 08, 2007 deadline for the FY 2008 wage index); and (3) CMS agreed that the fiscal intermediary (or if applicable, the MAC) or CMS made an error in tabulating the hospital's wage index data and the wage index should be corrected. In those circumstances where a hospital requests a correction to its wage index data before CMS calculates the final wage index (that is, by the June deadline), and CMS acknowledges that the error in the hospital's wage index data was caused by CMS's or the fiscal intermediary's (or, if applicable, the MAC's) mishandling of the data, we believe that the hospital should not be penalized by our delay in publishing or implementing the correction. As with our current policy, we indicated that the provision is not be available to a hospital seeking to revise another hospital's data. In addition, the provision cannot be used to correct prior years' wage index data; it can only be used for the current Federal fiscal year. In other situations where our policies would allow midyear corrections, we continue to believe that it is appropriate to make prospective-only corrections to the wage index. We note that, as with prospective changes to the wage index, the final retroactive correction will be made irrespective of whether the change increases or decreases a hospital's payment rate. In addition, we note that the policy of retroactive adjustment will still apply in those instances where a judicial decision reverses a CMS denial of a hospital's wage index data revision request. L. Labor-Related Share for the Proposed Wage Index for FY 2008 (If you choose to comment on issues in this section, please include the caption “Labor-Related Share” at the beginning of your comment.) Section 1886(d)(3)(E) of the Act directs the Secretary to adjust the proportion of the national prospective payment system base payment rates that are attributable to wages and wage-related costs by a factor that reflects the relative differences in labor costs among geographic areas. It also directs the Secretary to estimate from time to time the proportion of hospital costs that are labor-related: “The Secretary shall adjust the proportion (as estimated by the Secretary from time to time) of hospitals' costs which are attributable to wages and wage-related costs of the DRG prospective payment rates* * *” We refer to the portion of hospital costs attributable to wages and wage-related costs as the labor-related share. The labor-related share of the prospective payment rate is adjusted by an index of relative labor costs, which is referred to as the wage index. Section 403 of Pub. L. 108-173 amended section 1886(d)(3)(E) of the Act to provide that the Secretary must employ 62 percent as the labor-related share unless this “would result in lower payments to a hospital than would otherwise be made.” However, this provision of Pub. L. 108-173 did not change the legal requirement that the Secretary estimate “from time to time” the proportion of hospitals' costs that are “attributable to wages and wage-related costs.” We believe that this reflected Congressional intent that hospitals receive payment based on either a 62-percent labor-related share, or the labor-related share estimated from time to time by the Secretary, depending on which labor-related share resulted in a higher payment. We have continued our research into the assumptions employed in calculating the labor-related share. Our research involves analyzing the compensation share separately for urban and rural hospitals, using regression analysis to determine the proportion of costs influenced by the area wage index, and exploring alternative methodologies to determine whether all or only a portion of professional fees and nonlabor intensive services should be considered labor-related. In the FY 2006 IPPS final rule (70 FR 47392), we presented our analysis and conclusions regarding the frequency and methodology for updating the labor-related share for FY 2006. We also recalculated a labor-related share of 69.731 percent, using the FY 2002-based PPS market basket for discharges occurring on or after October 1, 2005. In addition, we implemented this revised and rebased labor-related share in a 
                        ( print page 24802)
                        budget neutral manner, but consistent with section 1886(d)(3)(E) of the Act, we did not take into account the additional payments that would be made as a result of hospitals with a wage index less than or equal to 1.0 being paid using a labor-related share lower than the labor-related share of hospitals with a wage index greater than 1.0. The labor-related share is used to determine the proportion of the national PPS base payment rate to which the area wage index is applied. In this proposed rule, we are not proposing to make any changes to the national average proportion of operating costs that are attributable to wages and salaries, fringe benefits, professional fees, contract labor, and labor intensive services. Therefore, we are proposing to continue to use a labor-related share of 69.731 percent for discharges occurring on or after October 1, 2007. Tables 1A and 1B will reflect this proposed labor-related share. We note that section 403 of Pub. L. 108-173 amended sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act to provide that the Secretary must employ 62 percent as the labor-related share unless this employment “would result in lower payments to a hospital than would otherwise be made.” We also are proposing to continue to use a labor-related share for the Puerto Rico-specific standardized amounts of 58.7 percent for discharges occurring on or after October 1, 2007. Consistent with our methodology for determining the national labor-related share, we added the Puerto Rico-specific relative weights for wages and salaries, fringe benefits, contract labor, nonmedical professional fees, and other labor-intensive services to determine the labor-related share. Puerto Rico hospitals are paid based on 75 percent of the national standardized amounts and 25 percent of the Puerto Rico-specific standardized amounts. For Puerto Rico hospitals, the national labor-related share will always be 62 percent because the wage index for all Puerto Rico hospitals is less than 1.0. A Puerto Rico-specific wage index is applied to the Puerto Rico-specific portion of payments to the hospitals. The labor-related share of a hospital's Puerto Rico-specific rate will be either 62 percent or the Puerto Rico-specific labor-related share depending on which results in higher payments to the hospital. If the hospital has a Puerto Rico-specific wage index of greater than 1.0, we will set the hospital's rates using a labor-related share of 62 percent for the 25 percent portion of the hospital's payment determined by the Puerto Rico standardized amounts because this amount will result in higher payments. Conversely, a hospital with a Puerto Rico-specific wage index of less than 1.0 will be paid using the Puerto Rico-specific labor-related share of 58.7 percent of the Puerto Rico-specific rates because the lower labor-related share will result in higher payments. The Puerto Rico labor-related share of 58.7 percent for FY 2007 is reflected in the Table 1C of the Addendum to this proposed rule. M. Wage Index Study Required Under Pub. L. 109-432 Section 106(b)(1) of the MIEA-TRHCA (Pub. L. 109-432) requires MedPAC to submit to Congress, not later than June 30, 2007, a report on the Medicare wage index classification system applied under the Medicare Prospective Payment System. Section 106(b) of MIEA-TRHCA requires the report to include any alternatives that MedPAC recommends to the method to compute the wage index under section 1886(d)(3)(E) of the Act. In addition, section 106(b)(2) of Pub. L. 109-432 instructs the Secretary of Health and Human Services, taking into account MedPAC's recommendations on the Medicare wage index classification system, to include in the FY 2009 IPPS proposed rule one or more proposals to revise the wage index adjustment applied under section 1886(d)(3)(E) of the Act for purposes of the IPPS. The proposal (or proposals) must consider each of the following: Problems associated with the definition of labor markets for the wage index adjustment;
                    The modification or elimination of geographic reclassifications and other adjustments;
                    The use of Bureau of Labor of Statistics data or other data or methodologies to calculate relative wages for each geographic area;
                    Minimizing variations in wage index adjustments between and within MSAs and statewide rural areas;
                    The feasibility of applying all components of CMS' proposal to other settings;
                    Methods to minimize the volatility of wage index adjustments while maintaining the principle of budget neutrality;
                    The effect that the implementation of the proposal would have on health care providers on each region of the country;
                    Methods for implementing the proposal(s) including methods to phase in such implementations; and
                    Issues relating to occupational mix such as staffing practices and any evidence on quality of care and patient safety including any recommendation for alternative calculations to the occupational mix. We look forward to reviewing the MedPAC report on the wage index later this year. As required by the law, we will consider MedPAC's recommendations and each of the factors specified above in making a proposal (or proposals) in the FY 2009 IPPS proposed rule. N. Proxy for the Hospital Market Basket (If you choose to comment on issues in this section, please include the caption “Hospital Market Basket” at the beginning of your comment.) In the FY 2006 IPPS final rule (70 FR 47387), we changed the base year cost structure for the IPPS hospital index for the hospital market basket for operating costs from FY 1997 to FY 2002. As discussed in that final rule, the IPPS hospital index primarily uses the BLS data as price proxies, which are grouped in one of the three BLS categories. The categories are Producer Price Indexes (PPIs), Consumer Price Indexes (CPIs), and Employment Cost Indexes (ECIs), discussed in detail in the FY 2006 IPPS final rule (70 FR 47388 through 47391). We evaluate the price proxies using the criteria of reliability, timeliness, availability, and relevance. The PPIs, CPIs, and ECIs selected by us and used for this proposed rule meet these criteria as described in the FY 2006 IPPS final rule. We believe they continue to be the best measures of price changes for the cost categories. Beginning April 2006 with the publication of March 2006 data, the BLS' ECI began using a different classification system, the North American Industrial Classification System (NAICS), instead of the Standard Industrial Codes (SIC), which no longer exists. We have consistently used the ECI as the data source for our wages and salaries and other price proxies in the IPPS market basket and are not making any changes to the usage at this time. Thus, we propose to use the BLS-NAICS-based ECIs as price proxies in the market basket. IV. Other Decisions and Proposed Changes to the IPPS for Operating Costs and GME Costs A. Reporting of Hospital Quality Data for Annual Hospital Payment Update (§ 412.64(d)(2)) (If you choose to comment on issues in this section, please include the caption “Hospital Quality Data” at the beginning of your comment.) 1. Background Section 5001(a) of the Deficit Reduction Act of 2005, Pub. L. 109-171 
                        ( print page 24803)
                        (DRA), set out new requirements for the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program. We established the RHQDAPU program in order to implement section 501(b) of Pub. L. 108-173. It builds on our ongoing voluntary Hospital Quality Initiative which is intended to empower consumers with quality of care information to make more informed decisions about their health care while also encouraging hospitals and clinicians to improve their quality of care. Section 5001(a) of the DRA revised the mechanism used to update the standardized amount for payment for hospital inpatient operating costs. Specifically, sections 1886(b)(3)(B)(viii)(I) and (II) of the Act provide that the payment update for FY 2007 and each subsequent fiscal year will be reduced by 2.0 percentage points for any “subsection (d) hospital” (that is, a hospital paid under the IPPS) that does not submit certain quality data in a form and manner, and at a time, specified by the Secretary. Sections 1886(b)(3)(B)(viii)(III) and (IV) of the Act required that we expand the “starter set” of 10 quality measures established by the Secretary as of November 1, 2003, provided certain requirements were met. In expanding this set of measures, section 1886(b)(3)(B)(viii)(IV) of the Act provides that we must begin to adopt the baseline set of performance measures as set forth in a 2005 report issued by the Institute of Medicine (IOM) of the National Academy of Sciences under section 238(b) of the MMA,[17]
                        
                         effective for payments beginning with FY 2007. The IOM measures include: Hospital Quality Alliance (HQA) quality measures (the HQA is a public-private collaboration to improve the quality of care provided by the nation's hospitals by measuring and publicly reporting on that care), the HCAHPS patient perspective survey, and three structural measures. The structural measures are: (1) Implementation of computerized provider order entry for prescriptions, (2) staffing of intensive care units with intensivists, and (3) evidence-based hospital referrals. These structural measures constitute the Leapfrog Group's original “three leaps,” and are part of the National Quality Forum's 30 Safe Practices for Better Healthcare. Sections 1886(b)(3)(B)(viii)(V) and (VI) of the Act require that, effective for payments beginning with FY 2008, we add other quality measures that reflect consensus among affected parties, and provide the Secretary with the discretion to replace any quality measures or indicators in appropriate cases, such as where all hospitals are effectively in compliance with a measure, or the measures or indicators have been subsequently shown to not represent the best clinical practice. Thus, the Secretary has broad discretion to replace measures on the basis that they are not appropriate. Section 1886(b)(3)(B)(viii)(VII) of the Act requires that we establish procedures for making quality data available to the public after ensuring that a hospital has the opportunity to review, in advance, its data that are to be made public. In addition, this section requires that we report quality measures of process, structure, outcome, patients' perspective on care, efficiency, and costs of care that relate to services furnished in inpatient settings on the CMS Web site. Section 1886(b)(3)(B)(viii)(I) of the Act also provides that any reduction in a hospital's payment update will apply only with respect to the fiscal year involved, and will not be taken into account for computing the applicable percentage increase for a subsequent fiscal year. The starter set of 10 quality measures we established as of November 1, 2003 are as follows: Heart Attack (Acute Myocardial Infarction or AMI) Was aspirin given to the patient upon arrival to the hospital?
                    Was aspirin prescribed when the patient was discharged?
                    Was a beta-blocker given to the patient upon arrival to the hospital?
                    Was a beta-blocker prescribed when the patient was discharged?
                    Was an ACE inhibitor given for the patient with heart failure? Heart Failure (HF) Did the patient get an assessment of his or her heart function?
                    Was an ACE inhibitor given to the patient? Pneumonia (PNE) Was an antibiotic given to the patient in a timely way?
                    Had the patient received a pneumococcal vaccination?
                    Was the patient's oxygen level assessed? We adopted these measures after the Secretary of HHS joined in a partnership with several collaborators intended to promote hospital quality improvement and public reporting of hospital quality information. These collaborators included the American Hospital Association, the Federation of American Hospitals, the Association of American Medical Colleges, the Joint Commission on Accreditation of Healthcare Organizations (the Joint Commission), the National Quality Forum (NQF), the American Medical Association, the Consumer-Purchaser Disclosure Project, the AARP, the American Federation of Labor-Congress of Industrial Organizations, the Agency for Healthcare Research and Quality (AHRQ), as well as CMS and others. This collaboration, originally known as the National Voluntary Hospital Reporting Initiative, is now known as the HQA. This starter set of 10 quality measures was endorsed by the NQF. NQF is a voluntary consensus standard-setting organization established to standardize health care quality measurement and reporting through its consensus development process. In addition, this starter set is a subset of measures currently collected for The Joint Commission as part of its certification program. We chose these 10 quality measures in order to collect data that will: (1) Provide useful and valid information about hospital quality to the public; (2) provide hospitals with a sense of predictability about public reporting expectations; (3) begin to standardize data and data collection mechanisms; and (4) foster hospital quality improvement. Hospitals submit quality data through the QualityNet Exchange secure Web site (
                        *http://www.qnetexchange.org*). We believe that this Web site meets or exceeds all current Health Insurance Portability and Accountability Act requirements for security of personal health information. Data from this initiative are used to populate the 
                        *Hospital Compare*
                         Web site, 
                        *http://www.hospitalcompare.hhs.gov.*
                         This Web site assists beneficiaries and the general public by providing information on hospital quality of care for consumers who need to select a hospital. It further serves to encourage consumers to work with their doctors and hospitals to discuss the quality of care they provide to patients, thereby providing an additional incentive to improve their quality of that care. In the FY 2007 IPPS final rule (71 FR 48137), we amended our regulations at § 412.64(d)(2) to reflect the 2.0 percentage point reduction in the payment update for FY 2007 and subsequent fiscal years for hospitals that do not comply with requirements for reporting quality data as provided for under section 5001(a) of the DRA. We also added 11 additional quality 
                        ( print page 24804)
                        measures to the 10 measure starter set to establish an expanded set of 21 quality measures (71 FR 48029 through 48037). These 21 measures are as follows: Topic
Quality measureHeart 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 status.Surgical Care Improvement Project (SCIP)—named SIP for discharges prior to July 2006 (3Q06)
• Prophylactic antibiotic received within 1 hour prior to surgical incision.• Prophylactic antibiotics discontinued within 24 hours after surgery end time.*Measure included in 10 measure starter set.
 In addition, in the FY 2007 IPPS final rule (71 FR 48031 through 48044), we set out RHQDAPU program procedures for data submission, program withdrawal, data validation, attestation, public display of hospitals' quality data, and reconsiderations. In response to public comments, we required that reporting of the expanded quality measures begin with discharges occurring on or after the third calendar quarter of 2006 (July through September discharges). We also responded to public comments regarding whether we should establish more structured reconsideration procedures for FY 2008 and what such procedures might include. Under section 1886(b)(3)(B)(viii)(V) of the Act, for payments beginning with FY 2008, we are required to add other measures that reflect consensus among affected parties, and, to the extent feasible and practicable, we must include measures set forth by one or more national consensus building entities. 2. FY 2008 Quality Measures Commenters on the FY 2007 IPPS proposed rule requested that we notify the public as far in advance as possible of any proposed expansions of the measurement set and program procedures in order to encourage broad collaboration and to give hospitals time to prepare for any anticipated change. Taking these concerns into account, in the CY 2007 OPPS final rule (71 FR 68201), we adopted additional quality measures for the FY 2008 update. The six additional measures we adopted are as follows: HCAHPS survey
                    SCIP Quality Measures —SCIP-VTE 1: Venous thromboembolism (VTE) prophylaxis ordered for surgery patient —SCIP-VTE 2: VTE prophylaxis within 24 hours pre/post surgery —SCIP Infection 2: Prophylactic antibiotic selection for surgical patients Mortality (Medicare Patients) —Acute Myocardial Infarction 30-day mortality Medicare patients —Heart Failure 30-day mortality Medicare patients For the FY 2008 payment determination, hospitals are required to report the following 27 measures: Topic
Quality measureHeart 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.*( print page 24805)• Discharge instructions.**• Adult smoking cessation advice/counseling.**Pneumonia (PNE)
• Initial antibiotic received within 4 hours of hospital arrival.*• Oxygenation assessment.*• Pneumococcal vaccination status.*• Blood culture performed before first antibiotic received in hospital.**• Adult smoking cessation advice/counseling.**• Appropriate initial antibiotic selection.**• Influenza vaccination status.**Surgical Care Improvement Project (SCIP)—named SIP for discharges prior to July 2006 (3Q06)
• Prophylactic antibiotic received within 1 hour prior to surgical incision.**• Prophylactic antibiotics discontinued within 24 hours after surgery end time.**• SCIP-VTE 1: Venous thromboembolism (VTE) prophylaxis ordered for surgery patients.***• SCIP-VTE 2: VTE prophylaxis within 24 hours pre/post surgery.***• SCIP Infection 2: Prophylactic antibiotic selection for surgical patients.***Mortality Measures (Medicare patients)
• Acute Myocardial Infarction 30-day mortality Medicare patients.***• Heart Failure 30-day mortality Medicare patients.***Patients' Experience of Care
• HCAHPS patient survey.****Measure included in 10 measure starter set.**Measure included in 21 measure expanded set.*** Measure added in CY 2007 OPPS final rule.
 We did not adopt any other new RHQDAPU measures for FY 2008. 3. New Quality Measures and Program Requirements for FY 2009 and Subsequent Years a. Proposed New Quality Measures for FY 2009 and Subsequent Years We are proposing to add 1 outcome measure and 4 process measures to the existing 27 measure set to establish a new set of 32 quality measures to be used for the FY 2009 annual payment determination. We plan to adopt these measures a year in advance in order to provide additional time for hospitals to prepare for changes related to the RHQDAPU program. We are proposing to add the following quality measures for the FY 2009 RHQDAPU program. Pneumonia 30-day Mortality (Medicare patients)
                    SCIP Infection 4: Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose
                    SCIP Infection 6: Surgery Patients with Appropriate Hair Removal
                    SCIP Infection 7: Colorectal Patients with Immediate Postoperative Normothermia
                    SCIP Cardiovascular 2: Surgery Patients on a Beta-Blocker Prior to Arrival Who Received a Beta-Blocker During the Perioperative Period The above measures reflect our continuing commitment to quality improvement in both clinical care and patient safety. These additional measures also demonstrate our commitment to include in the RHQDAPU program only those quality measures that reflect consensus among the affected parties and that have been reviewed by a consensus building process. The proposed measures have been put forth by the HQA for inclusion in its public reporting set, contingent on endorsement by the NQF. (In the case of SCIP Infection 7, the HQA recently withdrew its previous support unless the measure receives NQF endorsement.) We anticipate that the NQF will endorse these measures prior to the publication of the FY 2008 IPPS final rule. Any measure that has not been endorsed by that time will not be finalized in that rule. CMS requests public comment on these five measures, as well as whether to add other measures to the RHQDAPU program measure set for FY 2009 and subsequent years. CMS may, based on comments received, include one or more of the measures discussed below in the RHQDAPU program measure set for FY 2009 payments. We will finalize the FY 2009 RHQDAPU measure set in the FY 2008 IPPS final rule. The following table contains a list of 18 measures and 8 measure sets from which additional quality measures could be selected for inclusion in the RHQDAPU program. It includes measures and measure sets that highlight CMS' interest in improving patient safety and outcomes of care, with a particular focus on the quality of surgical care and patient outcomes. In order to engender a broad review of potential performance measures, the list includes measures that have not yet been considered for approval by the HQA or endorsement by the NQF consensus review process for public reporting. It also includes measures developed by organizations other than CMS as well as measures that are to be derived from administrative data (such as claims) that may need to be modified for specific use by the Medicare program if implemented under the RHQDAPU program. We hope to receive comment from a broad set of stakeholders on the measures and measure sets that are listed, as well as any critical gaps or “missing” measures or measure sets. We specifically requests input concerning the following: Which of the measures or measure sets should be included in the FY 2009 RHQDAPU program or in subsequent years?
                    What challenges for data collection and reporting are posed by the identified measures and measure sets? What improvements could be made to data collection or reporting that might offset or otherwise address those challenges?( print page 24806) Possible Measures and Measure Sets for the RHQDAPU Program for FY 2009 and Subsequent Years
Measure
Clinical condition**Intensive Care Unit (ICU) Critical Care Measures**1
Stress Ulcer Disease Prophylaxis
ICU/critical care.2
Urinary Catheter-Associated Urinary Tract Infection For Intensive Care Unit (ICU) Patients
ICU/critical care.**Readmission Measures**3
Readmission Heart Failure (HF) Within 30 Days Rate—Medicare Only (CMS Methodology)
Efficiency/HF.4
Readmission (same hospital) Acute Myocardial Infarction (AMI) Within 30 Days Rate
Efficiency/AMI.5
Readmission (same hospital) PNE Within 30 Days Rate
Efficiency/PNE.6
Readmission Within 30 Days Of Surgery—Medicare Only (SCIP Global-2)
Surgical Care.**NQF—Nursing Sensitive Condition Set (Outcomes Measures Only)**7
Failure To Rescue—Nursing Sensitive Measure
Patient centered.8
Pressure Ulcer Prevalence—Nursing Sensitive Measure
Patient centered.9
Patient Falls Prevalence—Nursing Sensitive Measure
Patient centered.10
Patient Falls With Injury—Nursing Sensitive Measure
Patient centered.**Cancer (Inpatient) Measures**11
Patients With Early Stage Breast Cancer Who Have Evaluation Of The Axilla
Cancer—Breast.12
College Of American Pathologists Breast Cancer Protocol
Cancer—Breast.13
Surgical Resection Includes At Least 12 Nodes (ACOS-02)
Cancer—Colon.14
College Of American Pathologists Colon And Rectum Protocol
Cancer—Colon.15
Completeness Of Pathologic Reporting (CCO-04)
Cancer—Colon.**Leapfrog Leaps, identified by IOM and Deficit  Reduction Act**16
Use Of Computerized Physician Order Entry (CPOE) Systems
Patient safety.17
Use of Intensivists in ICUs/ICU Physician Staffing (IPS)
Patient safety.18
Evidence-Based Hospital Referrals
Patient Safety.**Measure Sets of Potential Interest (Individual measures not specified in this proposed rule)****Sets Under Active Review by National Quality Forum (NQF)**1
Healthcare-Associated Infection measures—under consideration by the NQF National Voluntary Consensus Standards for Reporting of Healthcare-associated  Infections Data Project
Patient Safety.2
Readmission Rates by Condition—under consideration by NQF National Voluntary Consensus Standards for Hospital Care: Additional Priorities, 2007 Project
Efficiency.3
Average Length of Stay (ALOS) by Condition—under consideration by NQF National Voluntary Consensus Standards for Hospital Care: Additional Priorities, 2007 Project
Efficiency.4
AHRQ Quality Indicators, including Patient Safety Indicators—under consideration by NQF National Voluntary Consensus Standards for Hospital Care:  Additional Priorities, 2007 Project
Patient Safety, various conditions.**Measure Sets/Practices Previously Endorsed by NQF**5
Safe Practices for Better Healthcare
Patient Safety.6
Serious Reportable Events in Healthcare (“Never Events”)
Patient Safety.**Other Hospital Measure Sets**7
Hospital Emergency Department Measures
Various.8
Vascular Surgery Complications (for Carotid Endarterectomy, Lower Extremity Bypass, Open Surgery Abdominal Aortic Aneurysm Repair, Endovascular  Abdominal Aortic Aneurysm Repair)
Surgical Care.
 b. Data Submission In order to be eligible for the full FY 2009 market basket update, we are proposing that hospitals will be required to submit data on 32 measures (the 27 existing measures plus the 5 proposed new measures). The technical specifications for this requirement are published in the CMS/Joint Commission Specifications Manual for National Hospital Quality Measures. This manual can be found on the QualityNet.org Web site. For the additional SCIP measures that we are proposing to add through this rule, (SCIP Infection 4, 6, and 7 and SCIP-Card-2), hospitals will be required to submit data to the QIO Clinical Warehouse starting with discharges that occur in CY 2008. We are proposing that the deadline for hospitals to submit this data for first calendar quarter of 2008 would be August 15, 2008. Data must be submitted for each subsequent quarter by 4.5 months after the end of the quarter. We are proposing this time period to allow hospitals sufficient time to prepare for the data collection. The three SCIP Infection measures that we are proposing to include for FY 2009 were added to the Manual in version 2.0, effective with third calendar quarter of 2006 (3Q06) and the proposed SCIP Cardiovascular measure was added in version 2.1d of the Manual, effective with fourth calendar quarter of 2006 
                        ( print page 24807)
                        (4Q06). Hospitals may report data on these measures for discharges prior to CY 2008 discharges, if they so choose. For the proposed Pneumonia 30-day Mortality measure, we are proposing to use claims data that are already being collected for index hospitalizations to calculate the mortality rates. As is the case with the other 30-day mortality (outcome) measures already associated with the RHQDAPU program (AMI, HF), hospitals need not submit additional data. Claims data submitted to CMS for index hospitalizations occurring from July 2006 through June 2007 (3Q06 through 2Q07) will be used to calculate the Pneumonia 30-day mortality rate that will be used for FY 2009 annual payment determination. All measures that we have previously finalized, and that we finalize in the future through the rulemaking process, will be required for the RHQDAPU program annual payment determination each year until further notice. CMS, working in conjunction with The Joint Commission, maintains the specifications for the set of measures used both for the RHQDAPU program and for reporting under the HQA initiative. The specifications are updated semiannually and changes are made prospectively, except in exceptional circumstances. Revised specifications can be found at 
                        *http://www.qualitynet.org*. 4. Retiring or Replacing RHQDAPU Program Quality Measures Over time, CMS expects that the set of measures used for the RHQDAPU program will evolve and change. New measures will be added to reflect clinical and other program goals. Measures that are no longer supported by clinical evidence would be modified or dropped. Through its public reporting and RHQDAPU program activities, CMS seeks to balance the competing goals of assuring the development of a comprehensive yet parsimonious set of quality measures while reducing reporting burden on hospitals. Section 1886(b)(3)(B)(viii)(VI) of the Act gives the Secretary authority to replace any measures or indicators in appropriate cases, such as where all hospitals are effectively in compliance or the measures or indicators have been subsequently shown not to represent the best clinical practice. CMS recognizes the need to develop a process related to the retirement and/or replacement of measures that comprise the RHQDAPU program measure set. In this proposed rule, we solicit public comment and suggestions concerning the criteria and mechanism for a process that would identify and, where appropriate, retire or replace measures that comprise the RHQDAPU program measure set. 5. Procedures for the RHQDAPU Program for FY 2008 and FY 2009 a. Procedures for Participating in the RHQDAPU Program The “Reporting Hospital Quality Data for Annual Payment Update Reference Checklist” section of the QualityNet Exchange Web site contains all of the forms to be completed by hospitals participating in the program. In order to participate in the hospital reporting initiative for FY 2008, hospitals must follow these steps: Identify a QualityNet Exchange Administrator who follows the registration process and submits the information through the QIO Clinical Warehouse. This must be done regardless of whether the hospital uses a vendor for transmission of data.
                    Complete the revised “Reporting Hospital Quality Data for Annual Payment Update Notice of Participation” form. These hospitals must send this form to their QIO, no later than August 15, 2007. In effort to alleviate the burden associated with submitting this form annually, we are proposing that a hospital that submits this form will be considered an active RHQDAPU program participant until such time as the hospital submits a withdrawal form to CMS. In addition, before participating hospitals initially begin reporting data, they must register with the QualityNet Exchange, regardless of the method used for submitting data. Collect and report data for 24 of the 27 required measures (listed in Table—under the following headings: Acute Myocardial Infarction, Heart Failure, Pneumonia and SCIP). A hospital must report this data for discharges occurring in or after first quarter CY 2007. Hospitals must submit the data to the QIO Clinical Warehouse either using the CMS Abstraction & Reporting Tool (CART), the JCAHO ORYX® Core Measures Performance Measurement System, or using another third-party vendor tool that has met the measurement specification requirements for data transmission to QualityNet Exchange. All submissions will be executed through QualityNet Exchange. Because the information in the QIO Clinical Warehouse is considered QIO information, it is subject to the stringent QIO confidentiality regulations in42 CFR part 480. The QIO Clinical Warehouse will submit the data to CMS on behalf of the hospitals.
                    For each quality measure that requires hospitals to collect and report data, submit complete data regarding the quality measures in accordance with the joint CMS/Joint Commission sampling requirements located on the QualityNet Exchange Web site. These requirements specify that hospitals must submit a random sample or complete population of cases for each of topics covered by the quality measures. Hospitals must meet these sampling requirements for these quality measures for discharges in each quarter.
                    Submit aggregate population and sample size counts for Medicare and non-Medicare discharges for the four topic areas (AMI, HF, PNE, and SCIP) on a quarterly basis to CMS.
                    Continuously collect HCAHPS data beginning with July 2007 discharges in accordance with the HCAHPS Quality Assurance Guidelines, Version 2.0, located at*http://www.hcahpsonline.org*. The CY 2007 OPPS rule required HCAHPS-eligible hospitals to participate in the March 2007 dry run of the HCAHPS survey, if they have not already participated in a previous dry run. Hospitals must submit HCAHPS dry run data to the QIO Clinical Warehouse by July 13, 2007. As part of the March 2007 dry run, hospitals were required to survey HCAHPS-eligible discharges between 48 hours and 6 weeks following hospital discharge.
                    For the AMI 30-day and HF 30-day mortality measures, CMS will use Part A and Part B claims for Medicare fee-for-service patients to calculate the mortality measures. For FY 2008, hospital inpatient claims (Part A) from July 1, 2005 to June 30, 2006 will be used to identify the relevant patients and the index hospitalizations. Inpatient claims for the index hospitalization and Part A and Part B claims for all inpatient, outpatient and physician services received one year prior to the index hospitalizations are used to determine patient comorbidity, which is used in the risk adjustment calculation (see*http://www.qualitynet.org/​dcs/​ContentServer?​cid=​1163010398556&​pagename=​QnetPublic%2FPage%2FQnetTier2&​c=​Page*). No other hospital data submission is required to calculate the mortality rates. b. Procedures for Participating in the RHQDAPU Program for FY 2009 For FY 2009, the requirements for FY 2008 discussed above will apply, except that hospitals will be required to collect and report data on any additional measures that we finalize through the rulemaking process and for which we specify that data submission is required. Mortality measures will be expanded to 
                        ( print page 24808)
                        include pneumonia pending final NQF endorsement. c. Chart Validation Requirements (1) FY 2008 Validation Requirements For the FY 2008 update, and until further notice, we will continue to require that hospitals meet the chart validation requirements that we implemented in the FY 2006 IPPS final rule. There were no chart-audit validation criteria in place for FY 2005. Based upon our experience with the FY 2005 submissions and our requirement for reliable and validated data, in the FY 2006 IPPS final rule we discussed additional requirements that we had established for the data that hospitals were required to submit in order to receive the full FY 2006 payment update (70 FR 47421 and 47422). These requirements, as well as additional information on validation requirements, will continue and are being placed on the QualityNet Exchange Web site. For the FY 2008 payment update, and until further notice, hospitals must pass our validation requirement of a minimum of 80 percent reliability, based upon our chart-audit validation process, for the first three quarters of data from CY 2006. These data are due to the QIO Clinical Warehouse by August 15, 2006 (first quarter CY 2006 discharges), November 15, 2006 (second quarter CY 2006 discharges), and February 15, 2007 (third quarter CY 2006 discharges). We use confidence intervals to determine if a hospital has achieved an 80-percent reliability aggregated over the three quarters. The use of confidence intervals allows us to establish an appropriate range below the 80-percent reliability threshold that demonstrates a sufficient level of reliability to allow the data to still be considered validated. We estimate the percent reliability based upon a review of five charts, and then calculate the upper 95-percent confidence limit for that estimate. If this upper limit is above the required 80-percent reliability, the hospital data are considered validated. We are using the design-specific estimate of the variance for the confidence interval calculation, which, in this case, is a stratified single stage cluster sample, with unequal cluster sizes. (For reference, see Cochran, William G.: Sampling Techniques, John Wiley & Sons, New York, chapter 3, section 3.12 (1977); and Kish, Leslie.: Survey Sampling, John Wiley & Sons, New York, chapter 3, section 3.3 (1964).) Each quarter is treated as a stratum for variance estimation purposes. We will use a two-step process to determine if a hospital is submitting valid data. In the first step, we calculate the percent agreement for all of the variables submitted in all of the charts. If a hospital falls below the 80-percent cutoff, we proceed to the second step and restrict the comparison to those variables associated with payment. For first and second quarter CY 2006 discharges (1Q06, 2Q06), that means we limit the calculations to the 10-measure starter set. For third quarter CY 2006 discharges (3Q06), we include 21 measures. We recalculate the percent agreement and the estimated 95-percent confidence interval and again compare to the 80-percent cutoff point. If a hospital passes under this restricted set of variables, the hospital is considered to be submitting valid data for purposes of the RHQDAPU program. Due to time constraints, we will not apply the validation requirement for the FY 2008 update to 3 SCIP measures that are included in the RHQDAPU measure set, Infection 2, VTE 1 and VTE 2. For HCAHPS, hospitals and survey vendors must participate in a quality oversight process conducted by the HCAHPS project team. Prior to July 2007, the purpose of the oversight activities will be to provide feedback to hospitals and survey vendors on data collection procedures. Starting in July 2007, we may ask hospitals/survey vendors to correct any problems that are found and provide follow-up documentation of corrections for review within a defined time period. If the HCAHPS project team finds that the hospital has not made these corrections, CMS may determine that the hospital is not submitting appropriate HCAHPS data for the RHQDAPU program. As part of these activities, HCAHPS project staff will review and discuss with survey vendors and hospitals self-administering the survey their specific Quality Assurance Plans, survey management procedures, sampling and data collection protocols, and data preparation and submission. This review may take place in-person or through other means of communication. (2) FY 2009 Chart Validation Requirements For the FY 2009 update, all 2008 requirements apply, except for the following modifications. We will modify the validation requirement to pool the quarterly validation estimates for 4th quarter CY 2006 through 3rd quarter 2007 discharges. We will also expand the list of validated measures in the FY 2009 update to add SCIP Infection-2, SCIP VTE-1, and SCIP VTE-2 starting with 4th quarter CY 2006 discharges. We will also drop the current two-step process to determine if the hospital is submitting valid data. We propose for the FY 2009 update to pool validation estimates covering the 4 quarters (4th quarter CY 2006 discharges through 3rd quarter 2007 discharges) in a similar manner to the current 3 quarter pooled confidence interval. (3) Validation and Submission Requirements We plan to apply the validation and submission requirements for FY 2008 and FY 2009 payment determination for the quality measures. For the validation and submission requirements for the FY 2008 payment year, we plan to use the following: The 10 measure starter set for both submission and validation for 1st through 3rd quarters CY 2006 discharges.
                    The additional 11 measures that make up the expanded measure set for both submission and validation for 3rd quarter CY 2006 discharges.
                    SCIP VTE 1, 2, and SCIP Infection 2 submission only for 1Q 2007 discharges only.
                    HCAHPS measures, both submission of dry run data and continuous submission beginning with July 2007 discharges.
                    AMI and HF 30-day mortality measures as described previously. For FY 2009 payment year, we plan to use the following:
                    The 21 expanded measure set for submission and validation starting with fourth quarter CY 2006 (4Q06) through third quarter CY 2007 discharges.
                    SCIP VTE 1, 2, and SCIP Infection 2 submission and validation second quarter CY 2007 and 3rd Quarter CY 2007 discharges.
                    HCAHPS measures, continuous submission.
                    AMI, HF, and PN 30-day mortality measures as described previously. As additional measures are finalized for inclusion in the FY 2009 payment decision, we anticipate making changes to the above plan to incorporate those measures. c. Data Validation and Attestation For the FY 2008 update and in subsequent years, we will revise and post up-to-date confidence interval information on the QualityNet Exchange Web site explaining the application of the confidence interval to the overall validation results. The data are being validated at several levels. There are consistency and internal edit checks to ensure the integrity of the submitted data; there are external edit checks to 
                        ( print page 24809)
                        verify expectations about the volume of the data received. We will require for FY 2008 and subsequent years that hospitals attest each quarter to the completeness and accuracy of their data, including the volume of data, submitted to the QIO Clinical Warehouse in order to improve aspects of the validation checks. We will provide additional information to explain this attestation requirement, as well as provide the relevant form to be completed on the QualityNet Exchange Web site. d. Public Display We will continue to display quality information for public viewing as required by section 1886(b)(3)(B)(viii)(VII) of the Act. Before we display this information, hospitals will be permitted to review their information as recorded in the QIO Clinical Warehouse. Currently, hospitals that share the same Medicare Provider Number (MPN) must combine data collection and submission across their multiple campuses (for both clinical measures and for HCAHPS). These measures are then publicly reported as if they apply to a single hospital. We estimate that approximately 5 to 10 percent of the hospitals reported on the 
                        *Hospital Compare*
                         Web site share MPNs. For FY 2008 and subsequent years, we are proposing to require hospitals to begin to report the name and address of each hospital that shares the same MPN. This information will be gathered through the RHQDAPU program Notice of Participation form, which hospitals will submit to their QIOs by August 15, 2007. To increase transparency in public reporting and improve the usefulness of 
                        *Hospital Compare,*
                         CMS plans to note on the Web site where publicly reported measures combine results from two or more hospitals. e. Reconsideration and Appeal Procedures If we deny a hospital the full market basket update, the hospital may submit a letter requesting that we reconsider our decision that the hospital did not meet the RHQDAPU program requirements. For FY 2008, a hospital must submit such a request for reconsideration on or before November 1, 2007. We also are establishing additional procedural rules that will govern RHQDAPU program reconsiderations. We will post these rules on the QualityNet Exchange Web site. If a hospital is dissatisfied with the result of a RHQDAPU program reconsideration, the hospital may file a claim under 42 CFR Part 405, Subpart R (a Provider Reimbursement Review Board (PRRB) appeal). In this proposed rule we are again soliciting public comment and suggestions related to reconsideration. f. RHQDAPU Program Withdrawal Requirements For the FY 2008 update, hospitals may withdraw from the RHQDAPU program at any time up to August 15, 2007. If a hospital withdraws from the program, it will receive a 2.0 percentage point reduction in its payment update. 6. Electronic Medical Records In the FY 2006 IPPS final rule, we encouraged hospitals to take steps toward the adoption of electronic medical records (EMRs) that will allow for reporting of clinical quality data from the EMRs directly to a CMS data repository (70 FR 47420). We intend to begin working toward creating measures specifications and a system or mechanism, or both, that will accept the data directly without requiring the transfer of the raw data into an XML file as is currently done. The Department continues to work cooperatively with other Federal agencies in the development of Federal health architecture data standards. We encouraged hospitals that are developing systems to conform them to both industry standards and, when developed, the Federal Health Architecture Data standards, and to ensure that the data necessary for quality measures are captured. Ideally, such systems will also provide point-of-care decision support that enables high levels of performance on the measures. Hospitals using EMRs to produce data on quality measures will be held to the same performance expectations as hospitals not using EMRs. Due to the low volume of comments we received on this issue in response to the FY 2006 proposed IPPS rule, in the proposed IPPS rule for FY 2007 (71 FR 24095), we again invited comments on these requirements and options. In the FY 2007 IPPS final rule, we summarized and addressed the additional comments we received. We would welcome additional comments on this issue. 7. New Hospitals In addition, we are proposing a minor change to our policies regarding new hospitals. In the FY 2006 IPPS final rule, we noted that a new hospital should begin collecting and reporting data immediately and complete the registration requirements for the RHQDAPU. (70 FR 47421 and 47428). We also explained that a new hospital would be held to the same standard as established facilities when determining the expected number of discharges for the calendar quarters covered for each fiscal year. We also stated that fiscal intermediaries would provide information on new hospitals to the QIO in the state in which the hospital has opened for operations as a Medicare provider as soon as possible so that the QIO can enter the provider information into its Program Resource System (PRS) and follow through with ensuring provider participation with the requirements for quality data reporting under this rule. We believe that some new hospitals have found it difficult to start reporting RHQDAPU measures immediately after signing up to participate in the RHADAPU program. Therefore, we are proposing a modification to our policy to reduce burden on new hospitals. We are proposing that the fiscal intermediary would continue to provide information on the new hospital to the QIO in the state in which the hospital is located as soon as possible so that the QIO could enter the provider information into its PRS and follow through with ensuring provider participation with the requirements for quality data reporting. However, for a new hospital that receives a provider number on or after October 1st of each year (beginning with October 1, 2007), we are proposing that the hospital would be required to report RHQDAPU data beginning with the first day of the quarter following the date the hospital registers to participate in the RHQDAPU program. For example, a hospital that receives its MPN on October 2, 2007 and signs up to participate in RHQDAPU on November 1, 2007 will be expected to meet all data submission requirements for discharges on or after January 1, 2008. B. Development of the Medicare Hospital Value-Based Purchasing Plan (If you choose to comment on issues in this section, please include the caption “Value-Based Purchasing Plan” at the beginning of your comment.) Section 5001(b) of the DRA specifies that CMS develop a plan to implement a Value-Based Purchasing (VBP) Program for payments under the Medicare program for subsection (d) hospitals beginning with FY 2009. Congress specified that the “plan” include consideration of the following issues: The ongoing development, selection, and modification process for measures of quality and efficiency in hospital inpatient settings.( print page 24810)
                    The reporting, collection, and validation of quality data.
                    The structure of value-based payment adjustments, including the determination of thresholds or improvements in quality that would substantiate a payment adjustment, the size of such payments, and the sources of funding for the value-based payments.
                    The disclosure of information on hospital performance. In developing the plan, we must consult with relevant affected parties and consider experience with demonstrations that are relevant to the value-based purchasing program. We have created an internal Hospital Pay-for-Performance Workgroup that is charged with developing the VBP Plan for Medicare hospital services. The workgroup is organized into four subgroups to address each of the required planning issues: (1) measures; (2) data collection and validation; (3) incentive structure; and (4) public reporting. The workgroup has been charged with preparing a set of design options, narrowing the set of design options to prepare a draft plan, and preparing the final plan for implementing VBP for Medicare hospital services that will be provided to Congress. CMS is hosting two public “Listening Sessions” in early 2007 to solicit comments from relevant affected parties on outstanding design questions associated with development of the final plan. The first listening session was held on January 17, 2007, to consider design questions posed in an issues paper that has been posted since December 22, 2006, on the Medicare Web site, Hospital Center, under Spotlights at: 
                        *http://www.cms.hhs.gov/​center/​hospital.asp.*
                         An audio download of the listening session and the PowerPoint slides used during the session are also posted on this Web site. The second listening session will be held on April 12, 2007, to consider the draft plan, which will be posted on the Medicare Web site, Hospital Center, on March 22, 2007. A notice announcing this listening session was published in the 
                        **Federal Register**
                         on February 23, 2007 (71 FR 8179). It is hoped that hospitals, hospital associations, and other interested parties will attend and make comments on the draft plan in person. It will also be possible to participate by teleconference, and limited time will be allocated for verbal comments by telephone participants. Registration to participate in person or by telephone is open until April 5, 2007. The agenda and PowerPoint slides for the session will be posted by April 9, 2007. An audio download of the second listening session will be posted by April 17, 2007. Written comments are welcomed and will be accepted until 5 PM EDT on April 19, 2007. The perspectives expressed during this session and in writing will assist CMS in making revisions to the draft plan to create the final Medicare Hospital Value-Based Purchasing Plan expected to be completed by June 2007. While section 5001(b) of the DRA authorized development of this plan, additional legislation will be required to establish and implement the Medicare Hospital Value-Based Purchasing Program. As described in the draft plan, we proposed that the current RHQDAPU Program will provide the foundation for and be incorporated into the new Medicare Hospital Value-Based Purchasing Program. C. Rural Referral Centers (RRCs) (§ 412.96) (If you choose to comment on issues in this section, please include the caption “RRCs” at the beginning of your comment.) Under the authority of section 1886(d)(5)(C)(i) of the Act, the regulations at § 412.96 set forth the criteria that a hospital must meet in order to qualify under the IPPS as an RRC. For discharges occurring before October 1, 1994, RRCs received the benefit of payment based on the other urban standardized amount rather than the rural standardized amount. Although the other urban and rural standardized amounts are the same for discharges occurring on or after October 1, 1994, RRCs continue to receive special treatment under both the DSH payment adjustment and the criteria for geographic reclassification. Section 402 of Pub. L. 108-173 raised the DSH adjustment for other rural hospitals with less than 500 beds and RRCs. Other rural hospitals with less than 500 beds are subject to a 12-percent cap on DSH payments. RRCs are not subject to the 12-percent cap on DSH payments that is applicable to other rural hospitals (with the exception of rural hospitals with 500 or more beds). RRCs are not subject to the proximity criteria when applying for geographic reclassification, and they do not have to meet the requirement that a hospital's average hourly wage must exceed 106 percent of the average hourly wage of the labor market area where the hospital is located. Section 4202(b) of Pub. L. 105-33 states, in part, “[a]ny hospital classified as an RRC by the Secretary * * * for fiscal year 1991 shall be classified as such an RRC for fiscal year 1998 and each subsequent year.” In the August 29, 1997 final rule with comment period (62 FR 45999), we also reinstated RRC status for all hospitals that lost the status due to triennial review or MGCRB reclassification, but not to hospitals that lost RRC status because they were now urban for all purposes because of the OMB designation of their geographic area as urban. However, subsequently, in the August 1, 2000 final rule (65 FR 47089), we indicated that we were revisiting that decision. Specifically, we stated that we would permit hospitals that previously qualified as an RRC and lost their status due to OMB redesignation of the county in which they are located from rural to urban to be reinstated as an RRC. Otherwise, a hospital seeking RRC status must satisfy the applicable criteria. We used the definitions of “urban” and “rural” specified in Subpart D of 42 CFR Part 412. 1. Proposed Annual Update of RRC Status Criteria One of the criteria under which a hospital may qualify as a RRC is to have 275 or more beds available for use (§ 412.96(b)(1)(ii)). A rural hospital that does not meet the bed size requirement can qualify as an RRC if the hospital meets two mandatory prerequisites (a minimum CMI and a minimum number of discharges) and at least one of three optional criteria (relating to specialty composition of medical staff, source of inpatients, or referral volume) (§ 412.96(c)(1) through (c)(5)). (See also the September 30, 1988 
                        **Federal Register**
                         (53 FR 38513).) With respect to the two mandatory prerequisites, a hospital may be classified as an RRC if— The hospital's CMI is at least equal to the lower of the median CMI for urban hospitals in its census region, excluding hospitals with approved teaching programs, or the median CMI for all urban hospitals nationally; and
                    The hospital's number of discharges is at least 5,000 per year, or, if fewer, the median number of discharges for urban hospitals in the census region in which the hospital is located. (The number of discharges criterion for an osteopathic hospital is at least 3,000 discharges per year, as specified in section 1886(d)(5)(C)(i) of the Act.) a. Case-Mix Index Section 412.96(c)(1) provides that CMS will establish updated national and regional CMI values in each year's annual notice of prospective payment rates for purposes of determining RRC status. The methodology we use to determine the national and regional CMI values is set forth in regulations at § 412.96(c)(1)(ii). The proposed national 
                        ( print page 24811)
                        median CMI value for FY 2008 includes all urban hospitals nationwide, and the regional values for FY 2008 are the median CMI values of urban hospitals within each census region, excluding those hospitals with approved teaching programs (that is, those hospitals receiving indirect medical education payments as provided in § 412.105(f)). These values are based on discharges occurring during FY 2006 (October 1, 2005 through September 30, 2006) and include bills posted to CMS' records through December 2006. We are proposing that, in addition to meeting other criteria, if they are to qualify for initial RRC status for cost reporting periods beginning on or after October 1, 2007, rural hospitals with fewer than 275 beds must have a CMI value for FY 2006 that is at least— 1.2258; or
                    The median CMI value (not transfer-adjusted) for urban hospitals (excluding hospitals with approved teaching programs as identified in § 412.105(f)) calculated by CMS for the census region in which the hospital is located. The proposed median CMI values by region are set forth in the following table: Region
Case-mix  index value1. New England (CT, ME, MA, NH, RI, VT)
1.23892. Middle Atlantic (PA, NJ, NY)
1.26753. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)
1.35244. East North Central (IL, IN, MI, OH, WI)
1.34995. East South Central (AL, KY, MS, TN)
1.29096. West North Central (IA, KS, MN, MO, NE, ND, SD)
1.27807. West South Central (AR, LA, OK, TX)
1.40138. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)
1.42609. Pacific (AK, CA, HI, OR, WA)
1.3722
 The preceding numbers will be revised in the final rule to the extent required to reflect the updated FY 2006 MEDPAR file, which will contain data from additional bills received through March 2007. Hospitals seeking to qualify as RRCs or those wishing to know how their CMI value compares to the criteria should obtain hospital-specific CMI values (not transfer-adjusted) from their fiscal intermediaries. Data are available on the Provider Statistical and Reimbursement (PS&R) System. In keeping with our policy on discharges, these CMI values are computed based on all Medicare patient discharges subject to the IPPS DRG-based payment. b. Discharges Section 412.96(c)(2)(i) provides that CMS will set forth the national and regional numbers of discharges in each year's annual notice of prospective payment rates for purposes of determining RRC status. As specified in section 1886(d)(5)(C)(ii) of the Act, the national standard is set at 5,000 discharges. We are proposing to update the regional standards based on discharges for urban hospitals' cost reporting periods that began during FY 2004 (that is, October 1, 2003 through September 30, 2004), which is the latest available cost report data we have at this time. Therefore, we are proposing that, in addition to meeting other criteria, a hospital, if it is to qualify for initial RRC status for cost reporting periods beginning on or after October 1, 2007, must have as the number of discharges for its cost reporting period that began during FY 2004 a figure that is at least— 5,000 (3,000 for an osteopathic hospital); or
                    The median number of discharges for urban hospitals in the census region in which the hospital is located, as indicated in the following table: Region
Number of  discharges1. New England (CT, ME, MA, NH, RI, VT)
7,7492. Middle Atlantic (PA, NJ, NY)
10,6033. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)
10,5624. East North Central (IL, IN, MI, OH, WI)
9,2095. East South Central (AL, KY, MS, TN)
7,5966. West North Central (IA, KS, MN, MO, NE, ND, SD)
7,9637. West South Central (AR, LA, OK, TX)
7,1678. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)
9,1169. Pacific (AK, CA, HI, OR, WA)
8,420
 These numbers will be revised in the FY 2008 IPPS final rule based on the latest available cost report data. We note that the median number of discharges for hospitals in each census region is greater than the national standard of 5,000 discharges. Therefore, 5,000 discharges is the minimum criterion for all hospitals. We reiterate that if an osteopathic hospital is to qualify for RRC status for cost reporting periods beginning on or after October 1, 2007, the hospital would be required to have at least 3,000 discharges for its cost reporting period that began during FY 2004. 2. Acquired Rural Status and RRCs (§ 412.103(g)) With the following exceptions, a hospital must be rural to qualify as an RRC: Consistent with section 4202(b) ofPub. L. 105-33, any hospital designated as an RRC in FY 1991 retains that status for FY 1998 and each subsequent year.
                    Hospitals located in a rural county that would have lost their RRC status as a result of an OMB redesignation of the area from rural to urban were permitted to remain as RRCs (69 FR 49056).
                    Hospitals located in urban areas that apply for reclassification as rural under § 412.103 (that is, the hospital is located in an urban area but it( print page 24812)
                        “acquires” rural status under the regulations) also may qualify as RRCs. Under § 412.103(g), a hospital may cancel its rural reclassification by submitting a written request to the CMS Regional Office no less than 120 days prior to the end of its current cost reporting period. A hospital may choose to cancel its acquired rural status if it determines it may be more financially beneficial to return to urban status and the associated IPPS payments rather than remain rural and receive the special treatments of certain rural providers such as RRCs, SCHs and CAHs. The hospital's acquired rural status is canceled beginning with its next cost reporting period. We have received inquiries asking whether a hospital retains its RRC status once it voluntarily cancels its acquired rural status. As indicated above, a hospital generally must be rural to be classified as an RRC. However, a hospital may retain its RRC status only in the special circumstances where it would have lost status due to OMB redesignation of its area from rural to urban, or where it was already designated as an RRC in 1991. In these situations, there were either special statutory provisions that require the hospital to retain its RRC status or the hospital's geographic status changed from rural to urban through no action of its own. We do not believe that an urban hospital that acquires rural status under § 412.103 and subsequently is approved as an RRC should be able to retain the benefits of being an RRC when it voluntarily cancels that acquired rural status. For this reason, Medicare's policy has been that a hospital cannot continue to be an RRC once it cancels acquired rural status under § 412.103. It follows from the requirement that an RRC must be located in a rural area that cancellation of acquired rural status negates a hospital's RRC designation. In this proposed rule, we are clarifying our current policy that a hospital that cancels its acquired rural status, received under § 412.103, would also lose its RRC designation under § 412.96. In this situation, the hospital would lose its RRC designation under § 412.96 as of the date the cancellation of its acquired rural status takes effect. As indicated above, RRCs are not subject to a maximum DSH adjustment of 12 percent that applies to other rural hospitals with less than 500 beds. Further, RRCs are not subject to the proximity criteria when applying for geographic reclassification (§ 412.230(a)(3)), and they do not have to meet certain wage comparison tests for reclassification (§ 412.230(d)(1)(iii)). A hospital located in an urban area that cancels its acquired rural status under § 412.103 loses its RRC status and would become subject to a 12-percent cap on the DSH adjustment applicable to urban hospitals with less than 100 beds (if the hospital has 100 beds or more, it would not be subject to the cap on the DSH adjustment). Further, the hospital would also have to meet the proximity requirement for geographic reclassification at § 412.230(a)(3). We note that the hospital would maintain the benefit of being exempt from the average hourly wage criterion for geographic reclassification requiring the comparison of the hospital's wages to the wages of the area in which it is located, as stated in section 1886(d)(10)(D)(iii) of the Act. We are also proposing to revise the regulations at § 412.103(g) with respect to when cancellation of acquired rural status becomes effective. Currently, § 412.103(g)(2) states “The hospital's cancellation of the classification is effective beginning with the hospital's next full cost reporting period following the date of its request for cancellation.” While this policy is appropriate for hospitals paid under reasonable costs, such as CAHs, it is inconsistent with the IPPS that makes changes prospectively on the basis of a Federal fiscal year. In addition, to address concerns that some IPPS hospitals are acquiring rural status solely to benefit from reclassification rules applying to hospitals that were once RRCs and then canceling that rural status within a short period of time, such as a few months, we are proposing to require IPPS hospitals to retain acquired rural status for at least one 12-month cost reporting period. If the hospital chooses to cancel its rural reclassification, the effective date of that cancellation would occur both after at least one 12-month cost reporting period and at the start of the next Federal fiscal year. Thus, for example, if a hospital with a cost reporting period from July 1, 2008, to June 30, 2009, becomes rural on May 30, 2008, its acquired rural status under § 412.103 would remain in effect from May 30, 2008, through at least September 30, 2009 (that is, the date it acquired rural status through the end of the fiscal year containing a full cost reporting period). We believe this policy is reasonable, given that acquired rural status for IPPS hospitals should be a considered decision for hospitals that truly wish to be considered as rural, and not purely as a mechanism for reclassifying. We are not proposing a duration requirement for hospitals paid under cost reimbursement because we are not aware of similar manipulations of rural status in these cases. Therefore, we are proposing to change our current policy by revising § 412.103(g) to specify that a hospital's cancellation of its acquired rural status under § 412.103 is effective for hospitals under reasonable cost reimbursement (such as CAHs) with the hospital's next cost reporting period and for hospitals under the IPPS after at least one 12-month cost reporting period as rural and not until the beginning of a Federal fiscal year following both the request for cancellation and the 12-month cost reporting period. Under the proposed revised regulations, an IPPS hospital (such as an RRC or SCH) that cancels its acquired rural status would continue to be paid as rural until the beginning of the next fiscal year after at least one 12-month cost reporting period as rural. In addition, for these IPPS hospitals, the deadline for seeking cancellation of the acquired rural status would be not less than 120 days before the end of the fiscal year. D. Indirect Medical Education (IME) Adjustment (§ 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 § 412.105. The Balanced Budget Act of 1997 (Pub. L. 105-33) established a limit on the number of allopathic and osteopathic residents that a hospital may include in its full-time equivalent (FTE) resident count for direct GME and IME payment purposes. Under section 1886(h)(4)(F) of the Act, a hospital's unweighted FTE count of residents may not exceed the hospital's unweighted FTE count for its most recent cost reporting period ending on or before December 31, 1996. Under section 1886(d)(5)(B)(v) of the Act, the limit on the FTE resident count for IME purposes is effective for discharges occurring on or after October 1, 1997. A similar limit is effective for direct GME purposes for cost reporting periods beginning on or after October 1, 1997. 2. IME Adjustment Factor for FY 2008 The IME adjustment to the DRG payment is based in part on the 
                        ( print page 24813)
                        applicable IME adjustment factor. The IME adjustment factor is calculated using a hospital's ratio of residents to beds, which is represented as r, and a formula multiplier, which is represented as c, in the following equation: c × [{1 + r}.405
                        -1]. The formula is traditionally described in terms of a certain percentage increase in payment for every 10-percent increase in the resident-to-bed ratio. Section 502(a) of Pub. L. 108-173 modified the formula multiplier (c) to be used in the calculation of the IME adjustment. Prior to the enactment of Pub. L. 108-173, the formula multiplier was fixed at 1.35 for discharges occurring during FY 2003 and thereafter. Section 502(a) modified the formula multiplier beginning midway through FY 2004 and provided for a new schedule of formula multipliers for FY 2005 and thereafter. In the FY 2005 IPPS rule, we announced the schedule of formula multipliers to be used in the calculation of the IME adjustment and incorporated the schedule in our regulations at § 412.105(d)(3)(viii) through (d)(3)(xii). In this proposed rule, we are specifying that, for any discharges occurring during FY 2008, the statutorily mandated formula multiplier is 1.35. Previously, for discharges occurring during FY 2007, the mandated formula multiplier was 1.32. We estimate that application of the mandated formula multiplier for FY 2008 will result in an increase of 5.5 percent in IME payment for every approximately 10-percent increase in the resident-to-bed ratio. 3. Time Spent by Residents on Vacation or Sick Leave and in Orientation a. Background In the FY 2007 IPPS final rule (71 FR 48080), we clarified our policy with respect to the time that residents spend in nonpatient care activities (such as conferences and seminars) as part of approved residency programs. We amended our regulations concerning the FTE resident count at 42 CFR 412.105(f)(1)(iii)(C) to state, “In order to be counted, a resident must be spending time in patient care activities, as defined in § 413.75(b) * * *” The regulations at § 413.75(b) define patient care activities as “the care and treatment of particular patients, including services for which a physician or other practitioner may bill.” In light of this clarification, during the past year, we have received questions from the teaching hospital community as to whether the time that residents spend on vacation or sick leave, and in orientation activities that typically occur at the beginning of a residency training program, is counted for IME payment purposes. Historically, time spent by residents on vacation or sick leave and in initial orientation activities has been included in the FTE resident count for IME and direct GME. (The sick leave we are referring to throughout this discussion is sick leave that does 
                        *not*
                         require the resident to make up for his or her absence by adding additional training time at the end of the program.) The practice of allowing vacation and sick leave to be included in the IME count appears to be based on a provision in the Provider Reimbursement Manual, Part I, at section 2405.3.H.2. This manual provision discusses the treatment of residents who are on vacation or sick leave in the context of our prior “one day count” policy for counting residents for IME payment. Generally, effective with cost reporting periods beginning on or after October 1, 1984, and before July 1, 1991, residents were counted for IME purposes on a uniform reporting date of September 1. A hospital's FTE residents were counted based on their assignment to that hospital's IPPS or outpatient areas on September 1 of an academic year. Because it was possible that a resident might not actually be present in the hospital on September 1 because he or she was on approved vacation or sick leave, to ensure that the hospital's IME FTE count would not be understated for the entire year, section 2405.3.H.2 of the PRM-I states that “interns and residents using vacation and sick leave on the day of the count may be included in the count.” Although the regulations were changed effective for cost reporting periods beginning on or after July 1, 1991 (55 FR 36059) to reflect the current resident-counting methodology (that is, to count the number of FTE residents based on the amount of time required to fill a residency slot as specified at § 412.105(f)(1)(iii)(A)), the fiscal intermediary (or MAC) have continued to include time spent by residents on vacation and sick leave in the FTE resident counts for purposes of both IME and direct GME payments. Orientation time is time spent by residents in activities that typically take place at the beginning of a resident's training program, and include orientation regarding hospital employment, the hospital's policies and procedures in general, as well as policies and procedures specific to the residency training program. As is the case for vacation and sick leave, time spent by residents in orientation has continued to be included by intermediaries/MACs in the FTE resident counts for purposes of both IME and direct GME. We understand why we have received numerous questions regarding whether FTE resident time spent on vacation or sick leave, or in orientation activities, should be counted for purposes of IME payment. The time a resident spends on vacation or sick leave is not addressed within the current definition of “patient care activities” at § 413.75(b). In fact, time spent on vacation or sick leave would not be spent at the hospital location at all, so no patient care activities would occur during this time. Time spent in orientation might be spent in the hospital complex (or at a nonhospital setting), but would not involve the care and treatment of particular patients. Thus, although time spent by residents on vacation or sick leave or in orientation has historically been included in the IME and direct GME FTE counts, it seems apparent that this time should be carefully considered in light of our clarified policy and current regulations. We believe these types of activities (vacation time, sick leave, and orientation) are inherently different from the types of “patient care activities” and “nonpatient care activities” we have discussed in depth in previous rules, and most recently in the FY 2007 IPPS final rule. We believe the aforementioned activities should be distinguished from other activities, patient care or otherwise, in which the resident participates as part of the approved program. b. Vacation and Sick Leave Time We believe that approved vacation time and sick leave are not appropriately categorized as patient care activities, or as didactic, research, or other nonpatient care activities. In addition, although the Accreditation Council for Graduate Medical Education (ACGME) has some rules regarding resident duty hours and work environment, the ACGME is not explicit regarding resident vacation and sick leave policies. Rather, vacation and sick leave policies are determined by the resident's employer and can vary by residency training program. Consequently, although vacation and sick leave are fringe benefits to which every employee, hospital or otherwise, is typically entitled, vacation and sick leave are not, in fact, part of the training time spent by residents in an approved program. Therefore, we believe vacation and sick leave are not properly considered as either patient care time or nonpatient care time, but are within a distinct third category of time. As we noted above, it has been our policy to include the time spent by residents on 
                        ( print page 24814)
                        vacation or sick leave in the FTE resident count for IME and direct GME. However, we do not believe the continuation of this policy is appropriate in light of our current policy as clarified in the FY 2007 IPPS final rule and expressed in revised regulations that permit only time spent by residents in patient care activities to be counted for purposes of IME. We initially considered proposing a policy to no longer count the time spent by residents on vacation or sick leave for purposes of IME on the ground that this time is not spent in patient care activities in accordance with our regulations. However, we do not believe such a policy would have recognized the unique character of vacation and sick time as time that is not spent in any aspect of residency training—patient care or nonpatient care. Because we believe time spent by residents on vacation and sick leave is not properly considered patient care time or nonpatient care time, but fit within a distinct third category of time that is neither patient care nor nonpatient care, we believe it would be more appropriate to remove the time altogether from the FTE calculation for each resident for both IME and direct GME payment purposes. Accordingly, we are proposing to remove vacation and sick leave from the total time considered to constitute an FTE resident for purposes of IME payment effective for cost reporting periods beginning on or after October 1, 2007. Further, in order to have a consistent conception of an FTE resident for purposes of IME and direct GME payment, we are proposing to remove vacation and sick leave from the total FTE resident time for purposes of direct GME payment as well effective for cost reporting periods beginning on or after October 1, 2007. We acknowledge that removing vacation and sick leave time from the denominator of the FTE count for both IME and direct GME could have some impact on the FTE count, but the impact is fact-specific. In some cases, it would result in a lower FTE count, and in some cases, it would result in a higher FTE count. In addition, we note that under our current policy, residents who are on maternity leave or other approved sick leave of extended duration that prolongs the total time a resident is participating in the approved program beyond the normal duration of the program are 
                        *not*
                         counted while they are out on extended sick or maternity leave. This is because the FTE time spent by such residents is counted in accordance with our FTE counting policies during the training time they spend to make up for their absence. For example, a resident in an internal medicine program who takes 3 months of approved maternity leave and, therefore, must stay an additional 3 months beyond the normal 3 years to complete her training, would not be counted while she is on maternity leave for IME and direct GME payment purposes. Rather, time spent during the additional 3 months of training in which she must participate to make up for her 3 month absence will be counted in accordance with our FTE-counting policies for IME and direct GME. We are not proposing to change our policy with respect to time spent by residents on maternity leave or other approved sick leave of extended duration. c. Orientation Activities As discussed above, we believe that orientation activities in which residents participate, often prior to the start of their residency training program, are also distinct from the typical “patient care” and “nonpatient care” activities in which residents participate as part of their training program. For example, before residents begin training in an approved residency program, the hospital (or in many cases, the medical school as the employer of the residents) is required to provide orientation for their residents. Most of these orientation activities involve neither patient care nor the typical didactic or research activities that comprise the residency training program. Instead, such orientation consists of basic informational sessions in which all new employees, residents and other staff, must participate at the beginning of employment. There could also be other orientation activities designed specifically to prepare residents to furnish patient care in a particular setting or to participate in a particular approved residency training program. We recognize that certain portions of orientation activities are specific to residents in particular approved programs and are required by the accrediting organizations. Other components of orientation relate to employment and are common to all employees. Still other components of orientation may involve training regarding particular hospital policies and procedures, some of which would relate to patient care and safety. In many ways, these orientation activities resemble “didactic” activities. However, we believe there are important differences between the “didactic” activities that are part of orientation and the other conferences and seminars in which the residents engage throughout the course of their training. That is, we do not envision orientation activities as including scholarly didactic activities such as conferences or seminars that may occur throughout a residency training program. Rather, we believe orientation activities would occur either at the beginning of a particular specialty program, or when a resident goes to another facility for training. In orientation sessions, much of the information being imparted to the residents is essential knowledge for the residents in order to furnish patient care services in a particular hospital facility or approved program. Thus, the information furnished during orientation is not information that merely enhances the resident's patient care delivery knowledge and skills during the residency program, but it is a necessary prerequisite for the residents as they commence (or continue) their training program and is often required as a term of employment. Because we recognize the distinct character of orientation activities as essential to the provision of patient care by residents, and the fundamental differences between orientation and the typical didactic activities in which a resident may participate throughout a residency training program, we are proposing to continue to count the time spent by residents in orientation activities, whether they occur in the hospital or nonhospital setting, and are proposing to amend our regulations accordingly. (We note that orientation activities in the hospital setting have historically been counted for direct GME payment purposes in accordance with the regulations at § 413.78(a) which state “Residents in an approved program working in all areas of the hospital complex may be counted.”) We are proposing to amend § 413.75(b) to add a definition of the term “orientation activities,” to mean “activities that are principally designed to prepare an individual for employment as a resident in a particular setting, or for participation in a particular specialty program and patient care activities associated with that particular specialty program.” We understand that orientation activities typically occur at the beginning of a resident's first program year. However, we are interested in hearing from commenters on whether orientation activities typically occur during other times during an approved residency training program. We are proposing to amend the definition of “patient care activities” at § 413.75(b) as follows: “the care and treatment of particular patients, including services for which a physician or other practitioner may bill, and 
                        ( print page 24815)
                        orientation activities as defined at § 413.75(b).” In addition, we are proposing to amend the regulations at §§ 412.105(f)(1)(iii)(A) and 413.78(b) to specify that “Vacation and sick leave are not included in the determination of full-time equivalency.” d. Proposed Regulation Changes In summary, we are proposing, for cost reporting periods beginning on or after October, 1, 2007, for direct GME and IME, that time spent by residents on vacation or sick leave would not be included in the determination of what constitutes an FTE resident (or would be removed from both the numerator and denominator of the FTE count) for both IME and direct GME payment purposes. In addition, we are proposing to continue to count time spent by residents in orientation activities for both IME and direct GME payment purposes. We are proposing to amend the regulations at §§ 412.105(f)(1)(iii)(A) and 413.78(b). Lastly, we are proposing to amend § 413.75(b) to include the definition of the term “orientation activities” and to amend the definition of “patient care activities” to add “orientation activities.” E. Hospital Emergency Services Under EMTALA (§ 489.24) (If you choose to comment on issues in this section, please include the caption “EMTALA” at the beginning of your comments.) 1. Background Sections 1866(a)(1)(I), 1866(a)(1)(N), and 1867 of the Act impose specific obligations on certain Medicare-participating hospitals and CAHs. (Throughout this section of this proposed rule, when we reference the obligation of a “hospital” under these sections of the Act and in our regulations, we mean to include CAHs as well.) These obligations concern individuals who come to a hospital emergency department and request examination or treatment for medical conditions, and apply to all of these individuals, regardless of whether they are beneficiaries of any program under the Act. The statutory provisions cited above are frequently referred to as the Emergency Medical Treatment and Labor Act (EMTALA), also known as the patient antidumping statute. EMTALA was passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), Pub. L. 99-272. Congress enacted these antidumping provisions in the Social Security Act to ensure that individuals with emergency medical conditions are not denied essential lifesaving services because of a perceived inability to pay. Under section 1866(a)(1)(I)(i) of the Act, a hospital that fails to fulfill its EMTALA obligations under these provisions may be liable for termination of its Medicare provider agreement, which would result in loss of all Medicare and Medicaid payments. Section 1867 of the Act sets forth requirements for medical screening examinations for individuals who come to the hospital and request examination or treatment for a medical condition. The section further provides that if a hospital finds that such an individual has an emergency condition, it is obligated to provide that individual with either necessary stabilizing treatment or an appropriate transfer to another medical facility where stabilization can occur. The EMTALA statute also outlines the obligation of hospitals to receive appropriate transfers from other hospitals. Section 1867(g) of the Act states that a participating hospital that has specialized capabilities or facilities (such as burn units, shock-trauma units, neonatal intensive care units or (with respect to rural areas) regional referral centers as identified by the Secretary in regulation) shall not refuse to accept an appropriate transfer of an individual who requires these specialized capabilities or facilities if the hospital has the capacity to treat the individual. The regulations implementing section 1867 of the Act are found at 42 CFR 489.24. 2. Recent Legislation Affecting EMTALA Implementation a. Secretary's Authority To Waive Requirements During National Emergencies Section 1135 of the Act authorizes the Secretary to temporarily waive or modify the application of several requirements of titles XVIII, XIX, or XXI of the Act (the Medicare, Medicaid, and State Children's Health Insurance Program provisions) and their implementing regulations in an emergency area during an emergency period. Section 1135(g)(1) of the Act defines an “emergency area” as the geographical area in which there exists an emergency or disaster declared by the President pursuant to the National Emergencies Act or the Robert T. Stafford Disaster Relief and Emergency Assistance Act (subsection A) and a public health emergency declared by the Secretary pursuant to section 247d of Title 42 of the United States Code. Section 1135(g)(1) of the Act also defines an “emergency period” as the period during which such a disaster exists. Section 1135(b) of the Act lists the actions for which the otherwise applicable statutory provisions and implementing regulations may be waived. Included among these actions are, in subparagraph (b)(3)(A), a transfer of an individual who has not been stabilized in violation of the EMTALA requirements restricting transfer until an individual has been stabilized (section 1867(c) of the Act) and, in subparagraph (b)(3)(B), the direction or relocation of an individual to receive medical screening in an alternate location, in accordance with an appropriate State emergency preparedness plan. Section 1135(b) of the Act further states that a waiver or modification provided for under section 1135(b)(3) of the Act shall be limited to a 72-hour period beginning upon implementation of a hospital disaster protocol. All other waivers arising out of section 1135(b) of the Act (except for section 1135(b)(7)) ordinarily may continue in effect for the duration of the declaration of emergency or disaster, or the declaration of a public health emergency, or for 60-day periods as described in section 1135(e)(1) of the Act. To take into account the effect of section 1135 waivers on the EMTALA requirements, § 489.24(a)(2) of our regulations specifies that sanctions under the EMTALA regulations for inappropriate transfer during a national emergency do not apply to a hospital with a dedicated emergency department located in an emergency area, as specified in section 1135(g)(1) of the Act. For further information about section 1135 of the Act and its applicability, we refer readers to the CMS Web site: 
                        *http://www.cms.hhs.gov/​Emergency/​02_​Hurricanes.asp.* b. Provisions of the Pandemic and All-Hazards Preparedness Act On December 19, 2006, Congress enacted the Pandemic and All-Hazards Preparedness Act, Pub. L. 109-417. Section 302(b) of Pub. L. 109-417 makes two specific changes that affect EMTALA implementation in emergency areas during an emergency period. As noted above, section 1135(b)(3) of the Act authorizes the Secretary to waive sanctions for either the transfer of an unstabilized individual in violation of the requirements of section 1867(c) of the Act where such transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period or the direction or relocation of an individual to receive medical screening in an 
                        ( print page 24816)
                        alternate location in accordance with an appropriate State emergency preparedness plan. Section 302(b)(1)(A) of Pub. L. 109-417 amended section 1135(b)(3)(B) of the Act to state that sanctions for the direction or relocation of an individual for screening may be waived where, in the case of a public health emergency that involves a pandemic infectious disease, that direction or relocation occurs pursuant to a State pandemic preparedness plan or to an appropriate State emergency preparedness plan. In addition, sections 302(b)(1)(B) and (b)(1)(C) of Pub. L. 109-417 amended section 1135(b) of the Act to state that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the duration of a waiver or modification for such emergency shall be determined in accordance with section 1135(e) of the Act as that subsection applies to public health emergencies. The amendments to section 1135(b) of the Act made by section 302(b) of Pub. L. 109-417 are effective as of the date of enactment of that legislation (December 19, 2006) and apply to public health emergencies declared pursuant to section 247(d) of Title 42 of the United States Code. c. Proposed Revisions to the EMTALA Regulations Currently, the EMTALA regulation at 42 CFR 489.24(a)(2) specifies that sanctions under this section (§ 489.24) for inappropriate transfer during a national emergency do not apply to a hospital with a dedicated emergency department located in an emergency area, as specified in section 1135(g)(1) of the Act. To implement the changes made by section 302(b) of Pub. L. 109-417 and to ensure that our regulations accurately reflect section 1135 of the Act, we are proposing to make two changes to paragraph (a)(2) of § 489.24. First, we would specify that the sanctions that do not apply are those for either the inappropriate transfer of an individual who has not been stabilized or those for the direction or relocation of an individual to receive medical screening at an alternate location. We also are proposing to revise § 489.24 by adding a second sentence to paragraph (a)(2) to state that a waiver of these sanctions for EMTALA violations is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the duration of the waiver will be determined in accordance with subsection (e) of section 1135 of the Act as that subsection applies to public health emergencies. This proposed change would clarify that, in the case of public health emergencies involving pandemic infectious diseases, the waiver of EMTALA sanctions is not limited to 72 hours, but will remain in effect until the termination of the applicable declaration of a public health emergency as described in section 1135(e)(1)(B) of the Act. F. Disclosure of Physician Ownership in Hospitals and Patient Safety Measures 1. Disclosure of Physician Ownership in Hospitals (If you choose to comment on issues in this section, please include the caption “Physician Ownership in Hospitals” at the beginning of your comment.) Section 1866 of the Act states that any provider of services (except a fund designated for purposes of section 1814(g) and section 1835(e) of the Act) shall be qualified to participate in the Medicare program and shall be eligible for Medicare payments if it files a Medicare provider agreement and abides by the requirements applicable to Medicare provider agreements. These requirements are incorporated into our regulations in 42 CFR part 489, subparts A and B (Provider Agreements and Supplier Approval). Section 1861(e) of the Act defines the term “hospital.” Section 1861(e)(9) of the Act defines a hospital and authorizes the Secretary to establish requirements as he finds necessary in the interest of patient health and safety. Section 1820(e)(3) of the Act authorizes the Secretary to establish criteria necessary for an institution to be certified as a critical access hospital. Section 5006 of Pub. L. 109-171 (DRA) required the Secretary to develop a “strategic and implementing plan” to address certain issues related to physician investment in “specialty hospitals.” In the strategic and implementing plan included in our “Final Report to the Congress and Strategic and Implementing Plan Required under Section 5006 of the Deficit Reduction Act of 2005” issued on August 8, 2006 (page 69), available on our Web site at: 
                        *http://www.cms.hhs.gov/​PhysicianSelfReferral/​06a_​DRA_​Reports.asp*
                         (hereinafter referred to as the “DRA Report to Congress”), we stated that our plan for addressing issues related to physician investment in specialty hospitals involved promoting transparency of investment. Consistent with that approach, we stated that we would adopt a disclosure requirement that would require hospitals to disclose to patients whether they are physician-owned, and if so, disclose the names of the physician owners. Accordingly, we are proposing changes to regulations governing Medicare provider agreements to effectuate this change, under our authority at sections 1861(e)(9), 1820(e) and 1866 of the Act and under our rulemaking authority at sections 1871 and 1102 of the Act. We are seeking comment as to whether these changes best effectuated through changes to the Medicare provider agreement regulations or whether it would be more appropriate to include these changes in the conditions of participation requirements applicable to hospitals and critical access hospitals. Specifically, we are proposing to amend § 489.3 to define a “physician-owned hospital” as any participating hospital (as defined in § 489.24) in which a physician or physicians have an ownership or investment interest. We solicit comments on whether, for purposes of the ownership disclosure requirements only, the definition of “physician-owned hospital” should exclude certain physician ownership or investment interests based on the nature of the interest or the relative size of the interest or the entity's assets (for example, whether the interest would satisfy the exception at § 4111.356(a) for physician ownership or investment interest in public-traded securities and mutual funds). We are proposing to add a new provision at § 489.20(u)(1) to require that patients be given written notice that a hospital is physician-owned and that the list of physician owners is available upon request. We are proposing to require that the notice, in a manner reasonably designed to be understood by all patients, disclose the fact that the hospital meets the Federal definition of a “physician-owned hospital” and that patients will be provided the list of the hospital's physician owners upon request. In addition, we are proposing to add a new provision at § 489.20(u)(2) which will require hospitals to require that all physician owners who are also members of the hospital's medical staff disclose, in writing, their ownership interest in the hospital to all patients they refer to the hospital, as a condition of continued medical staff membership. Patient disclosure would be required at the time a physician makes a referral. We believe that these provisions are in the interest of the health and safety of individuals who are furnished services in these institutions. This notice requirement will permit individuals to make more informed decisions regarding their treatment and to 
                        ( print page 24817)
                        evaluate whether the existence of a financial relationship, in the form of an ownership interest, suggests a conflict of interest that is not in their best interest. In order to enforce these proposed requirements, we are proposing to amend § 489.12 to deny a provider agreement to a hospital that does not have procedures in place to notify patients of physician ownership in the hospital. In addition, we are proposing to amend § 489.53 to permit CMS to terminate a provider agreement with a physician-owned hospital if the hospital fails to comply with the requirements of § 489.20(u). 2. Patient Safety Measures (If you choose to comment on issues in this section, please include the caption “Patient Safety Measures” at the beginning of your comment.) In the DRA Report to Congress (page 67), we stated that it was appropriate to issue further guidance on what we expect of all hospitals with respect to the appraisal, initial treatment, and referral, when appropriate, of patients with medical emergencies.  The Medicare hospital conditions of participation regulations at 42 CFR part 482 impose requirements on hospitals that have emergency departments, as well as requirements on hospitals without emergency departments. We believe that hospitals should be required to disclose to patients at the time of inpatient admission or registration for an outpatient service information concerning whether a physician is available on the premises 24 hours a days, 7 days a week. Under the authority at sections 1861(e)(9), 1820(e)(3), 1866, 1871, and 1102 of the Act (described previously), we are proposing to add a new provision at § 489.20(v)(1) to require that hospitals furnish all patients notice at the beginning of their hospital stay or outpatient service if a doctor of medicine or a doctor of osteopathy is not present in the hospital 24 hours per day, 7 days a week, and to describe how the hospital will meet the medical needs of any patient who develops an emergency medical condition, at a time when no physician is present in the hospital. We are seeking comment as to whether this change best effectuated through changes to the Medicare provider agreement regulations or whether it would be more appropriate to include this change in the conditions of participation requirements applicable to hospitals and critical access hospitals. It has also come to our attention that some hospitals have called 9-1-1 when a patient has gone into respiratory arrest, a physician has not been on the premises, and the onsite clinical personnel have lacked the requisite equipment or training to provide the required assessment, initial treatment, and referral that are required of all hospitals. In some cases, required interventions to initiate emergency treatment may be outside the scope of practice of the clinical personnel onsite. This has occurred even in hospitals that operate emergency departments. Therefore, in this proposed rule, we are soliciting comments on whether current requirements for emergency service capability in hospitals with or without emergency departments should be strengthened in certain areas. Specifically, we are seeking feedback on whether present regulatory provisions should be expanded with respect to the type of clinical personnel that must be present at all times in hospitals with and without emergency departments; the competencies that such personnel must demonstrate, such as training in Advanced Cardiac Life Support, or successful completion of specified professional training programs; the type of emergency response equipment that must be available and the manner in which it must be available, such as in each emergency department, or inpatient unit, among others; and whether emergency departments must be operated 24 hours/day, 7 days a week. After evaluating the comments we receive, we will consider whether we should amend the Medicare hospital conditions of participation related to provision of emergency services in hospitals with and without emergency departments. G. Rural Community Hospital Demonstration Program (If you choose to comment on issues in this section, please include the caption “Rural Community Hospital Demonstration” at the beginning of your comments.) In accordance with the requirements of section 410A(a) of Pub. L. 108-173, the Secretary has established a 5-year demonstration program (beginning with selected hospitals' first cost reporting period beginning on or after October 1, 2004) to test the feasibility and advisability of establishing “rural community hospitals” for Medicare payment purposes for covered inpatient hospital services furnished to Medicare beneficiaries. A rural community hospital, as defined in section 410A(f)(1), is a hospital that— Is located in a rural area (as defined in section 1886(d)(2)(D) of the Act) or is treated as being located in a rural area under section 1886(d)(8)(E) of the Act;
                    Has fewer than 51 beds (excluding beds in a distinct part psychiatric or rehabilitation unit) as reported in its most recent cost report;
                    Provides 24-hour emergency care services; and
                    Is not designated or eligible for designation as a CAH. As we indicated in the FY 2005 IPPS final rule (69 FR 49078), in accordance with sections 410A(a)(2) and (a)(4) of Pub. L. 108-173 and using 2002 data from the U.S. Census Bureau, we identified 10 States with the lowest population density from which to select hospitals: Alaska, Idaho, Montana, Nebraska, Nevada, New Mexico, North Dakota, South Dakota, Utah, and Wyoming (Source: U.S. Census Bureau Statistical Abstract of the United States: 2003). Nine rural community hospitals located within these States are currently participating in the demonstration program for FY 2008. (Of the 13 hospitals that participated in the first 2 years of the demonstration program, 4 hospitals located in Nebraska have withdrawn from the program; they have become CAHs.) Under the demonstration program, participating hospitals are paid the reasonable costs of providing covered inpatient hospital services (other than services furnished by a psychiatric or rehabilitation unit of a hospital that is a distinct part), applicable for discharges occurring in the first cost reporting period beginning on or after the October 1, 2004, implementation date of the demonstration program. Payments to the participating hospitals will be the lesser amount of the reasonable cost or a target amount in subsequent cost reporting periods. The target amount in the second cost reporting period is defined as the reasonable costs of providing covered inpatient hospital services in the first cost reporting period, increased by the inpatient prospective payment update factor (as defined in section 1886(b)(3)(B) of the Act) for that particular cost reporting period. The target amount in subsequent cost reporting periods is defined as the preceding cost reporting period's target amount, increased by the inpatient prospective payment update factor (as defined in section 1886(b)(3)(B) of the Act) for that particular cost reporting period. Covered inpatient hospital services are inpatient hospital services (defined in section 1861(b) of the Act), and include extended care services furnished under an agreement under section 1883 of the Act. Section 410A of Pub. L. 108-173 requires that “in conducting the 
                        ( print page 24818)
                        demonstration program under this section, the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration program under this section was not implemented.” Generally, when CMS implements a demonstration program on a budget neutral basis, the demonstration program is budget neutral in its own terms; in other words, the aggregate payments to the participating providers do not exceed the amount that would be paid to those same providers in the absence of the demonstration program. This form of budget neutrality is viable when, by changing payments or aligning incentives to improve overall efficiency, or both, a demonstration program may reduce the use of some services or eliminate the need for others, resulting in reduced expenditures for the demonstration program's participants. These reduced expenditures offset increased payments elsewhere under the demonstration program, thus ensuring that the demonstration program as a whole is budget neutral or yields savings. However, the small scale of this demonstration program, in conjunction with the payment methodology, makes it extremely unlikely that this demonstration program could be viable under the usual form of budget neutrality. Specifically, cost-based payments to the nine participating small rural hospitals are likely to increase Medicare outlays without producing any offsetting reduction in Medicare expenditures elsewhere. Therefore, a rural community hospital's participation in this demonstration program is unlikely to yield benefits to the participant if budget neutrality were to be implemented by reducing other payments for these providers. In order to achieve budget neutrality for this demonstration program for FY 2008, we are proposing to adjust the national inpatient PPS rates by an amount sufficient to account for the added costs of this demonstration program. We are proposing to apply budget neutrality across the payment system as a whole rather than merely across the participants in this demonstration program. As we discussed in the FY 2005, FY 2006, and FY 2007 IPPS final rules (69 FR 49183; 70 FR 47462; and 71 FR 48100), we believe that the language of the statutory budget neutrality requirements permits the agency to implement the budget neutrality provision in this manner. For FY 2008, using cost report data for FY 2003, adjusted to account for the increased estimated costs for the remaining nine participating hospitals, we estimate that the adjusted amount would be $9,681,893. This proposed estimated adjusted amount reflects the estimated difference between the participating hospitals' costs and the IPPS payment based on data from the hospitals' cost reports. We discuss the proposed payment rate adjustment that would be required to ensure the budget neutrality of the demonstration program for FY 2008 in section II.A.4. of the Addendum to this proposed rule. V. Proposed Changes to the IPPS for Capital-Related Costs (If you choose to comment on issues in this section, please include the caption “Capital IPPS” at the beginning of your comment.) A. Background Section 1886(g) of the Act requires the Secretary to pay for the capital-related costs of inpatient acute hospital services “in accordance with a prospective payment system established by the Secretary.” Under the statute, the Secretary has broad authority in establishing and implementing the IPPS for acute care hospital inpatient capital-related costs. We initially implemented the IPPS for capital-related costs in the August 30, 1991 IPPS final rule (56 FR 43358), in which we established a 10-year transition period to change the payment methodology for Medicare hospital inpatient capital-related costs from a reasonable cost-based methodology to a prospective methodology (based fully on the Federal rate). Federal fiscal year (FFY) 2001 was the last year of the 10-year transition period established to phase in the IPPS for hospital inpatient capital-related costs. For cost reporting periods beginning in FY 2002, capital IPPS payments are based solely on the Federal rate for most acute care hospitals (other than certain new hospitals and hospitals receiving certain exception payments). The basic methodology for determining capital prospective payments using the Federal rate is set forth in § 412.312. For the purpose of calculating payments for each discharge, the standard Federal rate is adjusted as follows: (Standard Federal Rate) × (DRG Weight) × (Geographic Adjustment Factor (GAF)) × (Large Urban Add-on, if applicable) × (COLA for hospitals located in Alaska and Hawaii) × (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 § 412.312(c) of the regulations. The regulations at § 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 § 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 § 412.348(f) can be found in the FY 2005 IPPS final rule (69 FR 49185 and 49186). During the transition period, under §§ 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 (§ 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 § 412.348(g), which guarantees all eligible hospitals a minimum payment of 70 percent of its Medicare allowable capital-related costs provided that special exceptions payments do not exceed 10 percent of total capital IPPS payments. Special exceptions payments may be made only for the 10 years from the cost reporting year in which the hospital completes its qualifying project, and the hospital must have completed the project no later than the hospital's cost reporting period beginning before October 1, 2001. Thus, an eligible hospital may receive special exceptions payments for up to 10 years beyond the end of the capital IPPS transition period. Hospitals eligible for special exceptions payments were required to submit documentation to the intermediary indicating the completion date of their project. (For more detailed information regarding the special exceptions policy under § 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).) 
                        ( print page 24819) Under the IPPS for capital-related costs, § 412.300(b) of the regulations defines a new hospital as a hospital that has operated (under current or previous ownership) for less than 2 years. (For more detailed information, we refer readers to the August 30, 1991 final rule (56 FR 43418).) During the 10-year transition period, a new hospital was exempt from the capital IPPS for its first 2 years of operation and was paid 85 percent of its reasonable costs during that period. Originally, this provision was effective only through the transition period and, therefore, ended with cost reporting periods beginning in FY 2002. Because we believe that special protection to new hospitals is also appropriate even after the transition period, as discussed in the August 1, 2002 IPPS final rule (67 FR 50101), we revised the regulations at § 412.304(c)(2) to provide that, for cost reporting periods beginning on or after October 1, 2002, a new hospital (defined under § 412.300(b)) is paid 85 percent of its Medicare allowable capital-related costs through its first 2 years of operation, unless the new hospital elects to receive fully prospective payment based on 100 percent of the Federal rate. (We refer readers to the August 1, 2001 IPPS final rule (66 FR 39910) for a detailed discussion of the statutory basis for the system, the development and evolution of the system, the methodology used to determine capital-related payments to hospitals both during and after the transition period, and the policy for providing exception payments.) Section 412.374 provides for the use of a blended payment amount for prospective payments for capital-related costs to hospitals located in Puerto Rico. Accordingly, under the capital IPPS, we compute a separate payment rate specific to Puerto Rico hospitals using the same methodology used to compute the national Federal rate for capital-related costs. In general, hospitals located in Puerto Rico are paid a blend of the applicable capital IPPS Puerto Rico rate and the applicable capital IPPS Federal rate. Prior to FY 1998, hospitals in Puerto Rico were paid a blended capital IPPS rate that consisted of 75 percent of the capital IPPS Puerto Rico specific rate and 25 percent of the capital IPPS Federal rate. However, effective October 1, 1997 (FY 1998), in conjunction with the change to the operating IPPS blend percentage for Puerto Rico hospitals required by section 4406 of Pub. L. 105-33, we revised the methodology for computing capital IPPS payments to hospitals in Puerto Rico to be based on a blend of 50 percent of the capital IPPS Puerto Rico rate and 50 percent of the capital IPPS Federal rate. Similarly, in conjunction with the change in operating IPPS payments to hospitals in Puerto Rico for FY 2005 required by section 504 of Pub. L. 108-173, we again revised the methodology for computing capital IPPS payments to hospitals in Puerto Rico to be based on a blend of 25 percent of the capital IPPS Puerto Rico rate and 75 percent of the capital IPPS Federal rate effective for discharges occurring on or after October 1, 2004. B. Proposed Policy Change As we have noted above, the Secretary has broad authority under the statute in establishing and implementing the IPPS for hospital inpatient capital-related costs. We initially exercised that authority in the August 30, 1991 IPPS final rule (56 FR 43358). Among other provisions of that rule, we established the 10-year transition period to change the payment methodology for Medicare hospital inpatient capital-related costs from a reasonable cost-based methodology to a prospective methodology (based fully on the Federal rate). The purpose of that lengthy transition was to allow hospitals sufficient time to adjust to payment under a fully prospective system based on a uniform national rate. In that rule, we also established the initial standard Federal payment rate for capital-related costs, as well as the mechanism for updating that rate in subsequent years. For FY 1992, we computed the standard Federal payment rate for capital-related costs under the IPPS by updating the FY 1989 Medicare inpatient capital cost per case by an actuarial estimate of the increase in Medicare inpatient capital costs per case. Each year after FY 1992, we update the capital standard Federal rate, as provided at § 412.308(c)(1), to account for capital input price increases and other factors. The regulations at § 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, § 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 § 412.348. Section 412.308(c)(4)(ii) requires that the capital standard Federal rate be adjusted so that the effects of the annual DRG reclassification and the recalibration of DRG weights and changes in the geographic adjustment factor are budget neutral. Since the implementation of the IPPS for hospital inpatient capital-related costs, we have carefully monitored the adequacy of the standard Federal payment rate for capital-related costs and the updates provided under the existing regulations. On several occasions, the standard Federal payment rate has been adjusted. Section 1886(g)(1)(A) of the Act required a 7.4 percent reduction to the capital rate for discharges occurring after September 30, 1993. (We implemented that reduction to the rate in § 412.308(b)(2) of our regulations, effective in FY 1994.) Section 412.308(b)(3) of the regulations describes the 0.28 percent reduction to the capital rate made in FY 1996 as a result of the revised policy of paying for transfers. In FY 1998, we implemented section 4402 of Pub. L. 105-33, which required that, for discharges occurring on or after October 1, 1997, and before October 1, 2002, the unadjusted capital standard Federal rate be reduced by 17.78 percent (above the previous statutory reduction of 7.4 percent). (As a result of that reduction, the FY 1998 standard Federal payment rate for capital-related costs was $371.51, compared to $438.92 in FY 1997.) As we discussed in the FY 2003 IPPS final rule (67 FR 50102) and implemented in § 412.308(b)(6), a small part of that reduction was restored effective October 1, 2002. In general, under a PPS, standard payment rates should reflect the costs that an average, efficient provider would bear to provide the services required for quality patient care. Payment rate updates should also account for the changes necessary to continue providing such services. Updates should reflect, for example, the increased costs that are necessary to provide for the introduction of new technology that improves patient care. Updates should also take into account the productivity gains that, over time, allow providers to realize the same, or even improved, quality outcomes with reduced inputs and lower costs. Hospital margins, the difference between the costs of actually providing services and the payments received under a particular system, thus provide some evidence concerning whether payment rates have been established and updated at an appropriate level over time for efficient providers to provide necessary services. All other factors being equal, sustained substantial positive margins may suggest that payment rates and updates have exceeded what is required to provide those services. It is to be expected, under a PPS, that highly efficient providers might regularly realize positive margins, while less efficient providers might regularly 
                        ( print page 24820)
                        realize negative margins. However, a PPS that is correctly calibrated should not necessarily experience sustained periods in which providers generally realize substantial positive Medicare margins. Under the capital IPPS in particular, it seems especially appropriate that there should not be sustained significant positive margins across the system as a whole. Prior to the implementation of the capital IPPS, Congress mandated that the Medicare program pay only 85 percent of hospitals' inpatient Medicare capital costs. During the first 5 years of the capital IPPS, Congress also mandated a budget neutrality adjustment, under which the standard Federal capital rate was set each year so that payments under the system as a whole equaled 90 percent of estimated hospitals' inpatient Medicare capital costs for the year. Finally, as we discussed above, Congress has twice adjusted the standard Federal capital rate (a 7.4 percent reduction beginning in FY 1994, followed by a 17.78 percent reduction beginning in FY 1998). On the second occasion in particular, the specific congressional mandate was “to apply the budget neutrality factor used to determine the Federal capital payment rate in effect on September 30, 1995 * * * to the unadjusted standard Federal capital payment rate” for FY 1998 and beyond. (The designated budget neutrality factor constituted a 17.78 percent reduction.) This statutory language indicates that Congress considered the payment levels in effect during FYs 1992 through 1995, established under the budget neutrality provision to pay 90 percent of hospitals' inpatient Medicare capital costs in the aggregate, appropriate for the capital IPPS. The statutory history of the capital IPPS thus suggests that the system in the aggregate should not provide for continuous, large positive margins. In analyzing the adequacy of the existing capital IPPS rates, we recently conducted a comprehensive review of hospital experience under the IPPS for hospital inpatient capital-related costs, with particular attention to the relationship between acute care hospital capital Medicare costs and payments under the capital IPPS. Specifically, we examined the relationship between the Medicare inpatient capital costs of hospitals that are paid under the IPPS for hospital inpatient capital-related costs and their payments under that system over a number of years. We derived both cost and revenue data from the Medicare cost report. Specifically, cost data were derived from Worksheet D, Part I, columns 10 and 12 and Part II, columns 6 and 8, and revenue data from Worksheet E, Part A, Lines 9 and 10. We began our analysis with FY 1996, the year in which the statutory budget neutrality provision expired. (As we have discussed, for FYs 1992 through 1995, section 1886(g)(1)(A) of the Act required that the capital Federal rate also be adjusted by a budget neutrality factor so that aggregate payments for inpatient hospital capital costs were projected to equal 90 percent of the payments that would have been made for capital-related costs on a reasonable cost basis during the fiscal year. As discussed in section III. of the Addendum to this proposed rule, we employed an actuarial capital cost model (described in Appendix B of the FY 2002 IPPS final rule (66 FR 40099)) to estimate the aggregate payments that would have been made on the basis of reasonable cost in order to determine the required budget neutrality adjustment. As a result of the expiration of the budget neutrality provision, the standard Federal payment rate for capital-related costs increased to $461.96 in FY 1996 from $376.83 in FY 1995.) Our analysis extended through FY 2004, the most recent year for which we have relatively complete cost report information. We examined data across all hospitals subject to the capital IPPS and across the categories of hospitals (for example, urban and rural, and teaching and nonteaching) that we normally employ in conducting impact analyses. Specifically, we looked at the difference between aggregate hospital revenues from the capital IPPS and hospitals' aggregate Medicare inpatient capital costs. We determined the inpatient hospital Medicare capital margins for each year of the period from FY 1996 through FY 2004. (A margin is calculated as the difference between payments and costs, divided by payments.) We similarly calculated the aggregate margins for the period (the aggregate difference between payments and costs over the period, divided by total payments over the period). We also calculated aggregate margins for the period FY 1998 through FY 2004 (excluding FY 1996 and 1997). As a result of the expiration of the statutory budget neutrality provision, the capital standard Federal rate increased to $461.96 in FY 1996 from $376.83 in FY 1995. The capital standard Federal rate was $438.92 in FY 1997, before it was reduced to $371.51 in FY 1998 under section 4402 of Pub. L. 105-33, which required that the unadjusted capital standard Federal rate be reduced by 17.78 percent. The capital standard Federal rates for FYs 1996 and 1997 were thus substantially higher than the rates for the periods immediately preceding those years, and in the subsequent years (FY 1998 and beyond). The margins for those years are correspondingly higher than the margins for the other years in the period, and thus it could be argued that the margins for FYs 1996 and 1997 are unrepresentative. The table below summarizes the findings of this analysis. Hospital Inpatient Medicare Capital Margins
1996
1997
1998
1999
2000
2001
2002
2003
2004
1996-2004
1998-2004*U.S.
17.5
13.4
7.0
6.8
7.3
7.9
8.7
7.7
5.1
9.0
7.2URBAN
17.6
13.8
7.8
7.4
8.3
8.9
10.3
9.1
6.3
9.9
8.3RURAL
17.2
11.1
2.0
2.7
1.3
1.5
−1.7
−1.2
−2.9
3.4
0.26No DSH Payments
16.2
11.8
4.4
4.4
5.6
5.6
5.0
4.8
−0.9
6.9
4.2Has DSH Payments
18.3
14.4
8.5
8.1
8.2
8.7
9.9
8.6
6.7
9.9
8.4$1-$249,999
14.5
12.9
−0.4
3.1
1.6
4.2
2.5
0.6
−3.5
3.3
1.8$250,000-$999,999
15.5
9.3
2.2
1.5
3.0
2.5
−1.2
0.2
−3.8
2.9
0.5$1,000,000-$2,999,999
16.8
12.8
8.5
9.2
8.6
7.2
9.0
4.6
3.0
8.7
7.1$3,000,000 or more
20.1
16.6
10.4
9.1
9.7
11.6
13.4
12.5
10.1
12.4
11.1TEACHING
19.4
15.7
9.8
9.7
11.1
11.7
13.9
13.2
11.3
12.9
11.6NON-TEACHING
15.3
10.5
3.3
2.9
2.2
2.8
1.6
0.2
−3.2
3.9
1.3Census Division:New England (1)
26.9
25.8
17.0
15.1
18.2
20.5
21.3
21.2
20.5
20.9
19.3Middle Atlantic (2)
19.1
15.5
11.0
11.5
13.8
16.3
18.4
17.9
15.0
15.5
15.0South Atlantic (3)
17.9
13.9
5.8
3.9
5.9
5.2
6.3
7.5
4.9
7.9
5.7East North Central (4)
18.2
12.7
6.2
7.2
8.8
8.6
6.3
8.1
7.1
9.2
7.5( print page 24821)East South Central (5)
14.8
11.1
3.3
4.1
3.4
2.9
3.0
−1.8
−4.2
3.9
1.4West North Central (6)
14.2
6.9
0.0
−0.4
−1.6
1.9
2.6
3.3
1.1
3.2
1.1West South Central (7)
13.3
8.3
3.4
3.1
0.6
0.1
1.4
−1.2
−4.2
2.5
0.3Mountain (8)
17.3
14.8
8.4
7.6
7.4
6.4
3.2
3.1
0.7
7.2
4.9Pacific (9)
20.5
16.1
12.4
11.3
11.5
12.8
15.5
12.8
9.2
13.5
12.2Code 99
24.1
26.1
14.9
16.7
20.0
20.9
20.6
25.2
22.3
21.4
20.3Bed Size:< 100 beds
17.7
13.0
4.7
3.5
2.8
2.5
−1.7
−1.3
−5.6
3.5
0.5100-249 beds
15.1
10.6
3.5
4.5
4.7
6.0
6.1
4.5
1.1
6.2
4.4250-499 beds
18.9
14.0
8.7
8.3
10.4
10.5
11.7
11.6
10.6
11.7
10.4500-999 beds
19.7
17.5
11.1
10.3
10.7
10.4
12.5
10.3
6.8
12.0
10.2≥ 1000 beds
8.2
13.8
2.1
0.2
−6.6
−3.5
8.7
6.3
1.4
3.1
1.8**Notes:*** Excluding 1996 and 1997.Based on Medicare Cost Report hospital data updated as of the 4th quarter of 2006.Revenue are from Worksheet E, Part A, Lines 9 and 10.Expenses are from Worksheet D, Part I, columns 10 and 12 and Part II, columns 6 and 8.We apply the outlier trimming methodology developed by MedPAC.
 As the table shows, hospital inpatient Medicare capital margins have been very high across all hospitals during the period from FY 1996 through FY 2004. The margin for the entire period was 9.0 percent (7.2 percent, excluding FYs 1996 and 1997). For particular years, margins across all hospitals ranged from a high of 17.5 percent in FY 1996 to a low 5.1 percent in FY 2004. While the margins fell after a high in FY 1996 of 17.5 to 6.8 percent in FY 1999, they rose again to 8.7 percent in FY 2002 before declining modestly to 5.1 percent in FY 2004. There are similar results among most types of hospitals and groupings of hospitals by geographic region. For example, teaching hospitals have realized margins of 12.9 percent (11.6 percent, excluding FYs 1996 and 1997) during the period from FY 1996 through FY 2004, with a high margin of 19.4 percent in FY 1996 and a low margin of 9.7 percent in FY 1999. Urban hospitals realized margins of 9.9 percent during the period from FY 1996 through FY 2004 (8.3 percent, excluding FYs 1996 and 1997). DSH hospitals realized margins of 9.9 percent over the period (8.4 percent, excluding FYs 1996 and 1997), while non-DSH had aggregate margins of 6.9 percent (4.2 percent, excluding FYs 1996 and 1997). During the period from FY 1996 through FY 2004, every type of hospital and geographic grouping of hospitals has realized a positive aggregate margin from their capital IPPS payments. Of course, the aggregate capital margins for some types of hospitals have been lower than the margins for others. In particular, inpatient hospital Medicare capital margins for rural hospitals have lagged considerably behind the margins for urban hospitals. The aggregate margin for rural hospitals during the period from FY 1996 through FY 2004 was 3.4 percent (0.2 percent, excluding FYs 1996 and 1997), compared to 9.9 percent for urban hospitals and 9.0 percent for all hospitals. Rural hospitals have even experienced negative margins during several years of the period (−1.7 percent in FY 2002, −1.2 percent in FY 2003, and −2.9 percent in FY 2004). Similarly, nonteaching hospitals have experienced lower margins than teaching hospitals. Teaching hospitals have experienced an aggregate margin of 12.9 percent during the period from FY 1996 through FY 2004 (11.6 percent, excluding FYs 1996 and 1997). However, nonteaching hospitals have experienced an aggregate margin of 3.9 percent during that period (1.3 percent, excluding FYs 1996 and 1997). There may be various factors reflected in these margins. For example, one factor in the lower margins experienced by rural hospitals may be the transition of many rural hospitals to CAHs that are paid outside the IPPS. The number of rural hospitals in our analysis fell from 2,243 in FY 1996 to 1,211 in FY 2004, as the inpatient Medicare capital margins realized by rural hospitals fell from 17.2 percent to −2.9 percent. This suggests that more rural hospitals with relatively higher inpatient Medicare capital margins have made the transition to CAH status. However, it remains to be seen whether this trend in inpatient Medicare capital margins will continue as the relative numbers of CAHs and rural hospitals subject to the IPPS stabilize. The low aggregate for nonteaching hospitals is largely a function of the effect of the low, and for some years even negative, margin of the rural hospitals, as discussed earlier. We believe that there could be a number of reasons for the relatively high margins that most IPPS hospitals have realized under the capital IPPS. One possibility is that the updates to the capital IPPS rates have been higher than the actual increases in Medicare inpatient capital costs that hospitals have experienced in recent years. As we discuss in section III. of the Addendum to this proposed rule, we update the capital standard Federal rate on the basis of an analytical framework that takes into account changes in a capital input price index (CIPI) and several other policy adjustment factors. Specifically, we have adjusted the projected CIPI rate-of-increase as appropriate each year for case-mix index-related changes, for intensity, and for errors in previous CIPI forecasts. Under the framework that we have been using, the update factor for FY 2008 would be 0.8 percent, based on the best data available at this time. That update factor is derived from a projected 1.2 percent increase in the CIPI, a 0.0 percent adjustment for intensity, a 0.0 percent adjustment for case-mix, a −0.4 percent adjustment for the FY 2005 DRG reclassification and recalibration, and a forecast error correction of 0.0 percent. We discuss this update framework, and the computation of the policy adjustment factors, in section III. of the Addendum to this proposed rule. We believe that the CIPI is the most appropriate input price index for capital costs to measure capital price changes in a given year. We also believe that the update framework successfully captures several factors that should be taken into account in determining appropriate updates for hospitals subject to the capital IPPS. However, there may be factors affecting the rate-of-increase in 
                        ( print page 24822)
                        capital costs that are not yet captured in our analytical framework. For example, hospitals may be experiencing productivity gains in their use of capital equipment. As productivity increases, hospitals would be able to reduce the number of inputs required to produce a unit of service. MedPAC has taken the position that payment “rate for health care providers should be set so that the Federal Government benefits from providers' productivity gains, just as private purchasers of goods in competitive markets benefit from the productivity gains of their suppliers.” MedPAC has, therefore, included a productivity improvement target in its framework for updating Medicare hospital payments on the grounds that “as a prudent purchaser, Medicare should also require some productivity gains each year from its providers.” (MedPAC, Report to Congress, March 2006, p. 66) While we have not as yet included a specific productivity factor, such as MedPAC's productivity improvement target, in our analytical frameworks for updating the IPPS payment rates, we will continue to study the appropriateness of adopting such a measure. Another possible reason for the relatively high margins of most capital IPPS hospitals may be that the payment adjustments provided under the system are too high, or perhaps even unnecessary. Specifically, the adjustments for teaching hospitals, disproportionate share hospitals, and large urban hospitals appear to be contributing to excessive payment levels for these classes of hospitals. Since the inception of the capital IPPS in FY 1992, the system has provided adjustments for teaching hospitals (the IME adjustment factor, under § 412.322 of the regulations), disproportionate share hospitals (the DHS adjustment factor, under § 412.320), and large urban hospitals (the large urban location adjustment factor, under § 412.316((b)). The classes of hospitals eligible for these adjustments have been realizing much higher margins than other hospitals under the system. Specifically, teaching hospitals (11.6 percent for FYs 1998 through 2004), urban hospitals (8.3 percent), and disproportionate share hospitals (8.4 percent) have significant positive margins. Other classes of hospitals have experienced much lower margins, especially rural hospitals (0.2 percent for FYs 1998 through 2004) and nonteaching hospitals (1.3 percent). The three groups of hospitals that have been realizing especially high margins under the capital IPPS are, therefore, classes of hospitals that are eligible to receive one or more specific payment adjustments under the system. We believe that the evidence indicates that these adjustments have been contributing to the significantly large positive margins experienced by the classes of hospitals eligible for these adjustments. We believe that the data on inpatient hospital Medicare capital margins, as discussed above, provide sufficient evidence that some adjustment of the updates under the capital IPPS is warranted at this time. In light of the significant disparities in the margin performances of different classes of hospitals, we do not believe that an adjustment to the updates for FYs 2008 and 2009 should apply equally to all hospitals that are paid under the capital IPPS. In particular, an adjustment to the updates should take into account the much lower margins of rural hospitals (0.2 percent for the period from FY 1998 through FY 2004) compared to urban hospitals (8.3 percent during that period). We also believe that any initial adjustment to the rate should be relatively modest. One reason is that any adjustment should avoid unwarranted disruption to hospital finances: because of the nature of capital spending, long periods of time can be necessary for hospitals to adjust adequately to significant changes in payment. Therefore, for FYs 2008 and 2009, we are proposing that the update to the capital standard Federal rate for urban hospitals will be 0.0 percent, in place of the 0.8 percent update that would otherwise be provided in FY 2008 under the update framework that we have been employing. (We have not yet determined the update that would be provided for FY 2009 under the framework.) However, in light of the margin analysis, we are also proposing to give rural hospitals the full 0.8 percent update determined by the update framework in FY 2008. We anticipate that we will provide the full update to rural hospitals in FY 2009 as well, once we have determined what the update would be under the update framework. We are proposing to revise § 412.308(c)(1) of the regulations accordingly. For purposes of the update in FYs 2008 and 2009, an urban hospital is any hospital located in an area that meets the definitions under § 412.64(b)(1)(ii)(A) or (b)(1)(ii)(B), or § 412.64(b)(3). A rural hospital is any hospital that does not meet those definitions, or that is reclassified as rural under § 412.103. For subsequent years, we will continue to analyze the data concerning the adequacy of payments under the capital IPPS, and we may propose additional adjustments, positive or negative, as they are warranted. We will also continue to study our update framework and will consider whether adoption of additional or revised adjustments to account for other factors affecting capital cost changes may be warranted. In addition, we are also proposing to eliminate, for FYs 2008 and beyond, one of the payment adjustments that has been provided under the capital IPPS. Specifically, we are proposing to discontinue the 3.0 percent additional payment that has been provided to hospitals located in large urban areas. The consistent and significant positive margin of hospitals located in urban areas is strong evidence that it is not necessary to continue this adjustment. Therefore, we are proposing to amend § 412.316(b) of the regulations to provide that, effective for discharges on or after October 1, 2007, there will no longer be any additional payment for hospitals located in large urban areas, as currently provided under that section. When the payment adjustments were instituted at the inception of the program, the initial standard Federal payment rate was adjusted in a budget-neutral fashion to account for the expenditures that would be required by these adjustments. However, in light of the strong overall positive margins across the system, we are proposing not to increase the standard capital rate to account for expenditures otherwise payable due to this adjustment (approximately $147 million). Rather, in light of the excessive capital IPPS payments over the period of FYs 1996 through 2004, we believe that it is appropriate for the program to realize savings from this proposal. We will also continue to study the adequacy of payments under the capital IPPS, and will consider whether it is appropriate to make further adjustments to the standard Federal capital rate and updates of the rate. While we are formally proposing an update of 0.0 percent for urban hospitals, an update of 0.8 percent for rural hospitals in FY 2008, and elimination of the large urban add-on, we are also soliciting comment on additional adjustments to the capital payment structure. As we have noted above, the margin analysis indicates that several classes of hospitals have continuous, significant positive margins. The analysis indicates that the existing payment adjustments for teaching hospitals and disproportionate share hospitals are contributing to excessive payment levels for these classes of hospitals. Therefore, it may be appropriate to reduce these adjustments significantly, or even to eliminate them altogether, within the capital IPPS. 
                        ( print page 24823)
                        These payment adjustments, unlike the parallel adjustments under the operating IPPS, were not mandated by the Act. Rather, they were included within the original design of the capital IPPS under the Secretary's broad authority under sections 1886(g)(1)(A) and (g)(1)(B) of the Act to include appropriate adjustments and exceptions within a capital IPPS. Therefore, we are considering whether it may be appropriate to develop a proposal to reduce or to terminate these payment adjustments in the near future. It is difficult to justify indefinite continuation of these adjustments in the light of the continuous, substantial positive margins realized by the classes of hospitals that qualify for them. When the payment adjustments were instituted at the inception of the program, the initial standard Federal payment rate was adjusted in a budget-neutral fashion to account for the expenditures that would be required by these adjustments. Therefore, if we decide to propose to reduce or eliminate these adjustments, we will also consider whether we should similarly adjust the Federal capital payment rate to account for all or a portion of these adjustments, effectively increasing the base payment rate for all hospitals (including rural, nonteaching, and non-DSH hospitals that do not benefit from these adjustments), while removing these special adjustments for the hospitals that have been eligible to receive them. We are also considering whether, in light of the substantial positive margins experienced by these teaching and DSH hospitals, the discontinuation of these adjustments should not result in a change to the standard capital rate and should instead result in savings to the program. We welcome comments on these potential proposals and on other means of appropriately adjusting and targeting payments under the capital IPPS, as well as on the proposals that we are formally making in this proposed rule. VI. Proposed Changes for Hospitals and Hospital Units Excluded From the IPPS (If you choose to comment on the issues in this section, please include the caption “Excluded Hospitals and Hospital Units” at the beginning of your comment.) A. Payments to Existing and New Excluded Hospitals and Hospital Units Historically, hospitals and hospital units excluded from the prospective payment system received payment for inpatient hospital services they furnished on the basis of reasonable costs, subject to a rate-of-increase ceiling. An annual per discharge limit (the target amount as defined in § 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 § 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 § 403.752(a) of the regulations, RNHCIs are also subject to the rate-of-increase limits established under § 413.40 of the regulations. IRFs, IPFs, and LTCHs were paid previously under the reasonable cost methodology. However, the statute was amended to provide for the implementation of prospective payment systems for IRFs, IPFs, and LTCHs. In general, the prospective payment systems for IRFs, IPFs, and LTCHs provide(d) transition periods of varying lengths during which time a portion of the prospective payment is (was) based on cost-based reimbursement rules under Part 413 (certain providers do not receive a transition period or may elect to bypass the transition as applicable under Subparts N, O, and P). We note that the various transition periods provided for under the IRF PPS, IPF PPS, and LTCH PPS have ended or will soon end.) For cost reporting periods beginning on or after October 1, 2002, all IRFs are paid 100 percent of the adjusted Federal rate under the IRF PPS. Therefore, for cost reporting periods beginning on or after October 1, 2002, no portion of an IRF PPS payment is subject to Part 413. Similarly, for cost reporting periods beginning on or after October 1, 2006, all LTCHs are paid 100 percent of the adjusted Federal rate under the LTCH PPS. Therefore, for cost reporting periods beginning on or after October 1, 2006, no portion of the LTCH PPS payment is subject to 42 CFR part 413. However, except as provided in § 412.426(c), IPFs remain under a blend methodology for cost reporting periods beginning on or after January 1, 2005, and before January 1, 2008. For IPFs paid under the blend methodology, the portion of the IPF PPS payment that is based on reasonable cost principles is subject to the rules of 42 CFR part 413. In order to calculate the portion of the PPS payment that is based on reasonable cost principles, it is necessary to determine whether the IPF would be considered “existing” for purposes of section 1886(b)(3)(H) of the Act or “new” for purposes of section 1886(b)(7) of the Act. We note that readers should not confuse an IPF that is considered “new” for purposes of section 1886(b)(7) of the Act and § 413.40(f)(2)(ii) of the regulations with an IPF that is considered “new” under § 412.426(c) of the reguations. Any IPF that, under present or previous ownership or both, has its first cost reporting period as an IPF beginning on or after January 1, 2005, is considered “new” for purposes of § 412.426(c). An IPF that is considered “new” under § 412.426(c) is paid based on 100 percent of the Federal per diem payment amount. Consequently, only those IPFs considered “new” under section 1886(b)(7) of the Act, but not “new” under § 412.426(c) of the regulations will be paid under a PPS blended payment methodology. An IPF considered “new” for purposes of § 413.40(f)(2)(ii) would have its “reasonable cost-based” portion of its prospective payment subject to § 413.40(f)(2)(ii) and § 413.40(c)(4)(v), as applicable. An IPF considered “new” for purposes of section 1886(b)(7) of the Act has the target amount for its third cost reporting period determined in accordance with sections 1886(b)(7)(A)(ii) and 1886(b)(3)(A)(ii) of the Act. For the fourth and subsequent cost reporting periods, the target amount is calculated in accordance with section 1886(b)(3)(A)(ii) of the Act. An IPF that would be considered “existing” for purposes of section 1886(b)(3)(H) of the Act has the target amount for the “reasonable cost-based” portion of its prospective payment determined in accordance with section 1886(b)(3)(A)(ii) of the Act and the regulations at § 413.40(c)(4)(ii). We are proposing that the applicable percentage increase to update the target amount for the reasonable cost-based portion of the PPS payment of an IPF that is considered existing under section 1886(b)(3)(H) of the Act or new under section 1886(b)(7) of the Act, but not new under § 412.426(c), is 3.4 percent. (However, if more current data become available prior to publication of the final rule, we will use those data for updating the market basket.) B. Separate PPS for IRFs Section 1886(j) of the Act, as added by section 4421(a) of Pub. L. 105-33, 
                        ( print page 24824)
                        provided for a phase-in of a case-mix adjusted PPS for inpatient hospital services furnished by IRFs for cost reporting periods beginning on or after October 1, 2000, and before October 1, 2002, with payments based entirely on the adjusted Federal prospective payment for cost reporting periods beginning on or after October 1, 2002. Section 1886(j) of the Act was amended by section 125 of Pub. L. 106-113 to require the Secretary to use a discharge as the payment unit under the PPS for inpatient hospital services furnished by IRFs and to establish classes of patient discharges by functional-related groups. Section 305 of Pub. L. 106-554 further amended section 1886(j) of the Act to allow IRFs, subject to the blend methodology, to elect to be paid the full Federal prospective payment rather than the transitional period payments specified in the Act. On August 7, 2001, we issued a final rule in the 
                        **Federal Register**
                         (66 FR 41316) establishing the PPS for IRFs, effective for cost reporting periods beginning on or after January 1, 2002. There was a transition period for cost reporting periods beginning on or after January 1, 2002, and ending before October 1, 2002. For cost reporting periods beginning on or after October 1, 2002, payments are based entirely on the adjusted Federal prospective payment rate determined under the IRF PPS. C. Separate PPS for LTCHs On August 30, 2002, we issued a final rule in the 
                        **Federal Register**
                         (67 FR 55954) establishing the PPS for LTCHs, effective for cost reporting periods beginning on or after October 1, 2002. Except for a LTCH that made an election under § 412.533(c) or a LTCH that is defined as new under § 412.23(e)(4), there was a transition period for cost reporting periods beginning on or after October 1, 2002, and ending before October 1, 2007. For cost reporting periods beginning on or after October 1, 2006, total LTCH PPS payments are based on 100 percent of the Federal rate. D. Separate PPS for IPFs In accordance with section 124 of Pub. L. 106-113 and section 405(g)(2) of Pub. L. 108-173, we established a PPS for inpatient hospital services furnished in IPFs. On November 15, 2004, we issued in the 
                        **Federal Register**
                         a final rule (69 FR 66922) that established the IPF PPS, effective for IPF cost reporting periods beginning on or after January 1, 2005. Under the final rule, we compute a Federal per diem base rate to be paid to all IPFs for inpatient psychiatric services based on the sum of the average routine operating, ancillary, and capital costs for each patient day of psychiatric care in an IPF, adjusted for budget neutrality. The Federal per diem base rate is adjusted to reflect certain patient characteristics, including age, specified DRGs, selected high-cost comorbidities, days of the stay, and certain facility characteristics, including a wage index adjustment, rural location, indirect teaching costs, the presence of a full-service emergency department, and COLAs for IPFs located in Alaska and Hawaii. We have established a 3-year transition period during which IPFs whose first cost reporting periods began before January 1, 2005, will be paid based on a blend of reasonable cost-based payment and IPF PPS payments. For cost reporting periods beginning on or after January 1, 2008, all IPFs will be paid 100 percent of the Federal per diem payment amount. E. Determining Proposed LTCH Cost-to-Charge Ratios (CCRs) Under the LTCH PPS (If you choose to comment on the issues in this section, please include the caption “LTCH PPS CCRs and Outlier Payments” at the beginning of your comment.) In determining both high-cost outlier and short-stay outlier payments under the LTCH PPS (at § 412.525(a) and § 412.529, respectively), we calculate the estimated cost of the case by multiplying the LTCH's overall CCR by the Medicare allowable charges for the case. Under the LTCH PPS, a single prospective payment per discharge is made for both inpatient operating and capital-related costs, and, therefore, we compute a single “overall” or “total” LTCH-specific CCR based on the sum of LTCH operating and capital costs (as described in Chapter 3, section 150.24, of the Medicare Claims Processing Manual (CMS Pub. 100-4)) as compared to total charges. Specifically, a LTCH's CCR is calculated by dividing a LTCH's total Medicare costs (that is, the sum of its operating and capital inpatient routine and ancillary costs) by its total Medicare charges (that is, the sum of its operating and capital inpatient routine and ancillary charges) (72 FR 48117). In the June 9, 2003 IPPS high-cost outlier final rule (68 FR 34498), we made revisions to our policies concerning the determination of LTCHs' CCRs and the reconciliation of high-cost outlier and short-stay outlier payments under the LTCH PPS. As we stated in that final rule (68 FR 34507), because the LTCH PPS high-cost outlier and short-stay outlier policies are modeled after the IPPS outlier policy, we believe they are susceptible to the same payment vulnerabilities. In the FY 2007 IPPS final rule (71 FR 48115 through 48122), we amended our regulations and, for discharges occurring on or after October 1, 2006, refined the methodology for determining the annual CCR ceiling and statewide average CCRs. We also codified, with modifications and editorial clarifications, our policy for the reconciliation of high-cost outlier and short-stay outlier payments under the LTCH PPS. We indicated that because, historically, updates to the LTCH PPS CCR ceiling and statewide average CCRs have been effective on October 1, we would make these updates (and include relevant impact data) as a part of the IPPS rulemaking cycle. Specifically, in the FY 2007 IPPS final rule (71 FR 48117 through 48121), under the broad authority of section 123 of Pub. L. 106-113 and section 307(b)(1) of Pub. L. 106-554, we established under the LTCH PPS high-cost outlier policy at § 412.525(a)(4)(iv)(C) and the LTCH PPS short-stay outlier policy at § 412.529(c)(3)(iv)(C), for discharges occurring on or after October 1, 2006, that the fiscal intermediary (or currently the MAC, if applicable) may use a statewide average CCR, which is established annually by CMS, if it is unable to determine an accurate CCR for a LTCH in one of the following three circumstances: (1) new LTCHs that have not yet submitted their first Medicare cost report (for this purpose, a new LTCH is defined as an entity that has not accepted assignment of an existing hospital's provider agreement in accordance with § 489.18); (2) LTCHs whose CCR is in excess of the LTCH CCR ceiling; and (3) other LTCHs for whom data with which to calculate a CCR are not available (for example, missing or faulty data). (Other sources of data that the fiscal intermediary (or, if applicable, the MAC) may consider in determining a LTCH's CCR include data from a different cost reporting period for the LTCH, data from the cost reporting period preceding the period in which the hospital began to be paid as a LTCH (that is, the period of at least 6 months that it was paid as a short-term acute care hospital), or data from other comparable LTCHs, such as LTCHs in the same chain or in the same region.) As noted above, a LTCH is assigned the applicable statewide average CCR if, among other things, a LTCH's CCR is found to be in excess of the applicable maximum CCR threshold (that is, the LTCH CCR ceiling). As we explained in the FY 2007 IPPS final rule (71 FR 48117), CCRs above this threshold are 
                        ( print page 24825)
                        most likely due to faulty data reporting or entry, and, therefore, these CCRs should not be used to identify and make payments for outlier cases. Such data are clearly errors and should not be relied upon. Thus, under our established policy, if a LTCH's calculated CCR is above the applicable ceiling, the applicable LTCH PPS statewide average CCR is assigned to the LTCH instead of the CCR computed from its most recent (settled or tentatively settled) cost report data. We revised our methodology for determining the annual CCR ceiling and statewide average CCRs under the LTCH PPS effective October 1, 2006, as we explained in the FY 2007 IPPS final rule (71 FR 48117 through 48121), because we believe that those changes are consistent with the LTCH PPS single payment rate for inpatient operating and capital costs. Therefore, under the broad authority of section 123 of Pub. L. 106-113 and section 307(b)(1) of Pub. L. 106-554, in that same final rule, we revised our methodology used to determine the LTCH CCR ceiling. For discharges occurring on or after October 1, 2006, we established that the LTCH CCR ceiling specified under § 412.525(a)(4)(iv)(C)(
                        *2*) for high-cost outliers and under § 412.529(c)(3)(iv)(C)(
                        *2*) for short-stay outliers is calculated as 3 standard deviations above the corresponding national geometric mean total CCR (established and published annually by CMS). (The fiscal intermediary (or, if applicable, the MAC) may use a statewide average CCR if, among other things, a LTCH's CCR is in excess of the LTCH CCR ceiling.) The LTCH total CCR ceiling is determined based on IPPS CCR data, by first calculating the “total” (that is, operating and capital) IPPS CCR for each hospital and then determining the average “total” IPPS CCR for all IPPS hospitals. (Our rationale for using IPPS hospital data is discussed in the FY 2007 IPPS final rule (71 FR 48117).) The LTCH CCR ceiling is then established at 3 standard deviations from the corresponding national geometric mean total CCR. (For further detail on our methodology for annually determining the LTCH CCR ceiling, we refer readers to the FY 2007 IPPS final rule (71 FR 48117 through 48119).) We also established that the LTCH “total” CCR ceiling used under the LTCH PPS will continue to be published annually in the IPPS proposed and final rules, and the public should continue to consult the annual IPPS proposed and final rules for changes to the LTCH total CCR ceiling that would be effective for discharges occurring on or after October 1 of each year. Accordingly, in the FY 2007 IPPS final rule (71 FR 48119), we established a FY 2007 LTCH PPS total CCR ceiling of 1.321, effective for discharges occurring on or after October 1, 2006. In this proposed rule, in accordance with § 412.525(a)(4)(iv)(C)(
                        *2*) for high-cost outliers and § 412.529(c)(3)(iv)(C)(
                        *2*) for short-stay outliers, using our established methodology for determining the LTCH total CCR ceiling (described above), based on IPPS total CCR data from the December 2006 update to the Provider-Specific File, we are proposing a total CCR ceiling of 1.273 under the LTCH PPS that would be effective October 1, 2007. Furthermore, we are proposing that, if more recent data are available, we will use such data to determine the final total CCR ceiling under the LTCH PPS for FY 2008 using our established methodology described above. In addition, under the broad authority of section 123 of Pub. L. 106-113 and section 307(b)(1) of Pub. L. 106-554, in the FY 2007 IPPS final rule (71 FR 48120), we revised our methodology to determine the statewide average CCRs under § 412.525(a)(4)(iv)(C) for high-cost outliers and under § 412.529(c)(3)(iv)(C) for short-stay outliers for use under the LTCH PPS in a manner similar to the way we compute the “total” CCR ceiling using IPPS CCR data. Specifically, we first calculate the total (that is, operating and capital) CCR for each IPPS hospital. We then calculate the weighted average “total” CCR for all IPPS hospitals in the rural areas of the State and the weighted average “total” CCR for all IPPS hospitals in the urban areas of the State. (For further detail on our methodology for annually determining the LTCH urban and rural statewide average CCRs, we refer readers to the FY 2007 IPPS final rule (71 FR 48119 through 48121).) We also established that the applicable statewide average “total” (operating and capital) CCRs used under the LTCH PPS will continue to be published annually in the IPPS proposed and final rules, and the public should continue to consult the annual IPPS proposed and final rules for changes to the applicable statewide average total CCRs that would be effective for discharges occurring on or after October 1 each year. Accordingly, in the FY 2007 IPPS final rule (71 FR 48122), the FY 2007 LTCH PPS statewide average total CCRs for urban and rural hospitals, effective for discharges occurring on or after October 1, 2006, were presented in Table 8C of the Addendum of that final rule (71 FR 48303). In this proposed rule, in accordance with § 412.525(a)(4)(iv)(C) for high-cost outliers and § 412.529(c)(3)(iv)(C) for short-stay outliers, using our established methodology for determining the LTCH statewide average CCRs (described above), based on the most recent complete IPPS total CCR data from the December 2006 update of the Provider-Specific File, the proposed LTCH PPS statewide average total CCRs for urban and rural hospitals that would be effective October 1, 2007, are presented in Table 8C of the Addendum to this proposed rule. Furthermore, we are proposing that, if more recent data are available, we would use such data to determine the final statewide average total CCRs for urban and rural hospitals under the LTCH PPS for FY 2008 using our established methodology described above. We note that, for this proposed rule, as we established when we revised our methodology for determining the applicable LTCH statewide average CCRs in the FY 2007 IPPS final rule (71 FR 48119 through 48121), and as is the case under the IPPS, all areas in the District of Columbia, New Jersey, Puerto Rico, and Rhode Island are classified as urban, and therefore there are no proposed rural statewide average total CCRs listed for those jurisdictions in Table 8C of the Addendum to this proposed rule. In addition, as we established when we revised our methodology for determining the applicable LTCH statewide average CCRs in that same final rule, and as is the case under the IPPS, although Massachusetts has areas that are designated as rural, there are no short-term acute care IPPS hospitals or LTCHs located in those areas as of December 2006. Therefore, there is no proposed rural statewide average total CCR listed for rural Massachusetts in Table 8C of the Addendum of this proposed rule. As we also established when we revised our methodology for determining the applicable LTCH statewide average CCRs in the FY 2007 IPPS final rule (71 FR 48120 through 48121), in determining the urban and rural statewide average total CCRs for Maryland LTCHs paid under the LTCH PPS, we used, as a proxy, the national average total CCR for urban IPPS hospitals and the national average total CCR for rural IPPS hospitals, respectively. We use this proxy because we believe that the CCR data on the Provider-Specific File for Maryland hospitals may not be accurate (as discussed in greater detail in that same final rule (71 FR 48120)). VII. Services Furnished to Beneficiaries in Custody of Penal Authorities (If you choose to comment on issues in this section, please include the 
                        ( print page 24826)
                        caption “Beneficiaries in Custody” at the beginning of your comment.) Section 1862(a)(2) of the Act prohibits payment under Medicare Part A or Part B for any items or services for which the beneficiary has no legal obligation to pay, and which no other person or organization (such as a prepayment plan of which the beneficiary is a member) has a legal obligation to provide or pay for the service. Our current regulations at § 411.4(b) specify the special conditions when Medicare payment may be made for services furnished to individuals in custody of penal authorities. These regulatory conditions include: (1) State or local law requires those individuals or groups of individuals to repay the cost of medical services they receive while in custody; and (2) the State or local government entity enforces the requirement to pay by billing all such individuals, whether or not covered by Medicare or any other health insurance, and by pursuing collection of the amounts they owe in the same way and with the same vigor that it pursues the collection of other debts. However, § 411.4(b) does not define “custody” and does not clearly state that CMS will not defer to a particular State or local government's definition (or interpretation) of what constitutes “custody.” In this proposed rule, we are proposing to specify that, for purposes of Medicare payment, individuals who are in “custody” include, but are not limited to, individuals who are under arrest, incarcerated, imprisoned, escaped from confinement, under supervised release, required to reside in mental health facilities, required to reside in halfway houses, required to live under home detention, or confined completely or partially in any way under a penal statute or rule. We believe that this proposed definition of “custody” is in accordance with how custody has been defined by Federal courts for purposes of the habeas corpus protections of the Constitution. For example, the term “custody” is not limited solely to physical confinement. (
                        *Sanders*
                         v. 
                        *Freeman, 221 F.3d 846, 850-51 (6th Cir. 2000).*) Individuals on parole, probation, bail, or supervised release may be “in custody.” VIII. MedPAC Recommendations (If you choose to comment on issues in this section, please include the caption “MedPAC Update Recommendation” at the beginning of your comment.) We are required by section 1886(e)(4)(B) of the Act to respond to MedPAC's IPPS recommendations in our annual proposed IPPS rule. We have reviewed MedPAC's March 2007 “Report to the Congress: Medicare Payment Policy” and have given it careful consideration in conjunction with the proposed policies set forth in this document. MedPAC's Recommendation 2A-1 states that, “The Congress should increase payment rates for the acute inpatient and outpatient prospective payment systems in 2008 by the projected rate of increase in the hospital market basket index, concurrent with implementation of a quality incentive payment program.” This recommendation is discussed in Appendix B to this proposed rule. *Recommendation 2A-2:*
                         MedPAC recommended that, “Concurrent with implementation of severity adjustment to Medicare's diagnosis related group payments, the Congress should reduce the indirect medical education adjustment in fiscal year 2008 by 1 percentage point to 4.5 percent per 10 percent increment in the resident-to-bed ratio. The funds obtained from reducing the indirect medical education adjustment should be used to fund a quality incentive payment system.” MedPAC further states that the IME adjustment is “set above the empirical level which contributes to the large differences between teaching and nonteaching hospitals in financial performance under Medicare.” MedPAC asserts that since there is no accountability for how IME funds are used, and teaching hospitals will benefit from implementation of the severity adjusted DRGs the IME adjustment should be reduced in FY 2008. *Response:*
                         We note that, MedPAC stated in its March 2007 Report that Congress made a conscious decision to fund the IME adjustment above the empirical level due to the concern for how teaching hospitals would fare under the PPS. Because the IME adjustment is set by Congress, as cited in section 1886(d)(5)(B) of the Act, any change to the IME adjustment, whether it is a 1 percentage point reduction or reduction of the IME adjustment to its empirical level, would require a statutory change. Therefore, absent a change to the IME provision in the Medicare statute for FY 2008, the IME adjustment will remain at the current level required by the statute, as specified in section IV.D. of this preamble. *Recommendation 2A-3:*
                         MedPAC recommended that, “The Secretary should improve the form and accompanying instructions for collecting data on uncompensated care in the Medicare cost report and require hospitals to report using the revised form as soon as possible.” MedPAC indicated that “accurate data on hospitals” charity care and bad debts are crucial to any effort to help develop a federal payment mechanism to help hospitals with their uncompensated care.” *Response:*
                         MedPAC convened an “Expert Panel on Measuring Uncompensated Care” on May 5, 2005, to address concerns raised by stakeholders on the usefulness of the S-10 Worksheet data. CMS' representatives participated in the discussions on this expert panel, and listened carefully to the concerns of MedPAC and the stakeholders about the S-10 Worksheet. MedPAC is recommending that we adopt the list of recommended changes to the S-10 Worksheet that resulted from the panel's discussion. CMS is currently undertaking a major update of the hospital cost report and will be making changes to the S-10 Worksheet form and accompanying instructions based on the panel's discussions with MedPAC. In sections II.C. through E. of the preamble of this proposed rule, we further address the recommendations included in Recommendation 1 and Recommendation 3 in the March 2005 Report to Congress on Physician-Owned Specialty Hospitals. Recommendation 1 relates to refining the DRGs used under the IPPS to more fully capture differences in severity of illness among patients; basing the DRG relative weights on the estimated cost of providing care rather than on charges; and basing the weights on the national average of hospitals' relative values in each DRG. Recommendation 3 recommended that the Secretary implement MedPAC's recommended policies over a transition period. For further information relating specifically to the MedPAC reports or to obtain a copy of the reports, contact MedPAC at (202) 653-7220, or visit MedPAC's website at: 
                        *http://www.medpac.gov.* IX. Other Required Information A. Requests for Data from the Public In order to respond promptly to public requests for data related to the prospective payment system, we have established a process under which commenters can gain access to raw data on an expedited basis. Generally, the data are available in computer tape or cartridge format; however, some files are available on diskette as well as on the Internet at: 
                        *http://www.cms.hhs.gov/​providers/​hipps.*
                         Data files and the cost for each file, if applicable, are listed below. Anyone wishing to purchase 
                        ( print page 24827)
                        data tapes, cartridges, or diskettes should submit a written request along with a company check or money order (payable to CMS-PUF) to cover the cost to the following address: Centers for Medicare & Medicaid Services, Public Use Files, Accounting Division, P.O. Box 7520, Baltimore, MD 21207-0520, (410) 786-3691. Files on the Internet may be downloaded without charge. 1. CMS Wage Data Public Use File This file contains the hospital hours and salaries from Worksheet S-3, Parts II and Parts III from FY 2004 cost reports used to create the proposed FY 2008 IPPS wage index. The file is typically available by the end of February each year for the NPRM and will be available by the beginning of May for the final rule. Processing year
Wage data year
PPS fiscal year2007
2004
20082006
2003
20072005
2002
2006
 *Media:*
                         Internet at 
                        *http://www.cms.hhs.gov/​AcuteInpatientPPS/​WIFN/​list.asp#TopOfPage.* *Periods Available:*
                         FY 2006 through 2008 IPPS Updates. 2. CMS Occupational Mix Data Public Use File This file contains the occupational mix survey data to be used to compute the occupational mix adjusted wage indexes. The file is typically available by the end of February each year for the NPRM and will be available by the beginning of May for the final rule. *Media:*
                         Internet at 
                        *http://www.cms.hhs.gov/​AcuteInpatientPPS/​WIFN/​list.asp#TopOfPage.* *Periods Available:*
                         FY 2008 PPS Update. 3. Final AHWs for FY 2007 and Proposed AHWs for FY 2008 by CBSA Public Use File This file includes CBSAs, and the AHWs by CBSA for FY 2007 (final data) and FY 2008 (proposed data). This file is typically available by the end of February each year for the NPRM. Media: Internet at 
                        *http://www.cms.hhs.gov/​AcuteInpatientPPS/​WIFN/​list.asp#TopOfPage.* *Periods Available:*
                         FY 2008 IPPS Proposed Rule Update. 4. FY 2008 Occupational Mix Adjusted and Unadjusted AHWs by Provider This file is available after publication of each IPPS NPRM and final rule, and includes provider number, CBSA, the provider's unadjusted and occupational mix adjusted AHW, and the percent difference between the two. *Media:*
                         Internet at 
                        *http://www.cms.hhs.gov/​AcuteInpatientPPS/​WIFN/​list.asp#TopOfPage.* *Periods Available:*
                         FY 2008 IPPS Update. 5. FY 2008 Occupational Mix Adjusted and Unadjusted AHWs and Pre-Reclass Wage Indexes by CBSA This file is available after publication of each IPPS NPRM and final rule, and is organized by CBSA, and contains total CBSA occupational mix wages, total CBSA hours, CBSA occupational mix adjusted AHWs, CBSA occupational mix adjusted pre-reclass wage indexes, total CBS unadjusted wages, CBSA unadjusted AHWs, and unadjusted pre-reclass wage indexes. *Media:*
                         Internet at 
                        *http://www.cms.hhs.gov/​AcuteInpatientPPS/​WIFN/​list.asp#TopOfPage.* *Periods Available:*
                         FY 2008 IPPS Update. 6. FY 2008 Occupational Mix Factor by Provider Public Use File This file is available after publication of each IPPS NPRM and final rule, and is organized by provider, and includes occupational mix adjusted and unadjusted wages, occupational mix adjusted and unadjusted AHWs, the nurse occupational mix adjustment factor, and the CBSA nurse occupational mix adjustment factor. *Media:*
                         Internet at 
                        *http://www.cms.hhs.gov/​AcuteInpatientPPS/​WIFN/​list.asp#TopOfPage.* *Periods Available:*
                         FY 2008 IPPS Update. 7. FY 2008 Average Hourly Wage by Provider and CBSA Public Use File This file is available after publication of each IPPS NPRM and final rule, and includes occupational mix adjusted wages, hours, occupational mix adjusted AHWs, and pre-reclass occupational mix adjusted wage indexes, by provider and CBSA. *Media:*
                         Internet at 
                        *http://www.cms.hhs.gov/​AcuteInpatientPPS/​WIFN/​list.asp#TopOfPage.* *Periods Available:*
                         FY 2008 IPPS Update. 8. IPPS SSA/FIPS CBSA State and County Crosswalk This file contains a crosswalk of State and county codes used by the Social Security Administration (SSA) and the Federal Information Processing Standards (FIPS), county name, Core Based Statistical Area (CBSA), and the historical list of Metropolitan Statistical Areas (MSAs). *Media:*
                         Internet at 
                        *http://www.cms.hhs.gov/​AcuteInpatientPPS/​FFD/​list.asp#TopOfPage.* *Periods Available:*
                         FY 2008 IPPS Update. 9. FY 2008 Proposed Rule AHW by Provider Area Listing This file contains a spreadsheet with two tabs: One for providers that are geographically located in an area, and one for providers that are reclassifying. The first tab includes the pre-reclass occupational mix adjusted total wages and AHWs by provider and CBSA, and the second tab lists the providers that are reclassifying and their post-reclass occupational mix adjusted total wages and AHWs by provider and CBSA. This file is typically posted after publication of the IPPS NPRM each year. *Media:*
                         Internet at 
                        *http://www.cms.hhs.gov/​AcuteInpatientPPS/​WIFN/​list.asp#TopOfPage.* *Periods Available:*
                         FY 2008 IPPS Proposed Rule Update. 10. PPS-IV to PPS-XII Minimum Data Set The Minimum Data Set contains cost, statistical, financial, and other information from Medicare hospital cost reports. The data set includes only the most current cost report (as submitted, final settled, or reopened) submitted for a Medicare participating hospital by the Medicare fiscal intermediary to CMS. This data set is updated at the end of each calendar quarter and is available on the last day of the following month. *Media:*
                         Compact Disc (CD). *File Cost:*
                         $100.00 per year. Periods 
                                 beginning on or after
and beforePPS-IV
10/01/86
10/01/87PPS-V
10/01/87
10/01/88PPS-VI
10/01/88
10/01/89PPS-VII
10/01/89
10/01/90PPS-VIII
10/01/90
10/01/91PPS-IX
10/01/91
10/01/92PPS-X
10/01/92
10/01/93PPS-XI
10/01/93
10/01/94PPS-XII
10/01/94
10/01/95(Note: The PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS-XVIII, PPS-XIX PPS-XX, PPS-XXI, and PPS-XX-II Minimum Data Sets are part of the PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS-XVIII, PPS-XIX, PPS-XX, PPS-XXI, and PPS-XXII Hospital Data Set Files (refer to item 10 below).)
 11. PPS-XIII to PPS-XXII Hospital Data Set The file contains cost, statistical, financial, and other data from the Medicare Hospital Cost Report. The data set includes only the most current cost 
                        ( print page 24828)
                        report (as submitted, final settled, or reopened) submitted for a Medicare-certified hospital by the Medicare fiscal intermediary to CMS. The data set is updated at the end of each calendar quarter and is available on the last day of the following month. *Media:*
                         Compact Disc (CD). *File Cost:*
                         $100.00. Periods 
                                 beginning on or after
and beforePPS-XIII
10/01/95
10/01/96PPS-XIV
10/01/96
10/01/97PPS-XV
10/01/97
10/01/98PPS-XVI
10/01/98
10/01/99PPS-XVII
10/01/99
10/01/00PPS-XVIII
10/01/00
10/01/01PPS-XIX
10/01/01
10/01/02PPS-XX
10/01/02
10/01/03PPS-XXI
10/01/03
10/01/04PPS-XXII
10/01/04
10/01/05
 12. Provider-Specific File This file is a component of the PRICER program used in the fiscal intermediary's system to compute DRG payments for individual bills. The file contains records for all prospective payment system eligible hospitals, including hospitals in waiver States, and data elements used in the prospective payment system recalibration processes and related activities. Beginning with December 1988, the individual records were enlarged to include pass-through per diems and other elements. *Media:*
                         Internet at 
                        *http://www.cms.hhs.gov/​ProspMedicareFeeSvcPmtGen/​Downloads/​INP_​psf0107.zip.* *Periods Available:*
                         FY 2008 PPS Update. 13. CMS Medicare Case-Mix Index File The Medicare case-mix indexes by provider number are published in table 2 of each year's update of the Medicare hospital inpatient prospective payment system. The case-mix index is a measure of the costliness of cases treated by a hospital relative to the cost of the national average of all Medicare hospital cases, using DRG weights as a measure of relative costliness of cases. Two versions of this file are created each year. They support the following: NPRM published in the**Federal Register**
                        .
                    Final rule published in the**Federal Register**
                        . *Media:*
                         Internet at 
                        *http://www.cms.hhs.gov/​AcuteInpatientPPS/​WIFN/​list.asp#TopOfPage.* *Periods Available:*
                         FY 2006 through FY 2008. 14. DRG Relative Weights (Table 5 DRG) This file contains a listing of DRGs, DRG narrative descriptions, relative weights, and geometric and arithmetic mean lengths of stay as published in the 
                        **Federal Register**
                        . There are two versions of this file as published in the 
                        **Federal Register**
                        : NPRM.
                    Final rule. *Media:*
                         Internet at 
                        *http://www.cms.hhs.gov/​AcuteInpatientPPS/​FFD/​list.asp#TopOfPage.* *Periods Available:*
                         FY 2006 through FY 2008 PPS Update. 15. PPS Payment Impact File This file contains data used to estimate payments under Medicare's hospital inpatient prospective payment systems for operating and capital-related costs. The data are taken from various sources, including the Provider-Specific File, Minimum Data Sets, and prior impact files. The data set is abstracted from an internal file used for the impact analysis of the changes to the prospective payment systems published in the 
                        **Federal Register**
                        . *Media:*
                         Internet at 
                        *http://www.cms.hhs.gov/​AcuteInpatientPPS/​FFD/​list.asp#TopOfPage*
                         and 
                        *http://www.cms.hhs.gov/​AcuteInpatientPPS/​HIF/​list.asp#TopOfPage.* *Periods Available:*
                         FY 1994 through FY 2008 PPS Update 16. AOR/BOR Tables This file contains data used to develop the DRG relative weights. It contains mean, maximum, minimum, standard deviation, and coefficient of variation statistics by DRG for length of stay and standardized charges. The BOR tables are “Before Outliers Removed” and the AOR is “After Outliers Removed.” (Outliers refer to statistical outliers, not payment outliers.) Two versions of this file are created each year. They support the following: NPRM published in the**Federal Register**
                        .
                    Final rule published in the**Federal Register**
                        . *Media:*
                         Internet at 
                        *http://www.cms.hhs.gov/​AcuteInpatientPPS/​FFD/​list.asp#TopOfPage.* *Periods Available:*
                         FY 2008 PPS Update. 17. Prospective Payment System (PPS) Standardizing File This file contains information that standardizes the charges used to calculate relative weights to determine payments under the prospective payment system. Variables include wage index, cost-of-living adjustment (COLA), case-mix index, disproportionate share, and the Metropolitan Statistical Area (MSA). The file supports the following: NPRM published in the**Federal Register**
                        .
                    Final rule published in the**Federal Register**
                        . *Media:*
                         Internet. *Periods Available:*
                         FY 2008 PPS Update. For further information concerning these data tapes, contact the CMS Public Use Files Hotline at (410) 786-3691. Commenters interested in obtaining or discussing any other data used in constructing this proposed rule should contact Mark Hartstein at (410) 786-4548. B. Collection of Information Requirements Under the Paperwork Reduction Act of 1995 (PRA), we are required to provide 60-day notice in the 
                        **Federal Register**
                         and solicit public comment before a collection of information requirement is submitted to the Office of Management and Budget (OMB) for review and approval. In order to fairly evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) of the PRA requires that we solicit comment on the following issues: The need for the information collection and its usefulness in carrying out the proper functions of our agency.
                    The accuracy of our estimate of the information collection burden.
                    The quality, utility, and clarity of the information to be collected.
                    Recommendations to minimize the information collection burden on the affected public, including automated collection techniques. We are soliciting public comment on each of these issues for the following sections of this document that contain information collection requirements. Section 412.103 Special Treatment: Hospitals Located in Urban Areas and That Apply for Reclassifications as Rural Section 412.103(g)(1) states that (1) for a hospital paid on the basis of reasonable costs, the hospital may cancel its rural reclassification by submitting a written request to the CMS Regional Office not less than 120 days prior to the end of its current cost reporting period, and (2) for a hospital paid under the hospital inpatient prospective payment system, the hospital may cancel its rural reclassification by submitting a written request to the CMS Regional Office not less than 120 days prior to the end of a Federal fiscal year and after being paid as rural for at least one 12-month cost reporting period. 
                        ( print page 24829) The burden associated with these requirements is the time and effort required for a hospital to develop, draft, and submit its written request for the cancellation of its rural reclassification. While these requirements are subject to the PRA, we believe the burden is exempt under 5 CFR 1320.3(c)(4). We believe that the information collection requirements in § 412.103(g)(1) and § 421.103(g)(2), respectively, will impact less than 10 entities. The notices will be submitted by individual hospitals and will be reviewed on a case-by-case basis. Section 489.20 Basic Commitments Proposed § 489.20(u)(1) would require physician-owned hospitals, as defined in § 489.3, to furnish notice to all patients that the hospital is a physician-owned hospital. The notice must be furnished at the beginning of their hospital stay or outpatient visit. The burden associated with the aforementioned requirements is the time and effort associated with a physician-owned hospital developing a generic notice and providing notice to the patients. Approximately 175 physician-owned hospitals must comply with this requirement. We estimate that it will require a hospital's general counsel 4 hours to develop a standard notice to be furnished to all patients upon admission as an inpatient or an outpatient. In addition, we estimate that it will take 30 seconds to provide the notice to a patient and it will take another 30 seconds to maintain a copy of the disclosure in the patient's medical record. On average, each hospital will be required to make 1,092 disclosures per year. The total burden associated with the requirements in § 489.20(u)(1) is 3,885 annual burden hours. Proposed § 489.20(v) would require all hospitals, as defined in § 489.24(b), to furnish all patients notice, in accordance with § 482.13(b)(2), at the beginning of their hospital stay or outpatient visit if a doctor of medicine or a doctor of osteopathy is not present in the hospital 24 hours per day, 7 days per week. The notice must indicate how the hospital will meet the medical needs of any inpatient who develops an emergency medical condition, as defined in § 489.24(b), at a time when there is no physician present in the hospital. The burden associated with this requirement is the time and effort necessary for each hospital to develop a standard notice to furnish to its patients. We believe 2,504 hospitals will be required to comply with this requirement. Complying with the requirement will require a hospital's general counsel 4 hours to develop a standard notice. In addition, we estimate that it will take 30 seconds to provide the notice to a patient, and it will take another 30 seconds to maintain a copy of the disclosure in the patient's medical record. On average, each hospital will be required to make 1,092 disclosures per year. The total burden associated with the requirements in § 489.20(v)(1) is 55,588 annual burden hours. Estimated Annual Reporting and Recordkeeping Burden
Requirements
OMB control number
Respondents
Responses
Burden 
                                 per response  
                                 (hours)
Total annual 
                                 burden  
                                 (hours)§ 489.20(u)(1)
0938-New
175
75
4
700175
191,100
.016667
3,185§ 489.20(v)(1)
0938-New
2,504
2,504
4
10,0162,504
2,734,368
.016667
45,572Total




59,473
 This proposed rule imposes collection of information requirements as outlined in the regulation text and specified above. However, this proposed rule also makes reference to several associated information collections that are not discussed in the regulation text. The following is a discussion of these collections, which have already received the Office of Management and Budget's (OMB) approval. Proposed Add-on Payments for New Services and Technologies Section II.I.1 of the preamble of this proposed rule discusses proposed add-on payments for new services and technologies. Specifically, this section states that applicants for add-on payments for new medical services or technologies for FY 2009 must submit a formal request. A formal request includes a full description of the clinical applications of the medical service or technology and the results of any clinical evaluations demonstrating that the new medical service or technology represents a substantial clinical improvement. In addition, the request must contain a significant sample of the data to demonstrate that the medical service or technology meets the high-cost threshold. We also detailed the burden associated with this requirement in a final rule published in the 
                        **Federal Register**
                         on September 7, 2001 (66 FR 46902). As stated in that final rule, we believe the associated burden is exempt from the PRA as stipulated under 5 CFR 1320.3(h)(6). Collection of the information for this requirement will be conducted on individual case-by-case basis. Occupational Mix Adjustment to the FY 2008 Index (Hospital Wage Index Occupational Mix Survey) Section III. of the preamble of this proposed rule details the proposed changes to the hospital wage index. Specifically, section III.C addresses the proposed occupational mix adjustment to the proposed FY 2008 index. While the preamble does not contain any new information collection requirements, it is important to note that there is an OMB approved collection associated with the hospital wage index. As stated in section III.C. of the preamble of this proposed rule, section 304(c) of Pub. L. 106-554 amended section 1886(d)(3)(E) of the Act to require CMS to collect data at least once every 3 years on the occupational mix of employees for each short-term, acute care hospital participating in the Medicare program, in order to construct an occupational mix adjustment to the wage index. We collect the data via the occupational mix survey. The burden associated with this information collection request is the time and effort required to collect and submit the data in the Hospital Wage Index Occupational Mix Survey to CMS. While this burden is subject to the PRA, it is already approved under OMB control number 0938-0907, with an expiration date of May 31, 2009. 
                        ( print page 24830) Revisions to the Wage Index Based on Hospital Redesignations (Medicare Geographic Classification Review Board) As noted in section III.I of the preamble of this proposed rule, section 1886(d)(10) of the Act established the MGCRB, an entity that has the authority to accept IPPS hospital applications requesting geographic reclassification for wage index or standardized payment amounts and to issue decisions on these requests. It is important for CMS to ensure the accuracy of the MGCRB decisions and remain apprised of potential payment impacts. Our regulations at § 412.256 require a hospital to submit a copy of its MGCRB application to CMS. The burden associated with this requirement is the time and effort associated with a hospital compiling and submitting a copy of its MGCRB application to CMS. While this requirement is subject to the PRA, the burden is approved under OMB control number 0938-0573, with an expiration date of November 30, 2008. Reporting of Hospital Quality Data for Annual Hospital Payment Update As noted in section IV.A.1 of the preamble of this proposed rule, section 5001(a) of the DRA sets out new requirements for the RHQDAPU program. The RHQDAPU program was established to implement section 501(b) of Pub. L. 108-173, thereby expanding our Hospital Quality Initiative. The RHQDAPU program originally consisted of a “starter set” of 10 quality measures. Hospitals participating in the hospital quality initiative submit their quality data on the 10 measures to receive an increase in their Medicare Annual Payment Update. The Office of Management and Budget approved the collection of data associated with the original starter set of quality measures under OMB control number 0938-0918, with an expiration date of January 31, 2010. However, we recently submitted a new information collection request containing additional quality measures to OMB for approval. The new measures collect data for the Surgical Care Improvement Project (SCIP) and mortality measures. We announced and sought public comment on the information collection request in both 60-day and 30-day 
                        **Federal Register**
                         notices that published on October 13, 2006 (71 FR 60532), and December 22, 2006 (71 FR 77026), respectively. The revised information collection request is currently under review at OMB. Section IV.A.1 of the preamble of this proposed rule also discusses the use of the HCAHPS survey to capture quality data. The survey is designed to produce comparable data on the patient's perspective on care that allows objective and meaningful comparisons between hospitals on domains that are important to consumers. The HCAHPS survey is currently approved under OMB control number 0938-0981, with an expiration date of December 31, 2007. Section IV.A.2.h of the preamble of this proposed rule addresses the reconsideration and appeal procedures for a hospital that we believe did not meet the RHQDAPU program requirements. If a hospital disagrees with our determination, it may submit a written request to us requesting that we reconsider our decision. The hospital's letter must explain the reasons it believes it did meet the RHQDAPU program requirements. While this is a reporting requirement, the burden associated with it is not subject to the PRA under 5 CFR 1320.4(a)(2). The burden associated with information collection requirements imposed subsequent to an administrative action is not subject to the PRA. If you comment on these information collection and recordkeeping requirements, please mail copies directly to the following: Centers for Medicare & Medicaid Services, Office of Strategic Operations and Regulatory Affairs, Regulations Development Group, Attn: William N. Parham, III, CMS-1533-P, Room C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850; and Office of Information and Regulatory Affairs, Office of Management and Budget, Room 10235, New Executive Office Building, Washington, DC 20503, Attn: Carolyn Lovett, CMS Desk Officer, CMS-1533-P, 
                        *carolyn_lovett@omb.eop.gov.*
                         Fax (202) 395-6974. C. Response to Comments Because of the large number of comments we normally receive on 
                        **Federal Register**
                         documents, we are not able to acknowledge or respond to them individually. We will consider all comments we receive by the date and time specified in the 
                        **DATES**
                         section of this preamble, and, when we proceed with a subsequent document, we will respond to the comments in the preamble to that document. List of Subjects 42 CFR Part 411 Kidney diseases
Medicare
Physician referral
Reporting and recordkeeping requirements 42 CFR Part 412 Administrative practice and procedure
Health facilities
Medicare
Puerto Rico
Reporting and recordkeeping requirements 42 CFR Part 413 Health facilities
Kidney diseases
Medicare
Puerto Rico
Reporting and recordkeeping requirements 42 CFR Part 489 Health facilities
Medicare
Reporting and recordkeeping requirements
 For the reasons stated in the preamble of this proposed rule, the Centers for Medicare & Medicaid Services is proposing to amend 42 CFR Chapter IV as follows: PART 411—EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT 1. The authority citation for Part 411 continues to read as follows: Authority:
                            Secs. 1102, 1860D-4(e)(6), 1871, and 1877(b)(4) and (5) of the Social Security Act (42 U.S.C. 1302, 1395w-10(e)(6), 1395hh, and 1395nn(b)(4) and (5). 2. Section 411.4 is amended by revising the introductory text of paragraph (b) to read as follows: § 411.4
  
 (b) 
                                *Special conditions for services furnished to individuals in custody of penal authorities.*
                                 Individuals who are in custody include, but are not limited to, individuals who are under arrest, incarcerated, imprisoned, escaped from confinement, under supervised release, required to reside in mental health facilities, required to reside in halfway houses, required to live under home detention, or confined completely or partially in any way under a penal statute or rule. Payment may be made for services furnished to individuals or groups of individuals who are in the custody of police or other penal authorities or in the custody of a government agency under a penal statute only if the following conditions are met.
 PART 412—PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES 3. The authority citation for Part 412 is revised to read as follows: Authority:
                            Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh), and sec. 124 of Pub. L. 106-113 (113 Stat. 1501A-332). 4. Section 412.2 is amended by adding a new paragraph (g) to read as follows: § 412.2
  
 (g) 
                                *Payment adjustment for certain replaced devices.*
                                 CMS makes a payment adjustment for certain replaced devices, as provided under § 412.89. 5. Section 412.4 is amended by— a. Revising paragraphs (d)(3)(ii)(B) and (d)(3)(ii)(C). b. Adding a new paragraph (d)(3)(ii)(D). c. Revising paragraph (f)(3). d. Revising the introductory text of paragraph (f)(5). e. Revising paragraph (f)(5)(i). f. Revising paragraph (f)(5)(iv). g. Adding a new paragraph (f)(6). The revisions and additions read as follows:
 § 412.4
  
 (d) * * * (3) * * * 
 (ii) * * * (B) The proportion of short-stay discharges to postacute care to total discharges in the DRG exceeds the 55th percentile for all DRGs; (C) The DRG is paired with a DRG based on the presence or absence of a comorbidity or a complication or major cardiovascular condition that meets the criteria specified under paragraphs (d)(3)(ii)(A) and (d)(3)(ii)(B) of this section; and (D) In the case of MS-DRGs that share the same base MS-DRG, if one MS-DRG meets the criteria specified under paragraph (d)(3)(ii)(B) of this section, every MS-DRG that shares the same base MS-DRG is a qualifying DRG. 
 (f) * * * (3) 
                                *Transfer assigned to DRG for newborns that die or are transferred to another hospital.*
                                 If a transfer is classified into CMS DRG 385 (Neonates, Died or Transferred) prior to October 1, 2007, or into MS-DRG 789 (Neonates, Died or Transferred to Another Acute Care Facility) on or after October 1, 2007, the transferring hospital is paid in accordance with § 412.2(b). 
 (5) 
                                *Special rule for DRGs meeting specific criteria.*
                                 For discharges occurring on or after October 1, 2005, and prior to October 1, 2007, a hospital that transfers an inpatient under the circumstances described in paragraph (c) of this section is paid using the provisions of paragraphs (f)(2)(i) and (f)(2)(ii) of this section if the transfer case is assigned to one of the DRGs meeting the following criteria: (i) The DRG meets the criteria specified in paragraph (d)(3)(i) or (d)(3)(ii) of this section. 
 (iv) If a DRG is paired with a DRG based on the presence or absence of a comorbidity or complication or a major cardiovascular complication that meets the criteria specified in paragraphs (f)(5)(i) through (f)(5)(iii) of this section, that DRG will also be paid under the provisions of paragraphs (f)(2)(i) and (f)(2)(ii) of this section. (6) 
                                *Special rule for DRGs meeting specific criteria.*
                                 For discharges occurring on or after October 1, 2007, a hospital that transfers an inpatient under the circumstances described in paragraph (c) of this section is paid using the provisions of paragraphs (f)(2)(i) and (f)(2)(ii) of this section if the transfer case is assigned to one of the DRGs meeting the following criteria: (i) The DRG meets the criteria specified in paragraph (d)(3)(i) or (d)(3)(ii) of this section; (ii) The average charges of the 1-day discharge cases in the DRG must be at least 50 percent of the average charges for all cases in the DRG; and (iii) The geometric mean length of stay for the DRG is greater than 4 days. (iv) If a DRG is part of an MS-DRG group that meets the criteria specified in paragraphs (f)(6)(i) through (f)(6)(iii) of this section, that DRG will also be paid under the provisions of paragraphs (f)(2)(i) and (f)(2)(ii) of this section. 6. Section 412.64 is amended by— a. Revising paragraph (b)(1)(ii)(B). b. In paragraph (b)(3), designating the existing text as (b)(3)(i) and adding a new paragraph (b)(3)(ii). c. Adding a new paragraph (e)(3). d. Revising paragraph (i)(2). The revisions read as follows:
 § 412.64
  
 (b) * * * (1) * * * (ii) * * * (B) For discharges occurring on or after October 1, 1983, and before October 1, 2007, the following New England counties, which are deemed to be parts of urban areas under section 601(g) of the Social Security Amendments of 1983 (Public Law 98-21, 42 U.S.C. 1395ww (note); Litchfield County, Connecticut; York County, Maine; Sagadahoc County, Maine; Merrimack County, New Hampshire; and Newport County, Rhode Island. 
 (3)(i) * * * (ii) For discharges occurring on or after October 1, 2007, hospitals in the following New England counties, if not already located in an urban area, are deemed to be located in urban areas under section 601(g) of the Social Security Amendments of 1983 (Public Law 98-21, 42 U.S.C. 1395ww (note)): Litchfield County, Connecticut; York County, Maine; Sagadahoc County, Maine; Merrimack County, New Hampshire; and Newport County, Rhode Island. 
 (e) * * * (3) To the extent CMS determines that changes to the DRG classification and recalibrations of the DRG relative weights for a previous year (or estimates that such adjustments for a future fiscal year) did (or are likely to) result in a change in aggregate payments under this subsection during the fiscal year that are a result of changes in coding or classification of discharges that do not reflect real changes in case mix, CMS may adjust the standardized amount for subsequent fiscal years so as to eliminate the effect of such coding and classification changes. (i) * * * (2) 
                                *Amount of adjustment.*
                                 A hospital located in a county that meets the criteria under paragraphs (i)(1)(i) through (i)(1)(iii) of this section will receive an increase in its wage index that is equal to a weighted average of the difference between the postreclassified wage index of the MSA (or MSAs) with the higher wage index (or wage indices) and the postreclassified wage index of the MSA or rural statewide area in which the qualifying county is located, weighted by the overall percentage of the hospital employees residing in the qualifying county who are employed in any MSA with a higher wage index. 
 7. The heading of Subpart F is revised to read as follows:
 Subpart F—Payments for Outlier Cases, Special Treatment Payment for New Technology, and Payment Adjustment for Certain Replaced Devices
 8. Section 412.88 is amended by revising the introductory text of paragraph (a)(2) to read as follows: § 412.88
  (a) * * * (2) If the costs of the discharge (determined by applying the operating cost-to-charge ratios as described in § 412.84(h)) exceed the full DRG payment, an additional amount equal to the lesser of— 
 9. A new undesignated center heading and a new § 412.89 are added under Subpart F following § 412.88 to read as follows: Payment Adjustment for Certain Replaced Devices
 § 412.89
  (a) 
                                *General rule.*
                                 For discharges occurring on or after October 1, 2007, the amount of payment for a discharge described in paragraph (b) of this section is reduced when— (1) A device is replaced without cost to the hospital; (2) The provider received full credit for the cost of a device; or (3) The provider receives a credit equal to 20 percent or more of the cost of the device. (b) 
                                *Discharges subject to payment adjustment.*
                                 (1) Payment is reduced in accordance with paragraph (a) of this section only if the implantation of the device determines the DRG assignment. (2) CMS lists the DRGs that qualify under paragraph (b)(1) of this section in the annual final rule for the hospital inpatient prospective payment system. (c) 
                                *Amount of reduction.*
                                 (1) For a device provided to the hospital without cost, the cost of the device is subtracted from the DRG payment. (2) For a device for which the hospital received a full or partial credit, the amount credited is subtracted from the DRG payment. 10. Section 412.103 is amended by revising paragraph (g) to read as follows:
 § 412.103
  
 (g) 
                                *Cancellation of classification*
                                —(1) 
                                *Hospitals paid on basis of reasonable costs.*
                                 For a hospital paid on the basis of reasonable costs— (i) A hospital may cancel its rural reclassification by submitting a written request to the CMS Regional Office not less than 120 days prior to the end of its current cost reporting period. (ii) The hospital's cancellation of the classification is effective beginning with the next full cost reporting period. (2) 
                                *Hospitals paid under the hospital inpatient prospective payment system.*
                                 For a hospital paid under the hospital inpatient prospective payment system— (i) A hospital may cancel its rural reclassification by submitting a written request to the CMS Regional Office not less than 120 days prior to the end of a Federal fiscal year and after being paid as rural for at least one 12-month cost reporting period. (ii) The hospital's cancellation of the classification is not effective until it has been paid as rural for at least one 12-month cost reporting period, and not until the beginning of the Federal fiscal year following such 12-month cost reporting period. 11. Section 412.105 is amended by adding a sentence at the end of paragraph (f)(1)(iii)(A) to read as follows:
 § 412.105
  
 (f) * * * (1) * * * (iii) * * * (A) * * * Effective for cost reporting periods beginning on or after October 1, 2007, vacation leave and sick leave (that do not prolong the total time a resident is participating in the approved program beyond the normal duration of the program) are not included in the determination of full-time equivalency. 
 12. Section 412.308 is amended by— a. Revising paragraph (c)(1)(ii). b. Adding new paragraphs (c)(1)(iii) and (c)(1)(iv). The revision and addition read as follows:
 § 412.308
  
 (c) * * * (1) * * * (ii) 
                                *Effective FY 1996.*
                                 Except as specified in paragraph (c)(1)(iii) of this section, effective FY 1996, the standard Federal rate is updated based on an analytical framework. The framework includes a capital input price index, which measures the annual change in the prices associated with capital-related costs during the year. CMS adjusts the capital input price index rate of change to take into account forecast errors, changes to the case-mix index, the effect of changes to DRG classification and relative weights, and allowable changes in the intensity of hospital services. (iii) 
                                *Effective FY 2008.*
                                 Effective FY 2008, the update to the standard Federal rate for urban hospitals equals 0 and the update for rural hospitals is determined based on an analytical framework as described in paragraph (c)(1)(ii) of this section. (iv) 
                                *Definition of urban and rural hospital.*
                                 For purposes of paragraph (c)(1)(iii) of this section, an urban hospital is a hospital located in an area that meets the definition under § 412.64(b)(1)(ii)(A) or § 412.64(b)(1)(ii)(B) or that is deemed to be located in an urban area under § 412.64(b)(3). A rural hospital includes a hospital reclassified under § 412.103. 
 13. Section 412.316 is amended by— a. Revising the introductory text of paragraph (b). b. Revising paragraph (b)(2). c. Revising paragraph (b)(3). The revisions read as follows:
 § 412.316
  
 (b) 
                                *Large urban location.*
                                 For discharges occurring on or before September 30, 2007, CMS provides an additional payment to a hospital located in a large urban area equal to 3.0 percent of what would otherwise be payable to the hospital based on the Federal rate. 
 (2) For discharges occurring on or after October 1, 2004, and before October 1, 2007, the definition of large urban areas under § 412.63(c)(6) continues to be in effect for purposes of the payment adjustment under this section, based on the geographic classification under § 412.64, except as provided for in paragraph (b)(3) of this section. (3) For purposes of this section, the geographic classifications specified under § 412.64 apply, except that, effective for discharges occurring on or after October 1, 2006, and before October 1, 2007, for an urban hospital that is reclassified as rural as set forth in § 412.103, the geographic classification is rural. 
 14. Section 412.517 is amended by— a. Redesignating the introductory text and paragraphs (a), (b), (c), and (d) as paragraphs (a) introductory text, (a)(1), (a)(2), (a)(3), and (a)(4), respectively. b. Reserving paragraph (b). c. Adding a new paragraph (c). 
                                ( print page 24833) The additions read as follows:
 § 412.517
  
 (b) [Reserved] (c) To the extent CMS determines that changes to the DRG classifications and recalibrations of the DRG relative weights for a previous year (or estimates that such adjustments for a future fiscal year) did (or are likely to) result in a change in aggregate payments under this subpart during the fiscal year that are a result of changes in coding or classification of discharges that do not reflect real changes in case mix, CMS may adjust the DRG relative weights for subsequent fiscal years so as to eliminate the effect of such coding and classification changes.
 PART 413—PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES 15. The authority citation for Part 413 is revised to read as follows: Authority:
                            Secs. 1102, 1812(d), 1814(b), 1815, 1833(a), (i), and (n), 1861(v), 1871, 1881, 1883, and 1886 of the Social Security Act (42 U.S.C. 1302, 1395d(d), 1395f(b), 1395g, 1395l(a), (i), and (n), 1395x(v), 1395hh, 1395rr, 1395tt, and 1395ww); and sec. 124 of Pub. L. 106-133 (113 Stat. 1501A-332). 16. Section 413.75(b) is amended by— a. Adding in alphabetical order a definition of “orientation activities”. b. Revising the definition of “patient care activities”. The addition and revision read as follows: § 413.75
  
 (b) * * * *Orientation activities*
                                 means activities that are principally designed to prepare an individual for employment as a resident in a particular setting, or for participation in a particular specialty program and patient care activities associated with that particular specialty program. *Patient care activities*
                                 means the care and treatment of particular patients, including services for which a physician or other practitioner may bill, and orientation activities as defined in this section. 
 17. Section 413.78 is amended by adding a sentence at the end of paragraph (b) to read as follows:
 § 413.78
  
 (b) * * * Effective for cost reporting periods beginning on or after October 1, 2007, vacation leave and sick leave (that do not prolong the total time a resident is participating in the approved program beyond the normal duration of the program) are not included in the determination of full-time equivalency.
 PART 489—PROVIDER AGREEMENTS AND SUPPLIER APPROVAL 18. The authority citation for part 489 is amended to read as follows: Authority:
                            Secs. 1102, 1819, 1820(e), 1861, 1864(m), 1866, 1869, and 1871 of the Social Security Act (41 U.S.C. 1302, 1395i-3, 1395x, 1395aa(m), 1395cc, 1395ff, and 1395hh) 19. Section 489.3 is amended by adding a definition of “physician-owned hospital” in alphabetical order to read as follows: § 489.3
  
 *Physician-owned hospital*
                                 means any participating hospital (as defined in § 489.24) in which a physician or physicians have an ownership or investment interest. The ownership or investment interest may be through equity, debt, or other means, and includes an interest in an entity that holds an ownership or investment interest in the hospital. 20. Section 489.12 is amended by— a. Revising paragraph (a)(2). b. Redesignating paragraph (a)(3) as paragraph (a)(4). c. Adding a new paragraph (a)(3). The revision and addition read as follows:
 § 489.12
  (a) * * * (2) The prospective provider has failed to disclose ownership and control interests in accordance with § 420.206 of this chapter; (3) The prospective provider is a physician-owned hospital as defined in § 489.3 and does not have procedures in place for making physician ownership disclosures to patients in accordance with § 489.20(u) of this chapter; or 
 21. Section 489.20 is amended by adding new paragraphs (u) and (v) to read as follows:
 § 489.20
  
 (u) In the case of a physician-owned hospital as defined in § 489.3— (1) To furnish all patients notice, in accordance with § 482.13(b)(2), at the beginning of their hospital stay or outpatient visit that the hospital is a physician-owned hospital. The notice should disclose, in a manner reasonably designed to be understood by all patients, the fact that the hospital meets the Federal definition of a physician-owned hospital specified in § 489.3 and that the list of the hospital's physician owners or investors is available upon request. For the purposes of this paragraph, the hospital stay or outpatient visit begins with the provision of a package of information regarding scheduled preadmission testing and registration for a planned hospital admission for inpatient care or outpatient service. (2) To require all physician owners who also are members of the hospital's medical staff to agree, as a condition of continued medical staff membership, to disclose in writing their ownership interest in the hospital to all patients they refer to the hospital. Disclosure shall be required at the time the referral is made. (v) In the case of a hospital as defined in § 489.24(b), to furnish all patients written notice, in accordance with § 482.13(b)(2), at the beginning of their hospital stay or outpatient visit if a doctor of medicine or a doctor of osteopathy is not present in the hospital 24 hours per day, seven days per week. The notice must indicate how the hospital will meet the medical needs of any inpatient who develops an emergency medical condition, as defined in § 489.24(b), at a time when there is no physician present in the hospital. For purposes of this paragraph, the hospital stay or outpatient visit begins with the provision of a package of information regarding scheduled preadmission testing and registration for a planned hospital admission for inpatient care or the provision of a package of information regarding an outpatient service. 22. Section 489.24 is amended by revising paragraph (a)(2) to read as follows:
 § 489.24
  (a) * * * (2) 
                                *Nonapplicability of provisions of this section.*
                                 Sanctions under this section for an inappropriate transfer during a national emergency or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department located in an emergency area, as specified in section 1135(g)(1) of 
                                ( print page 24834)
                                the Act. A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided for by section 1135(e)(1)(B) of the Act. 
 23. Section 489.53 is amended by— a. Redesignating paragraph (c) and (d) as paragraphs (d) as (e), respectively. b. Adding a new paragraph (c). c. In newly redesignated paragraph (d) introductory text, removing the cross-reference “paragraph (c)(2) of this section” and adding the reference “paragraph (d)(2) of this section” in its place. The revisions and additions read as follows:
 § 489.53
  
 (c) 
                                *Termination of agreements with physician-owned hospitals.*
                                 In the case of a physician-owned hospital, as defined at § 489.3, CMS may terminate the provider agreement if the hospital failed to comply with the requirements of § 489.20(u). 
 (Catalog of Federal Domestic Assistance Program No. 93.773, Medicare—Hospital Insurance; and Program No. 93.774, Medicare—Supplementary Medical Insurance Program) Dated: April 13, 2007. Leslie Norwalk, Acting Administrator, Centers for Medicare & Medicaid Services. Dated: April 13, 2007. Michael O. Leavitt, Secretary.
 Editorial Note: The following Addendum and appendices will not appear in the Code of Federal Regulations.
 Addendum—Proposed Schedule of Standardized Amounts, Update Factors, and Rate-of-Increase Percentages Effective With Cost Reporting Periods Beginning On or After October 1, 2007 I. Summary and Background In this Addendum, we are setting forth the proposed methods and data we are using to determine the proposed prospective payment rates for Medicare hospital inpatient operating costs and Medicare hospital inpatient capital-related costs. We are also setting forth the proposed rate-of-increase percentages for updating the target amounts for certain hospitals and hospital units excluded from the IPPS. In general, except for SCHs, MDHs, and hospitals located in Puerto Rico, each hospital's payment per discharge under the IPPS is based on 100 percent of the Federal national rate, also known as the national adjusted standardized amount. This amount reflects the national average hospital cost per case from a base year, updated for inflation. SCHs are paid based on whichever of the following rates yields the greatest aggregate payment: the Federal national rate; the updated hospital-specific rate based on FY 1982 costs per discharge; the updated hospital-specific rate based on FY 1987 costs per discharge; or the updated hospital-specific rate based on FY 1996 costs per discharge. Under section 1886(d)(5)(G) of the Act, MDHs historically have been paid based on the Federal national rate or, if higher, the Federal national rate plus 50 percent of the difference between the Federal national rate and the updated hospital-specific rate based on FY 1982 or FY 1987 costs per discharge, whichever is higher. (MDHs did not have the option to use their FY 1996 hospital-specific rate.) Section 5003(a)(1) of Pub. L. 109-171 extended and modified the MDH special payment provision which was previously set to expire on October 1, 2006, to discharges occurring on or after October 1, 2006, but before October 1, 2011. Under section 5003(b) of Pub. L. 109-171, if the change results in an increase to its target amount, an MDH must rebase its hospital-specific rates to its FY 2002 cost report. In addition, under section 5003(c) of Pub. L. 109-171, MDHs are now paid based on the Federal national rate or, if higher, the Federal national rate plus 75 percent of the difference between the Federal national rate and the updated hospital-specific rate. Further, based upon section 5003(d) of Pub. L. 109-171, MDHs are no longer subject to the 12-percent cap on their DSH payment adjustment factor. For hospitals in Puerto Rico, the payment per discharge is based on the sum of 25 percent of a Puerto Rico rate that reflects base year average costs per case of Puerto Rico hospitals and 75 percent of the Federal national rate. (See section II.D.3. of this Addendum for a complete description.) As discussed below in section II. of this Addendum, we are proposing to make changes in the determination of the prospective payment rates for Medicare inpatient operating costs for FY 2008. In section III. of this Addendum, we discuss our proposed changes for determining the prospective payment rates for Medicare inpatient capital-related costs for FY 2008. Section IV. of this Addendum sets forth our proposed changes for determining the rate-of-increase limits for certain hospitals excluded from the IPPS for FY 2008. The tables to which we refer in the preamble of this proposed rule are presented in section VI. of this Addendum of this proposed rule. II. Proposed Changes to Prospective Payment Rates for Hospital Inpatient Operating Costs The basic methodology for determining prospective payment rates for hospital inpatient operating costs for FY 2005 and subsequent fiscal years is set forth at § 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 §§ 412.211 and 412.212. Below we discuss the factors used for determining the prospective payment rates. In summary, the proposed standardized amounts set forth in Tables 1A, 1B, 1C, and 1D of section VI. of this Addendum reflect— Equalization of the standardized amounts for urban and other areas at the level computed for large urban hospitals during FY 2004 and onward, as provided for under section 1886(d)(3)(A)(iv) of the Act, updated by the applicable percentage increase required under sections 1886(b)(3)(B)(i)(XX) and 1886(b)(3)(B)(viii) of the Act.
                                The labor-related share that is applied to the standardized amounts and Puerto Rico-specific standardized amounts to give the hospital the highest payment, as provided for under sections 1886(d)(3)(E), and 1886(d)(9)(C)(iv) of the Act.
                                Proposed updates of 3.3 percent for all areas (that is, the estimated full market basket percentage increase of 3.3 percent), as required by section 1886(b)(3)(B)(i)(XX) of the Act, as amended by section 5001(a)(1) ofPub. L. 109-171, and reflecting the requirements of section 1886(b)(3)(B)(viii) of the Act, as added by section 5001(a)(3) of Pub. L. 109-171, to reduce the applicable percentage increase by 2.0 percentage points for a hospital that fails to submit data, in a form and manner specified by the Secretary, relating to the quality of inpatient care furnished by the hospital.
                                An adjustment to the standardized amount to ensure budget neutrality for DRG recalibration and reclassification, as provided for under section 1886(d)(4)(C)(iii) of the Act.
                                An adjustment to ensure the wage index update and changes are budget neutral, as provided for under section 1886(d)(3)(E) of the Act.
                                An adjustment to ensure the effects of geographic reclassification are budget neutral, as provided for in section 1886(d)(8)(D) of the Act, by removing the FY 2007 budget neutrality factor and applying a revised factor.
                                An adjustment to remove the FY 2007 outlier offset and apply an offset for FY 2008.
                                An adjustment to ensure the effects of the rural community hospital demonstration required under section 410A ofPub. L. 108-173 are budget neutral, as required under section 410A(c)(2) of Pub. L. 108-173.
                                An adjustment to eliminate the effect of coding or classification changes that do not reflect real changes in case-mix using the Secretary's authority under section 1886(d)(3)(A)(vi) of the Act (as discussed in section II.D.6. of the preamble to this proposed rule). We note that two budget neutrality provisions will no longer be applied to the standardized amounts beginning with FY 2008. First, in the FY 2005 IPPS final rule (69 FR 49032 through 49034), we allowed urban hospitals that became rural under the new labor market area definitions to maintain their assignment to the MSA where they were previously located for the 3-year period of FY 2005, FY 2006, and FY 2007. In these years, we provided for a budget neutrality 
                                    ( print page 24835)
                                    adjustment to the standardized amount to ensure that this policy did not increase Medicare expenditures for hospital inpatient services. For FY 2008, this budget neutrality adjustment to the IPPS standardized amounts will no longer be necessary because the provision has expired. Second, in this proposed rule, we are proposing a prospective change to how budget neutrality is applied to implement the rural floor for FY 2008 and subsequent years. As discussed in section III.G.4. of the preamble of this proposed rule, we are proposing to apply the budget neutrality adjustment to hospital wage indices rather than the standardized amount. A. Calculation of the Proposed Adjusted Standardized Amount 1. Standardization of Base-Year Costs or Target Amounts In general, the national standardized amount is based on per discharge averages of adjusted hospital costs from a base period (section 1886(d)(2)(A) of the Act) or, for Puerto Rico, adjusted target amounts from a base period (section 1886(d)(9)(B)(i) of the Act), updated and otherwise adjusted in accordance with the provisions of section 1886(d) of the Act. The September 1, 1983 interim final rule (48 FR 39763) contained a detailed explanation of how base-year cost data (from cost reporting periods ending during FY 1981) were established in the initial development of standardized amounts for the IPPS. The September 1, 1987 final rule (52 FR 33043 and 33066) contains a detailed explanation of how the target amounts were determined, and how they are used in computing the Puerto Rico rates. Sections 1886(d)(2)(B) and (d)(2)(C) of the Act require us to update base-year per discharge costs for FY 1984 and then standardize the cost data in order to remove the effects of certain sources of cost variations among hospitals. These effects include case-mix, differences in area wage levels, cost-of-living adjustments for Alaska and Hawaii, indirect medical education costs, and costs to hospitals serving a disproportionate share of low-income patients. In accordance with section 1886(d)(3)(E) of the Act, the Secretary estimates, from time-to-time, the proportion of hospitals' costs that are attributable to wages and wage-related costs. In general, the standardized amount is divided into labor-related and nonlabor-related amounts; only the proportion considered the labor-related amount is adjusted by the wage index. Section 1886(d)(3)(E) of the Act requires that 62 percent of the standardized amount be adjusted by the wage index, unless doing so would result in lower payments to a hospital than would otherwise be made. (Section 1886(d)(9)(C)(iv)(II) of the Act extends this provision to the labor-related share for hospitals located in Puerto Rico.) For FY 2008, we are not proposing to change the national and Puerto Rico-specific labor-related and nonlabor-related shares from the percentages established for FY 2007. Therefore, the labor-related share would continue to be 69.7 percent for the national standardized amounts and 58.7 percent for the Puerto Rico specific standardized amount. Consistent with section 1886(d)(3)(E) of the Act, we will apply the wage index to a labor-related share of 62 percent for all non-Puerto Rico hospitals whose wage indexes are less than or equal to 1.0000. For all non-Puerto Rico hospitals whose wage indices are greater than 1.0000, we will apply the wage index to a labor share of 69.7 percent of the national standardized amount. For a Puerto Rico hospital, we will apply a labor share of 58.7 percent if its Puerto Rico-specific wage index is less than or equal to 1.0000. For Puerto Rico hospitals whose Puerto Rico-specific wage index values are greater than 1.0000, we will apply a labor share of 62 percent. The standardized amounts for operating costs appear in Table 1A, 1B, and 1C of the Addendum to this proposed rule. 2. Computing the Average Standardized Amount Section 1886(d)(3)(A)(iv) of the Act requires that, beginning with FY 2004 and thereafter, an equal standardized amount is to be computed for all hospitals at the level computed for large urban hospitals during FY 2003, updated by the applicable percentage update. Section 1886(d)(9)(A) of the Act equalizes the Puerto Rico-specific urban and rural area rates. Accordingly, we are calculating FY 2008 national and Puerto Rico standardized amounts, irrespective of whether a hospital is located in an urban or rural location. 3. Updating the Average Standardized Amount In accordance with section 1886(d)(3)(A)(iv)(II) of the Act, we are updating the equalized standardized amount for FY 2008 by the full estimated market basket percentage increase for hospitals in all areas, as specified in section 1886(b)(3)(B)(i)(XX) of the Act, as amended by section 5001(a)(1) of Pub. L. 109-171. The percentage change in the market basket reflects the average change in the price of goods and services purchased by hospitals to furnish inpatient care. The most recent forecast of the hospital market basket increase for FY 2008 is 3.3 percent. Thus, for FY 2008, the proposed update to the average standardized amount is 3.3 percent for hospitals in all areas. The estimated market basket increase of 3.3 percent is based on the 2007 first quarter forecast of the hospital market basket increase by the Office of the Actuary (as discussed in Appendix B of this proposed rule). Section 1886(b)(3)(B) of the Act specifies the mechanism used to update the standardized amount for payment for inpatient hospital operating costs. Section 1886(b)(3)(B)(viii) of the Act, as added by section 5001(a)(3) of Pub. L. 109-171, provides for a reduction of 2.0 percentage points to the update percentage increase (also known as the market basket update) for FY 2007 and each subsequent fiscal year for any “subsection (d) hospital” that does not submit quality data as discussed in section IV.A. of the preamble of this proposed rule. The standardized amounts in Tables 1A through 1C of section VI. of the Addendum to this proposed rule reflect these differential amounts. Although the update factors for FY 2008 are set by law, we are required by section 1886(e)(4) of the Act to recommend, taking into account MedPAC's recommendations, appropriate update factors for FY 2008 for both IPPS hospitals and hospitals and hospital units excluded from the IPPS. Our recommendation on the update factors (which is required by sections 1886(e)(4)(A) and (e)(5)(A) of the Act) is set forth in Appendix B of this proposed rule. 4. Other Adjustments to the Average Standardized Amount As in the past, we are adjusting the FY 2008 standardized amount to remove the effects of the FY 2007 geographic reclassifications and outlier payments before applying the FY 2008 updates. We then apply budget neutrality offsets for outliers and geographic reclassifications to the standardized amount based on FY 2008 payment policies. We do not remove the prior year's budget neutrality adjustments for reclassification and recalibration of the DRG weights and for updated wage data because, in accordance with sections 1886(d)(4)(C)(iii) and 1886(d)(3)(E) of the Act, estimated aggregate payments after the changes in the DRG relative weights and wage index should equal estimated aggregate payments prior to the changes. If we removed the prior year adjustment, we would not satisfy these conditions. Budget neutrality is determined by comparing aggregate IPPS payments before and after making the changes that are required to be budget neutral (for example, changes to DRG classifications, recalibration of the DRG relative weights, updates to the wage index, and different geographic reclassifications). We include outlier payments in the simulations because they may be affected by changes in these parameters. We are also proposing to adjust the standardized amount this year by an estimated amount to ensure that aggregate IPPS payments do not exceed the amount of payments that would have been made in the absence of the rural community hospital demonstration required under section 410A of Pub. L. 108-173. This demonstration is required to be budget neutral under section 410A(c)(2) of Pub. L. 108-173. For FY 2008 and FY 2009, we are also proposing an adjustment to eliminate the effect of coding or classification changes that do not reflect real changes in case-mix using the Secretary's authority under section 1886(d)(3)(A)(vi) of the Act. a. Proposed Recalibration of DRG Weights and Updated Wage Index—Budget Neutrality Adjustment Section 1886(d)(4)(C)(iii) of the Act specifies that, beginning in FY 1991, the annual DRG reclassification and recalibration of the relative weights must be made in a manner that ensures that aggregate payments to hospitals are not affected. As discussed in section II. of the preamble of this proposed rule, we normalized the recalibrated DRG weights by an adjustment factor, so that the average case weight after recalibration is equal to the average case weight prior to 
                                    ( print page 24836)
                                    recalibration. However, equating the average case weight after recalibration to the average case weight before recalibration does not necessarily achieve budget neutrality with respect to aggregate payments to hospitals because payments to hospitals are affected by factors other than average case weight. Therefore, as we have done in past years, we are proposing to make a budget neutrality adjustment to ensure that the requirement of section 1886(d)(4)(C)(iii) of the Act is met. Section 1886(d)(3)(E) of the Act requires us to update the hospital wage index on an annual basis beginning October 1, 1993. This provision also requires us to make any updates or adjustments to the wage index in a manner that ensures that aggregate payments to hospitals are not affected by the change in the wage index. Consistent with current policy, for FY 2008, we are adjusting 100 percent of the wage index factor for occupational mix. We describe the occupational mix adjustment in section III.C. of the preamble to this proposed rule. To comply with the requirement that DRG reclassification and recalibration of the relative weights and the updated wage index be budget neutral, we are using FY 2006 discharge data to simulate payments and compare aggregate payments using the FY 2007 relative weights and wage indexes to aggregate payments using the proposed FY 2008 relative weights and wage indexes. The same methodology was used for the FY 2007 budget neutrality adjustment. Based on this comparison, we computed a budget neutrality adjustment factor equal to 0.999317 to be applied to the national standardized amount. We also are adjusting the Puerto Rico-specific standardized amount for the effect of DRG reclassification and recalibration. We computed a budget neutrality adjustment factor of 0.998557 to be applied to the Puerto Rico-specific standardized amount. These budget neutrality adjustment factors are applied to the standardized amounts for FY 2007 without removing prior year budget neutrality adjustments. In addition, as discussed in section IV. of this addendum, we are applying the same DRG reclassification and recalibration budget neutrality factor of 0.998557 to the hospital-specific rates that are to be effective for cost reporting periods beginning on or after October 1, 2007. b. Reclassified Hospitals—Budget Neutrality Adjustment Section 1886(d)(8)(B) of the Act provides that, effective with discharges occurring on or after October 1, 1988, certain rural hospitals are deemed urban. In addition, section 1886(d)(10) of the Act provides for the reclassification of hospitals based on determinations by the MGCRB. Under section 1886(d)(10) of the Act, a hospital may be reclassified for purposes of the wage index. Under section 1886(d)(8)(D) of the Act, the Secretary is required to adjust the standardized amount to ensure that aggregate payments under the IPPS after implementation of the provisions of sections 1886(d)(8)(B) and (C) and 1886(d)(10) of the Act are equal to the aggregate prospective payments that would have been made absent these provisions. We note that the wage index adjustments provided under section 1886(d)(13) of the Act are not budget neutral. Section 1886(d)(13)(H) of the Act provides that any increase in a wage index under section 1886(d)(13) shall not be taken into account “in applying any budget neutrality adjustment with respect to such index” under section 1886(d)(8)(D) of the Act. To calculate the budget neutrality factor, we used FY 2006 discharge data to simulate payments, and compared total IPPS payments prior to any reclassifications under sections 1886(d)(8)(B) and (C) and 1886(d)(10) of the Act to total IPPS payments after such reclassifications. Based on these simulations, we calculated an adjustment factor of 0.991938 to ensure that the effects of this reclassification are budget neutral, consistent with the statute. The proposed adjustment factor is applied to the standardized amount after removing the effects of the FY 2007 budget neutrality adjustment factor. We note that the FY 2008 adjustment reflects FY 2008 wage index reclassifications approved by the MGCRB or the Administrator. (Section 1886(d)(10)(D)(v) of the Act makes wage index reclassifications effective for 3 years. Therefore, the FY 2008 geographic reclassification could either be the continuation of a 3-year reclassification that began in FY 2006 or FY 2007 or a new one beginning in FY 2008.) c. Case-Mix Budget Neutrality Adjustment The proposed MS-DRGs will increase the total number of DRGs from 538 to 745. Such a significant expansion in the number of DRGs could lead hospitals to improve coding and documentation in order to have a case assigned to a DRG with a higher payment. As explained above, we make an adjustment to ensure that the DRG relative weights remain budget neutral assuming constant utilization. However, without an adjustment to the IPPS rates to account for expected case mix growth due to improved coding rather than to underlying changes in patient status, the change to severity DRGs will not be budget neutral. Section 1886(d)(3)(A)(vi) of the Act provides the Secretary with explicit authority to adjust the standardized amounts to account for case mix growth due to improved documentation and coding. Further, the Secretary may subsequently revisit this adjustment if actual data is different than the projection. Based on the Actuary's analysis, using the Secretary's authority under section 1886(d)(3)(A)(vi) of the Act to adjust the standardized amount to eliminate the effect of changes in coding or classification of discharges that do not reflect real changes in case-mix, we are proposing to reduce the IPPS standardized amounts by 2.4 percent each year for FY 2008 and FY 2009. Section 1886(d)(3)(A)(vi) further gives the Secretary authority to revisit adjustments to the standardized amounts for changes in coding or classification of discharges that were based on estimates in a future year. Consistent with the statute, we will compare the actual increase in case-mix due to documentation and coding to our projection once we have actual data for FY 2008 and FY 2009 for the FY 2010 and FY 2011 IPPS rules. As that time, if necessary, we may make a further adjustment to the standardized amounts to account for the difference between our projection and actual data. d. Outliers Section 1886(d)(5)(A) of the Act provides for payments in addition to the basic prospective payments for “outlier” cases involving extraordinarily high costs. To qualify for outlier payments, a case must have costs greater than the sum of the prospective payment rate for the DRG, any IME and DSH payments, any new technology add-on payments, and the “outlier threshold” or “fixed loss” amount (a dollar amount by which the costs of a case must exceed payments in order to qualify for an outlier payment). We refer to the sum of the prospective payment rate for the DRG, any IME and DSH payments, any new technology add-on payments, and the outlier threshold as the outlier “fixed-loss cost threshold.” To determine whether the costs of a case exceed the fixed-loss cost threshold, a hospital's CCR is applied to the total covered charges for the case to convert the charges to estimated costs. Payments for eligible cases are then made based on a marginal cost factor, which is a percentage of the estimated costs above the fixed-loss cost threshold. The marginal cost factor for FY 2008 is 80 percent, the same marginal cost factor we have used since FY 1995 (59 FR 45367). In accordance with section 1886(d)(5)(A)(iv) of the Act, outlier payments for any year are projected to be not less than 5 percent nor more than 6 percent of total operating DRG payments plus outlier payments. Section 1886(d)(3)(B) of the Act requires the Secretary to reduce the average standardized amount by a factor to account for the estimated proportion of total DRG payments made to outlier cases. Similarly, section 1886(d)(9)(B)(iv) of the Act requires the Secretary to reduce the average standardized amount applicable to hospitals in Puerto Rico to account for the estimated proportion of total DRG payments made to outlier cases. More information on outlier payments may be found on the CMS Web site at 
                                    *http://www.cms.hhs.gov/​AcuteInpatientPPS/​04_​outlier.asp#TopOfPage.* (1) Proposed FY 2008 Outlier Fixed-Loss Cost Threshold For FY 2008, we are proposing to use the same methodology used for FY 2007 (71 FR 48148 through 484151) to calculate the outlier threshold. Similar to the methodology used in the FY 2007 final rule, for FY 2008, we are applying an adjustment factor to the CCRs to account for cost and charge inflation (as explained below). As we have done in the past, to calculate the proposed FY 2008 outlier threshold, we simulated payments by applying FY 2008 rates and policies using cases from the FY 2006 MedPAR files. Therefore, in order to determine the proposed FY 2008 outlier threshold, we inflate the charges on the MedPAR claims by 2 years, from FY 2006 to FY 2008. We are proposing to continue using a refined methodology that takes into account the lower inflation in hospital charges that is occurring as a result of the outlier final rule (68 FR 34494), which changed our methodology for determining outlier 
                                    ( print page 24837)
                                    payments by implementing the use of more current CCRs. Our refined methodology uses more recent data that reflect the rate-of-change in hospital charges under the new outlier policy. Using the most recent data available, we calculated the 1-year average annualized rate-of-change in charges-per-case from the last quarter of FY 2005 in combination with the first quarter of FY 2006 (July 1, 2005 through December 31, 2005) to the last quarter of FY 2006 in combination with the first quarter of FY 2007 (July 1, 2006 through December 31, 2006). This rate of change was 7.26 percent (1.0726) or 15.04 percent (1.1504) over 2 years. As we have done in the past, we are proposing to establish the proposed FY 2008 outlier threshold using hospital CCRs from the December 2006 update to the Provider-Specific File—the most recent available at the time of this proposed rule. This file includes CCRs that reflect implementation of the changes to the policy for determining the applicable CCRs that became effective August 8, 2003 (68 FR 34494). As discussed in the FY 2007 final rule (71 FR 48150), we worked with the Actuary to derive the methodology described below to develop the CCR adjustment factor. For FY 2008, we are proposing to use the same methodology by using the operating cost per discharge increase in combination with the final updated market basket increase determined by Global Insight, Inc., as well as the charge inflation factor described above to estimate the adjustment to the CCRs. By using the market basket rate-of-increase and the increase in the average cost per discharge from hospital cost reports, we are using two different measures of cost inflation. For FY 2008, we determined the adjustment by taking the percentage increase in the operating costs per discharge from FY 2004 to FY 2005 (1.0529) from the cost report and dividing it by the final market basket increase from FY 2005 (1.043) We repeated this calculation for 2 prior years to determine the 3-year average of the rate of adjusted change in costs between the market basket rate-of-increase and the increase in cost per case from the cost report (FY 2002 to FY 2003 percentage increase of operating costs per discharge of 1.0721 divided by FY 2003 final market basket increase of 1.041, FY 2003 to FY 2004 percentage increase of operating costs per discharge of 1.0624 divided by FY 2004 final market basket increase of 1.04). For FY 2008, we averaged the differentials calculated for FY 2003, FY 2004, and FY 2005 which resulted in a mean ratio of 1.0203. We multiplied the 3-year average of 1.0203 by the 2006 market basket percentage increase of 1.0420, which resulted in an operating cost inflation factor of 6.32 percent or 1.0632. We then divided the operating cost inflation factor by the 1-year average change in charges (1.0726) and applied an adjustment factor of 0.9912 to the operating CCRs from the Provider-Specific File. As stated in the FY 2007 final rule, we continue to believe it is appropriate to apply only a one year adjustment factor to the CCRs. On average, it takes approximately 9 months for fiscal intermediaries (or, if applicable, the MAC) to tentatively settle a cost report from the fiscal year end of a hospital's cost reporting period. The average “age” of hospitals” CCRs from the time the fiscal intermediary or the MAC inserts the CCR in the PSF until the beginning of FY 2007 is approximately 1 year. Therefore, as stated above, we believe a one year adjustment to the CCRs is appropriate. We used the same methodology for the capital CCRs and applied an adjustment factor of 0.964 (cost inflation factor of 1.0340 divided by a charge inflation factor of 1.0726) to the capital CCRs. We are using the same charge inflation factor for the capital CCRs that was used for the operating CCRs. The charge inflation factor is based on the overall billed charges. Therefore, we believe it is appropriate to apply the charge factor to both the operating and capital CCRs. Using this methodology, we are proposing an outlier fixed-loss cost threshold for FY 2008 equal to the prospective payment rate for the DRG, plus any IME and DSH payments, and any add-on payments for new technology, plus $23,015. With this threshold, we are projecting that outlier payments will equal 5.1 percent of total IPPS payments. As we did in establishing the FY 2007 outlier threshold (71 FR 48149), in our projection of FY 2008 outlier payments, we are not making any adjustments for the possibility that hospitals' CCRs and outlier payments may be reconciled upon cost report settlement. We continue to believe that, due to the policy implemented in the outlier final rule (68 FR 34494, June 9, 2003), CCRs will no longer fluctuate significantly and, therefore, few hospitals will actually have these ratios reconciled upon cost report settlement. In addition, it is difficult to predict the specific hospitals that will have CCRs and outlier payments reconciled in any given year. We also noted that reconciliation occurs because hospitals' actual CCRs for the cost reporting period are different than the interim CCRs used to calculate outlier payments when a bill is processed. Our simulations assume that CCRs accurately measure hospital costs based on information available to us at the time we set the outlier threshold. For these reasons, we are not making any assumptions about the effects of reconciliation on the outlier threshold calculation. We also note that there are several factors that contributed to a lower fixed loss outlier threshold for FY 2008 compared to FY 2007. First, the case-weighted national average operating CCR declined by approximately an additional 1.3 percentage points from the March 2006 (used to calculate the FY 2007 outlier threshold) to the December 2006 update of the Provider-Specific File. Second, we further reduced the CCRs by applying an adjustment to reflect the differential increase between costs and charges. As noted above, using lower CCRs from the December 2006 Provider-Specific File, in combination with the FY 2006 MedPAR claims and inflated charges, contributes to a lower outlier threshold for FY 2008 in this proposed rule compared to an outlier threshold of $24,485 in FY 2007. Finally, as discussed in section II.D. of the preamble of this proposed rule, we are proposing to adopt the use of MS-DRGs under the IPPS for FY 2008. The proposed MS-DRG system would increase the number of DRGs from 538 to 745 and better recognize severity of illness than the CMS DRGs. Better recognition of severity of illness with the MS-DRGs means that nonoutlier payments will compensate hospitals for the higher costs of some cases that previously received outlier payments. As cases are paid more accurately, in order to meet the 5.1 percent target, we would need to decrease the fixed-loss outlier threshold so that more cases qualify for outlier payments. Therefore, we believe that all of the above factors cumulatively contributed to a lower proposed fixed-loss outlier threshold in FY 2008 compared to FY 2007. (2) Other Proposed Changes Concerning Outliers As stated in the FY 1994 IPPS final rule (58 FR 46348, September 1, 1993), we establish outlier thresholds that are applicable to both hospital inpatient operating costs and hospital inpatient capital-related costs. When we modeled the combined operating and capital outlier payments, we found that using a common set of thresholds resulted in a lower percentage of outlier payments for capital-related costs than for operating costs. We are project that the proposed thresholds for FY 2008 would result in outlier payments equal to 5.1 percent of operating DRG payments and 4.87 percent of capital payments based on the Federal rate. In accordance with section 1886(d)(3)(B) of the Act, we are reducing the FY 2008 standardized amount by the same percentage to account for the projected proportion of payments paid to outliers. The outlier adjustment factors that would be applied to the standardized amount for the proposed FY 2008 outlier threshold are as follows: Operating
                                             standardized  
                                             amounts
Capital 
                                             federal  
                                             rateNational
0.948989
0.948377Puerto Rico
0.965244
0.954922
 Consistent with current policy, we are applying the outlier adjustment factors to FY 2008 rates after removing the effects of the FY 2007 outlier adjustment factors on the standardized amount. To determine whether a case qualifies for outlier payments, we apply hospital-specific CCRs to the total covered charges for the case. Estimated operating and capital costs for the case are calculated separately by applying separate operating and capital CCRs. These costs are then combined and compared with the outlier fixed-loss cost threshold. The outlier final rule (68 FR 34494) eliminated the application of the statewide average CCRs for hospitals with CCRs that fall below 3 standard deviations from the national mean CCR. However, for those hospitals for which the fiscal intermediary or MAC computes operating CCRs greater than 1.221 or capital CCRs greater than 0.150, or hospitals for whom the fiscal intermediary or MAC is unable to calculate a CCR (as described at § 412.84(i)(3) of our regulations), 
                                    ( print page 24838)
                                    we are still using statewide average CCRs to determine whether a hospital qualifies for outlier payments.[18]
                                    
                                     Table 8A in section VI. of this Addendum contains the statewide average operating CCRs for urban hospitals and for rural hospitals for which the fiscal intermediary or MAC is unable to compute a hospital-specific CCR within the above range. Effective for discharges occurring on or after October 1, 2007, these statewide average ratios would replace the ratios published in the IPPS final rule for FY 2007 (71 FR 48303). Table 8B in section VI. of this Addendum contains the comparable statewide average capital CCRs. Again, the CCRs in Tables 8A and 8B would be used during FY 2008 when hospital-specific CCRs based on the latest settled cost report are either not available or are outside the range noted above. For an explanation of Table 8C, please see section VI. of this Addendum. We finally note that we published a manual update (Change Request 3966) to outliers on October 12, 2005 which updated Chapter 3, Section 20.1.2 of the Medicare Claims Processing Manual. The manual update covered an array of topics, including CCRs, reconciliation, and the time value of money. We encourage hospitals that are assigned the statewide average operating and/or capital CCRs to work with their fiscal intermediaries or MAC on a possible alternative operating and/or capital CCR as explained in Change Request 3966. Use of an alternative CCR developed by the hospital in conjunction with the fiscal intermediary or MAC can avoid possible overpayments or underpayments at cost report settlement thus ensuring better accuracy when making outlier payments and negating the need for outlier reconciliation. We also note a hospital may request an alternative operating or capital CCR ratio at any time as long as the guidelines of Change Request 3966 are followed. To download and view the manual instructions on outlier and cost-to-charge ratios, please visit the Web site: 
                                    *http://www.cms.hhs.gov/​manuals/​downloads/​clm104c03.pdf.* (3) FY 2006 and FY 2007 Outlier Payments In the FY 2007 IPPS final rule (70 FR 47496), we stated that, based on available data, we estimated that actual FY 2006 outlier payments would be approximately 4.62 percent of actual total DRG payments. This estimate was computed based on simulations using the FY 2005 MedPAR file (discharge data for FY 2005 bills). That is, the estimate of actual outlier payments did not reflect actual FY 2006 bills, but instead reflected the application of FY 2006 rates and policies to available FY 2005 bills. Our current estimate, using available FY 2006 bills, is that actual outlier payments for FY 2006 were approximately 4.50 percent of actual total DRG payments. Thus, the data indicate that, for FY 2006, the percentage of actual outlier payments relative to actual total payments is lower than we projected before FY 2006. Consistent with the policy and statutory interpretation we have maintained since the inception of the IPPS, we do not plan to make retroactive adjustments to outlier payments to ensure that total outlier payments for FY 2006 are equal to 5.1 percent of total DRG payments. We currently estimate that actual outlier payments for FY 2007 will be approximately 4.9 percent of actual total DRG payments, 0.2 percentage points lower than the 5.1 percent we projected in setting the outlier policies for FY 2007. This estimate is based on simulations using the FY 2006 MedPAR file (discharge data for FY 2006 bills). We used these data to calculate an estimate of the actual outlier percentage for FY 2007 by applying FY 2007 rates and policies, including an outlier threshold of $24,485 to available FY 2006 bills. We believe the 0.2 percentage point difference between the projected estimate of outlier payments for FY 2007 and our current estimate of actual outlier payments in this proposed rule provides preliminary evidence that incorporating an adjustment factor to the CCRs for FY 2007 in response to public comments has improved our estimating methodology. e. Proposed Rural Community Hospital Demonstration Program Adjustment (Section 410A of Pub. L. 108-173) Section 410A of Pub. L. 108-173 requires the Secretary to establish a demonstration that will modify reimbursement for inpatient services for up to 15 small rural hospitals. Section 410A(c)(2) of Pub. L. 108-173 requires that “in conducting the demonstration program under this section, the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration program under this section was not implemented.” As discussed in section IV.G. of the preamble to this proposed rule, we have satisfied this requirement by adjusting national IPPS rates by a factor that is sufficient to account for the added costs of this demonstration. We estimate that the average additional annual payment that will be made to each participating hospital under the demonstration will be approximately $1,075,765. We based this estimate on the recent historical experience of the difference between inpatient cost and payment for hospitals that are participating in the demonstration. For 9 participating hospitals, the total annual impact of the demonstration program is estimated to be $9,681,893. The required adjustment to the Federal rate used in calculating Medicare inpatient prospective payments as a result of the demonstration is 0.999899. In order to achieve budget neutrality, we are adjusting the national IPPS rates by an amount sufficient to account for the added costs of this demonstration. In other words, we are applying budget neutrality across the payment system as a whole rather than merely across the participants of this demonstration, consistent with past practice. We believe that the language of the statutory budget neutrality requirement permits the agency to implement the budget neutrality provision in this manner. The statutory language requires that “aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration * * * was not implemented,” but does not identify the range across which aggregate payments must be held equal. 5. Proposed FY 2008 Standardized Amount The proposed adjusted standardized amount is divided into labor-related and nonlabor-related portions. Tables 1A and 1B in section VI. of this Addendum contain the national standardized amount that we are proposing to apply to all hospitals, except hospitals in Puerto Rico. The proposed Puerto Rico-specific amounts are shown in Table 1C. The proposed amounts shown in Tables 1A and 1B differ only in that the labor-related share applied to the standardized amounts in Table 1A is 69.7 percent, and Table 1B is 62 percent. In accordance with sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act, we are applying a labor-related share of 62 percent, unless the application of that percentage would result in lower payments to a hospital than would otherwise be made. In effect, the statutory provision means that we will apply a labor-related share of 62 percent for all hospitals (other than those in Puerto Rico) whose wage indexes are less than or equal to 1.0000. In addition, Tables 1A and 1B include proposed standardized amounts reflecting the proposed full 3.3 percent update for FY 2008, and proposed standardized amounts reflecting the 2.0 percentage point reduction to the update (a 1.3 percent update) applicable for hospitals that fail to submit quality data consistent with section 1886(b)(3)(B)(viii) of the Act. Under section 1886(d)(9)(A)(ii) of the Act, the Federal portion of the Puerto Rico payment rate is based on the discharge-weighted average of the national large urban standardized amount (this proposed amount is set forth in Table 1A). The proposed labor-related and nonlabor-related portions of the national average standardized amounts for Puerto Rico hospitals for FY 2008 are set forth in Table 1C of section VI. of this Addendum. This table also includes the proposed Puerto Rico standardized amounts. The labor-related share applied to the proposed Puerto Rico specific standardized amount is 58.7 percent, or 62 percent, depending on which provides higher payments to the hospital. (Section 1886(d)(9)(C)(iv) of the Act, as amended by section 403(b) of Pub. L. 108-173, provides that the labor-related share for hospitals in Puerto Rico will be 62 percent, unless the application of that percentage would result in lower payments to the hospital.) The following table illustrates the proposed changes from the FY 2007 national average standardized amount. The second column shows the proposed changes from the FY 2007 standardized amounts for hospitals that satisfy the quality data submission requirement for receiving the full update (3.3 percent). The third column shows the proposed changes for hospitals receiving the reduced update (1.3 percent). The first row of the table shows the proposed updated (through FY 2007) average standardized amount after restoring the FY 2007 offsets for outlier payments, demonstration budget neutrality, the wage index transition budget neutrality, and the 
                                    ( print page 24839)
                                    geographic reclassification budget neutrality. The DRG reclassification and recalibration and wage index budget neutrality factor is cumulative. Therefore, the FY 2007 factor is not removed from this table. We have added two additional rows: One for the documentation and coding adjustment and the other for the rural floor adjustment. (For a complete discussion on the documentation and coding adjustment and the rural floor adjustment, see sections II.D.1.c and III.G.4 of the Addendum to this proposed rule). We have also added separate rows to this table to reflect the different labor related shares that apply to hospitals. Comparison of FY 2007 Standardized Amounts to Proposed FY 2008 Single Standardized Amount With Full Update and Reduced Update
Full update 
                                             (3.3 percent)
Reduced update 
                                             (1.3  percent)FY 2007 Base Rate, after removing  reclassification budget neutrality,  demonstration budget neutrality, wage index  transition budget neutrality factors and outlier offset (based on the labor and market share percentage for FY 2008)
Labor: $3,609.23 
                                             Nonlabor: $1,569.01
Labor: $3,609.23 
                                             Nonlabor: $1,569.01FY 2008 Update Factor
1.033
1.013FY 2008 DRG Recalibrations and Wage Index Budget Neutrality Factor
0.999317
0.999317FY 2008 Reclassification Budget Neutrality Factor
0.991938
0.991938Adjusted for Blend of FY 2007 DRG Recalibration and Wage Index Budget Neutrality Factors
Labor:  $3,695.75 
                                             Nonlabor: $1,606.62
Labor: $3,624.20 
                                             Nonlabor: $1,575.51FY 2008 Outlier Factor
0.948989
0.948989Rural Demonstration Budget Neutrality Factor
0.999899
0.999899Proposed FY 2008 Documentation and Coding Adjustment
0.976
0.976Rural Floor Adjustment
1.002214
1.002214Proposed Rate for FY 2008 (after multiplying FY 2007 base rate by above factors) where the wage index is less than or equal to 1.0000
Labor: $3,051.33 
                                             Nonlabor: $1,870.17
Labor: $2,992.26 
                                             Nonlabor: $1,833.96Proposed Rate for FY 2008 (after multiplying FY 2007 base rate by above factors) where the wage index is greater than 1.0000
Labor: $3,430.29 
                                             Nonlabor: $1,491.21
Labor: $3,363.88 
                                             Nonlabor: $1,462.34
 Under section 1886(d)(9)(A)(ii) of the Act, the Federal portion of the Puerto Rico payment rate is based on the discharge-weighted average of the national large urban standardized amount (as set forth in Table 1A). The labor-related and nonlabor-related portions of the national average standardized amounts for Puerto Rico hospitals are set forth in Table 1C of section VI. of this Addendum. This table also includes the Puerto Rico standardized amounts. The labor-related share applied to the Puerto Rico standardized amount is 58.7 percent, or 62 percent, depending on which results in higher payments to the hospital. (Section 1886(d)(9)(C)(iv) of the Act, as amended by section 403(b) of Pub. L. 108-173, provides that the labor-related share for hospitals in Puerto Rico will be 62 percent, unless the application of that percentage would result in lower payments to the hospital.) B. Proposed Adjustments for Area Wage Levels and Cost-of-Living Tables 1A through 1C, as set forth in section VI. of this Addendum, contain the proposed labor-related and nonlabor-related shares that we are using to calculate the proposed prospective payment rates for hospitals located in the 50 States, the District of Columbia, and Puerto Rico for FY 2008. This section addresses two types of adjustments to the standardized amounts that are made in determining the proposed prospective payment rates as described in this Addendum. 1. Proposed Adjustment for Area Wage Levels Sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act require that we make an adjustment to the labor-related portion of the national and Puerto Rico prospective payment rates, respectively, to account for area differences in hospital wage levels. This adjustment is made by multiplying the labor-related portion of the adjusted standardized amounts by the appropriate wage index for the area in which the hospital is located. In section III. of the preamble to this proposed rule, we discuss the data and methodology for the proposed FY 2008 wage index. 2. Proposed Adjustment for Cost-of-Living in Alaska and Hawaii Section 1886(d)(5)(H) of the Act authorizes an adjustment to take into account the unique circumstances of hospitals in Alaska and Hawaii. Higher labor-related costs for these two States are taken into account in the adjustment for area wages described above. For FY 2008, we are proposing to adjust the payments for hospitals in Alaska and Hawaii by multiplying the nonlabor-related portion of the standardized amount by the applicable adjustment factor contained in the table below. Table of Cost-of-Living Adjustment Factors: Alaska and Hawaii Hospitals
Area
Cost of living adjustment factorAlaska:City of Anchorage and 80-kilometer (50-mile) radius by road
1.24City of Fairbanks and 80-kilometer (50-mile) radius by road
1.24City of Juneau and 80-kilometer (50-mile) radius by  road
1.24Alaska-All areas
1.25Hawaii:City and County of Honolulu
1.25County of Hawaii
1.17County of Kauai
1.25County of Maui and County of Kalawao
1.25(The above factors are based on data obtained from the U.S. Office of Personnel Management.)
 
 
 C. Proposed DRG Relative Weights As discussed in section II. of the preamble of this proposed rule, we are proposing to adopt a revised classification system for all hospital discharges, assigning them into proposed MS-DRGs, and have developed proposed relative weights for each MS-DRG that reflect the resource utilization of cases in each proposed MS-DRG relative to Medicare cases in other proposed MS-DRGs. Table 5 of section VI. of this Addendum contains the proposed relative weights that we would use for discharges occurring in FY 2008. These factors have been recalibrated as explained in section II. of the preamble of this proposed rule. D. Calculation of the Proposed Prospective Payment Rates General Formula for Calculation of the Proposed Prospective Payment Rates for FY 2008 In general, the operating prospective payment rate for all hospitals paid under the IPPS located outside of Puerto Rico, except SCHs and MDHs, for FY 2008 equals the Federal rate. The prospective payment rate for SCHs for FY 2008 equals the higher of the applicable Federal rate or the hospital-specific rate as described below. The prospective payment rate for MDHs for FY 2008 equals the higher of the Federal rate, or the Federal rate plus 75 percent of the difference between the Federal rate and the hospital-specific rate as described below. The prospective payment rate for Puerto Rico for FY 2008 equals 25 percent of the Puerto Rico rate plus 75 percent of the applicable national rate. 1. Federal Rate The Federal rate is determined as follows: *Step 1*
                                    —Select the applicable average standardized amount depending on whether the hospital has submitted qualifying quality data (full update for qualifying hospitals, update minus 2.0 percentage points for nonqualifying hospitals). *Step 2*
                                    —Multiply the labor-related portion of the standardized amount by the applicable wage index for the geographic area in which the hospital is located or the area to which the hospital is reclassified. *Step 3*
                                    —For hospitals in Alaska and Hawaii, multiply the non-labor-related portion of the standardized amount by the applicable cost-of-living adjustment factor. *Step 4*
                                    —Add the amount from Step 2 and the non-labor-related portion of the standardized amount (adjusted, if applicable, under Step 3). *Step 5*
                                    —Multiply the final amount from Step 4 by the relative weight corresponding to the applicable MS-DRG (see Table 5 of section VI. of this Addendum). The Federal rate as determined in Step 5 may then be further adjusted if the hospital qualifies for either the IME or DSH adjustment. In addition, for hospitals that qualify for a low-volume payment adjustment under section 1886(d)(12) of the Act, the payment in Step 5 would be increased by 25 percent. 2. Hospital-Specific Rate (Applicable Only to SCHs and MDHs) a. Calculation of Hospital-Specific Rate Section 1886(b)(3)(C) of the Act provides that SCHs are paid based on whichever of the following rates yields the greatest aggregate payment: the Federal rate; the updated hospital-specific rate based on FY 1982 costs per discharge; the updated hospital-specific rate based on FY 1987 costs per discharge; or the updated hospital-specific rate based on FY 1996 costs per discharge. As discussed previously, MDHs are required to rebase their hospital-specific rates to their FY 2002 cost reports if doing so results in higher payments. In addition, effective for discharges occurring on or after October 1, 2006, MDHs are to be paid based on the Federal national rate or, if higher, the Federal national rate plus 75 percent (changed from 50 percent) of the difference between the Federal national rate and the greater of the updated hospital-specific rates based on either FY 1982, FY 1987 or FY 2002 costs per discharge. Further, MDHs will no longer be subject to the 12-percent cap on their DSH payment adjustment factor. Hospital-specific rates have been determined for each of these hospitals based on the FY 1982 costs per discharge, the FY 1987 costs per discharge, or, for SCHs, the FY 1996 costs per discharge and for MDHs, the FY 2002 cost per discharge. For a more detailed discussion of the calculation of the hospital-specific rates, we refer the reader to the FY 1984 IPPS interim final rule (48 FR 39772); the April 20, 1990 final rule with comment (55 FR 15150); the FY 1991 IPPS final rule (55 FR 35994); and the FY 2001 IPPS final rule (65 FR 47082). In addition, for both SCHs and MDHs, the hospital-specific rate is adjusted by the budget neutrality adjustment factor as discussed in section IV.C. of the preamble to this proposed rule. The resulting rate will be used in determining the payment rate an SCH or MDH will receive for its discharges beginning on or after October 1, 2007. b. Updating the FY 1982, FY 1987, FY 1996, and FY 2002 Hospital-Specific Rates for FY 2008 We are proposing to increase the hospital-specific rates by 3.3 percent (the proposed estimated hospital market basket percentage increase) for SCHs and MDHs for FY 2008. Section 1886(b)(3)(C)(iv) of the Act provides that the update factor applicable to the hospital-specific rates for SCHs is equal to the update factor provided under section 1886(b)(3)(B)(iv) of the Act, which, for SCHs in FY 2007, is the market basket rate-of-increase. Section 1886(b)(3)(D) of the Act provides that the update factor applicable to the hospital-specific rates for MDHs also equals the update factor provided under section 1886(b)(3)(B)(iv) of the Act, which, for FY 2007, is the market basket rate-of-increase. 3. General Formula for Calculation of Proposed Prospective Payment Rates for Hospitals Located in Puerto Rico Beginning On or After October 1, 2007, and Before October 1, 2008 Section 1886(d)(9)(E)(iv) of the Act provides that, effective for discharges occurring on or after October 1, 2004, hospitals located in Puerto Rico are paid based on a blend of 75 percent of the national prospective payment rate and 25 percent of the Puerto Rico-specific rate. a. Puerto Rico Rate The Puerto Rico prospective payment rate is determined as follows: *Step 1*
                                    —Select the applicable average standardized amount considering the applicable wage index (see Table 1C). *Step 2*
                                    —Multiply the labor-related portion of the standardized amount by the applicable Puerto Rico-specific wage index. *Step 3*
                                    —Add the amount from Step 2 and the nonlabor-related portion of the standardized amount. *Step 4*
                                    —Multiply the amount from Step 3 by the applicable MS-DRG relative weight (see Table 5 of section IV. of the Addendum). *Step 5*
                                    —Multiply the result in Step 4 by 25 percent. b. National Rate The national prospective payment rate is determined as follows: *Step 1*
                                    —Select the applicable average standardized amount. *Step 2*
                                    —Multiply the labor-related portion of the standardized amount by the applicable wage index for the geographic area in which the hospital is located or the area to which the hospital is reclassified. *Step 3*
                                    —Add the amount from Step 2 and the nonlabor-related portion of the national average standardized amount. *Step 4*
                                    —Multiply the amount from Step 3 by the applicable MS-DRG relative weight (see Table 5 of section VI. of the Addendum). *Step 5*
                                    —Multiply the result in Step 4 by 75 percent. The sum of the Puerto Rico rate and the national rate computed above equals the prospective payment for a given discharge for a hospital located in Puerto Rico. This rate may then be further adjusted if the hospital qualifies for either the IME or DSH adjustment. III. Proposed Changes to Payment Rates for Acute Care Hospital Inpatient Capital-Related Costs for FY 2008 (If you choose to comment on issues in this section, please include the caption “Capital Payment Rate” at the beginning of your comment.) The PPS for acute care hospital inpatient capital-related costs was implemented for cost reporting periods beginning on or after October 1, 1991. Effective with that cost reporting period, hospitals were paid during a 10-year transition period (which extended through FY 2001) to change the payment methodology for Medicare acute care hospital inpatient capital-related costs from a reasonable cost-based methodology to a prospective methodology (based fully on the Federal rate). The basic methodology for determining Federal capital prospective rates is set forth in regulations at §§ 412.308 through 412.352. Below we discuss the factors that we are proposing to use to determine the capital Federal rate for FY 2008, which will be effective for discharges occurring on or after October 1, 2007. 
                                    ( print page 24841) The 10-year transition period ended with hospital cost reporting periods beginning on or after October 1, 2001 (FY 2002). Therefore, for cost reporting periods beginning in FY 2002, all hospitals (except “new” hospitals under § 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 § 412.308(c)(1), to account for capital input price increases and other factors. The regulations at § 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, § 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 § 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, § 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 § 412.308(b)(3) describes the 0.28 percent reduction to the capital rate made in FY 1996 as a result of the revised policy of paying for transfers. In FY 1998, we implemented section 4402 of Pub. L. 105-33, which required that, for discharges occurring on or after October 1, 1997, the budget neutrality adjustment factor in effect on September 30, 1995, be applied to the unadjusted capital standard Federal rate and the unadjusted hospital-specific rate. That factor was 0.8432, which was equivalent to a 15.68 percent reduction to the unadjusted capital payment rates. An additional 2.1 percent reduction to the rates was effective from October 1, 1997 through September 30, 2002, making the total reduction 17.78 percent. As we discussed in the FY 2003 IPPS final rule (67 FR 50102) and implemented in § 412.308(b)(6), the 2.1 percent reduction was restored effective October 1, 2002. To determine the appropriate budget neutrality adjustment factor and the regular exceptions payment adjustment during the 10-year transition period, we developed a dynamic model of Medicare inpatient capital-related costs; that is, a model that projected changes in Medicare inpatient capital-related costs over time. With the expiration of the budget neutrality provision, the capital cost model was only used to estimate the regular exceptions payment adjustment and other factors during the transition period. As we explained in the FY 2002 IPPS final rule (66 FR 39911), beginning in FY 2002, an adjustment for regular exception payments is no longer necessary because regular exception payments were only made for cost reporting periods beginning on or after October 1, 1991, and before October 1, 2001 (see § 412.348(b)). Because payments are no longer being made under the regular exception policy effective with cost reporting periods beginning in FY 2002, we no longer use the capital cost model. The capital cost model and its application during the transition period are described in Appendix B of the FY 2002 IPPS final rule (66 FR 40099). Section 412.374 provides for the use of a blended payment system for payments to Puerto Rico hospitals under the IPPS for acute care hospital inpatient capital-related costs. Accordingly, under the capital PPS, we compute a separate payment rate specific to Puerto Rico hospitals using the same methodology used to compute the national Federal rate for capital-related costs. In accordance with section 1886(d)(9)(A) of the Act, under the IPPS for acute care hospital operating costs, hospitals located in Puerto Rico are paid for operating costs under a special payment formula. Prior to FY 1998, hospitals in Puerto Rico were paid a blended operating rate that consisted of 75 percent of the applicable standardized amount specific to Puerto Rico hospitals and 25 percent of the applicable national average standardized amount. Similarly, prior to FY 1998, hospitals in Puerto Rico were paid a blended capital rate that consisted of 75 percent of the applicable capital Puerto Rico-specific rate and 25 percent of the applicable capital Federal rate. However, effective October 1, 1997, in accordance with section 4406 of Pub. L. 105-33, operating payments to hospitals in Puerto Rico were revised to be based on a blend of 50 percent of the applicable standardized amount specific to Puerto Rico hospitals and 50 percent of the applicable national average standardized amount. In conjunction with this change to the operating blend percentage, effective with discharges occurring on or after October 1, 1997, we also revised the methodology for computing capital payments to hospitals in Puerto Rico to be based on a blend of 50 percent of the Puerto Rico capital rate and 50 percent of the capital Federal rate. As we discussed in the FY 2005 IPPS final rule (69 FR 49185), section 504 of Pub. L. 108-173 increased the national portion of the operating IPPS payments for Puerto Rico hospitals from 50 percent to 62.5 percent and decreased the Puerto Rico portion of the operating IPPS payments from 50 percent to 37.5 percent for discharges occurring on or after April 1, 2004 through September 30, 2004 (see the March 26, 2004 One-Time Notification (Change Request 3158)). In addition, section 504 of Pub. L. 108-173 provided that the national portion of operating IPPS payments for Puerto Rico hospitals is equal to 75 percent and the Puerto Rico portion of operating IPPS payments is equal to 25 percent for discharges occurring on or after October 1, 2004. Consistent with that change in operating IPPS payments to hospitals in Puerto Rico, for FY 2005 (as we discussed in the FY 2005 IPPS final rule), we revised the methodology for computing capital payments to hospitals located in Puerto Rico to be based on a blend of 25 percent of the Puerto Rico capital rate and 75 percent of the capital Federal rate for discharges occurring on or after October 1, 2004. A. Determination of Proposed Federal Hospital Inpatient Capital-Related Prospective Payment Rate Update In the FY 2007 IPPS final rule (71 FR 48161), we established a tentative capital Federal rate of $427.38 for FY 2007. In the 
                                    **Federal Register**
                                     notice establishing the occupational mix adjusted payment rates for FY 2007 (71 FR 59891), we established the final FY 2007 Federal rate of $427.03 for FY 2007. In the discussion that follows, we explain the factors that we are proposing to use to determine the proposed FY 2008 capital Federal rate. However, as discussed in section V. of the preamble of this proposed rule, we are proposing two separate capital Federal rates for FY 2008: a capital Federal rate for rural hospitals and a capital Federal rate for urban hospitals. In particular, we explain why the proposed FY 2008 capital Federal rate for rural hospitals would decrease approximately 2.3 percent, compared to the FY 2007 capital Federal rate, and why the proposed FY 2008 capital Federal rate for urban hospitals would decrease approximately 3.1 percent, compared to the FY 2007 capital Federal rate. Consequently, despite an estimated increase in Medicare fee-for-service discharges in FY 2008 as compared to FY 2007, we estimate aggregate capital payments would decrease by 0.13 percent during this same period. Total payments to hospitals under the IPPS are relatively unaffected by changes in the capital prospective payments. Since capital payments constitute about 10 percent of hospital payments, a 1-percent change in the capital Federal rate yields only about 0.1 percent change in actual payments to hospitals. As noted above, aggregate payments under the capital IPPS are estimated to decrease in FY 2008 compared to FY 2007. 1. Projected Capital Standard Federal Rate Update a. Description of the Update Framework Under § 412.308(c)(1), the capital standard Federal rate is updated on the basis of an analytical framework that takes into account changes in a capital input price index (CIPI) and several other policy adjustment factors. Specifically, we have adjusted the projected CIPI rate-of-increase as appropriate each year for case-mix index-related changes, for intensity, and for errors in previous CIPI forecasts. The proposed update factor for FY 2008 under that framework is 0.8 percent based on the best data available at this time. The proposed update factor under that framework is based on a projected 1.2 percent increase in the CIPI, a 0.0 percent adjustment for intensity, a 0.0 percent adjustment for case-mix, a −0.4 percent adjustment for the FY 2006 DRG 
                                    ( print page 24842)
                                    reclassification and recalibration, and a forecast error correction of 0.0 percent. As discussed below in section III.C. of this Addendum, we believe that the CIPI is the most appropriate input price index for capital costs to measure capital price changes in a given year. We also explain the basis for the FY 2008 CIPI projection in that same section of this Addendum. (However, as discussed in greater detail in section V. of the preamble of this proposed rule, we are proposing a zero percent update factor for urban hospitals instead of the 0.8 percent proposed update factor that we are proposing for rural hospitals. In addition, as also note below, the proposed capital rates would be further adjusted to account for upcoding under the proposed MS-DRGs discussed in section II.D. of the preamble of this proposed rule.) Below we describe the policy adjustments that have been applied in the update framework for FY 2008. The case-mix index is the measure of the average DRG weight for cases paid under the IPPS. Because the DRG weight determines the prospective payment for each case, any percentage increase in the case-mix index corresponds to an equal percentage increase in hospital payments. The case-mix index can change for any of several reasons: The average resource use of Medicare patients changes (“real” case-mix change);
                                Changes in hospital coding of patient records result in higher weight DRG assignments (“coding effects”); and
                                The annual DRG reclassification and recalibration changes may not be budget neutral (“reclassification effect”). We define real case-mix change as actual changes in the mix (and resource requirements) of Medicare patients as opposed to changes in coding behavior that result in assignment of cases to higher weighted DRGs but do not reflect higher resource requirements. The capital update framework includes the same case-mix index adjustment used in the former operating IPPS update framework (as discussed in the May 18, 2004 IPPS proposed rule for FY 2005 (69 FR 28816)). (We are no longer using an update framework in making a recommendation for updating the operating IPPS standardized amounts as discussed in section II. of Appendix B in the FY 2006 IPPS final rule (70 FR 47707).) Absent the proposed change to the MS-DRGs, for FY 2008, we are projecting a 1.0 percent total increase in the case-mix index. We estimate that the real case-mix increase will also equal 1.0 percent in FY 2008. The net adjustment for change in case-mix is the difference between the projected real increase in case-mix and the projected total increase in case-mix. Therefore, the net adjustment for case-mix change in FY 2008 is 0.0 percentage points. The capital update framework also contains an adjustment for the effects of DRG reclassification and recalibration. This adjustment is intended to remove the effect on total payments of prior year changes to the DRG classifications and relative weights, in order to retain budget neutrality for all case-mix index-related changes other than those due to patient severity. Due to the lag time in the availability of data, there is a 2-year lag in data used to determine the adjustment for the effects of DRG reclassification and recalibration. For example, we are adjusting for the effects of the FY 2006 DRG reclassification and recalibration as part of our proposed update for FY 2008. We estimate that FY 2006 DRG reclassification and recalibration resulted in a 0.4 percent change in the case-mix when compared with the case-mix index that would have resulted if we had not made the reclassification and recalibration changes to the DRGs. Therefore, we are proposing to make a −0.4 percent adjustment for DRG reclassification in the proposed update for FY 2008 to maintain budget neutrality. The capital update framework also contains an adjustment for forecast error. The input price index forecast is based on historical trends and relationships ascertainable at the time the update factor is established for the upcoming year. In any given year, there may be unanticipated price fluctuations that may result in differences between the actual increase in prices and the forecast used in calculating the update factors. In setting a prospective payment rate under the framework, we make an adjustment for forecast error only if our estimate of the change in the capital input price index for any year is off by 0.25 percentage points or more. There is a 2-year lag between the forecast and the measurement of the forecast error. A forecast error of 0.10 percentage point was calculated for the FY 2006 update. That is, current historical data indicate that the forecasted FY 2006 CIPI (0.80 percent) used in calculating the FY 2006 update factor slightly understated the actual realized price increases (0.90 percent) by 0.10 percentage point. This slight underprediction was mostly due to the incorporation of newly available source data for fixed asset prices into the market basket. However, because this estimation of the change in the CIPI is less than 0.25 percentage points, it is not reflected in the update recommended under this framework. Therefore, we are proposing to make a 0.0 percent adjustment for forecast error in the update for FY 2008. Under the capital IPPS update framework, we also make an adjustment for changes in intensity. We calculate this adjustment using the same methodology and data that were used in the past under the framework for operating IPPS. The intensity factor for the operating update framework reflects how hospital services are utilized to produce the final product, that is, the discharge. This component accounts for changes in the use of quality-enhancing services, for changes in within-DRG severity, and for expected modification of practice patterns to remove noncost-effective services. We calculate case-mix constant intensity as the change in total charges per admission, adjusted for price level changes (the CPI for hospital and related services) and changes in real case-mix. The use of total charges in the calculation of the intensity factor makes it a total intensity factor; that is, charges for capital services are already built into the calculation of the factor. Therefore, we have incorporated the intensity adjustment from the operating update framework into the capital update framework. Without reliable estimates of the proportions of the overall annual intensity increases that are due, respectively, to ineffective practice patterns and to the combination of quality-enhancing new technologies and within-DRG complexity, we assume, as in the operating update framework, that one-half of the annual increase is due to each of these factors. The capital update framework thus provides an add-on to the input price index rate of increase of one-half of the estimated annual increase in intensity, to allow for within-DRG severity increases and the adoption of quality-enhancing technology. We have developed a Medicare-specific intensity measure based on a 5-year average. Past studies of case-mix change by the RAND Corporation (“Has DRG Creep Crept Up? Decomposing the Case Mix Index Change Between 1987 and 1988” by G.M. Carter, J. P. Newhouse, and D.A. Relles, R-4098-HCFA/ProPAC (1991)) suggest that real case-mix change was not dependent on total change, but was usually a fairly steady 1.0 to 1.5 percent per year. However, we use 1.4 percent as the upper bound because the RAND study did not take into account that hospitals may have induced doctors to document medical records more completely in order to improve payment. We calculate case-mix constant intensity as the change in total charges per admission, adjusted for price level changes (the CPI for hospital and related services), and changes in real case-mix. As we noted above, in accordance with § 412.308(c)(1)(ii), we began updating the capital standard Federal rate in FY 1996 using an update framework that takes into account, among other things, allowable changes in the intensity of hospital services. For FYs 1996 through 2001, we found that case-mix constant intensity was declining and we established a 0.0 percent adjustment for intensity in each of those years. For FYs 2002 and 2003, we found that case-mix constant intensity was increasing and we established a 0.3 percent adjustment and 1.0 percent adjustment for intensity, respectively. For FYs 2004 and 2005, we found that the charge data appeared to be skewed (as discussed in greater detail below) and we established a 0.0 percent adjustment in each of those years. Furthermore, we stated that we would continue to apply a 0.0 percent adjustment for intensity until any increase in charges can be tied to intensity rather than attempts to maximize outlier payments. As noted above, our intensity measure is based on a 5-year average, and therefore, the intensity adjustment for FY 2008 is based on data from the 5-year period FY 2002 through FY 2006. We found a dramatic increase in hospital charges for each of those 5 years without a corresponding increase in the hospital case-mix index. These findings are similar to the considerable increase in hospitals' charges, which we found when we were determining the intensity factor in the FY 2004, FY 2005 and FY 2006 update recommendations as discussed in the FY 2004 IPPS final rule (68 FR 45482), the FY 2005 IPPS final rule (69 FR 49285) the FY 2006 IPPS final rule (70 FR 47500), and the 
                                    ( print page 24843)
                                    FY 2007 IPPS final rule (72 FR 47500), respectively. If hospitals were treating new or different types of cases, which would result in an appropriate increase in charges per discharge, then we would expect hospitals' case-mix to increase proportionally. As we discussed in the FY 2006 IPPS final rule (70 FR 47500) and the FY 2007 IPPS final rule (71 FR 48157), because our intensity calculation relies heavily upon charge data and we believe that these charge data may be inappropriately skewed, we established a 0.0 percent adjustment for intensity for FY 2006 and FY 2007, respectively. On June 9, 2003, we published revisions to our outlier policy for determining the additional payment for extraordinarily high-cost cases (68 FR 34494 through 34515). These revised policies were effective on August 8, 2003, and October 1, 2003. While it does appear that a response to these policy changes is beginning to occur, that is, the change in charges for FYs 2004 and 2005 are somewhat less than the previous 4 years, and the change in charges for FY 2006 is slightly less than FY 2005, they still show a significant annual increase in charges without a corresponding increase in hospital case-mix. The increase in charges in FY 2004, for example, is approximately 12 percent, which, while less than the increase in the previous 3 years, is still much higher than increases in years prior to FY 2001. In addition, this approximate 12-percent increase in charges for FY 2004 significantly exceeds the case-mix increase for the same period. Based on the approximate 12-percent increase in charges for FY 2004, we believe residual effects of hospitals' charge practices prior to the implementation of the outlier policy revisions established in the June 9, 2003 final rule continue to appear in the data because hospitals may not have had enough time to adopt changes in their behavior in response to the new outlier policy. Thus, we believe that the FY 2004, FY 2005, and FY 2006 charge data may still be skewed. Because the intensity adjustment is based on a 5-year average, and although the new outlier policy was generally effective in FY 2004, we believe the effects of hospitals attempting to maximize outlier payments, while lessening, continue to skew the charge data. Therefore, we are proposing to make a 0.0 percent adjustment for intensity for FY 2008. In the past (FYs 1996 through 2001) when we found intensity to be declining, we believed a zero (rather than negative) intensity adjustment was appropriate. Similarly, we believe that it is appropriate to apply a zero intensity adjustment for FY 2008 until any increase in charges can be tied to intensity rather than to attempts to maximize outlier payments. Above, we described the basis of the components used to develop the proposed 0.8 percent capital update factor under the capital update framework for FY 2008 as shown in the table below. However, as discussed in section V. of the preamble of this proposed rule, we are proposing that the proposed 0.8 percent capital update be applied to rural hospitals only. We are proposing a 0.0 percent update for urban hospitals for reasons also discussed in section V. of the preamble of this proposed rule. CMS Proposed FY 2008 Update Factor to the Capital Federal Rate for Rural Hospitals
Capital Input Price Index
1.2Intensity:
0.0Case-Mix Adjustment Factors:Real Across DRG Change
1.0Projected Case-Mix Change
−1.0Subtotal
0.0Effect of FY 2005 Reclassification and Recalibration
−0.4Forecast Error Correction
0.0Total Update for Rural Hospitals
0.8
 b. Comparison of CMS and MedPAC Update Recommendation In the past, MedPAC has included update recommendations for capital PPS in a Report to Congress. In its March 2007 Report to Congress, MedPAC did not make an update recommendation for capital IPPS payments for FY 2008. However, in that same report, MedPAC made an update recommendation for hospital inpatient and outpatient services (page 67). MedPAC reviews inpatient and outpatient services together because they are so closely interrelated. For FY 2008, MedPAC recommended an increase in the payment rate for the operating IPPS by the projected increase in the hospital market basket index concurrent with implementation of a quality incentive payment policy. (MedPAC's Report to the Congress: Medicare Payment Policy, March 2007, Section 2A.) 2. Proposed Outlier Payment Adjustment Factor Section 412.312(c) establishes a unified outlier methodology for inpatient operating and inpatient capital-related costs. A single set of thresholds is used to identify outlier cases for both inpatient operating and inpatient capital-related payments. Section 412.308(c)(2) provides that the standard Federal rate for inpatient capital-related costs be reduced by an adjustment factor equal to the estimated proportion of capital-related outlier payments to total inpatient capital-related PPS payments. The outlier thresholds are set so that operating outlier payments are projected to be 5.1 percent of total operating DRG payments. In the 
                                    **Federal Register**
                                     notice establishing the final occupational mix adjusted payment rates for FY 2007 (71 FR 59890), we estimated that outlier payments for capital would equal 4.32 percent of inpatient capital-related payments based on the capital Federal rate in FY 2007. Based on the proposed thresholds as set forth in section II.A.4.c. of this Addendum, we estimate that proposed outlier payments for capital-related costs would equal 5.16 percent for inpatient capital-related payments based on the proposed Federal rate in FY 2008. Therefore, we are proposing to apply an outlier adjustment factor of 0.9484 to the capital Federal rate. Thus, we estimate that the percentage of capital outlier payments to total capital standard payments for FY 2008 will be slightly higher than the percentages for FY 2007. The outlier reduction factors are not built permanently into the capital rates; that is, they are not applied cumulatively in determining the capital Federal rate. The proposed FY 2008 outlier adjustment of 0.9484 is a -0.88 percent change from the FY 2007 outlier adjustment of 0.9568. Therefore, the net change in the proposed outlier adjustment to the proposed capital Federal rate for FY 2008 is 0.9912 (0.9484/0.9568). Thus, the proposed outlier adjustment decreases the proposed FY 2008 capital Federal rate by 0.88 percent compared with the FY 2007 outlier adjustment. 3. Proposed Budget Neutrality Adjustment Factor for Changes in DRG Classifications and Weights and the GAF Section 412.308(c)(4)(ii) requires that the capital Federal rate be adjusted so that aggregate payments for the fiscal year based on the capital Federal rate after any changes resulting from the annual DRG reclassification and recalibration and changes in the GAF are projected to equal aggregate payments that would have been made on the basis of the capital Federal rate without such changes. Because we implemented a separate GAF for Puerto Rico, we apply separate budget neutrality adjustments for the national GAF and the Puerto Rico GAF. We apply the same budget neutrality factor for DRG reclassifications and recalibration nationally and for Puerto Rico. Separate adjustments were unnecessary for FY 1998 and earlier because the GAF for Puerto Rico was implemented in FY 1998. In the past, we used the actuarial capital cost model (described in Appendix B of the FY 2002 IPPS final rule (66 FR 40099)) to estimate the aggregate payments that would have been made on the basis of the capital Federal rate with and without changes in the DRG classifications and weights and in the GAF to compute the adjustment required to maintain budget neutrality for changes in DRG weights and in the GAF. During the transition period, the capital cost model was also used to estimate the regular exception payment adjustment factor. As we explain in section III.A.4. of this Addendum, beginning in FY 2002, an adjustment for regular exception payments is no longer necessary. Therefore, we are no longer using the capital cost model. Instead, we are using historical data based on hospitals' actual cost experiences to determine the exceptions payment adjustment factor for special exceptions payments. To determine the proposed factors for FY 2008, we compared (separately for the national capital rate and the Puerto Rico capital rate) estimated aggregate capital Federal rate payments based on the FY 2007 DRG relative weights and the FY 2007 GAF to estimated aggregate capital Federal rate payments based on the proposed FY 2008 relative weights and the proposed FY 2008 GAF. As we established in the final FY 2007 occupational mix adjusted payment rates notice (71 FR 59890), the budget neutrality factors were 0.9906 for the national capital 
                                    ( print page 24844)
                                    rate and 0.9968 for the Puerto Rico capital rate. In making the comparison, we set the exceptions reduction factor to 1.00. To achieve budget neutrality for the changes in the national GAF, based on calculations using updated data, we propose to apply an incremental budget neutrality adjustment of 1.0026 for FY 2008 to the previous cumulative FY 2007 adjustments of 0.9906, yielding a proposed adjustment of 0.9932, through FY 2008 (calculations done on unrounded numbers). For the Puerto Rico GAF, we are proposing to apply a proposed incremental budget neutrality adjustment of 1.0009 for FY 2008 to the previous cumulative FY 2007 adjustment of 0.9968, yielding a proposed cumulative adjustment of 0.9978 through FY 2008 (calculations done on unrounded numbers). We then compared estimated aggregate capital Federal rate payments based on the FY 2007 DRG relative weights and the FY 2007 GAF to estimated aggregate capital Federal rate payments based on the proposed FY 2008 DRG relative weights and the proposed FY 2008 GAF. The proposed incremental adjustment for DRG classifications and changes in relative weights is 0.9992 both nationally and for Puerto Rico. The proposed cumulative adjustments for DRG classifications and changes in relative weights and for changes in the GAF through FY 2008 are 0.9924 nationally and 0.9970 for Puerto Rico. The following table summarizes the adjustment factors for each fiscal year: 
                                    ( print page 24845) Budget Neutrality Adjustment for DRG Reclassifications and Recalibration and the Geographic Adjustment Factors
Fiscal year
National
Puerto RicoIncremental adjustment
Cumulative
Incremental adjustment
CumulativeGeographic adjustment factor
DRG reclassifications and recalibration
Combined
Geographic adjustment factor
DRG reclassifications and recalibration
Combined1992



1.000001993


0.99800
0.998001994


1.00531
1.003301995


0.99980
1.003101996


0.99940
1.002501997


0.99873
1.001231998


0.99892
1.00015



1.000001999
0.99944
1.00335
1.00279
1.00294
0.99898
1.00335
1.00233
1.002332000
0.99857
0.99991
0.99848
1.00142
0.99910
0.99991
0.99901
1.001342001 1
0.99782
1.00009
0.99791
0.99933
1.00365
1.00009
1.00374
1.005082001 2
3
                                             0.99771
3
                                             1.00009
3
                                             0.99780
0.99922
3
                                             1.00365
3
                                             1.00009
3
                                             1.00374
1.005082002
4
                                             0.99666
4
                                             0.99668
4
                                             0.99335
0.99268
4
                                             0.98991
4
                                             0.99668
4
                                             0.99662
0.991642003 5
0.99915
0.99662
0.99577
0.98848
1.00809
0.99662
1.00468
0.996282003 6
7
                                             0.99896
7
                                             0.99662
7
                                             0.99558
0.98830
1.00809
0.99662
1.00468
0.996282004 8
9
                                             1.00175
9
                                             1.00081
9
                                             1.00256
0.99083
1.00028
1.00081
1.00109
0.997362004 10
9
                                             1.00164
9
                                             1.00081
9
                                             1.00245
0.99072
1.00028
1.00081
1.00109
0.997362005 11
12
                                             0.99967
1.00094
12
                                             1.00061
0.99137
0.99115
1.00094
0.99208
0.989462005 13
12
                                             0.99946
1.00094
12
                                             1.00040
0.99117
0.99115
1.00094
0.99208
0.989462006
14
                                             1.00185
0.99892
14
                                             1.00076
0.99198
1.00762
0.99892
1.00653
0.995922007
1.00000
0.99858
0.99858
0.99057
1.00234
0.99858
1.00092
0.996832008
15
                                             1.00261
0.99921
15
                                             1.00182
15
                                             0.99237
15
                                             1.00093
0.99921
15
                                             1.00014
15
                                             0.996971
                                         Factors effective for the first half of FY 2001 (October 2000 through March 2001).2
                                         Factors effective for the second half of FY 2001 (April 2001 through September 2001).3
                                         Incremental factors are applied to FY 2000 cumulative factors.4
                                         Incremental factors are applied to the cumulative factors for the first half of FY 2001.5
                                         Factors effective for the first half of FY 2003 (October 2002 through March 2003).6
                                         Factors effective for the second half of FY 2003 (April 2003 through September 2003).7
                                         Incremental factors are applied to FY 2002 cumulative factors.8
                                         Factors effective for the first half of FY 2004 (October 2003 through March 2004).9
                                         Incremental factors are applied to the cumulative factors for the second half of FY 2003.10
                                         Factors effective for the second half of FY 2004 (April 2004 through September 2004).11
                                         Factors effective for the first quarter of FY 2005 (September 2004 through December 2004).12
                                         Incremental factors are applied to average of the cumulative factors for the first half (October 1, 2003 through March 31, 2004) and second half (April 1, 2004 through September 30, 2004) of FY 2004.13
                                         Factors effective for the last three quarters of FY 2005 (January 2005 through September 2005).14
                                         Incremental factors are applied to average of the cumulative factors for 2005.15
                                         Proposed factors for FY 2008, as discussed above in section III. of this Addendum.
 
 
 The methodology used to determine the recalibration and geographic (DRG/GAF) budget neutrality adjustment factor is similar to that used in establishing budget neutrality adjustments under the PPS for operating costs. One difference is that, under the operating PPS, the budget neutrality adjustments for the effect of geographic reclassifications are determined separately from the effects of other changes in the hospital wage index and the DRG relative weights. Under the capital PPS, there is a single DRG/GAF budget neutrality adjustment factor (the national capital rate and the Puerto Rico capital rate are determined separately) for changes in the GAF (including geographic reclassification) and the DRG relative weights. In addition, there is no adjustment for the effects that geographic reclassification has on the other payment parameters, such as the payments for serving low-income patients, indirect medical education payments, or the large urban add-on payments. In the 
                                    **Federal Register**
                                     notice establishing the final FY 2007 occupational mix adjusted payment rates (71 FR 59890), we calculated a GAF/DRG budget neutrality factor of 0.9986 for FY 2007. For FY 2008, we are proposing to establish a proposed GAF/DRG budget neutrality factor of 1.0018. The GAF/DRG budget neutrality factors are built permanently into the capital rates; that is, they are applied cumulatively in determining the capital Federal rate. This follows from the requirement that estimated aggregate payments each year be no more or less than they would have been in the absence of the annual DRG reclassification and recalibration and changes in the GAF. The incremental change in the proposed adjustment from FY 2007 to FY 2008 is 1.0018. The cumulative change in the proposed capital Federal rate due to this proposed adjustment is 0.9924 (the product of the incremental factors for FYs 1994 through 2007 and the proposed incremental factor of 1.0018 for FY 2008). (We note that averages of the incremental factors that were in effect during FYs 2004 and 2005, respectively, were used in the calculation of the proposed cumulative adjustment of 0.9924 for FY 2008.) This proposed factor accounts for DRG reclassifications and recalibration and for changes in the GAF. It also incorporates the effects on the proposed GAF of FY 2008 geographic reclassification decisions made by the MGCRB compared to FY 2007 decisions. However, it does not account for changes in payments due to changes in the DSH and IME adjustment factors or in the large urban add-on. 4. Exceptions Payment Adjustment Factor Section 412.308(c)(3) requires that the capital standard Federal rate be reduced by an adjustment factor equal to the estimated proportion of additional payments for both regular exceptions and special exceptions under § 412.348 relative to total capital PPS payments. In estimating the proportion of regular exception payments to total capital PPS payments during the transition period, we used the actuarial capital cost model originally developed for determining budget neutrality (described in Appendix B of the FY 2002 IPPS final rule (66 FR 40099)) to determine the exceptions payment adjustment factor, which was applied to both the Federal and hospital-specific capital rates. An adjustment for regular exception payments is no longer necessary in determining the FY 2008 capital Federal rate because, in accordance with § 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 § 412.308(c), we still need to compute a budget neutrality adjustment for special exception payments under § 412.348(g). We describe our methodology for determining the exceptions adjustment used in calculating the FY 2007 capital Federal rate below. Under the special exceptions provision specified at § 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 § 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 § 412.348(g)(2), which, in the case of certain urban hospitals, includes an excess capacity test as described at § 412.348(g)(4); (2) an age of assets test as described at § 412.348(g)(3); and (3) a project size requirement as described at § 412.348(g)(5). Based on information compiled from our fiscal intermediaries, six hospitals have qualified for special exceptions payments under § 412.348(g). Because we have cost reports ending in FY 2006 for all of these hospitals, we calculated the adjustment based on actual cost experience. Using data from cost reports ending in FY 2006 from the December 2006 update of the HCRIS data, we divided the capital special exceptions payment amounts for the six hospitals that qualified for special exceptions by the total capital PPS payment amounts (including special exception payments) for all hospitals. Based on the data from cost reports ending in FY 2006, this ratio is rounded to 0.0003. Because we have not received all cost reports ending in FY 2006, we also divided the FY 2005 special exceptions payments by the total capital PPS payment amounts for all hospitals with cost reports ending in FY 2005. This ratio also rounds to 0.0003. Because special exceptions are budget neutral, we are offsetting the proposed capital Federal rate by 0.03 percent for special exceptions payments for FY 2008. Therefore, the exceptions adjustment factor is equal to 0.9997 (1 − 0.0003) to account for special exceptions payments in FY 2008. In the FY 2007 IPPS final rule (71 FR 48161) we estimated that total (special) exceptions payments for FY 2007 would equal 0.03 percent of aggregate payments based on the capital Federal rate. Therefore, we applied an exceptions adjustment factor of 0.9997 (1 − 0.0003) in determining the FY 2007 capital Federal rate. As we stated above, we estimate that exceptions payments in FY 2008 will equal 0.03 percent of aggregate payments based on the proposed FY 2008 capital Federal rate. Therefore, we are proposing to apply an exceptions payment adjustment factor of 0.9997 to the capital Federal rate for FY 2008. The proposed exceptions adjustment factor for FY 2008 is the same as the factor used in determining the FY 2007 capital Federal rate in the FY 2007 IPPS final rule (71 FR 48161) and is the same factor used for the occupational mix adjusted payment rates since the adjustments made to the wage index had no effect on capital exceptions payments (71 FR 59890). The exceptions reduction factors are not built permanently into the capital rates; that is, the factors are not applied cumulatively in determining the capital Federal rate. Therefore, the net change in the proposed exceptions adjustment factor used in determining the proposed FY 2008 capital Federal rate is 1.0000(0.9997/0.9997). 5. Proposed Capital Standard Federal Rate for FY 2008 In the 
                                    **Federal Register**
                                     notice that established the occupational mix adjusted payment rates for FY 2007 (71 FR 59891), we established a capital Federal rate of $427.03 for FY 2007. As discussed above and in section V. of the preamble of this proposed rule, we are proposing two separate capital Federal rates for FY 2008: a rural capital Federal rate based on an update of 0.8 percent and an urban capital Federal rate based on a 0.0 percent update. However, under the statutory authority at section 1886(d)(3)(A)(vi) of the Act, we are proposing an additional 2.4 percent reduction to the proposed standardized amounts for both capital and operating Federal payment rates. The proposed 2.4 percent reduction is based on our actuary's analysis to eliminate the effect of changes in coding or classification of discharges that do not reflect real changes in case-mix in light of the proposed MS-DRGs. Although the proposed 2.4 percent reduction is outside the established process for developing the proposed capital Federal payment rate, it nevertheless is a factor in the final prospective payment rate to hospitals for capital-related costs. For that reason, the capital Federal payment rates proposed in this proposed rule were determined by applying the proposed 2.4 percent reduction. As a result of the proposed 0.8 percent update for rural hospitals, the proposed 0.0 percent update for urban hospitals, the proposed 2.4 percent reduction to account for upcoding (for all hospitals), and the other factors as discussed above, we are proposing to establish a capital Federal rate for rural hospitals of $417.26 for FY 2008, and we are proposing to establish a capital Federal rate for urban hospitals of $413.87 for FY 2008. The proposed capital Federal rates for FY 2008 were calculated as follows: The proposed FY 2008 update factor for rural hospitals is 1.0080, that is, the update is 0.8 percent; and the proposed FY 2008 update factor for urban hospitals is 1.0000, that is, the update is 0.0 percent.
                                The proposed FY 2008 budget neutrality adjustment factor that is applied to the capital standard Federal payment rate for( print page 24847)
                                    changes in the DRG relative weights and in the GAF (for all hospitals) is 1.0018.
                                The proposed FY 2008 outlier adjustment factor is 0.9484.
                                The proposed FY 2008 (special) exceptions payment adjustment factor is 0.9997.
                                The proposed FY 2008 reduction for upcoding under the proposed MS-DRGs is −2.40 percent. Because the proposed capital Federal rate has already been adjusted for differences in case-mix, wages, cost-of-living, indirect medical education costs, and payments to hospitals serving a disproportionate share of low-income patients, we are not making additional adjustments in the capital standard Federal rate for these factors, other than the proposed budget neutrality factor for changes in the DRG relative weights and the GAF. We are providing the following charts that show how each of the proposed factors and adjustments for FY 2008 affected the computation of the proposed FY 2008 capital Federal rate for urban hospitals and the proposed FY 2008 capital Federal rate for rural hospitals in comparison to the FY 2007 capital Federal rate. The proposed FY 2008 update factor for urban hospitals of zero percent would have a 0.0 percent net effect on the proposed FY 2008 capital Federal compared to the FY 2007 capital Federal rate. The proposed FY 2008 update factor for rural hospitals has the effect of increasing the proposed capital Federal rate by 0.80 percent compared to the FY 2007 capital Federal rate. The proposed GAF/DRG budget neutrality factor has the effect of increasing the proposed capital Federal rate by 0.18 percent for both urban and rural hospitals. The proposed FY 2008 outlier adjustment factor has the effect of decreasing the proposed capital Federal rate by 0.89 percent compared to the FY 2007 capital Federal rate for both urban and rural hospitals. The proposed FY 2008 exceptions payment adjustment factor remains unchanged from the FY 2007 exceptions payment adjustment factor, and therefore, has a 0.0 percent net effect on the proposed FY 2008 capital Federal rate for both urban and rural hospitals. In addition to the factors historically used to determine the capital Federal rate, for FY 2008, we are proposing an adjustment factor to account for upcoding expected to result if the proposed MS-DRGs are adopted, as discussed above in section III. of this Addendum, in determining the capital Federal rate for FY 2008. The combined effect of all the changes is to decrease the proposed capital Federal rate by 3.09 percent compared to the FY 2007 capital Federal rate for urban hospitals and to decrease the proposed capital Federal rate by 2.29 percent compared to the FY 2007 capital Federal rate for rural hospitals. Comparison of Factors and Adjustments: FY 2007 Capital Federal Rate and Proposed FY 2008 Capital Federal Rate for Urban Hospitals
FY 2007
Proposed FY 20084
Change
Percent change5Update Factor1
1.0110
1.0000
0.0000
0.00GAF/DRG Adjustment Factor1
0.9986
1.0018
1.0018
0.18Outlier Adjustment Factor 2
0.9568
0.9484
0.9912
−0.88Exceptions Adjustment Factor 2
0.9997
0.9997
1.0000
0.00MS-DRG Upcoding Adjustment Factor 3

0.9760
0.9760
−2.40Capital Federal Rate
$427.03
$413.87
0.9692
−3.101
                                         The proposed update factor for rural hospitals and the proposed GAF/DRG budget neutrality factors are built permanently into the capital rates. Thus, for example, the incremental change from FY 2007 to FY 2008 resulting from the application of the proposed 1.0018 GAF/DRG budget neutrality factor for FY 2008 is 1.0018.2
                                         The proposed outlier reduction factor and the proposed exceptions adjustment factor are not built permanently into the capital rates; that is, these factors are not applied cumulatively in determining the capital rates. Thus, for example, the net change resulting from the application of the proposed FY 2008 outlier adjustment factor would be 0.9484/0.9568, or 0.9912.3
                                         Proposed adjustment to FY 2008 IPPS rates to account for upcoding expected to result if the proposed MS-DRGs are adopted, as discussed above in section III. of this Addendum.4
                                         Proposed factors for FY 2008, as discussed above in section III. of this Addendum.5
                                         Percent change of individual proposed factors may not sum due to rounding.
 Comparison of Factors and Adjustments: FY 2007 Capital Federal Rate and Proposed FY 2008 Capital Federal Rate for Rural Hospitals
FY 2007
Proposed FY 20084
Change
Percent change5Update Factor 1
1.0110
1.0080
1.0080
0.80GAF/DRG Adjustment Factor 1
0.9986
1.0018
1.0018
0.18Outlier Adjustment Factor 2
0.9568
0.9484
0.9912
−0.88Exceptions Adjustment Factor 2
0.9997
0.9997
1.0000
0.00MS-DRG Upcoding Adjustment Factor 3

0.9760
0.9760
−2.40Capital Federal Rate
$427.03
$417.26
0.9771
−2.291
                                         The proposed update factor for rural hospitals and the proposed GAF/DRG budget neutrality factors are built permanently into the capital rates. Thus, for example, the incremental change from FY 2007 to FY 2008 resulting from the application of the proposed 1.0018 GAF/DRG budget neutrality factor for FY 2008 is 1.0018.2
                                         The proposed outlier reduction factor and the proposed exceptions adjustment factor are not built permanently into the capital rates; that is, these factors are not applied cumulatively in determining the capital rates. Thus, for example, the net change resulting from the application of the proposed FY 2008 outlier adjustment factor would be 0.9484/0.9568, or 0.9912.3
                                         Proposed adjustment to FY 2008 IPPS rates to account for upcoding expected to result if the proposed MS-DRGs are adopted, as discussed above in section III. of this Addendum.4
                                         Proposed factors for FY 2008, as discussed above in section III. of this Addendum.5
                                         Percent change of individual proposed factors may not sum due to rounding.
 6. Proposed Special Capital Rate for Puerto Rico Hospitals Section 412.374 provides for the use of a blended payment system for payments to Puerto Rico hospitals under the PPS for acute care hospital inpatient capital-related costs. Accordingly, under the capital PPS, we compute a separate payment rate specific to Puerto Rico hospitals using the same methodology used to compute the national Federal rate for capital-related costs. Under the broad authority of section 1886(g) of the Act, as discussed in section V. of the preamble of this proposed rule, beginning with discharges occurring on or after October 
                                    ( print page 24848)
                                    1, 2004, capital payments to hospitals in Puerto Rico are based on a blend of 25 percent of the Puerto Rico capital rate and 75 percent of the capital Federal rate. The Puerto Rico capital rate is derived from the costs of Puerto Rico hospitals only, while the capital Federal rate is derived from the costs of all acute care hospitals participating in the IPPS (including Puerto Rico). To adjust hospitals' capital payments for geographic variations in capital costs, we apply a GAF to both portions of the blended capital rate. The GAF is calculated using the operating IPPS wage index and varies, depending on the labor market area or rural area in which the hospital is located. We use the Puerto Rico wage index to determine the GAF for the Puerto Rico part of the capital-blended rate and the national wage index to determine the GAF for the national part of the blended capital rate. Because we implemented a separate GAF for Puerto Rico in FY 1998, we also apply separate budget neutrality adjustments for the national GAF and for the Puerto Rico GAF. However, we apply the same budget neutrality factor for DRG reclassifications and recalibration nationally and for Puerto Rico. As we stated above in section III.A.4. of this Addendum, for Puerto Rico, the proposed GAF budget neutrality factor is 1.0009, while the DRG adjustment is 0.9992, for a combined proposed cumulative adjustment of 1.0001. In computing the payment for a particular Puerto Rico hospital, the Puerto Rico portion of the capital rate (25 percent) is multiplied by the Puerto Rico-specific GAF for the labor market area in which the hospital is located, and the national portion of the capital rate (75 percent) is multiplied by the national GAF for the labor market area in which the hospital is located (which is computed from national data for all hospitals in the United States and Puerto Rico). In FY 1998, we implemented a 17.78 percent reduction to the Puerto Rico capital rate as a result of Pub. L. 105-33. In FY 2003, a small part of that reduction was restored. For FY 2007, before application of the GAF, the special capital rate for Puerto Rico hospitals was $203.06 for discharges occurring on or after October 1, 2006 through September 30, 2007. With the changes we are making to the factors used to determine the capital rate, in addition to the proposed zero percent update for urban hospitals, the proposed FY 2008 special capital rate for rural hospitals in Puerto Rico is $197.21 For urban hospitals in Puerto Rico, the proposed FY 2008 special capital rate is $195.60. B. Calculation of the Proposed Inpatient Capital-Related Prospective Payments for FY 2008 Because the 10-year capital PPS transition period ended in FY 2001, all hospitals (except “new” hospitals under § 412.324(b) and under § 412.304(c)(2)) are paid based on 100 percent of the capital Federal rate in FY 2007. The applicable capital Federal rate was determined by making adjustments as follows: For outliers, by dividing the capital standard Federal rate by the outlier reduction factor for that fiscal year; and
                                For the payment adjustments applicable to the hospital, by multiplying the hospital's GAF, disproportionate share adjustment factor, and IME adjustment factor, when appropriate. For purposes of calculating payments for each discharge during FY 2008, the capital standard Federal rate would be adjusted as follows: (Standard Federal Rate) x (DRG weight) × (GAF) × (COLA for hospitals located in Alaska and Hawaii) × (1 + Disproportionate Share Adjustment Factor + IME Adjustment Factor, if applicable). The result is the adjusted capital Federal rate. (As discussed above and in section V. of the preamble of this proposed rule, we are proposing to eliminate the large urban add-on adjustment in existing regulations at § 412.316, beginning in FY 2008.) Hospitals also may receive outlier payments for those cases that qualify under the thresholds established for each fiscal year. Section 412.312(c) provides for a single set of thresholds to identify outlier cases for both inpatient operating and inpatient capital-related payments. The proposed outlier thresholds for FY 2008 are in section II.A.4.c. of this Addendum. For FY 2008, a case qualifies as a cost outlier if the cost for the case plus the IME and DSH payments is greater than the prospective payment rate for the DRG plus the proposed fixed-loss amount of $23,015. An eligible hospital may also qualify for a special exceptions payment under § 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 § 412.348(g)(2), which in the case of certain urban hospitals includes an excess capacity test as described at § 412.348(g)(4); and (2) a project size requirement as described at § 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 § 412.106(c)(2), and hospitals that have a combined Medicare and Medicaid inpatient utilization of at least 70 percent. Under § 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 § 412.348(g)(6), the minimum payment level is 70 percent for all eligible hospitals. During the transition period, new hospitals (as defined under § 412.300) were exempt from the capital IPPS for their first 2 years of operation and were paid 85 percent of their reasonable costs during that period. Effective with the third year of operation through the remainder of the transition period, under § 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 § 412.304(c)(2), for cost reporting periods beginning on or after October 1, 2002, we pay a new hospital 85 percent of its reasonable costs during the first 2 years of operation unless it elects to receive payment based on 100 percent of the capital Federal rate. Effective with the third year of operation, we pay the hospital based on 100 percent of the capital Federal rate (that is, the same methodology used to pay all other hospitals subject to the capital PPS). C. Capital Input Price Index 1. Background Like the operating input price index, the capital input price index (CIPI) is a fixed-weight price index that measures the price changes associated with capital costs during a given year. The CIPI differs from the operating input price index in one important aspect—the CIPI reflects the vintage nature of capital, which is the acquisition and use of capital over time. Capital expenses in any given year are determined by the stock of capital in that year (that is, capital that remains on hand from all current and prior capital acquisitions). An index measuring capital price changes needs to reflect this vintage nature of capital. Therefore, the CIPI was developed to capture the vintage nature of capital by using a weighted-average of past capital purchase prices up to and including the current year. We periodically update the base year for the operating and capital input prices to reflect the changing composition of inputs for operating and capital expenses. The CIPI was last rebased to FY 2002 in the FY 2006 IPPS final rule (70 FR 47387). 2. Forecast of the CIPI for FY 2008 Based on the latest forecast by Global Insight, Inc. (first quarter of 2007), we are forecasting the CIPI to increase 1.20 percent in FY 2008. This reflects a projected 1.9 percent increase in vintage-weighted depreciation prices (building and fixed equipment, and movable equipment) and a 3.0 percent increase in other capital expense prices in FY 2008, partially offset by a 2.5 percent decline in vintage-weighted interest expenses in FY 2008. The weighted average of these three factors produces the 1.2 percent increase for the CIPI as a whole in FY 2008. IV. Proposed Changes to Payment Rates for Excluded Hospitals and Hospital Units: Rate-of-Increase Percentages (If you choose to comment on issues in this section, please include the caption “Excluded Hospitals Rate of Increase” at the beginning of your comments.) Historically, hospitals and hospital units excluded from the prospective payment system received payment for inpatient hospital services they furnished on the basis of reasonable costs, subject to a rate-of-increase ceiling. An annual per discharge 
                                    ( print page 24849)
                                    limit (the target amount as defined in § 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 § 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 § 403.752(a), RNHCIs are also subject to the rate-of-increase limits established under § 413.40. IRFs, IPFs, and LTCHs were paid previously under the reasonable cost methodology. However, the statute was amended to provide for the implementation of prospective payment systems for IRFs, IPFs, and LTCHs. In general, the prospective payment systems for IRFs, IPFs, and LTCHs provide(d) transition periods of varying lengths during which time a portion of the prospective payment is (was) based on cost-based reimbursement rules under Part 413 (certain providers do not receive a transition period or may elect to bypass the transition as applicable under Subparts N, O, and P.) We note that the various transition periods provided for under the IRF PPS, IPF PPS, and LTCH PPS have ended or will soon end. For cost reporting periods beginning on or after October 1, 2002, all IRFs are paid 100 percent of the adjusted Federal rate under the IRF PPS. Therefore, for cost reporting periods beginning on or after October 1, 2002, no portion of an IRF PPS payment is subject to Part 413. Similarly, for cost reporting periods beginning on or after October 1, 2006, all LTCHs are paid 100 percent of the adjusted Federal rate under the LTCH PPS. Therefore, for cost reporting periods beginning on or after October 1, 2006, no portion of the LTCH PPS payment is subject to Part 413. However, except as provided in § 412.426(c), IPFs remain under a blend methodology for cost reporting periods beginning on or after January 1, 2005, and before January 1, 2008. For IPFs paid under the blend methodology, the portion of the IPF PPS payment that is based on reasonable cost principles is subject to the rules of Part 413. In order to calculate the portion of the PPS payment that is based on reasonable cost principles, it is necessary to determine whether the IPF would be considered “existing” for purposes of section 1886(b)(3)(H) of the Act or “new” for purposes of section 1886(b)(7) of the Act. We note that readers should not confuse an IPF that is considered “new” for purposes of section 1886(b)(7) of the Act and § 413.40(f)(2)(ii) with an IPF that is considered “new” under § 412.426(c). Any IPF that, under present or previous ownership or both, has its first cost reporting period as an IPF beginning on or after January 1, 2005, is considered “new” for purposes of § 412.426(c). An IPF that is considered “new” under § 412.426(c) is paid based on 100 percent of the Federal per diem payment amount. Consequently, only those IPFs considered “new” under section 1886(b)(7) of the Act, but not “new” under § 412.426(c) will be paid under a PPS blended payment methodology. An IPF considered “new” for purposes of § 413.40(f)(2)(ii) would have its “reasonable-cost based” portion of its prospective payment subject to § 413.40(f)(2)(ii) and § 413.40(c)(4)(v), as applicable. An IPF considered “new” for purposes of section 1886(b)(7) of the Act has the target amount for its third cost reporting period determined in accordance with sections 1886(b)(7)(A)(ii) and 1886(b)(3)(A)(ii) of the Act. For the fourth and subsequent cost reporting periods, the target amount is calculated in accordance with section 1886(b)(3)(A)(ii) of the Act. An IPF that would be considered “existing” for purposes of section 1886(b)(3)(H) of the Act has the target amount for the “reasonable-cost based” portion of its prospective payment determined in accordance with section 1886(b)(3)(A)(ii) of the Act and § 413.40(c)(4)(ii). We are proposing that the applicable percentage increase to update the target amount for the reasonable cost-based portion of the PPS payment of an IPF that is considered existing under section 1886(b)(3)(H) of the Act or new under section 1886(b)(7) of the Act, but not new under § 412.426(c), is 3.4 percent using the first quarter of the 2007 forecast made by Global Insight, Inc. V. Tables This section contains the tables referred to throughout the preamble to this proposed rule and in this Addendum. Tables 1A, 1B, 1C, 1D, 2, 3A, 3B, 4A, 4B, 4C, 4D, 4F, 4G, 4H, 4J, 5, 6A, 6B, 6C, 6D, 6E, 6F, 6J, 6K, 7A, 7B, 8A, 8B, 8C, 9A, 9C, 10, and 11 are presented below. As explained in sections II.D. 2. and II.G.8. of the preamble of this final rule, Table 6G—Additions to the CC Exclusions List, Table 6H, Deletions from the CC Exclusions List, and Table 6I—Complete List of Complication and Comorbidity (CC) Exclusions are available only through the Internet on the CMS Web site at: 
                                    *http://www.cms.hhs.gov/​AcuteInpatientPPS/​.*
                                     The tables presented below are as follows: Table 1A—National Adjusted Operating Standardized Amounts, Labor/Nonlabor (69.7 Percent Labor Share/30.3 Percent Nonlabor Share If Wage Index Is Greater Than 1) Table 1B—National Adjusted Operating Standardized Amounts, Labor/Nonlabor (62 Percent Labor Share/38 Percent Nonlabor Share If Wage Index Is Less Than or Equal To 1) Table 1C—Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor Table 1D—Capital Standard Federal Payment Rate Table 2—Hospital Case-Mix Indexes for Discharges Occurring in Federal Fiscal Year 2006; Hospital Wage Indexes for Federal Fiscal Year 2008; Hospital Average Hourly Wages for Federal Fiscal Years 2006 (2002 Wage Data), 2007 (2003 Wage Data), and 2008 (2004 Wage Data); and 3-Year Average of Hospital Average Hourly Wages Table 3A—FY 2008 and 3-Year Average Hourly Wage for Urban Areas by CBSA Table 3B—FY 2008 and 3-Year Average Hourly Wage for Rural Areas by CBSA Table 4A—Wage Index and Capital Geographic Adjustment Factor (GAF) for Urban Areas by CBSA—FY 2008 Table 4B—Wage Index and Capital Geographic Adjustment Factor (GAF) for Rural Areas by CBSA—FY 2008 Table 4C—Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That Are Reclassified by CBSA—FY 2008 Table 4F—Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF) by CBSA—FY 2008 Table 4J—Out-Migration Adjustment—FY 2008 Table 5—List of Proposed Medicare Severity Diagnosis-Related Groups (MS-DRGs), Relative Weighting Factors, and Geometric and Arithmetic Mean Length of Stay Table 6A—New Diagnosis Codes Table 6B—New Procedure Codes Table 6C—Invalid Diagnosis Codes Table 6D—Invalid Procedure Codes Table 6E—Revised Diagnosis Code Titles Table 6F—Revised Procedure Code Titles Table 6J—Major Complication and Comorbidity (MCC) List Table 6K—Complications and Comorbidity (CC) List Table 7A—Medicare Prospective Payment System Selected Percentile Lengths of Stay: FY 2006 MedPAR Update—December 2006 GROUPER V24.0 CMS DRGs Table 7B—Medicare Prospective Payment System Selected Percentile Lengths of Stay: FY 2006 MedPAR Update—December 2006 GROUPER V25.0 MS-DRGs Table 8A—Proposed Statewide Average Operating Cost-to-Charge Ratios—March 2007 Table 8B—Proposed Statewide Average Capital Cost-to-Charge Ratios—March 2007 Table 8C—Proposed Statewide Average Total Cost-to-Charge Ratios for LTCHs—March 2007 Table 9A—Revised Hospital Reclassifications and Redesignations—FY 2008 Table 9C—Hospitals Redesignated as Rural under Section 1886(d)(8)(E) of the Act—FY 2008 Table 10—Geometric Mean Plus the Lesser of .75 of the National Adjusted Operating Standardized Payment Amount (Increased to Reflect the Difference Between Costs and Charges) or .75 of One Standard Deviation of Mean Charges by Proposed Medicare Severity Diagnosis-Related Group (MS-DRG)—April 2007 Table 11—Proposed FY 2008 MS-LTC-DRGs, Relative Weights, Geometric Average Length of Stay, and 5/6ths of the Geometric Average Length of Stay 
                                    ( print page 24850) Table 1A.—National Adjusted Operating Standardized Amounts; Labor/Nonlabor (69.7 Percent Labor Share/30.3 Percent Nonlabor Share if Wage Index Greater Than 1)
Full update (3.3 percent)
Reduced update (1.3 percent)Labor-related
Nonlabor-related
Labor-related
Nonlabor-related$3,430.29
$1,491.21
$3,363.88
$1,462.34
 Table 1B.—National Adjusted Operating Standardized Amounts, Labor/Nonlabor (62 Percent Labor Share/38 Percent Nonlabor Share if Wage Index Less Than or Equal to 1)
Full update (3.3 percent)
Reduced update (1.3 percent)Labor-related
Nonlabor-related
Labor-related
Nonlabor-related$3,051.33
$1,870.17
$2,992.26
$1,833.96
 Table 1C.—Adjusted Operating Standardized Amounts for Puerto Rico Labor, Labor/Nonlabor
Rates if wage index greater than 1
Rates if wage index less than or equal to 1Labor
Nonlabor
Labor
NonlaborNational
$3,430.29
$1,491.21
$3,051.33
$1,870.17Puerto Rico
1,442.56
884.15
1,365.78
960.93
 Table 1D.—Capital Standard Federal Payment Rate
Urban rate
Rural rateNational
$413.87
$417.26Puerto Rico
195.60
197.21
 1 2 
 
 TABLE 2.—Hospital Case-Mix Indexes for Discharges Occurring in Federal Fiscal Year 2006; Hospital Wage Indexes for Federal Fiscal Year 2008; Hospital Average Hourly Wages for Federal Fiscal Years 2006 (2002 Wage Data), 2007 (2003 Wage Data, and 2008 (2004 Wage Data); and 3-Year Average of Hospital Average Hourly Wages
Provider No.
Case-mix index 2
FY 2008 wage index
Average hourly wage 
                                 FY 2006
Average hourly wage 
                                 FY 2007
Average hourly wage 
                                 
                                    FY 2008 1
Average hourly wage** 
                                 (3 years)010001
1.5195
0.7598
21.6546
22.1989
23.2171
22.3607010005
1.1370
0.8760
22.4906
23.6022
23.0192
23.0412010006
1.5127
0.7971
23.4823
23.4975
25.1891
23.9924010007
1.0231
0.7598
18.2429
19.9329
21.2159
19.8249010008
1.0409
0.7843
20.4591
17.9533
22.0766
19.9260010009
0.9710
0.8760
23.2228
23.5626
25.8995
24.2263010010
1.1050
0.8737
21.4974
27.0385
22.8588
23.5938010011
1.6744
0.8873
27.4850
27.6658
27.4650
27.5387010012
1.2346
0.9391
22.7020
24.4059
25.5764
24.1955010015
1.0427
0.7641
21.5111
22.3383
27.0786
23.3434010016
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***
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***
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***
*
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*
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*
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*
*
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***
*
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*
*
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***
*
*
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*
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***
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*
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0.8043
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*010165
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***
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*010168
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*
*
*
*020001
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*020019
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*030001
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***
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***
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***
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25.8805040119
1.4199
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21.0103
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24.2386
23.2176040126
***
*
14.0700
15.6985
17.3697
15.6131040132
***
*
28.1393
*
22.0041
24.3526040134
2.3675
0.8965
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26.8841( print page 24855)040142
1.4686
0.9110
27.9696
21.4222
23.8619
24.1239040143
***
*
*
37.1976
*
37.1976040144
***
*
*
21.4008
*
21.4008040145
1.7857
0.8507
*
*
24.4378
24.4378040146
***
*
*
*
33.7847
33.7847040147
1.7126
0.8965
*
*
*
*050002
1.3851
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35.2529050015
1.3326
*
30.7940
32.2188
*
31.5274050016
1.3291
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***
*
32.2172
*
*
32.2172050063
1.3855
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36.3153
34.5052050065
***
*
34.0280
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35.9583050088
***
*
25.7385
*
*
25.7385050089
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1.7182
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36.8825
37.7999
36.4915050117
***
*
32.4413
34.2020
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1.2267
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1.3250
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***
*
33.5109
33.6662
38.2322
35.1744050145
1.4358
1.4408
42.3134
42.2921
47.7276
44.2033050146
1.7437
*
*
*
*
*050148
1.0844
*
27.3005
28.2305
*
27.7734050149
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43.3190
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44.7561050155
***
*
21.8550
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***
*
28.5604
*
*
28.5604050173
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***
*
30.5733
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***
*
25.1442
24.0717
*
24.6196050179
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50.3390( print page 24857)050196
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***
*
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***
*
23.9972
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*
24.7211050215
***
*
43.7985
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***
*
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35.3864
*
37.5312
36.3536050251
***
*
27.2675
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***
*
24.0044
23.5381
*
23.7879050254
1.2481
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***
*
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***
*
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***
*
31.5435
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***
*
33.9022
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35.1423050313
1.2017
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46.2016
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***
*
32.9576
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*
32.9576050380
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42.0781
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***
*
18.1005
17.2141
*
17.6460050393
1.4106
1.1633
30.0661
34.1743
35.6327
33.2864050394
1.6045
1.1607
27.5061
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1.6169
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0.7585
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28.3671
29.6760
28.7665050407
1.1110
1.4766
37.9066
42.2748
44.6803
41.6942050410
***
*
21.3814
*
*
21.3814050411
1.2156
1.1633
37.8064
38.8294
38.6322
38.4661050414
1.3232
1.2999
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41.8000
38.4949050417
1.2775
1.1607
29.5031
32.9341
35.4935
32.6699050419
0.8450
*
33.3124
*
*
33.3124050420
***
*
24.9401
35.2869
39.9207
32.7471050423
1.0736
1.1607
30.6416
28.3768
31.9703
30.4039050424
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33.2031
34.9839
32.9980050430
0.9735
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25.0604
23.9045
24.5322
24.4190050432
***
*
30.8030
33.1876
35.2390
33.0678050433
1.6238
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23.0807
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21.1315
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45.5828
47.8947
50.0192
47.8408050464
1.6913
1.1989
37.3692
38.3058
41.6239
39.0263( print page 24859)050468
1.5319
1.1633
29.5448
31.1111
35.7762
32.2134050469
1.0269
*
28.9080
30.6502
*
29.7684050470
1.1011
1.1607
24.6755
27.8678
31.0441
28.1043050471
1.7564
1.1633
34.5211
35.4768
36.9130
35.6374050476
1.4491
1.3959
34.6585
38.7856
40.0425
37.8312050477
***
*
34.6995
37.7668
40.1536
37.8017050478
0.9888
1.1607
33.3999
40.2558
41.1616
38.4325050481
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36.1488
34.6206
34.0200050488
1.3383
1.5308
42.9904
42.6854
44.0641
43.2687050491
***
*
32.1379
34.3598
*
33.1420050492
1.2507
1.1607
27.1540
28.0826
30.7637
28.6534050494
1.3609
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1.0428
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26.9420
27.1974
28.3319
27.4850050534
1.4831
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29.8603
33.1666
36.6525
33.1997050535
***
*
32.3723
34.6143
37.8210
35.0693050537
1.4155
1.2999
31.3844
34.9931
37.4208
34.7283050539
***
*
29.8242
*
*
29.8242050541
1.5613
1.5299
46.1121
52.5908
48.0854
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39.2234
41.0903
36.6511050549
1.5395
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34.9818
35.2792
38.3717
36.2083050550
***
*
30.2301
30.9612
34.9589
31.9521050551
1.3357
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31.6165
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37.2494
34.3696050552
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1.3174
*
33.0259
31.6785
*
32.3431050570
1.5427
1.1607
34.0171
34.5161
38.5202
35.7251050571
***
*
33.6156
34.7627
39.0735
35.8473050573
1.6272
1.1607
34.1991
34.7279
35.2835
34.7592050575
1.2410
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25.2513
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23.7972
24.6719050577
***
*
30.8841
32.3744
*
31.6437050578
1.4930
1.1633
33.8825
35.2390
31.3598
33.5038050579
***
*
39.4976
42.5081
*
40.8657050580
1.2328
1.1607
31.6256
31.5806
34.1537
32.4723050581
1.4907
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37.4560
35.0083050584
1.3234
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24.8180
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30.7795
28.6016050585
***
*
22.7121
22.2521
29.4264
24.4704050586
1.2846
1.1607
27.4173
26.4782
31.3482
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32.8212
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37.7367
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1.1523
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30.9546
34.5100
37.6873
34.3938( print page 24860)050590
1.2935
1.2999
32.2142
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41.6861
37.3399050591
***
*
28.8549
30.6106
34.7108
31.3299050592
***
*
24.4542
27.3606
31.8084
27.4577050594
***
*
34.7946
36.5256
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37.6368050597
1.2589
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29.5731050609
1.2823
1.1607
41.1797
41.7208
39.7400
40.7274050613
***
*
*
42.8108
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42.8888050615
***
*
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36.7844
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0.9805
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27.4539
31.3182
33.1445
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***
*
32.0627
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*
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1.2791
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32.2907
33.9594
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34.1562050625
1.7399
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36.3631
38.6591
40.4646
38.5119050630
***
*
30.9410
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*
30.9410050633
1.2279
1.1912
35.3734
36.8302
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36.8992050636
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*
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0.8701
1.5378
32.6362
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34.5797
39.7191
36.4072050694
1.0504
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28.9544
30.7858
32.1040
30.6710050695
***
*
35.6548
39.6004
49.0312
41.9280050696
2.2819
1.1633
35.9220
37.3837
39.9251
37.7376050697
1.1042
1.2827
25.1984
16.6605
22.1435
20.8109050699
***
*
26.8211
28.9083
21.5729
25.9116050701
1.3266
1.1607
29.6253
31.9529
34.9885
32.5135050704
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24.5600
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1.4517
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39.9858
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44.2474
43.5806050713
***
*
20.2803
21.1273
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20.8075050714
1.3837
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33.6676
31.9527
33.6833
33.1222050717
1.4243
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38.0796
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38.8757
38.7310050718
***
*
21.4996
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26.0532050720
0.9023
1.1607
30.0811
29.4726
30.3598
29.9464050722
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1.1607
*
31.4867
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29.3768050727
1.1939
1.1633
24.3026
33.9118
32.7726
30.6197( print page 24861)050728
***
*
36.0820
39.3581
41.8244
38.7029050729
***
*
34.2580
36.5432
38.1758
36.3888050730
***
*
51.5425
37.0629
39.2017
42.2681050732
2.3945
1.1607
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*
33.6903
33.6903050733
1.6526
1.2827
*
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40.1993
40.1993050734
***
*
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31.2860
31.2860050735
1.3420
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1.1633
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1.1633
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1.1633
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1.1633
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26.8470
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30.9980
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37.6040
34.1974( print page 24862)060076
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34.9272
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1.2439
*
*
*
*080001
1.6239
1.0778
30.0242
32.0105
33.5308
31.8695080002
***
*
27.7932
29.6800
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1.5693
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27.1080( print page 24863)100004
0.9210
*
16.5974
*
*
16.5974100006
1.6439
0.9383
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1.6615
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27.6179
28.6630
30.2983
28.8662100020
***
*
23.9414
27.1257
*
25.5458100022
1.7406
1.0245
29.9345
32.8088
36.7902
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1.5155
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24.0623100026
1.5785
0.8749
21.4703
23.4730
25.3313
23.5015100027
***
*
16.1223
18.9432
*
17.4007100028
1.3559
0.9385
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*
*
*
*
*100080
1.7074
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26.9516( print page 24864)100090
1.4902
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*
*
*
*
*100275
1.2874
1.0245
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*
*
41.9448
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*
28.4722
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0.8749
*
26.7063
27.7643
27.2417100293
***
*
*
32.7963
*
32.7963100294
***
*
*
30.7557
*
30.7557100295
***
*
*
26.1983
*
26.1983100296
1.3420
1.0023
*
*
29.3841
29.3841100297
***
*
*
*
32.1504
32.1504100298
0.8097
0.9032
*
*
19.0284
19.0284100299
1.2650
0.9758
*
*
34.3125
34.3125100300
1.5491
0.9758
*
*
*
*100301
2.4311
0.8749
*
*
*
*100302
1.1202
0.9383
*
*
*
*( print page 24866)110001
1.3403
0.8587
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1.5291
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*
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1.1568
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*
25.2689110050
1.0878
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30.0314110079
1.4284
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23.1024
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28.0337
25.8338110080
***
*
22.3213
18.4714
*
20.3904110082
1.9490
0.9845
29.8366
30.8320
30.1059
30.2637110083
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16.2575
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17.8654110101
1.0211
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16.4269
19.4257
23.2580
19.5226( print page 24867)110104
1.0874
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18.7951
20.3777
21.8924
20.4307110105
1.3393
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20.2502
21.2623
20.2550110135
1.2755
0.7864
20.4412
22.5346
23.7098
22.3469110136
***
*
15.8573
18.8212
*
17.2827110142
0.9496
0.8066
18.1980
21.3935
21.6229
20.4888110143
1.4028
0.9845
27.7055
28.6583
29.9107
28.7952110146
1.0440
0.9129
23.9067
27.0987
29.0166
26.6342110149
***
*
27.1477
28.4040
*
27.8380110150
1.3057
0.9845
22.6624
25.3742
26.9867
24.9549110153
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28.6570110165
1.3818
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26.8378
27.0977
28.7885
27.5696110166
***
*
26.8070
*
*
26.8070110168
1.8211
0.9845
27.0022
28.5700
29.7626
28.4639110172
1.3224
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29.1703
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30.5995110177
1.7871
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26.7504
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29.7970
28.4770110179
***
*
26.0759
*
*
26.0759110183
1.2702
0.9845
29.6132
28.6208
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28.8287110184
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28.4664110192
1.3983
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30.0811
28.6170110193
***
*
27.3341
27.9161
*
27.6234110194
0.9362
0.7864
18.4776
19.1920
21.0803
19.6202110198
1.3960
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21.2405
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1.1996
0.8208
40.5120
*
*
40.5120110214
***
*
*
37.1450
*
37.1450110215
1.2923
0.9845
25.7886
27.5566
29.5222
27.7244110219
1.4243
0.9845
27.0362
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32.1875
29.3856110220
***
*
*
37.5741
*
37.5741110221
***
*
*
28.0500
*
28.0500110222
***
*
*
35.6189
*
35.6189110223
***
*
*
*
25.3054
25.3054110224
***
*
*
*
33.6431
33.6431110225
1.1643
0.9845
*
*
29.5367
29.5367110226
1.1727
0.9845
*
*
*
*120001
1.7822
1.1289
34.7715
34.1385
39.6365
36.0758( print page 24868)120002
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1.0751
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39.1930
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30.9833
30.0254120016
***
*
19.6039
*
*
19.6039120019
1.1324
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30.3809
30.4257
33.0105
31.2828120022
1.9143
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29.5900120025
***
*
30.2367
*
*
30.2367120026
1.4053
1.1289
30.3293
32.4566
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1.3450
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***
*
*
*
44.6372
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1.4431
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23.6078
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25.0585
24.5110130003
1.3979
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28.2893130005
***
*
25.7523
*
*
25.7523130006
1.7739
0.9501
25.3221
27.2158
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1.8211
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***
*
16.1658
*
*
16.1658130024
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***
*
20.6642
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1.3933
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25.3649130065
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*
21.9792
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*
*
28.9875
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*
*
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*
*
*
*140001
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1.0141
*
18.1242
*
*
18.1242140018
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0.9079
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***
*
17.5249
*
*
17.5249140026
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***
*
20.6548
*
*
20.6548140046
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30.1641( print page 24869)140052
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***
*
20.8063
*
*
20.8063140062
1.3499
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35.0300
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1.2813
*
19.5675
*
*
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25.1498
26.0383
26.1931
25.7916140116
1.2809
1.0455
31.9902
34.5537
34.3854
33.6663140117
1.5470
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27.8446140118
1.5344
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29.7570
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1.8434
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36.1419
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28.4188
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29.7745140124
1.2574
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36.1327
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36.8811
36.2568140125
1.1737
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20.4014
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1.5914
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31.5415140133
1.2957
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1.4311
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23.3196
24.6627
23.4674140137
1.0306
0.8885
21.4699
23.4174
31.4330
24.5875140141
***
*
21.7872
*
*
21.7872140143
1.1599
1.0455
26.2954
27.4499
26.1598
26.6232140145
1.0894
0.8885
23.4608
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25.2020
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27.4471
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32.1785
29.6154140164
1.8228
0.8885
23.7457
24.6009
25.9708
24.8069( print page 24870)140165
***
*
16.6304
*
*
16.6304140166
1.1618
0.8355
23.1005
26.4800
26.2861
25.2805140167
1.1617
0.8355
22.8911
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29.8568
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31.3490
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22.5610
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27.6376
29.3657
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29.0241140180
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28.3629
27.8887
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25.0101
25.0226
28.8391
26.2494140182
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31.5975
29.8792140184
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26.5377
25.2109140186
1.5405
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30.6951
29.8022
38.6436
32.7202140187
1.5457
0.8885
23.2892
24.8332
25.5863
24.5665140189
1.1672
0.8355
23.7198
22.5965
24.6993
23.6830140190
***
*
19.8296
*
*
19.8296140191
1.3320
1.0455
25.8678
28.5836
31.2506
28.4103140197
1.2420
1.0455
23.0684
24.0463
24.9086
23.9560140199
1.0545
*
22.0315
*
*
22.0315140200
1.4398
1.0455
26.3379
28.8435
30.7340
28.6128140202
1.5519
1.0455
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32.7915
32.9414
31.9574140206
1.2672
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30.6561
29.7953
29.0219
29.8266140207
1.2156
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24.1048
26.0535
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26.0077140208
1.6599
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29.4708
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29.9911140209
1.5590
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1.0674
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19.2640
20.6954
19.2050
19.6893140211
1.3080
1.0455
29.7054
30.3286
31.2117
30.4786140213
1.2474
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30.2945
31.6926
32.1006
31.3680140217
1.5469
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31.5324
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33.6828140223
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1.4308
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30.6410
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34.5759
31.7645140233
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28.6305
29.7093
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31.1879
29.9224
30.0310140240
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29.9537140242
1.5035
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32.0522
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33.9219140250
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1.3945
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27.1687
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27.9306140252
1.4015
1.0455
33.3351
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34.5696140258
1.5168
1.0455
30.2639
34.2333
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32.5344140275
1.3109
0.8898
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23.4447
24.9401
26.6521
24.9136140281
1.7579
1.0455
30.4838
33.3903
35.4009
33.0950140285
***
*
20.7576
*
*
20.7576140286
1.1525
1.0455
29.1543
30.3237
30.9916
30.1576140288
1.5216
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29.3988
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1.1893
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34.8568
35.1494
41.7895
37.1471140301
1.1592
1.0455
31.7073
49.9507
36.3852
36.8862140303
2.2098
1.0455
*
29.6470
*
29.6470150001
1.1317
0.9723
29.6844
28.9075
31.8065
30.1183150002
1.4425
1.0455
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26.6689150003
1.7495
0.8682
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26.3732( print page 24871)150004
1.4758
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30.9613
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27.1181150009
1.4332
0.9045
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1.2442
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24.3490
25.3178
26.7670
25.4609150012
1.5635
0.9649
27.3029
30.0348
31.2245
29.5420150013
***
*
21.8465
*
*
21.8465150015
1.3255
0.8876
26.2434
28.0931
27.3806
27.2242150017
1.8579
0.9046
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26.0050150018
1.7216
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1.8099
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1.5634
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28.4136
27.8886150026
1.3156
0.9488
28.1127
28.6517
30.4957
29.1720150027
1.0482
*
17.4862
*
*
17.4862150029
1.4693
0.9649
26.9680
28.7187
29.9297
28.4268150030
1.1962
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1.3921
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1.4897
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21.9369
24.5593
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24.4151150047
1.7148
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25.5194
25.8493
25.7349150048
1.3885
0.9654
27.1817
27.1233
28.1517
27.5020150049
1.3621
*
22.3370
*
*
22.3370150051
1.6351
0.9723
23.7061
26.5655
28.9114
26.4833150052
1.0751
*
20.6339
*
*
20.6339150056
1.9411
0.9723
28.2842
28.8727
29.3498
28.8452150057
2.0977
0.9723
24.8605
28.9529
30.3290
27.8808150058
1.5682
0.9649
27.5341
29.1444
29.1247
28.6422150059
1.5558
0.9723
28.5715
31.4987
31.3363
30.4971150060
***
*
24.8544
*
*
24.8544150061
1.1276
0.8599
22.2822
21.3711
22.6744
22.1017150062
1.1339
*
24.6088
*
*
24.6088150064
1.2004
0.8599
23.7707
25.4987
28.7959
26.0974150065
1.2639
0.9723
25.9461
27.9283
30.2038
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25.8557150072
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21.2120
21.7638
21.1631150074
1.4434
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25.9321
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26.5896150075
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25.1568
25.7242
24.9786150076
1.2878
0.9488
28.1874
29.3249
30.1109
29.2163150079
1.1099
*
21.4067
*
*
21.4067150082
1.6791
0.8599
25.5860
28.3494
26.4526
26.8041150084
1.8404
0.9723
29.3905
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23.9404
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25.3038150088
1.2755
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26.6296150089
1.6030
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30.4835
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32.1616
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25.0367
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29.1332
27.3211150100
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24.3530
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26.9731
25.6241150101
1.0674
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29.1657
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29.5655150102
1.0330
0.9246
24.5923
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25.4594( print page 24872)150104
1.0855
0.9723
25.5872
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28.7782
27.5175150106
1.0158
*
20.9387
*
*
20.9387150109
1.4646
0.8682
23.5865
25.3367
26.8460
25.2374150112
1.4973
0.9723
26.5643
28.0068
29.8515
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1.2888
0.9723
24.8760
24.7960
25.9794
25.2152150115
1.4221
0.8599
19.3411
22.0747
22.5784
21.2668150122
1.3185
0.9723
26.0173
*
29.1651
27.6449150124
***
*
21.3933
*
*
21.3933150125
1.5108
1.0455
26.7666
27.6535
29.3573
27.9334150126
1.4163
1.0455
26.9887
28.9454
29.4277
28.4460150128
1.4408
0.9723
26.4976
28.7810
29.4982
28.2798150129
1.1548
0.9723
29.9099
29.7398
31.4309
30.3982150130
1.6136
*
21.7400
*
*
21.7400150132
***
*
25.6257
27.6560
*
26.6249150133
1.2465
0.9046
22.7292
25.1322
24.2528
24.0310150134
1.0184
0.9045
23.8525
26.3249
21.6507
23.7520150136
***
*
26.2704
*
*
26.2704150146
1.1375
0.9046
29.3383
29.5256
30.3340
29.7675150147
1.5119
1.0455
22.8456
27.2339
26.1631
25.6991150149
1.0014
0.8599
23.6360
23.7026
24.9628
24.1402150150
1.3168
0.9046
25.5331
27.0542
26.7708
26.4923150151
***
*
38.1445
*
*
38.1445150152
***
*
44.7145
*
*
44.7145150153
2.4179
0.9723
*
32.1022
35.0601
33.7419150154
2.5731
0.9723
*
29.8514
29.8867
29.8697150155
***
*
*
45.0121
*
45.0121150156
***
*
*
25.9681
*
25.9681150157
1.6752
0.9723
*
*
32.3095
32.3095150158
1.2386
0.9723
*
*
*
*150160
2.0084
0.9723
*
*
*
*150161
1.4704
0.9723
*
*
*
*150162
1.7757
0.9723
*
*
*
*150163
1.1085
0.9045
*
*
*
*160001
1.2040
0.9227
25.1220
24.5108
25.7253
25.1337160005
1.2097
0.8480
21.8949
23.1034
24.7751
23.2876160008
1.0520
0.8480
20.7200
22.1402
22.4752
21.7844160013
1.2954
0.8659
23.7163
24.0956
24.4092
24.0732160014
***
*
20.5882
*
*
20.5882160016
1.5631
0.9227
23.3619
24.5338
27.1450
24.9572160020
1.1531
*
19.5554
*
*
19.5554160024
1.5664
0.9162
26.2392
27.4158
29.3740
27.6163160026
***
*
24.7424
*
*
24.7424160028
1.3103
0.9419
26.2948
27.8535
30.0834
28.2015160029
1.6376
0.9428
27.9277
28.7324
30.6688
29.0932160030
1.3828
0.9982
26.7068
28.7786
30.9401
28.8516160031
0.7988
*
19.7368
*
*
19.7368160032
1.0670
0.8715
23.4727
25.4662
26.2923
25.1089160033
1.7494
0.8898
24.6768
26.5315
27.2044
26.1333160034
1.0217
*
19.3503
*
*
19.3503160039
0.9129
*
22.1180
*
*
22.1180160040
1.2918
0.8891
23.9053
25.9032
26.8096
25.5667160045
1.6888
0.8689
25.4153
26.6463
27.5279
26.5336160047
1.3942
0.9419
25.2072
26.0227
28.1257
26.4461160048
***
*
19.5831
*
*
19.5831160050
1.0566
*
24.5402
*
*
24.5402160057
1.2586
0.9142
23.0937
25.1272
25.6262
24.6658160058
1.9687
0.9428
27.1646
28.4167
28.9914
28.2022160064
1.6018
0.8891
28.6139
28.7668
28.4201
28.5965160066
0.9354
*
22.7709
*
*
22.7709160067
1.3642
0.8891
23.4060
24.8137
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24.7707160069
1.5288
0.8874
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27.6151
26.8148( print page 24873)160079
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0.8689
23.7234
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26.1612
24.8785160080
1.2820
0.8898
23.1837
25.8252
27.2360
25.4030160081
***
*
23.1930
*
*
23.1930160082
1.7712
0.9162
26.4398
27.4718
28.7814
27.5576160083
1.6609
0.9162
28.2193
27.3004
28.3914
27.9723160089
1.2895
0.9142
22.6551
23.2149
23.2885
23.0561160091
***
*
17.9862
*
*
17.9862160101
1.0822
0.9162
25.1000
25.0503
25.4729
25.2118160104
1.6559
0.8898
24.9134
28.1891
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27.8792160110
1.5339
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24.7957
25.2879
24.4324160117
1.3812
0.8874
25.0278
25.4659
27.3401
25.9559160118
***
*
19.7764
*
*
19.7764160122
1.0949
0.8480
22.5872
23.9177
24.4983
23.6840160124
1.1525
0.8480
23.1690
22.5482
24.2654
23.3247160126
1.0265
*
19.8323
*
*
19.8323160146
1.3905
0.9220
22.9897
22.6949
25.9575
23.8222160147
1.2917
0.9227
26.6438
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29.8976
28.4670160153
1.7355
0.9220
28.9881
29.9378
30.6170
29.8519160154
0.9478
*
*
*
*
*170001
1.1452
0.7989
21.9131
23.1260
23.8847
22.9700170006
1.3255
0.9040
21.9019
24.2068
27.1291
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1.0521
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25.2476
26.7123
25.6576170014
1.0198
0.9321
23.5960
23.8135
24.1592
23.8605170015
***
*
20.2368
*
*
20.2368170016
1.6404
0.8561
25.9482
25.8061
26.7533
26.1670170017
1.0741
0.9009
24.7771
26.9657
25.7301
25.8416170019
1.1990
*
22.0251
*
*
22.0251170020
1.5979
0.8761
23.1800
23.2757
24.1120
23.5234170022
1.1485
*
22.2878
*
*
22.2878170023
1.4202
0.8761
23.9808
24.0561
23.9805
24.0052170027
1.3965
0.7989
22.5103
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23.0164170033
1.3534
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22.2849170039
0.9441
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21.5203
26.9852
26.0906
24.6284170040
1.9811
0.9321
28.2856
28.4458
30.2460
29.0254170049
1.5233
0.9321
24.7895
25.2070
26.4091
25.4878170052
***
*
18.5291
*
*
18.5291170058
1.1011
0.9321
23.3398
22.9210
26.5943
24.2597170068
1.2238
0.9141
22.6087
23.0635
23.8790
23.1876170070
***
*
16.0162
*
*
16.0162170074
1.2234
0.7989
21.0565
23.7829
23.1854
22.7215170075
0.8299
0.7989
16.5444
19.7760
19.9316
18.7462170085
0.6104
*
*
*
*
*170086
1.5817
0.8561
24.0812
26.1362
26.3581
25.5514170093
***
*
16.5553
*
*
16.5553170094
0.9370
0.7989
21.3887
21.5295
16.5371
19.6987170098
***
*
20.1242
*
*
20.1242170103
1.2881
0.9009
22.8707
23.8042
24.1990
23.6448170104
1.4659
0.9321
26.9671
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23.8520
23.4043170110
0.8843
0.7989
22.9195
23.3260
23.9496
23.4209170114
0.9064
*
18.9158
*
*
18.9158170120
1.3879
0.9040
21.0499
22.0253
22.2797
21.7557170122
1.6841
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25.3982
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22.9309
23.1226
25.2821
23.8233170137
1.2780
0.7989
23.8862
24.7096
25.4425
24.7034( print page 24874)170142
1.4027
0.8455
22.5778
23.9527
24.5814
23.7373170143
***
*
20.4459
*
*
20.4459170144
***
*
24.6259
*
*
24.6259170145
1.0836
0.7989
21.5756
23.2162
23.3953
22.7060170146
1.5040
0.9321
29.1358
29.8858
29.0538
29.3514170147
***
*
21.4753
22.4973
24.3378
22.5659170150
1.1592
0.8165
18.5744
20.9448
19.5537
19.7042170166
0.9974
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25.6281
26.7215
25.4230170176
1.5962
0.9321
26.2366
27.2332
29.0423
27.5653170180
***
*
25.1368
32.5010
17.4887
26.4266170182
1.4423
0.9321
25.7443
27.3503
29.0642
27.4067170183
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1.0788
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27.9903
29.9014
27.6979
28.5234170195
2.2822
0.9321
*
30.1001
29.5948
29.8108170196
2.3751
0.9009
*
*
33.9653
33.9653180001
1.2529
0.9654
25.4217
27.6917
29.7401
27.6436180002
1.0605
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19.5437
22.0797
20.8790
20.8280180005
1.1216
0.8706
24.5561
24.9779
25.6139
25.0800180006
***
*
14.8011
*
*
14.8011180007
1.5270
0.9027
22.7606
25.7042
27.1922
25.2358180009
1.7023
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29.7116180025
1.1404
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19.1543
22.6897
28.5920
23.5032180026
1.0693
*
18.2120
*
*
18.2120180027
1.2463
0.8116
23.8763
20.8303
21.7638
22.0496180028
0.9145
*
24.7967
*
*
24.7967180029
1.3855
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23.0536
25.6479
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24.9987180035
1.6206
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29.8438
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29.4298
27.6399180046
0.9468
0.9027
27.2244
27.1034
27.0962
27.1405180047
***
*
21.8036
*
*
21.8036180048
1.2958
0.9045
21.6571
23.9230
24.3681
23.3115180049
1.4452
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22.6473
26.3604
25.9528
24.9966180051
1.2881
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21.3312
23.5299
24.3892
23.1284( print page 24875)180053
0.9917
0.7812
19.1578
21.3044
22.1656
20.9703180055
1.1922
*
20.7237
*
*
20.7237180056
1.1792
0.8469
22.8910
24.3074
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23.9076180063
1.1034
*
17.9741
*
*
17.9741180064
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1.4706
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25.3772
24.5770180134
0.9988
*
18.6779
*
*
18.6779180138
1.2338
0.9045
27.3400
28.1901
29.3488
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0.9711
0.7812
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1.7986
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25.3357
27.7799
26.1558180143
1.6391
0.9027
25.1613
28.1924
30.8722
28.2377180144
***
*
*
29.5052
*
29.5052180146
***
*
*
*
39.8522
39.8522180147
***
*
*
*
31.1601
31.1601180148
***
*
*
*
30.1239
30.1239180149
0.9790
0.7812
*
*
*
*190001
1.1333
0.7591
19.7516
22.1394
22.1542
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1.6405
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22.0056
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26.3623
24.9673190009
1.2905
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19.8404
21.1005
24.0685
21.5282190010
***
*
21.6889
*
*
21.6889190011
0.9928
0.7872
19.7319
21.4052
21.6962
20.9421190013
1.4551
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1.6703
0.7787
21.2526
24.3006
26.7106
24.0302( print page 24876)190034
1.2388
0.7779
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20.7334
21.2104
20.5402190036
1.7113
0.8732
24.8152
25.4164
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28.6297
28.0162
27.7945190041
1.4784
0.8615
24.6734
28.5376
28.9554
27.3327190043
***
*
17.3477
*
*
17.3477190044
1.3215
0.7850
19.5567
20.9993
21.2561
20.6002190045
1.6092
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27.1982
26.1752190046
1.4988
0.8732
24.2128
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24.7362
24.2695190048
1.0173
*
19.6288
*
*
19.6288190050
1.0982
0.7635
19.1076
21.0259
20.9111
20.3638190053
1.1453
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23.4081190065
1.6040
0.8014
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22.1880
23.1207
23.0049190077
0.9332
*
18.8409
*
*
18.8409190078
1.0564
0.7775
21.3786
22.2431
22.2313
21.9581190079
1.2248
0.8732
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23.8562
23.1624
23.1091190090
1.0652
0.7591
20.2045
23.1241
24.3261
22.5629190095
***
*
18.0174
*
*
18.0174190098
1.7622
0.8615
24.6353
25.6854
25.7430
25.3592190099
1.0523
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1.1180
0.7982
21.7228
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26.6201
23.8308190109
1.2707
*
18.6524
*
*
18.6524190111
1.6579
0.8615
24.4998
25.5729
26.5701
25.5474190114
1.0545
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22.8809
21.2519
21.3058190122
1.3212
0.8014
23.7082
22.0072
22.2352
22.6295190124
***
*
24.6675
26.0032
27.7799
26.1591190125
1.6008
0.7872
23.9649
25.5463
24.8247
24.7613190128
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27.8465
28.6764
27.2755190133
0.9001
0.7692
13.6266
18.2045
22.4265
19.4499190135
***
*
26.8238
27.7540
30.5687
28.1641190140
0.9712
0.7625
17.6936
18.9652
23.0383
19.9091190144
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1.5652
0.8732
26.1792
27.4824
28.7186
27.4154190149
1.0427
*
18.8819
*
*
18.8819190151
0.9491
0.7591
18.6293
18.7467
18.8350
18.7414190152
1.5642
0.8732
27.6099
28.1334
30.8510
28.8848190158
***
*
26.3042
26.4787
30.6477
27.6762190160
1.6099
0.7872
21.6740
22.9325
24.7806
22.9867190161
1.2439
0.7787
19.1022
22.6187
22.9017
21.4139190162
***
*
25.0328
25.2953
*
25.1543190164
1.1710
0.8204
22.8599
25.2560
26.6165
24.9924190167
1.2685
0.8323
24.3185
26.4669
25.3251
25.3437190175
1.3812
0.8732
27.1531
26.0547
27.4234
26.8723190176
1.7573
0.8732
25.6997
25.8826
26.2601
25.9478190177
1.7189
0.8732
27.4621
27.7792
28.2738
27.8343190182
***
*
28.4799
27.1682
29.8646
28.5185190183
1.1704
0.7980
19.8084
22.6928
22.0098
21.4396190184
1.0119
0.7766
23.9608
24.9476
24.1551
24.3727( print page 24877)190185
***
*
24.7912
25.6394
28.9749
26.4361190190
0.9347
0.7666
16.1195
24.3327
26.6988
22.8823190191
1.3282
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0.9301
0.8323
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1.3888
0.7872
24.3735
25.8071
26.4794
25.5487190199
0.9962
0.8014
14.1409
27.3304
31.9843
22.9932190200
***
*
27.5681
28.8173
27.4772
27.9970190201
1.2434
0.7787
24.5877
25.1010
24.4557
24.7118190202
1.4035
0.8014
24.7944
27.6084
29.6583
27.4867190203
***
*
26.8795
28.1832
29.9743
28.2126190204
1.5156
0.8732
28.3684
28.1033
30.5137
28.9471190205
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24.4540
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1.5774
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24.3286190245
1.7065
0.7872
27.1786
25.5751
26.7636
26.5208190246
1.6693
0.7666
*
*
22.7824
22.7824190247
***
*
*
32.7499
*
32.7499190248
***
*
*
23.2220
*
23.2220190249
1.8972
0.8014
*
20.0468
25.2505
22.1285190250
2.1200
0.8732
*
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33.3274
32.3417190251
1.2888
0.8014
*
21.4464
23.8397
22.5827190252
***
*
*
23.6924
*
23.6924190253
***
*
*
22.8060
23.8029
23.3045190254
***
*
*
32.9290
*
32.9290190255
0.7428
0.8323
*
22.2412
16.1597
18.3000190256
0.7572
0.8732
*
*
25.9565
25.9565190257
1.6034
0.7641
*
*
26.5480
26.5480190258
1.0329
0.8615
*
31.3715
26.1129
28.3727190259
1.8027
0.8323
*
*
26.5073
26.5073190260
***
*
*
*
29.3937
29.3937190261
1.6302
0.7872
*
*
27.0423
27.0423190262
***
*
*
*
30.3709
30.3709190263
2.4724
0.8323
*
*
26.1353
26.1353190264
***
*
*
*
26.5809
26.5809190265
0.7095
0.7872
*
*
22.6214
22.6214190266
1.9489
0.8014
*
*
*
*190267
1.1620
0.8732
*
*
*
*190268
1.3593
0.8323
*
*
*
*190270
1.7989
0.8732
*
*
*
*190272
1.5539
0.8323
*
*
*
*190273
1.6476
0.8014
*
*
*
*200001
1.3871
0.9860
25.1144
25.2542
25.8813
25.4247200002
1.0767
0.8412
25.7478
25.7212
27.1134
26.1897200008
1.3366
1.0008
27.4412
27.7137
29.1729
28.1437200009
1.9757
1.0008
31.1056
30.7510
32.5792
31.4767200012
1.3501
*
25.7623
*
*
25.7623200013
***
*
24.4131
*
*
24.4131200018
1.2572
0.8412
23.6337
23.5632
22.5017
23.1550200019
1.2471
1.0008
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27.8456200025
1.1474
1.0008
26.0573
26.3124
28.5747
27.0014200027
***
*
26.3118
*
*
26.3118200028
***
*
24.3271
*
*
24.3271200031
1.2585
0.8412
21.9489
21.2370
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21.8009200032
1.1124
0.8728
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26.2491( print page 24878)200033
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1.3348
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25.2833
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26.1400210009
1.6952
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26.2360
27.7900
30.2658
28.0854210010
***
*
25.7775
*
*
25.7775210011
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1.0108
27.5031
30.8575
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30.0101210012
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1.2013
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1.1256
30.3598
32.4356
33.6641
32.2134220003
1.1827
*
22.0549
*
*
22.0549220006
***
*
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32.0429( print page 24879)220010
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29.2908220025
1.0403
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***
*
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1.1325
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30.5607
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30.1999220075
1.5111
1.1710
29.1588
30.9175
31.3628
30.4689220076
***
*
29.7507
27.5148
*
28.6235220077
1.6760
1.0955
30.2684
31.7325
33.0291
31.6979220080
1.2069
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34.3947220088
1.8786
1.1710
28.5462
35.8255
37.4460
33.3973220089
***
*
31.1708
32.6305
34.7959
32.8331220090
1.1952
1.1256
30.8685
32.9011
33.8958
32.6221220095
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30.9197220133
***
*
33.6003
29.4855
34.8935
32.6268220135
1.3229
1.2617
33.9866
36.0203
37.5164
35.8937220153
***
*
*
*
19.8073
19.8073220154
0.9781
1.1710
28.6461
*
28.7843
28.7087220162
1.6507
*
*
*
*
*220163
1.5700
1.1256
33.6484
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37.4931
35.2930( print page 24880)220171
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1.2036
1.1256
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*
*
*
*
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1.6837
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*
*
*
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1.2951
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1.0740
*
23.8835
*
*
23.8835230013
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1.0649
*
23.5511
*
*
23.5511230029
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***
*
26.2037
*
*
26.2037230046
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27.9091
28.5859
27.3987230060
1.2198
0.8899
25.5015
28.2874
27.0286
26.9332230065
***
*
28.4631
32.6255
*
29.9929230066
1.3087
0.9935
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30.6184
30.2070
29.5125230069
1.1594
1.0138
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24.5418
23.3433230081
1.1913
0.8899
23.0788
24.7374
26.4321
24.7713230082
1.6774
*
22.2165
*
*
22.2165230085
1.1930
1.0505
22.7313
23.4959
25.4277
23.9142230087
***
*
16.9168
*
*
16.9168230089
1.3349
1.0138
28.7015
31.0522
32.8429
30.6482230092
1.3637
1.0138
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24.1881
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23.7860230101
1.2004
0.8899
24.3772
25.4839
28.4355
26.1552230103
***
*
21.6609
*
*
21.6609( print page 24881)230104
1.5972
1.0138
30.5570
32.4634
32.4102
31.7987230105
1.8553
0.9399
27.2705
32.4583
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1.0456
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24.8873
23.5918230119
1.3915
1.0138
30.2441
30.7488
31.9681
31.0533230120
1.1881
*
24.1485
*
*
24.1485230121
1.2797
0.9933
24.5220
26.4940
26.8351
25.9742230130
1.7334
1.0272
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31.6152
33.8730
31.3710230142
1.2441
1.0138
26.9433
27.8377
29.7407
28.1855230143
***
*
21.4083
*
*
21.4083230144
2.3494
1.0504
*
*
*
*230146
1.3935
1.0138
26.3432
26.8156
27.2610
26.8176230151
1.3152
1.0272
28.2243
27.4546
29.8352
28.4827230153
***
*
22.8644
*
*
22.8644230156
1.6276
1.0504
31.1909
32.3755
33.9016
32.4963230165
1.6917
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29.6376
31.4221
30.0161230167
1.6184
1.0053
27.4562
29.8071
31.0585
29.4605230169
***
*
31.8442
*
*
31.8442230172
1.1867
*
25.7402
*
*
25.7402230174
1.2752
0.9472
27.6920
30.0563
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1.2857
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25.8188
27.0655230180
1.1332
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24.7358
26.0707
24.9693
25.2513230184
***
*
23.6706
34.6295
*
25.2502230186
***
*
26.2282
*
*
26.2282230189
***
*
23.0100
*
*
23.0100230190
0.8738
1.0505
29.9603
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1.5219
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29.6591230235
1.0691
*
21.8777
*
*
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29.1973
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30.1455230279
0.4947
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24.7673
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27.9709
26.6920( print page 24882)230283
***
*
26.2622
33.5531
*
27.8105230289
***
*
29.7721
*
*
29.7721230291
***
*
30.9656
*
*
30.9656230292
***
*
31.8943
*
*
31.8943230294
***
*
*
31.6195
*
31.6195230295
***
*
*
27.1298
*
27.1298230296
***
*
*
*
34.2091
34.2091230297
1.6725
1.0092
*
*
*
*230299
0.7569
1.0092
*
*
*
*230300
2.9372
1.0092
*
*
*
*240001
1.5321
1.0961
31.5753
33.1499
34.9488
33.2343240002
1.8802
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31.6000
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34.0824
31.7954240010
2.0488
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31.3733
33.4668
33.9391
32.9198240013
***
*
28.3860
*
*
28.3860240014
1.0233
1.0961
29.8623
29.8905
31.5902
30.4899240016
1.2758
*
26.7814
*
*
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1.1862
*
24.4417
24.3596
*
24.4015240018
1.2795
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32.0413240021
1.0320
*
27.1236
*
*
27.1236240022
1.0296
0.9212
25.2066
26.1920
27.4384
26.3075240027
0.9334
*
18.2482
*
*
18.2482240029
0.9036
*
25.3568
*
*
25.3568240030
1.3356
1.0390
24.7154
26.5508
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26.1210240031
***
*
26.7778
*
*
26.7778240036
1.6917
1.0961
28.0812
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33.5022240080
1.9135
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31.6828
32.5725
34.9990
33.0567240083
1.2282
*
26.6582
*
*
26.6582240084
1.1715
1.0151
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1.2868
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30.0094240101
1.1577
0.9212
25.5355
25.6963
26.8837
26.0839240103
***
*
22.7077
*
*
22.7077240104
1.1355
1.0961
31.4306
31.6511
34.8590
32.7610240106
1.6068
1.0961
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31.1028240109
0.8676
*
16.5051
*
*
16.5051240115
1.5324
1.0961
31.3869
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33.7716
32.4047( print page 24883)240117
1.1786
0.9805
23.6230
24.5750
27.6916
25.3192240123
***
*
21.7500
*
*
21.7500240128
***
*
21.5791
23.3334
*
22.4504240132
1.2801
1.0961
31.7139
32.1233
34.6782
32.8020240141
1.1202
1.0961
26.4016
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32.3861
30.2635240143
0.8966
*
21.7416
*
*
21.7416240152
***
*
29.6196
*
*
29.6196240162
***
*
22.2722
*
*
22.2722240166
1.1548
0.9212
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1.4406
*
*
*
*240207
1.1958
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31.7665
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***
*
20.3564
*
*
20.3564250023
0.8676
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*
17.4012
*
*
17.4012250038
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0.9692
*
17.3155
*
*
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0.8706
*
26.3831
*
*
26.3831250048
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38.0032
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24.7909( print page 24884)250082
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27.0283
25.6565250101
***
*
19.3543
*
*
19.3543250102
1.5948
0.8273
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24.7878250104
1.4895
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23.5414250105
0.9250
*
18.1195
*
*
18.1195250107
0.5882
*
17.8999
*
*
17.8999250112
0.9900
0.7915
21.2824
24.3069
26.3311
23.9682250117
1.1064
0.8223
23.3673
22.2450
23.7325
23.1044250120
***
*
23.4277
24.6370
26.6502
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1.1114
0.7915
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0.9502
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21.7112
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25.6980
23.8290250127
0.8851
1.4406
*
*
*
*250128
0.9292
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24.4952250141
1.5450
0.9291
27.6158
28.5922
30.5462
28.9990250146
0.7934
*
18.6486
*
*
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0.7915
15.0641
16.8796
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18.8846
22.8221
18.4859250152
0.8555
0.8273
25.7837
26.9334
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26.3576250153
***
*
29.0461
*
*
29.0461250155
***
*
*
22.5728
*
22.5728250156
***
*
*
*
16.8646
16.8646250157
***
*
*
*
29.6366
29.6366250160
1.4401
0.8308
*
*
*
*250161
2.1565
0.8273
*
*
*
*260001
1.6521
0.9318
25.9250
27.9230
29.5231
27.7476260002
***
*
26.4879
*
*
26.4879260004
0.9694
0.8145
16.9422
20.3217
21.3539
19.5722260005
1.5541
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26.5773
27.7855
27.9465
27.4311260006
1.4864
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26.7587
30.3440
27.3734
28.2406260008
***
*
18.9522
*
*
18.9522260009
1.1616
0.9321
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24.2360
25.7517
24.0687260011
1.5006
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25.6387
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25.2802260012
***
*
20.3061
*
*
20.3061260013
***
*
20.5007
*
*
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0.8507
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*
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*
*
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27.1644
25.5181( print page 24885)260035
***
*
17.8741
*
*
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***
*
22.1913
*
*
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24.3938
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25.2261260047
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25.0309260052
1.3110
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1.0761
*
21.6607
*
*
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*
17.6256
*
*
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26.0295
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26.1290260070
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***
*
21.6214
*
*
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*
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*
*
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*
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1.3299
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31.5417
28.0654260122
***
*
20.8015
*
*
20.8015260127
0.9486
*
21.8533
*
*
21.8533260137
1.7247
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***
*
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*
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*
*
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1.5777
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33.9109
40.9821
35.9066
37.0319260213
***
*
*
*
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34.8944260214
1.2355
0.9321
*
*
*
*260215
0.8925
*
*
*
*
*260216
1.1874
0.9321
*
*
*
*260217
1.9096
0.8145
*
*
*
*270002
1.1595
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***
*
21.7056
*
*
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1.5491
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26.7576
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26.1753270032
1.0285
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20.4332
20.1360270036
***
*
20.4241
*
*
20.4241270049
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***
*
17.7564
*
*
17.7564270074
0.9141
1.4406
*
*
*
*270081
0.9750
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*
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*
*
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*
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20.4830
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*
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*
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*
*
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*
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*
*
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*
*
*
*280123
0.9968
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*
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*
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*
*
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1.3728
0.9419
*
*
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30.5784( print page 24887)290001
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***
*
23.9655
*
*
23.9655290012
1.3586
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32.3966
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33.1284290016
***
*
26.1925
*
*
26.1925290019
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35.3803290042
***
*
*
*
22.4809
22.4809290044
***
*
*
37.1662
*
37.1662290045
1.5925
1.1431
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1.3247
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*
*
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*
*
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*
*
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*
*
*
*290052
0.8797
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*
*
*
*300001
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***
*
23.3200
*
*
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***
*
27.5028
*
*
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33.1810310042
***
*
30.7357
34.4986
*
32.5359310044
1.3429
1.0879
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32.4207310049
***
*
27.8565
*
*
27.8565310050
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36.4280
38.0643
37.5145
37.3322310077
***
*
32.6644
34.6085
*
33.6290310078
***
*
29.8014
30.5761
*
30.1919310081
1.2439
1.0778
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29.2535
33.3847
31.2917310122
***
*
*
*
41.9008
41.9008( print page 24889)310123
***
*
*
*
37.1088
37.1088310124
***
*
*
*
41.8807
41.8807310125
***
*
*
*
36.2250
36.2250310126
1.5770
1.1681
*
*
*
*310127
2.1663
1.0652
*
*
*
*320001
1.6846
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***
*
24.3534
*
*
24.3534320057
0.8707
1.4406
*
*
*
*320058
0.7716
1.4406
*
*
*
*320059
0.8741
1.4406
*
*
*
*320060
0.9480
1.4406
*
*
*
*320061
0.8805
1.4406
*
*
*
*320062
0.8907
1.4406
*
*
*
*320063
1.3149
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25.0031
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1.1001
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*
*
*
*320074
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26.8652330001
***
*
33.4718
*
*
33.4718330002
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1.3215
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***
*
28.4391
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35.6905( print page 24890)330029
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35.7856330062
2.5188
*
21.0464
*
*
21.0464330064
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***
*
31.9873
*
*
31.9873330096
1.2270
0.8440
22.0337
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23.4149
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1.0476
*
20.3189
*
*
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24.2010
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1.7054
*
*
*
*
*330157
1.3498
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45.3774
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43.5617330171
***
*
30.0122
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***
*
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*
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1.1593
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***
*
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*
*
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***
*
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35.2111330333
***
*
26.1917
*
*
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***
*
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37.7497
*
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0.7038
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*
*
*
*
*330357
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*
*
*
*330405
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*
*
*
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*
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*
*340001
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*
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***
*
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*
*
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***
*
23.1918
*
*
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***
*
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*
*
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*
*
*
*340158
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*
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*
24.7471
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*
25.7127340178
***
*
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***
*
*
34.1895
*
34.1895340182
***
*
*
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*
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*
*
*
*350002
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*
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*
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***
*
23.5793
*
*
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*
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*
*
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0.9276
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29.3415
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***
*
25.8367
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*
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1.6982
0.9283
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*
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*
*
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***
*
26.6348
*
*
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1.4017
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25.7083( print page 24896)360100
1.2005
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23.6159
24.0347360101
1.3623
0.9365
26.6209
27.6030
29.7806
28.0278360106
***
*
24.1588
*
*
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1.1250
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1.1982
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24.1388
25.9042
23.9896360128
***
*
21.0067
*
*
21.0067360130
1.4718
0.9365
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*
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*
*
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*
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*
*
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***
*
24.7001
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*
*
*
*
*360245
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*
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***
*
27.3903
*
*
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***
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*
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*
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***
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*
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*
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***
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*
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***
*
*
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1.7180
0.9654
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*
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1.1022
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1.4810
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*
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1.6114
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*
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*370001
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*
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*
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***
*
25.4733
*
*
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***
*
17.1361
*
*
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*
*
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***
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*
*
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*
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*
*
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*
*
*
*370183
0.9349
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***
*
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***
*
29.3777
*
*
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0.7824
*
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*
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***
*
*
26.8677
*
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*370222
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0.9950
27.1861
30.3385
31.5214
29.7041380004
1.7236
1.1233
30.5172
32.6901
34.5430
32.6119380005
1.4094
1.0304
30.2210
30.9087
33.2838
31.5051380007
2.0573
1.1233
33.9969
33.9601
35.1698
34.3879380008
***
*
25.8356
*
*
25.8356( print page 24899)380009
2.0468
1.1233
31.7042
32.4016
34.5626
32.8910380010
***
*
30.2957
34.4208
*
32.1520380014
1.9254
1.0708
29.9648
33.6078
33.1920
32.2199380017
1.8307
1.1233
32.2447
34.2605
35.3727
33.9499380018
1.9127
1.0304
28.0701
30.9923
31.8162
30.3574380020
1.4175
1.1008
28.3563
29.6053
34.6178
30.5328380021
1.4799
1.1233
29.3295
29.2164
32.6143
30.3295380022
1.3427
1.0322
29.2642
30.1742
29.6225
29.6961380023
1.1613
*
26.5439
*
*
26.5439380025
1.2130
1.1233
33.2105
35.5084
36.4904
35.1203380027
1.2891
1.0713
25.5161
26.4982
28.0232
26.6747380029
1.2598
1.0404
26.9967
28.7994
29.4458
28.4963380033
1.7477
1.1008
30.8767
33.4828
34.0066
32.8324380037
1.3213
1.1233
30.5818
32.4033
32.7927
31.9695380038
1.3172
1.1233
34.2303
34.5971
35.1114
34.6434380039
***
*
32.3959
38.0989
*
34.9720380040
1.4149
0.9950
32.0103
31.2286
32.9082
32.0782380047
1.8758
1.0592
29.8627
31.0584
32.8186
31.2890380050
1.4603
1.0151
25.6190
27.1814
29.7312
27.5470380051
1.6397
1.0404
29.7219
30.8891
32.8537
31.1839380052
1.2960
0.9950
24.9476
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28.6112
26.2863380056
1.1337
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27.7253
29.1649
27.4834380060
1.4638
1.1233
30.7041
32.0101
33.8855
32.2257380061
1.6749
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34.5222
32.2741380071
1.3167
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31.7761
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1.3427
1.0304
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33.8962
31.6899
31.4887380081
0.6765
0.9950
21.8850
26.8149
28.9626
25.5794380082
1.2728
1.1233
32.3002
35.6708
35.7815
34.6173380089
1.3127
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33.4214
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35.4845
34.5150380090
1.3031
1.0713
34.4536
33.0990
35.5491
34.3699380091
1.3581
1.1233
33.8950
39.9703
40.5058
38.1381380100
1.6492
1.1233
*
*
*
*390001
1.5910
0.8366
22.5309
23.6075
24.3387
23.5011390002
1.2796
0.8388
22.4388
24.7867
25.0846
24.1306390003
1.1972
0.8366
21.6477
23.3672
24.6385
23.2157390004
1.5727
0.9240
24.3249
24.4068
25.3218
24.7131390006
1.9184
0.9130
25.1216
26.8581
28.7849
27.0024390008
1.1369
0.8421
22.2680
22.8042
22.6293
22.5687390009
1.8139
0.8507
25.5482
26.7462
26.7227
26.3592390010
1.1864
0.8388
23.5390
24.5785
24.8175
24.2866390011
***
*
21.9279
21.4856
20.2276
21.2239390012
1.2254
1.0906
28.5076
30.7542
32.3118
30.5163390013
1.3340
0.9130
24.0044
25.0037
26.2309
25.0972390016
1.2391
0.8701
21.9549
23.2095
24.3473
23.2182390019
1.1019
1.0024
23.4636
24.0538
25.7506
24.3568390022
***
*
29.0710
30.3565
29.6304
29.6954390023
1.2530
1.0906
31.7149
35.4452
34.7747
34.0474390024
1.0208
1.0906
35.3960
33.5186
39.7191
35.9814390025
0.4785
1.0906
17.2977
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20.3840
18.9796390026
1.2151
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31.0655390027
1.7286
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35.8381
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36.9324390028
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26.6793390030
1.1566
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22.1581
23.6063
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23.4864390031
1.2252
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22.6828
26.2654
27.2007
25.3401390032
1.2843
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22.7205
23.9466
24.5233
23.7226390035
1.1523
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26.2647
28.4564
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28.1286390036
1.4372
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24.6032
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25.1463390039
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21.5925
22.9814
24.2252
22.9571390042
1.3531
0.8388
25.6328
28.3633
28.0982
27.3600( print page 24900)390043
1.2012
0.8366
22.2549
23.2378
24.2078
23.2254390044
1.6708
1.0778
27.1505
28.7758
29.4037
28.4744390045
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1.6479
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28.9961390048
1.0778
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24.9759
28.5342
28.3118
27.3366390049
1.5920
1.0024
27.1366
29.6121
30.7411
29.2421390050
2.0718
0.8388
26.6931
27.2599
27.3478
27.1027390052
1.1793
0.8410
23.3474
24.9510
25.1446
24.4778390054
***
*
22.8087
24.4435
27.4795
24.7386390055
***
*
25.6945
*
*
25.6945390056
1.0633
0.8366
19.5537
23.5077
23.5637
22.1096390057
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27.9583
29.7982
30.8283
29.5698390058
1.3199
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27.4799
26.9546
27.7268
27.3837390061
1.4182
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28.4538
29.1318
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29.1849390062
1.1297
0.8366
21.4051
21.2999
21.0708
21.2582390063
1.8004
0.8507
24.7614
26.4998
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26.0645390065
1.2577
1.0108
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27.6249
29.5649
27.4343390066
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25.2120390067
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26.3287
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28.8535390068
1.3351
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25.8291
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29.0944
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33.3185
34.4930
32.9334390071
1.0299
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21.8367
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24.9389
25.3029
26.2548
25.5020390073
1.7429
0.8366
26.3698
25.7822
26.4077
26.2014390074
***
*
22.8545
23.6500
25.4092
23.9492390075
***
*
24.6359
*
*
24.6359390076
1.4123
1.0906
27.9004
31.8500
32.7649
30.8669390079
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23.3053
22.5607
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1.3296
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28.4487390081
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19.8606
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1.9853
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25.2014
27.3528
27.0118
26.5228390091
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21.7010
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1.2329
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27.2661
27.8171
28.5901
27.9019390109
1.1589
*
19.9156
*
*
19.9156390110
1.6020
0.8388
23.9808
27.7311
25.3386
25.6176390111
2.1643
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20.5614
21.8906
21.3374390119
1.3029
0.8366
22.2746
23.0928
24.3227
23.2316390121
***
*
23.1408
25.4826
*
24.2748390122
1.0760
0.8415
22.5786
23.1866
23.3220
23.0325390123
1.1933
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34.0037
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22.4033
22.8792
22.0898390127
1.3278
1.0906
30.9374
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33.6955
32.1928( print page 24901)390128
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29.6396
31.1131
29.5021390133
1.7198
1.0778
28.7162
31.1083
32.9942
31.0177390135
***
*
24.4738
*
*
24.4738390136
***
*
22.1415
23.9813
*
23.0891390137
1.4877
0.8366
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24.2878
26.1444
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1.1925
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32.8234
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22.8331
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24.1667390174
1.7023
1.0906
32.6265
34.2069
35.2897
34.0693390176
1.0556
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*
23.9779
24.1240
24.0542390178
1.3607
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20.7270
22.6006
23.1440
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1.4433
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27.1111
25.2264390189
1.1536
0.8366
22.3722
22.6796
23.6210
22.9386390191
1.1480
*
20.8761
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*
20.8761390192
0.9891
0.8366
21.2619
20.5459
23.6172
21.8230390193
***
*
20.1024
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*
20.1024390194
1.1200
1.0024
25.4235
27.5890
26.3138
26.4431390195
1.6265
1.0906
31.0019
34.2980
34.5552
33.3460390196
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*
*
*
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1.3824
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25.7739
26.8270
27.2431
26.6095390198
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18.7222
20.5979
20.4340
19.9083390199
1.1706
0.8366
21.3157
22.3224
23.0031
22.2033390200
***
*
23.7471
*
*
23.7471390201
1.3000
0.8366
26.3658
27.0054
27.3536
26.9243390203
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28.9054
29.4930
29.1367
29.1780390204
1.2999
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29.5251
30.3378
29.5558390211
1.2565
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23.1450
25.1689
26.5027
24.9525390215
***
*
28.0403
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28.0403390217
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24.3610
23.5879
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24.0510390219
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25.4886
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30.9464
31.7312
30.5055390223
2.0315
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27.6407
30.2523
34.3250
30.7316390224
***
*
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24.9391
27.5803
27.2537
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1.7791
1.0906
28.5890
32.6658
32.6482
31.2951( print page 24902)390228
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0.8388
23.3078
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24.2239
23.8473390231
1.4024
1.0906
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25.8427390270
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24.1496
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*
*
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23.6843
26.6664
28.6253
26.2989390279
***
*
17.0012
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*
17.0012390285
1.4982
1.0906
35.0426
36.7163
37.6664
36.3989390286
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28.1761
29.5281
31.3380
29.6274390287
***
*
37.6569
39.3176
42.2395
39.3145390288
***
*
29.7287
30.9701
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30.3388390289
***
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28.8826
30.7583
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29.8023390290
1.8483
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37.9040
38.3776
41.1403
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***
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***
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29.3209390306
***
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24.5413390308
***
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36.1732
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***
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***
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*
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1.1482
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*
*
*
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12.6107( print page 24903)400048
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*
17.8303
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*
*
12.3508
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***
*
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27.4319( print page 24904)420043
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***
*
27.4767
28.0765
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*
30.7532
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30.0328420099
***
*
*
*
30.2160
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*
*
*
*430005
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***
*
16.0346
*
*
16.0346430047
1.0090
*
18.8982
*
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20.4120( print page 24906)440110
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***
*
24.0146
*
*
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24.9849
23.5732440144
1.3047
0.9408
23.3828
23.9241
25.2267
24.2122440145
1.0761
*
20.7875
*
*
20.7875440147
***
*
31.4012
33.1756
35.3815
33.3203440148
1.1126
0.9408
24.6412
23.9810
22.6179
23.6901440149
***
*
20.4563
*
*
20.4563440150
1.3903
0.9675
26.8308
28.1012
29.4367
28.1239440151
1.1741
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1.8708
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28.6971
28.7074
29.9892
29.1536440162
***
*
21.1418
27.6837
24.8692
24.4630440166
***
*
31.0779
35.3064
*
32.7296440168
0.9651
0.9291
22.8768
28.1215
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28.9141440200
0.9726
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17.7491
21.1860
23.8598
20.9517440203
***
*
19.3864
23.7451
17.9024
20.1678440217
1.3238
0.9291
28.5968
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29.9206
29.1168440218
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0.8974
0.9675
*
*
*
*440225
0.7984
0.8043
*
24.8328
27.8866
26.2413440226
1.5497
0.8043
*
26.5831
28.3236
27.4254440227
1.3258
0.9675
*
*
30.7783
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1.4433
0.9291
*
*
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26.6971( print page 24907)450015
1.5327
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29.4897
28.9233450018
1.5156
1.0048
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29.2592450020
0.9414
*
18.3047
*
*
18.3047450021
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*
23.3044
*
*
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*
21.9082
*
*
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1.6718
*
*
*
*
*450078
0.9157
0.8204
15.8968
21.4716
20.0665
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1.1888
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23.2071
24.9917
26.0863
24.7978450094
***
*
25.2434
*
*
25.2434450096
***
*
24.1618
26.5103
28.1877
26.1057450097
1.4833
1.0048
26.4965
29.0142
29.8695
28.4563450098
0.9764
*
22.6626
*
*
22.6626450099
1.2850
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26.6796
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20.1279450113
***
*
54.6663
*
*
54.6663450119
1.3063
0.9140
25.7008
27.8027
31.0620
28.0085450121
***
*
25.7051
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1.2264
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24.3295
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23.4123( print page 24908)450131
***
*
23.7098
25.9494
*
24.6979450132
1.5741
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***
*
22.2915
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***
*
16.6319
*
*
16.6319450280
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21.4558
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19.7033( print page 24909)450315
1.8055
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*
37.1721
*
37.1721450324
1.5715
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***
*
24.4454
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1.9691
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30.4280
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31.5502450362
***
*
25.4372
*
*
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*
23.2283
*
*
23.2283450378
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0.9328
*
22.0482
*
*
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*
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*
20.0351
*
*
20.0351450418
***
*
26.8434
28.4362
*
27.5264450419
1.2715
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22.0918
23.1798
21.3680450498
0.9453
0.8204
17.7822
18.6563
20.2424
18.8921450508
1.5948
0.8875
23.9572
28.4471
27.2884
26.5810450514
***
*
22.6552
26.3704
26.9571
25.3918450518
1.4362
0.8587
24.1194
28.1755
28.0142
26.7922450530
1.2781
1.0048
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29.1349
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29.2956450537
1.4003
0.9795
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27.7757
28.7442
28.0479450539
1.1997
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21.0442
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24.2118
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0.9677
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21.6542
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34.3322
25.8915450558
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30.8332
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26.7942
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26.2638450571
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20.1479
22.0797
22.1565
21.5134450578
0.9614
0.8204
20.2696
22.5167
25.0487
22.6269( print page 24910)450580
1.0846
0.8204
21.1574
22.3886
23.8964
22.4730450584
1.1129
0.8204
21.0808
20.5257
22.5149
21.3615450586
0.9359
0.8204
16.1003
18.9107
20.6563
18.6521450587
1.2013
0.8204
20.4512
23.1202
25.0153
22.8383450591
1.2535
1.0048
23.9992
25.7031
27.0806
25.5834450596
1.2190
0.9646
25.3317
27.4011
29.8448
27.4270450597
0.9772
0.8204
23.1711
24.7853
24.2555
24.0721450604
1.3487
0.8204
20.9514
24.4743
25.9097
23.8485450605
0.9394
0.8460
22.2205
20.9276
23.9323
22.2907450610
1.5913
1.0048
26.8710
27.7317
28.3923
27.6892450615
0.9880
0.8204
20.3028
21.8442
24.1786
22.0818450617
1.5099
1.0048
26.5026
28.0225
28.8304
27.8233450620
1.0016
0.8204
17.7138
18.6183
20.3650
18.9167450623
1.1755
*
28.3552
*
*
28.3552450626
***
*
26.8374
*
*
26.8374450630
1.5447
1.0048
29.6796
29.1462
29.8420
29.5559450634
1.7057
0.9795
28.1705
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30.3207
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30.2610
30.0728
27.8676450662
1.5737
0.9577
28.0913
29.0535
29.0508
28.7285450665
***
*
18.6054
*
*
18.6054450668
1.5281
0.9144
26.2375
28.8635
30.6109
28.5359450669
1.2115
0.9795
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1.3493
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28.5103
30.1696
28.9691450730
1.3611
0.9795
29.9430
31.3324
32.7866
31.3503450733
***
*
26.4977
*
*
26.4977450742
1.1915
0.9795
26.1189
27.2023
30.0561
27.8905450743
1.4606
0.9795
27.3213
28.3362
28.4726
28.0740( print page 24911)450746
0.9236
0.8204
12.4748
20.6343
22.7521
18.2376450747
1.2814
0.9190
22.2870
23.8314
25.8165
23.8624450749
0.9915
0.8204
17.8227
20.0487
22.1526
19.9050450751
***
*
19.3267
18.7456
21.4208
19.9009450754
0.9278
0.8204
20.8968
22.1819
24.7752
22.6387450755
0.9399
0.8499
18.0092
19.8988
22.1950
20.0118450758
***
*
25.6547
28.7342
28.2792
27.5628450760
1.0571
0.9144
24.6349
24.7489
25.1612
24.8383450761
0.8818
*
15.7483
*
*
15.7483450763
1.0706
*
22.4905
*
*
22.4905450766
1.9343
0.9795
30.0441
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30.3516450770
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23.7554
24.1907
23.0383450828
1.3232
0.8204
22.3667
24.4740
24.8207
24.1285450829
***
*
19.5014
20.6016
19.5826
19.9024450830
1.0196
0.9527
28.1617
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28.1873450831
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22.1335
21.9266
31.9567
24.7538450851
2.5569
0.9795
30.1213
32.6950
35.1080
32.6759450852
***
*
30.0191
*
*
30.0191450853
1.9527
0.9795
*
36.1169
37.1028
36.6720450854
***
*
*
27.1868
*
27.1868450855
1.5585
0.9577
*
30.8855
32.6866
31.8325450856
1.9086
0.8916
*
39.0865
37.7287
38.3752450857
***
*
*
30.4632
*
30.4632450860
1.9631
1.0048
*
24.0171
29.1020
26.9520450861
***
*
*
34.9290
*
34.9290450862
1.4583
1.0048
*
31.2224
31.8086
31.4626450863
***
*
*
24.8825
*
24.8825450864
2.0626
0.9190
*
23.3765
24.5033
24.0201( print page 24912)450865
1.0659
0.9518
*
29.1763
30.1175
29.6697450866
***
*
*
15.2959
*
15.2959450867
1.1897
0.9518
*
28.2289
29.8401
29.0248450868
1.8341
0.9959
*
27.9579
25.3483
26.8245450869
2.0520
0.9140
*
22.6253
26.1586
24.9890450870
***
*
*
37.4364
*
37.4364450871
1.8013
0.9518
*
*
28.6667
28.6667450872
1.3856
0.9681
*
*
27.2839
27.2839450873
***
*
*
*
14.8808
14.8808450874
1.5449
0.9795
*
*
34.6069
34.6069450875
1.6403
0.9141
*
*
23.2771
23.2771450876
2.0787
0.8678
*
*
28.4327
28.4327450877
1.5503
0.9144
*
*
26.1823
26.1823450878
2.5581
0.8916
*
*
31.4363
31.4363450879
1.2943
0.8484
*
*
35.5585
35.5585450880
1.6579
0.9681
*
*
35.9522
35.9522450881
***
*
*
*
24.5455
24.5455450882
***
*
*
*
27.8226
27.8226450883
2.5235
0.9795
*
*
35.2632
35.2632450884
0.9913
0.8925
*
*
27.8171
27.8171450885
1.4982
0.9795
*
*
34.1144
34.1144450886
1.9390
0.9670
*
*
*
*450888
1.4581
0.9670
*
*
*
*450889
1.5257
0.9795
*
*
*
*450890
2.0977
0.9795
*
*
*
*450891
1.3643
0.9795
*
*
*
*450893
1.2518
0.9795
*
*
*
*450894
1.7048
0.9795
*
*
*
*450895
***
*
*
*
18.4129
18.4129460001
1.8847
0.9488
27.0757
28.7150
30.0024
28.5948460003
1.5181
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20.1162460036
1.4454
*
27.2866
*
*
27.2866460037
0.8447
*
21.1035
*
*
21.1035460039
1.0810
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28.5657
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26.6702
28.5026
26.6084( print page 24913)460051
1.2358
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27.0160
27.8836
26.8632460052
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25.3163
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1.3073
1.0401
29.8255
30.7872
33.1968
31.2956470006
1.2524
*
26.9651
*
*
26.9651470010
***
*
26.1273
*
*
26.1273470011
1.1764
1.0401
28.3911
28.1330
29.6899
28.7438470012
1.1947
1.0401
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27.0128
25.8090470018
1.1133
*
28.3419
*
*
28.3419470024
1.2025
1.0401
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27.0394
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1.0892
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23.1144490002
1.0509
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19.5613
20.8609
21.7073
20.6687490003
***
*
27.3456
*
*
27.3456490004
1.3087
0.9353
25.4597
27.1676
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26.8453490005
1.6418
1.0679
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21.9117490031
***
*
22.0579
*
*
22.0579490032
1.9589
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*
22.5423
*
*
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25.0947( print page 24914)490088
1.1004
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17.3295
*
17.0546
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24.0812490133
***
*
26.5684
*
*
26.5684490134
0.7623
0.8095
*
*
33.2227
33.2227490135
0.7016
0.9441
*
*
25.9889
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1.4665
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*
*
*
*490137
1.2895
0.8785
*
*
*
*500001
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30.1178( print page 24915)500049
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*
*
*
*500053
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*
30.1396
*
*
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*
*
*
*
*500139
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*
24.5744
*
*
24.5744500148
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*
*
*
*510001
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***
*
21.7135
*
*
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*
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*
*
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24.6968( print page 24916)510082
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***
*
27.7061
*
*
27.7061510090
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*
*
*
*520002
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***
*
24.8184
*
*
24.8184520070
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25.8208520094
***
*
25.7567
*
*
25.7567520095
1.2940
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***
*
23.1941
25.0006
27.3413
25.0303520136
1.7254
1.0296
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32.2056
30.1520( print page 24917)520138
1.8836
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*
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1.0909
*
24.9392
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*
27.4042520160
1.8643
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25.7588
27.9548
29.7288
27.8043520170
1.4772
1.0296
27.2221
30.4309
31.4684
29.7182520173
1.0835
0.9635
28.0995
29.2429
31.0590
29.4644520177
1.6145
1.0296
30.7317
31.4555
32.5695
31.6043520178
1.0240
*
20.2666
*
*
20.2666520189
1.2031
1.0455
28.4720
28.0014
29.0284
28.4995520193
1.6998
0.9635
26.0885
27.8113
29.2005
27.7864520194
1.7148
1.0296
24.9408
30.1668
31.4969
28.9141520195
0.3556
1.0296
36.6973
36.3116
36.2864
36.4358520196
1.6798
0.9635
35.1043
36.9266
31.1197
34.0263520197
***
*
*
*
30.1026
30.1026520198
1.4193
0.9635
*
*
28.5962
28.5962520199
2.2788
1.0296
*
*
36.5679
36.5679520200
0.9180
*
*
*
*
*520201
0.6866
*
*
*
*
*520202
1.4519
1.0011
*
*
*
*530002
1.1242
0.9214
26.8356
28.3063
29.2066
28.1166530006
1.1836
0.9214
24.9318
27.2421
29.2091
27.0634530007
***
*
20.4391
*
*
20.4391530008
1.1673
0.9214
23.8589
24.0090
26.5170
24.7922530009
0.9239
0.9214
26.8316
24.6719
25.9366
25.7848530010
1.3065
0.9214
25.8482
25.9852
27.4111
26.4398530011
1.1127
0.9214
24.8245
27.8772
27.8600
26.9105530012
1.7049
0.9277
25.2526
26.9582
28.7554
26.9872530014
1.5650
0.9219
24.5947
26.7156
28.5771
26.7011530015
1.1585
0.9352
27.6876
29.8310
31.1119
29.5109530017
1.1052
0.9214
25.3362
29.8503
31.1044
28.7212530023
***
*
21.3813
*
*
21.3813530025
1.2406
0.9214
28.6938
24.4392
29.3697
27.4106530032
1.0164
0.9214
25.7728
23.9004
24.6562
24.73271
                             Based on salaries adjusted occupational mix, according to the calculation in section II.D.6. of the preamble to this final rule.2
                             The transfer-adjusted case-mix index is based on the billed DRG on the FY 2006 MedPAR.* Denotes wage data not available for the provider for that year.** Based on the sum of the salaries and hours computed for Federal FYs 2006, 2007, and 2008.*** Denotes MedPAR data not available for the provider for FY 2006.
 
 
  Table 3A.—FY 2008 and 3-Year* Average Hourly Wage for Uurban Areas by CBSA
[*Based on the salaries and hours computed for Federal FYs 2006, 2007, and 2008.]
CBSA code
Urban area
FY 2008 average hourly wage
3-Year average hourly wage10180
Abilene, TX
25.5538
24.133110380
Aguadilla-Isabela-San Sebastián, PR
10.2251
11.434110420
Akron, OH
27.1423
25.914010500
Albany, GA
26.5075
25.866110580
Albany-Schenectady-Troy, NY
26.8799
25.765810740
Albuquerque, NM
30.1918
28.636210780
Alexandria, LA
24.6475
23.544510900
Allentown-Bethlehem-Easton, PA-NJ
31.0725
29.562511020
Altoona, PA
25.8968
25.401111100
Amarillo, TX
28.3367
27.134811180
Ames, IA
30.9401
28.851711260
Anchorage, AK
36.4624
35.034111300
Anderson, IN
27.8019
26.023811340
Anderson, SC
28.1687
26.606611460
Ann Arbor, MI
32.5597
31.591411500
Anniston-Oxford, AL
24.7339
23.289411540
Appleton, WI
29.3844
27.6794( print page 24918)11700
Asheville, NC
28.5462
27.374712020
Athens-Clarke County, GA
32.6801
28.970212060
Atlanta-Sandy Springs-Marietta, GA
30.5185
28.986112100
Atlantic City, NJ
37.4892
34.954712220
Auburn-Opelika, AL
25.0667
23.919612260
Augusta-Richmond County, GA-SC
29.7570
28.567312420
Austin-Round Rock, TX
29.5055
27.877112540
Bakersfield, CA
35.1655
32.355312580
Baltimore-Towson, MD
31.3329
29.497512620
Bangor, ME
30.5654
29.044912700
Barnstable Town, MA
39.1116
37.301612940
Baton Rouge, LA
24.8394
24.302712980
Battle Creek, MI
31.1266
28.733713020
Bay City, MI
27.9569
27.383313140
Beaumont-Port Arthur, TX
26.6188
25.316813380
Bellingham, WA
34.9165
33.402513460
Bend, OR
32.8324
31.406113644
Bethesda-Gaithersburg-Frederick, MD
32.4256
32.230213740
Billings, MT
27.5180
26.302313780
Binghamton, NY
28.1230
26.243113820
Birmingham-Hoover, AL
27.5033
26.318013900
Bismarck, ND
22.5429
21.862213980
Blacksburg-Christiansburg-Radford, VA
25.0343
23.936214020
Bloomington, IN
28.9114
26.483314060
Bloomington-Normal, IL
29.4126
27.284114260
Boise City-Nampa, ID
29.4529
27.581114484
Boston-Quincy, MA
36.2971
34.549614500
Boulder, CO
31.3644
29.579714540
Bowling Green, KY
25.0757
24.023814740
Bremerton-Silverdale, WA
33.5585
31.934114860
Bridgeport-Stamford-Norwalk, CT
39.9455
37.717515180
Brownsville-Harlingen, TX
29.6861
28.689415260
Brunswick, GA
30.2808
29.136515380
Buffalo-Niagara Falls, NY
29.7130
28.143815500
Burlington, NC
26.6539
25.645615540
Burlington-South Burlington, VT
29.7238
28.015415764
Cambridge-Newton-Framingham, MA
34.6193
32.846515804
Camden, NJ
32.6154
31.073415940
Canton-Massillon, OH
27.6520
26.505415980
Cape Coral-Fort Myers, FL
29.4170
27.919816180
Carson City, NV
29.0596
29.030516220
Casper, WY
28.7554
26.987216300
Cedar Rapids, IA
26.9340
25.816116580
Champaign-Urbana, IL
28.8897
28.070516620
Charleston, WV
26.0301
25.145516700
Charleston-North Charleston, SC
28.3391
27.140216740
Charlotte-Gastonia-Concord, NC-SC
29.4846
28.216716820
Charlottesville, VA
29.6186
29.321216860
Chattanooga, TN-GA
27.7965
26.606416940
Cheyenne, WY
28.5771
26.701116974
Chicago-Naperville-Joliet, IL
32.4104
31.430117020
Chico, CA
34.8348
32.352817140
Cincinnati-Middletown, OH-KY-IN
29.9257
28.370517300
Clarksville, TN-KY
25.4889
24.564917420
Cleveland, TN
25.3391
24.181217460
Cleveland-Elyria-Mentor, OH
29.0283
27.581717660
Coeur d'Alene, ID
29.0137
27.848817780
College Station-Bryan, TX
28.4460
26.569517820
Colorado Springs, CO
29.3600
27.953617860
Columbia, MO
26.4878
24.974417900
Columbia, SC
27.2473
26.417817980
Columbus, GA-AL
27.9688
25.774718020
Columbus, IN
29.8515
28.256218140
Columbus, OH
31.1465
29.597718580
Corpus Christi, TX
26.2244
25.062918700
Corvallis, OR
33.1920
32.219919060
Cumberland, MD-WV
24.6964
24.872119124
Dallas-Plano-Irving, TX
30.3645
29.526319140
Dalton, GA
26.6179
26.1939( print page 24919)19180
Danville, IL
28.6735
27.313319260
Danville, VA
26.3059
25.115419340
Davenport-Moline-Rock Island, IA-IL
27.2960
25.922619380
Dayton, OH
28.7758
27.144219460
Decatur, AL
24.4009
24.013419500
Decatur, IL
25.1642
24.053819660
Deltona-Daytona Beach-Ormond Beach, FL
27.7363
27.049019740
Denver-Aurora, CO
32.5162
31.436919780
Des Moines-West Des Moines, IA
28.4004
27.553119804
Detroit-Livonia-Dearborn, MI
31.1509
30.376720020
Dothan, AL
22.9355
22.319720100
Dover, DE
32.2239
29.999020220
Dubuque, IA
27.5076
26.478820260
Duluth, MN-WI
31.4670
30.102420500
Durham, NC
30.4233
29.256120740
Eau Claire, WI
29.1319
27.840820764
Edison, NJ
34.3248
32.955720940
El Centro, CA
28.4214
26.833121060
Elizabethtown, KY
26.7267
25.668621140
Elkhart-Goshen, IN
29.2579
28.041121300
Elmira, NY
25.8434
24.604221340
El Paso, TX
28.3459
26.997821500
Erie, PA
26.3706
25.686921660
Eugene-Springfield, OR
34.1215
32.304621780
Evansville, IN-KY
26.2541
25.672021820
Fairbanks, AK
33.9363
32.838721940
Fajardo, PR
12.7755
12.117322020
Fargo, ND-MN
24.6368
24.197922140
Farmington, NM
28.7944
25.711022180
Fayetteville, NC
30.7692
28.381522220
Fayetteville-Springdale-Rogers, AR-MO
27.5150
26.203422380
Flagstaff, AZ
35.8265
34.681822420
Flint, MI
34.3384
32.051622500
Florence, SC
26.5418
25.834722520
Florence-Muscle Shoals, AL
24.6505
23.696522540
Fond du Lac, WI
30.6626
29.564222660
Fort Collins-Loveland, CO
29.6510
28.424222744
Fort Lauderdale-Pompano Beach-Deerfield Beach, FL
31.1393
30.015422900
Fort Smith, AR-OK
24.9728
23.747223020
Fort Walton Beach-Crestview-Destin, FL
26.8666
25.730523060
Fort Wayne, IN
28.0400
27.665623104
Fort Worth-Arlington, TX
29.9000
28.309423420
Fresno, CA
34.2325
32.241823460
Gadsden, AL
25.1998
23.767223540
Gainesville, FL
28.8449
27.711223580
Gainesville, GA
29.2101
27.281123844
Gary, IN
28.6613
27.614624020
Glens Falls, NY
26.4297
25.375824140
Goldsboro, NC
28.7525
26.856524220
Grand Forks, ND-MN
23.9585
23.180024300
Grand Junction, CO
30.0980
28.499624340
Grand Rapids-Wyoming, MI
29.0748
27.944824500
Great Falls, MT
26.4350
25.635924540
Greeley, CO
30.9980
29.162124580
Green Bay, WI
29.4038
28.102024660
Greensboro-High Point, NC
28.2420
26.837224780
Greenville, NC
28.7422
27.611724860
Greenville-Mauldin-Easley, SC
29.9557
28.786025020
Guayama, PR
09.1324
09.203325060
Gulfport-Biloxi, MS
26.7144
25.832325180
Hagerstown-Martinsburg, MD-WV
28.7017
27.684825260
Hanford-Corcoran, CA
33.0694
30.955425420
Harrisburg-Carlisle, PA
28.6428
27.530425500
Harrisonburg, VA
27.8236
26.845325540
Hartford-West Hartford-East Hartford, CT
33.9586
32.509725620
Hattiesburg, MS
23.3662
22.392425860
Hickory-Lenoir-Morganton, NC
27.8269
26.508725980
1
                                Hinesville-Fort Stewart, GA26100
Holland-Grand Haven, MI
28.1052
26.9690( print page 24920)26180
Honolulu, HI
34.9939
32.906526300
Hot Springs, AR
28.2398
26.558826380
Houma-Bayou Cane-Thibodaux, LA
24.7338
23.633226420
Houston- Sugar Land-Baytown, TX
31.1464
29.709426580
Huntington-Ashland, WV-KY-OH
27.4177
26.723726620
Huntsville, AL
28.4420
26.878426820
Idaho Falls, ID
28.6678
27.291126900
Indianapolis-Carmel, IN
30.1383
28.965626980
Iowa City, IA
29.2276
28.330727060
Ithaca, NY
29.5522
28.842527100
Jackson, MI
29.3419
28.055827140
Jackson, MS
24.9313
24.180727180
Jackson, TN
26.6283
25.938427260
Jacksonville, FL
28.2991
27.302327340
Jacksonville, NC
25.6323
24.557727500
Janesville, WI
30.4182
28.801027620
Jefferson City, MO
26.9868
25.336927740
Johnson City, TN
24.0384
23.450227780
Johnstown, PA
23.6933
24.121827860
Jonesboro, AR
24.5409
23.382627900
Joplin, MO
28.8838
26.216928020
Kalamazoo-Portage, MI
32.5642
31.211228100
Kankakee-Bradley, IL
36.1982
31.845928140
Kansas City, MO-KS
28.8920
27.705428420
Kennewick-Richland-Pasco, WA
30.5712
30.086528660
Killeen-Temple-Fort Hood, TX
25.7516
25.418128700
Kingsport-Bristol-Bristol, TN-VA
24.1118
23.580128740
Kingston, NY
29.5032
27.805728940
Knoxville, TN
24.9295
24.343229020
Kokomo, IN
29.3510
28.254929100
La Crosse, WI-MN
30.0801
28.406829140
Lafayette, IN
26.9108
25.788729180
Lafayette, LA
25.7276
24.735529340
Lake Charles, LA
24.1373
23.180629404
Lake County-Kenosha County, IL-WI
31.8873
30.955929420
2
                                Lake Havasu City-Kingman, AZ
28.9023
27.603629460
Lakeland, FL
27.3993
26.464329540
Lancaster, PA
29.5748
28.739229620
Lansing-East Lansing, MI
31.1620
29.419329700
Laredo, TX
26.2982
24.395429740
Las Cruces, NM
26.4505
25.612829820
Las Vegas-Paradise, NV
35.4313
33.555729940
Lawrence, KS
25.4425
24.703430020
Lawton, OK
26.0576
24.469530140
Lebanon, PA
25.4393
25.212030300
Lewiston, ID-WA
28.6132
28.289330340
Lewiston-Auburn, ME
28.8104
27.489230460
Lexington-Fayette, KY
27.9807
26.665930620
Lima, OH
28.7195
26.971030700
Lincoln, NE
30.4893
29.543530780
Little Rock-North Little Rock-Conway, AR
27.7885
27.059930860
Logan, UT-ID
28.4774
27.028130980
Longview, TX
27.2722
26.000531020
Longview, WA
34.1983
30.298331084
Los Angeles-Long Beach-Glendale, CA
36.0596
34.611331140
Louisville-Jefferson County, KY-IN
28.0357
27.052431180
Lubbock, TX
26.8986
25.616831340
Lynchburg, VA
26.2578
25.381231420
Macon, GA
30.2300
28.669131460
Madera, CA
26.0875
25.290331540
Madison, WI
34.6597
32.270131700
Manchester-Nashua, NH
30.9773
30.106431900
Mansfield, OH
28.5629
27.892832420
Mayaguez, PR
11.3424
11.295432580
McAllen-Edinburg-Mission, TX
28.3334
26.490932780
Medford, OR
31.9390
30.846832820
Memphis, TN-MS-AR
28.7998
27.598432900
Merced, CA
37.0756
33.905833124
Miami-Miami Beach-Kendall, FL
31.0677
29.1861( print page 24921)33140
Michigan City-La Porte, IN
27.2497
26.808633260
Midland, TX
31.0460
28.644033340
Milwaukee-Waukesha-West Allis, WI
31.9156
30.322733460
Minneapolis-St. Paul-Bloomington,  MN-WI
33.9752
32.306333540
Missoula, MT
26.9875
26.372533660
Mobile, AL
24.6422
23.332233700
Modesto, CA
36.8586
35.038433740
Monroe, LA
24.4029
23.596733780
Monroe, MI
29.3700
28.317633860
Montgomery, AL
25.9300
24.542134060
Morgantown, WV
26.0745
25.060234100
Morristown, TN
22.9428
22.978634580
Mount Vernon-Anacortes, WA
31.5880
30.330534620
Muncie, IN
24.8038
24.859434740
Muskegon-Norton Shores, MI
30.7959
29.358434820
Myrtle Beach-Conway-North Myrtle Beach, SC
26.8331
26.052934900
Napa, CA
42.8545
38.822734940
Naples-Marco Island, FL
30.2428
29.540334980
Nashville-Davidson-Murfreesboro-Franklin,
29.9892
28.846735004
Nassau-Suffolk, NY
39.6471
37.952535084
Newark-Union, NJ-PA
36.2090
34.767535300
New Haven-Milford, CT
37.0244
35.408035380
New Orleans-Metairie-Kenner, LA
27.0691
25.959735644
New York-White Plains-Wayne, NY-NJ
40.9653
39.152435660
Niles-Benton Harbor, MI
28.3260
26.560935980
Norwich-New London, CT
35.7729
34.460836084
Oakland-Fremont-Hayward, CA
47.2281
45.388736100
Ocala, FL
26.6182
25.757536140
Ocean City, NJ
33.3167
31.821936220
Odessa, TX
30.8710
29.494536260
Ogden-Clearfield, UT
28.0897
26.760436420
Oklahoma City, OK
27.1668
26.208436500
Olympia, WA
35.5354
32.856336540
Omaha-Council Bluffs, NE-IA
29.1986
27.965136740
Orlando-Kissimmee, FL
29.0828
28.008936780
Oshkosh-Neenah, WI
29.1236
27.423536980
Owensboro, KY
27.2813
25.999937100
Oxnard-Thousand Oaks-Ventura, CA
35.2562
33.619537340
Palm Bay-Melbourne-Titusville, FL
29.0897
28.333937380
2
                                Palm Coast, FL
27.0971
27.518437460
Panama City-Lynn Haven, FL
25.7289
24.167337620
Parkersburg-Marietta-Vienna, WV-OH
25.5355
24.291137700
Pascagoula, MS
26.4838
24.508037764
Peabody, MA (Formerly, Essex County, MA)
31.6602
30.756137860
Pensacola-Ferry Pass-Brent, FL
25.1925
23.736537900
Peoria, IL
29.0576
26.964737964
Philadelphia, PA
33.8074
32.452138060
Phoenix-Mesa-Scottsdale, AZ
31.3564
29.978738220
Pine Bluff, AR
25.2804
25.190838300
Pittsburgh, PA
26.0038
25.386238340
Pittsfield, MA
31.2160
30.071438540
Pocatello, ID
28.3768
27.263538660
Ponce, PR
12.8969
13.532938860
Portland-South Portland-Biddeford, ME
31.0222
29.790038900
Portland-Vancouver-Beaverton, OR-WA
34.8208
33.181538940
Port St. Lucie, FL
30.9663
29.552239100
Poughkeepsie-Newburgh-Middletown, NY
33.6441
32.264939140
Prescott, AZ
30.7280
29.155639300
Providence-New Bedford-Fall River, RI-MA
33.0234
31.884139340
Provo-Orem, UT
29.4108
28.031539380
Pueblo, CO
27.0881
25.637539460
Punta Gorda, FL
29.6415
28.141939540
Racine, WI
29.7218
27.617939580
Raleigh-Cary, NC
29.0544
28.334839660
Rapid City, SD
26.9357
25.983139740
Reading, PA
29.1969
28.393539820
Redding, CA
39.7597
36.788739900
Reno-Sparks, NV
34.2896
33.615440060
Richmond, VA
28.6347
27.1477( print page 24922)40140
Riverside-San Bernardino-Ontario,  CA
33.2757
32.024040220
Roanoke, VA
29.2663
26.317740340
Rochester, MN
33.3540
32.610040380
Rochester, NY
27.5839
26.725040420
Rockford, IL
29.9396
29.217940484
Rockingham County-Strafford County, NH
31.1882
30.124240580
Rocky Mount, NC
27.9510
26.464240660
Rome, GA
29.6009
28.285240900
Sacramento—Arden-Arcade—Roseville, CA
40.2929
38.422940980
Saginaw-Saginaw Township North, MI
28.2929
27.055941060
St. Cloud, MN
34.2927
31.615141100
St. George, UT
29.5906
28.199441140
St. Joseph, MO-KS
27.3734
28.240641180
St. Louis, MO-IL
27.5406
26.439741420
Salem, OR
32.2483
30.693741500
Salinas, CA
44.6611
42.151541540
Salisbury, MD
27.6293
26.451741620
Salt Lake City, UT
29.3945
28.005341660
San Angelo, TX
26.8517
25.030341700
San Antonio, TX
27.6376
26.437841740
San Diego-Carlsbad-San Marcos, CA
34.4952
33.211541780
Sandusky, OH
27.1537
26.608741884
San Francisco-San Mateo-Redwood City, CA
45.7716
44.527241900
San Germán-Cabo Rojo, PR
14.2741
13.860841940
San Jose-Sunnyvale-Santa Clara, CA
47.5716
45.168341980
San Juan-Caguas-Guaynabo, PR
14.0009
13.392942020
San Luis Obispo-Paso Robles, CA
36.9259
33.866642044
Santa Ana-Anaheim-Irvine, CA
35.8808
33.997242060
Santa Barbara-Santa Maria-Goleta, CA
35.4727
33.443242100
Santa Cruz-Watsonville, CA
48.5637
45.301742140
Santa Fe, NM
33.1322
31.953142220
Santa Rosa-Petaluma, CA
44.2225
41.491942260
Sarasota-Bradenton-Venice, FL
30.2493
28.720842340
Savannah, GA
27.8554
27.173342540
Scranton-Wilkes-Barre, PA
25.8844
24.750742644
Seattle-Bellevue-Everett, WA
35.1860
33.667742680
Sebastian-Vero Beach, FL
30.0922
28.610543100
Sheboygan, WI
28.0832
26.740743300
Sherman-Denison, TX
26.4564
26.240543340
Shreveport-Bossier City, LA
26.7055
25.821443580
Sioux City, IA-NE-SD
28.5808
27.205343620
Sioux Falls, SD
29.6276
28.106643780
South Bend-Mishawaka, IN-MI
29.9084
28.919943900
Spartanburg, SC
28.9299
27.154944060
Spokane, WA
32.1950
31.176744100
Springfield, IL
27.7341
26.261044140
Springfield, MA
31.7303
30.194144180
Springfield, MO
28.5068
25.624244220
Springfield, OH
26.3899
25.044844300
State College, PA
26.7336
25.206944700
Stockton, CA
36.3757
34.060144940
Sumter, SC
27.5115
25.313945060
Syracuse, NY
30.7252
28.879945104
Tacoma, WA
33.9097
31.961945220
Tallahassee, FL
27.9967
26.326645300
Tampa-St. Petersburg-Clearwater, FL
28.2629
27.205545460
Terre Haute, IN
27.3665
25.337945500
Texarkana, TX-Texarkana, AR
25.2054
24.125445780
Toledo, OH
28.7526
27.852945820
Topeka, KS
26.5384
25.836045940
Trenton-Ewing, NJ
33.2291
31.968346060
Tucson, AZ
29.4005
27.568046140
Tulsa, OK
26.3616
25.013546220
Tuscaloosa, AL
26.4544
25.547646340
Tyler, TX
28.4878
26.871846540
Utica-Rome, NY
27.1982
25.559546660
Valdosta, GA
25.4416
25.142146700
Vallejo-Fairfield, CA
44.6372
43.559747020
Victoria, TX
25.1770
24.3401( print page 24923)47220
Vineland-Millville-Bridgeton, NJ
33.0209
30.461847260
Virginia Beach-Norfolk-Newport News,  VA-NC
27.2314
26.002947300
Visalia-Porterville, CA
31.6337
30.070447380
Waco, TX
26.6527
25.492347580
Warner Robins, GA
29.8152
26.810947644
Warren-Troy-Farmington Hills, MI
31.1213
29.588247894
Washington-Arlington-Alexandria,  DC-VA-MD-WV
33.1020
32.090447940
Waterloo-Cedar Falls, IA
27.0404
25.529148140
Wausau, WI
30.5699
29.060548260
Weirton-Steubenville, WV-OH
24.4652
23.343048300
Wenatchee, WA
34.9702
31.343948424
West Palm Beach-Boca Raton-Boynton Beach,
29.7173
28.718948540
Wheeling, WV-OH
21.7311
20.933048620
Wichita, KS
27.9249
26.736748660
Wichita Falls, TX
26.3114
24.993748700
Williamsport, PA
24.6486
23.955648864
Wilmington, DE-MD-NJ
33.0781
31.315048900
Wilmington, NC
28.9440
28.241949020
Winchester, VA-WV
30.5335
29.640849180
Winston-Salem, NC
28.1564
26.927749340
Worcester, MA
35.1528
32.716849420
Yakima, WA
31.6557
29.715649500
Yauco, PR
09.9275
11.127949620
York-Hanover, PA
28.8489
27.762749660
Youngstown-Warren-Boardman, OH-PA
27.8858
25.993449700
Yuba City, CA
32.6357
31.571049740
Yuma, AZ
29.3504
27.37491
                             This area has no average hourly wage because there are no short-term, acute care hospitals in the area.2
                             This is a new CBSA for fiscal year 2008. To calculate the 3-year average hourly wage for this new area, we included the hospitals' data from their previous geographic location for fiscal year 2006 and fiscal year 2007.
 Table 3B.—FY 2008 and 3-Year* Average Hourly Wage for Rural Areas by CBSA
[*Based on the sum of the salaries and hours computed for Federal fiscal years 2006, 2007, and 2008]
CBSA code
Nonurban area
FY 2008 average hourly wage
3-Year average hourly wage01
Alabama
23.5521
22.367602
Alaska
36.6306
33.898503
Arizona
27.8285
26.219504
Arkansas
23.2785
22.114905
California
35.9780
33.187606
Colorado
29.2965
27.498107
Connecticut
36.3353
34.899108
Delaware
30.2968
28.825010
Florida
26.6274
25.537611
Georgia
24.3756
23.031912
Hawaii
33.3239
31.516513
Idaho
24.4240
23.607814
Illinois
25.8984
24.599915
Indiana
26.6535
25.349616
Iowa
26.2882
25.129717
Kansas
24.6946
23.603918
Kentucky
24.2146
23.038119
Louisiana
23.5312
22.336620
Maine
26.0760
25.217521
Maryland
27.6395
26.736622
Massachusetts 123
Michigan
27.5837
26.403224
Minnesota
28.5541
27.043325
Mississippi
24.5289
23.037726
Missouri
25.0101
23.692127
Montana
25.8421
25.348728
Nebraska
27.1777
25.634729
Nevada
30.0298
27.411430
New Hampshire
33.8547
32.165031
New Jersey 1( print page 24924)32
New Mexico
27.7898
25.638033
New York
25.8757
24.492734
North Carolina
26.6830
25.398435
North Dakota
22.6664
21.596136
Ohio
26.9698
25.802537
Oklahoma
23.8387
22.796838
Oregon
30.7212
28.951439
Pennsylvania
25.8767
24.578640
Puerto Rico 141
Rhode Island 142
South Carolina
27.2502
25.784243
South Dakota
25.8592
24.795044
Tennessee
24.3749
23.483445
Texas
25.4299
24.080746
Utah
25.6240
24.242547
Vermont
30.2045
28.632149
Virginia
25.0426
23.831750
Washington
31.5068
30.382651
West Virginia
23.4572
22.693752
Wisconsin
29.8668
28.318953
Wyoming
28.5623
27.07291
                             All counties within the State or territory are classified as urban.
 Table 4A.—Wage Index and Capital Geographic Adjustment Factor (GAF) for Urban Areas by CBSA—FY 2008
CBSA code
Urban area  (constituent counties)
Wage index
GAF10180
Abilene, TX
0.8244
0.8761Callahan County, TXJones County, TXTaylor County, TX10380
Aguadilla-Isabela-San Sebastián, PR
0.3298
0.4678Aguada Municipio, PRAguadilla Municipio, PRAñasco Municipio, PRIsabela Municipio, PRLares Municipio, PRMoca Municipio, PRRincón Municipio, PRSan Sebastián Municipio, PR10420
Akron, OH
0.8854
0.9200Portage County, OHSummit County, OH10500
Albany, GA
0.8671
0.9070Baker County, GADougherty County, GALee County, GATerrell County, GAWorth County, GA10580
Albany-Schenectady-Troy, NY
0.8672
0.9070Albany County, NYRensselaer County, NYSaratoga County, NYSchenectady County, NYSchoharie County, NY10740
Albuquerque, NM
0.9740
0.9821Bernalillo County, NMSandoval County, NMTorrance County, NMValencia County, NM10780
Alexandria, LA
0.7982
0.8570Grant Parish, LARapides Parish, LA10900
Allentown-Bethlehem-Easton, PA-NJ
1.0024
1.0016Warren County, NJCarbon County, PA( print page 24925)Lehigh County, PANorthampton County, PA11020
2
                                 Altoona, PA
0.8366
0.8850Blair County, PA11100
Amarillo, TX
0.9141
0.9403Armstrong County, TXCarson County, TXPotter County, TXRandall County, TX11180
Ames, IA
0.9982
0.9988Story County, IA11260
Anchorage, AK
1.1840
1.1226Anchorage Municipality, AKMatanuska-Susitna Borough, AK11300
Anderson, IN
0.8969
0.9282Madison County, IN11340
Anderson, SC
0.9087
0.9365Anderson County, SC11460
Ann Arbor, MI
1.0504
1.0342Washtenaw County, MI11500
Anniston-Oxford, AL
0.8042
0.8614Calhoun County, AL11540
2
                                 Appleton, WI
0.9635
0.9749Calumet County, WIOutagamie County, WI11700
Asheville, NC
0.9209
0.9451Buncombe County, NCHaywood County, NCHenderson County, NCMadison County, NC12020
Athens-Clarke County, GA
1.0543
1.0369Clarke County, GAMadison County, GAOconee County, GAOglethorpe County, GA12060
1
                                 Atlanta-Sandy Springs-Marietta, GA
0.9845
0.9894Barrow County, GABartow County, GAButts County, GACarroll County, GACherokee County, GAClayton County, GACobb County, GACoweta County, GADawson County, GADeKalb County, GADouglas County, GAFayette County, GAForsyth County, GAFulton County, GAGwinnett County, GAHaralson County, GAHeard County, GAHenry County, GAJasper County, GALamar County, GAMeriwether County, GANewton County, GAPaulding County, GAPickens County, GAPike County, GARockdale County, GASpalding County, GAWalton County, GA12100
Atlantic City, NJ
1.2095
1.1391Atlantic County, NJ12220
Auburn-Opelika, AL
0.8086
0.8646Lee County, AL12260
Augusta-Richmond County, GA-SC
0.9600
0.9724Burke County, GA( print page 24926)Columbia County, GAMcDuffie County, GARichmond County, GAAiken County, SCEdgefield County, SC12420
1
                                 Austin-Round Rock, TX
0.9518
0.9667Bastrop County, TXCaldwell County, TXHays County, TXTravis County, TXWilliamson County, TX12540
2
                                 Bakersfield, CA
1.1607
1.1074Kern County, CA12580
1
                                 Baltimore-Towson, MD
1.0108
1.0074Anne Arundel County, MDBaltimore County, MDCarroll County, MDHarford County, MDHoward County, MDQueen Anne's County, MDBaltimore City, MD12620
Bangor, ME
0.9860
0.9904Penobscot County, ME12700
Barnstable Town, MA
1.2617
1.1726Barnstable County, MA12940
Baton Rouge, LA
0.8014
0.8593Ascension Parish, LAEast Baton Rouge Parish, LAEast Feliciana Parish, LAIberville Parish, LALivingston Parish, LAPointe Coupee Parish, LASt. Helena Parish, LAWest Baton Rouge Parish, LAWest Feliciana Parish, LA12980
Battle Creek, MI
1.0042
1.0029Calhoun County, MI13020
Bay City, MI
0.9399
0.9584Bay County, MI13140
Beaumont-Port Arthur, TX
0.8587
0.9009Hardin County, TXJefferson County, TXOrange County, TX13380
Bellingham, WA
1.1264
1.0849Whatcom County, WA13460
Bend, OR
1.0592
1.0402Deschutes County, OR13644
1
                                 Bethesda-Gaithersburg-Frederick, MD
1.0990
1.0668Frederick County, MDMontgomery County, MD13740
Billings, MT
0.8877
0.9217Carbon County, MTYellowstone County, MT13780
Binghamton, NY
0.9072
0.9355Broome County, NYTioga County, NY13820
1
                                 Birmingham-Hoover, AL
0.8873
0.9214Bibb County, ALBlount County, ALChilton County, ALJefferson County, ALSt. Clair County, ALShelby County, ALWalker County, AL13900
Bismarck, ND
0.7329
0.8083Burleigh County, NDMorton County, ND13980
2
                                 Blacksburg-Christiansburg-Radford,  VA
0.8095
0.8653Giles County, VAMontgomery County, VA( print page 24927)Pulaski County, VARadford City, VA14020
Bloomington, IN
0.9327
0.9534Greene County, INMonroe County, INOwen County, IN14060
Bloomington-Normal, IL
0.9488
0.9646McLean County, IL14260
Boise City-Nampa, ID
0.9501
0.9656Ada County, IDBoise County, IDCanyon County, IDGem County, IDOwyhee County, ID14484
1
                                 Boston-Quincy, MA
1.1710
1.1142Norfolk County, MAPlymouth County, MASuffolk County, MA14500
Boulder, CO
1.0118
1.0081Boulder County, CO14540
Bowling Green, KY
0.8089
0.8648Edmonson County, KYWarren County, KY14740
Bremerton-Silverdale, WA
1.0826
1.0559Kitsap County, WA14860
Bridgeport-Stamford-Norwalk, CT
1.2886
1.1896Fairfield County, CT15180
Brownsville-Harlingen, TX
0.9577
0.9708Cameron County, TX15260
Brunswick, GA
0.9768
0.9841Brantley County, GAGlynn County, GAMcIntosh County, GA15380
1
                                 Buffalo-Niagara Falls, NY
0.9586
0.9715Erie County, NYNiagara County, NY15500
2
                                 Burlington, NC
0.8608
0.9024Alamance County, NC15540
2
                                 Burlington-South Burlington, VT
1.0401
1.0273Chittenden County, VTFranklin County, VTGrand Isle County, VT15764
1
                                 Cambridge-Newton-Framingham, MA
1.1168
1.0786Middlesex County, MA15804
1
                                 Camden, NJ
1.0522
1.0355Burlington County, NJCamden County, NJGloucester County, NJ15940
Canton-Massillon, OH
0.8921
0.9248Carroll County, OHStark County, OH15980
Cape Coral-Fort Myers, FL
0.9490
0.9648Lee County, FL16180
2
                                 Carson City, NV
0.9688
0.9785Carson City, NV16220
Casper, WY
0.9277
0.9499Natrona County, WY16300
Cedar Rapids, IA
0.8689
0.9083Benton County, IAJones County, IALinn County, IA16580
Champaign-Urbana, IL
0.9320
0.9529Champaign County, ILFord County, ILPiatt County, IL16620
Charleston, WV
0.8397
0.8872Boone County, WVClay County, WVKanawha County, WVLincoln County, WV( print page 24928)Putnam County, WV16700
Charleston-North Charleston, SC
0.9144
0.9406Berkeley County, SCCharleston County, SCDorchester County, SC16740
1
                                 Charlotte-Gastonia-Concord, NC-SC
0.9512
0.9663Anson County, NCCabarrus County, NCGaston County, NCMecklenburg County, NCUnion County, NCYork County, SC16820
Charlottesville, VA
0.9555
0.9693Albemarle County, VAFluvanna County, VAGreene County, VANelson County, VACharlottesville City, VA16860
Chattanooga, TN-GA
0.8967
0.9281Catoosa County, GADade County, GAWalker County, GAHamilton County, TNMarion County, TNSequatchie County, TN16940
Cheyenne, WY
0.9219
0.9458Laramie County, WY16974
1
                                 Chicago-Naperville-Joliet, IL
1.0455
1.0309Cook County, ILDeKalb County, ILDuPage County, ILGrundy County, ILKane County, ILKendall County, ILMcHenry County, ILWill County, IL17020
2
                                 Chico, CA
1.1607
1.1074Butte County, CA17140
1
                                 Cincinnati-Middletown, OH-KY-IN
0.9654
0.9762Dearborn County, INFranklin County, INOhio County, INBoone County, KYBracken County, KYCampbell County, KYGallatin County, KYGrant County, KYKenton County, KYPendleton County, KYBrown County, OHButler County, OHClermont County, OHHamilton County, OHWarren County, OH17300
Clarksville, TN-KY
0.8223
0.8746Christian County, KYTrigg County, KYMontgomery County, TNStewart County, TN17420
Cleveland, TN
0.8174
0.8710Bradley County, TNPolk County, TN17460
1
                                 Cleveland-Elyria-Mentor, OH
0.9365
0.9561Cuyahoga County, OHGeauga County, OHLake County, OHLorain County, OHMedina County, OH17660
Coeur d'Alene, ID
0.9360
0.9557Kootenai County, ID( print page 24929)17780
College Station-Bryan, TX
0.9177
0.9429Brazos County, TXBurleson County, TXRobertson County, TX17820
Colorado Springs, CO
0.9471
0.9635El Paso County, COTeller County, CO17860
Columbia, MO
0.8545
0.8979Boone County, MOHoward County, MO17900
2
                                 Columbia, SC
0.8791
0.9155Calhoun County, SCFairfield County, SCKershaw County, SCLexington County, SCRichland County, SCSaluda County, SC17980
Columbus, GA-AL
0.9023
0.9320Russell County, ALChattahoochee County, GAHarris County, GAMarion County, GAMuscogee County, GA18020
Columbus, IN
0.9630
0.9745Bartholomew County, IN18140
1
                                 Columbus, OH
1.0048
1.0033Delaware County, OHFairfield County, OHFranklin County, OHLicking County, OHMadison County, OHMorrow County, OHPickaway County, OHUnion County, OH18580
Corpus Christi, TX
0.8460
0.8918Aransas County, TXNueces County, TXSan Patricio County, TX18700
Corvallis, OR
1.0708
1.0480Benton County, OR19060
2
                                 Cumberland, MD-WV (MD Hospitals)
0.8917
0.9245Allegany County, MDMineral County, WV19060
Cumberland, MD-WV (WV Hospitals)
0.7967
0.8559Allegany County, MDMineral County, WV19124
1
                                 Dallas-Plano-Irving, TX
0.9795
0.9859Collin County, TXDallas County, TXDelta County, TXDenton County, TXEllis County, TXHunt County, TXKaufman County, TXRockwall County, TX19140
Dalton, GA
0.8587
0.9009Murray County, GAWhitfield County, GA19180
Danville, IL
0.9250
0.9480Vermilion County, IL19260
Danville, VA
0.8486
0.8937Pittsylvania County, VADanville City, VA19340
Davenport-Moline-Rock Island, IA-IL
0.8898
0.9232Henry County, ILMercer County, ILRock Island County, ILScott County, IA19380
Dayton, OH
0.9283
0.9503Greene County, OH( print page 24930)Miami County, OHMontgomery County, OHPreble County, OH19460
Decatur, AL
0.7927
0.8529Lawrence County, ALMorgan County, AL19500
2
                                 Decatur, IL
0.8355
0.8842Macon County, IL19660
Deltona-Daytona Beach-Ormond Beach,  FL
0.8948
0.9267Volusia County, FL19740
1
                                 Denver-Aurora, CO
1.0490
1.0333Adams County, COArapahoe County, COBroomfield County, COClear Creek County, CODenver County, CODouglas County, COElbert County, COGilpin County, COJefferson County, COPark County, CO19780
Des Moines-West Des Moines, IA
0.9162
0.9418Dallas County, IAGuthrie County, IAMadison County, IAPolk County, IAWarren County, IA19804
1
                                 Detroit-Livonia-Dearborn, MI
1.0091
1.0062Wayne County, MI20020
2
                                 Dothan, AL
0.7598
0.8285Geneva County, ALHenry County, ALHouston County, AL20100
Dover, DE
1.0396
1.0270Kent County, DE20220
Dubuque, IA
0.8874
0.9215Dubuque County, IA20260
Duluth, MN-WI
1.0151
1.0103Carlton County, MNSt. Louis County, MNDouglas County, WI20500
Durham, NC
0.9814
0.9872Chatham County, NCDurham County, NCOrange County, NCPerson County, NC20740
2
                                 Eau Claire, WI
0.9635
0.9749Chippewa County, WIEau Claire County, WI20764
1
                                 Edison, NJ
1.1131
1.0761Middlesex County, NJMonmouth County, NJOcean County, NJSomerset County, NJ20940
2
                                 El Centro, CA
1.1607
1.1074Imperial County, CA21060
Elizabethtown, KY
0.8622
0.9035Hardin County, KYLarue County, KY21140
Elkhart-Goshen, IN
0.9438
0.9612Elkhart County, IN21300
2
                                 Elmira, NY
0.8440
0.8903Chemung County, NY21340
El Paso, TX
0.9144
0.9406El Paso County, TX21500
Erie, PA
0.8507
0.8952Erie County, PA21660
Eugene-Springfield, OR
1.1008
1.0680Lane County, OR21780
2
                                 Evansville, IN-KY (IN Hospitals)
0.8599
0.9018( print page 24931)Gibson County, INPosey County, INVanderburgh County, INWarrick County, INHenderson County, KYWebster County, KY21780
Evansville, IN-KY (KY Hospitals)
0.8469
0.8924Gibson County, INPosey County, INVanderburgh County, INWarrick County, INHenderson County, KYWebster County, KY21820
2
                                 Fairbanks, AK
1.1817
1.1211Fairbanks North Star Borough, AK21940
Fajardo, PR
0.4121
0.5449Ceiba Municipio, PRFajardo Municipio, PRLuquillo Municipio, PR22020
2
                                 Fargo, ND-MN (MN Hospitals)
0.9212
0.9453Clay County, MNCass County, ND22020
Fargo, ND-MN (ND Hospitals)
0.8189
0.8721Clay County, MNCass County, ND22140
Farmington, NM
0.9289
0.9507San Juan County, NM22180
Fayetteville, NC
0.9926
0.9949Cumberland County, NCHoke County, NC22220
Fayetteville-Springdale-Rogers, AR-MO
0.8876
0.9216Benton County, ARMadison County, ARWashington County, ARMcDonald County, MO22380
Flagstaff, AZ
1.1558
1.1042Coconino County, AZ22420
Flint, MI
1.1078
1.0726Genesee County, MI22500
2
                                 Florence, SC
0.8791
0.9155Darlington County, SCFlorence County, SC22520
Florence-Muscle Shoals, AL
0.7971
0.8562Colbert County, ALLauderdale County, AL22540
Fond du Lac, WI
0.9892
0.9926Fond du Lac County, WI22660
Fort Collins-Loveland, CO
0.9577
0.9708Larimer County, CO22744
1
                                 Fort Lauderdale-Pompano Beach-Deerfield Beach, FL
1.0245
1.0167Broward County, FL22900
Fort Smith, AR-OK
0.8056
0.8624Crawford County, ARFranklin County, ARSebastian County, ARLe Flore County, OKSequoyah County, OK23020
2
                                 Fort Walton Beach-Crestview-Destin,  FL
0.8749
0.9125Okaloosa County, FL23060
Fort Wayne, IN
0.9046
0.9336Allen County, INWells County, INWhitley County, IN23104
1
                                 Fort Worth-Arlington, TX
0.9646
0.9756Johnson County, TXParker County, TXTarrant County, TXWise County, TX23420
2
                                 Fresno, CA
1.1607
1.1074Fresno County, CA( print page 24932)23460
Gadsden, AL
0.8129
0.8677Etowah County, AL23540
Gainesville, FL
0.9306
0.9519Alachua County, FLGilchrist County, FL23580
Gainesville, GA
0.9423
0.9601Hall County, GA23844
Gary, IN
0.9246
0.9477Jasper County, INLake County, INNewton County, INPorter County, IN24020
Glens Falls, NY
0.8526
0.8965Warren County, NYWashington County, NY24140
Goldsboro, NC
0.9276
0.9498Wayne County, NC24220
2
                                 Grand Forks, ND-MN (MN Hospitals)
0.9212
0.9453Polk County, MNGrand Forks County, ND24220
Grand Forks, ND-MN (ND Hospitals)
0.7729
0.8383Polk County, MNGrand Forks County, ND24300
Grand Junction, CO
1.0141
1.0096Mesa County, CO24340
Grand Rapids-Wyoming, MI
0.9380
0.9571Barry County, MIIonia County, MIKent County, MINewaygo County, MI24500
Great Falls, MT
0.8765
0.9137Cascade County, MT24540
Greeley, CO
1.0000
1.0000Weld County, CO24580
2
                                 Green Bay, WI
0.9635
0.9749Brown County, WIKewaunee County, WIOconto County, WI24660
Greensboro-High Point, NC
0.9111
0.9382Guilford County, NCRandolph County, NCRockingham County, NC24780
Greenville, NC
0.9272
0.9496Greene County, NCPitt County, NC24860
Greenville-Mauldin-Easley, SC
0.9664
0.9769Greenville County, SCLaurens County, SCPickens County, SC25020
Guayama, PR
0.2946
0.4330Arroyo Municipio, PRGuayama Municipio, PRPatillas Municipio, PR25060
Gulfport-Biloxi, MS
0.8618
0.9032Hancock County, MSHarrison County, MSStone County, MS25180
Hagerstown-Martinsburg, MD-WV
0.9259
0.9486Washington County, MDBerkeley County, WVMorgan County, WV25260
2
                                 Hanford-Corcoran, CA
1.1607
1.1074Kings County, CA25420
Harrisburg-Carlisle, PA
0.9240
0.9473Cumberland County, PADauphin County, PAPerry County, PA25500
Harrisonburg, VA
0.8976
0.9287Rockingham County, VAHarrisonburg City, VA( print page 24933)25540
1
                                 2
                                 Hartford-West Hartford-East Hartford, CT
1.2439
1.1612Hartford County, CTLitchfield County, CTMiddlesex County, CTTolland County, CT25620
2
                                 Hattiesburg, MS
0.7915
0.8520Forrest County, MSLamar County, MSPerry County, MS25860
Hickory-Lenoir-Morganton, NC
0.8977
0.9288Alexander County, NCBurke County, NCCaldwell County, NCCatawba County, NC25980
Hinesville-Fort Stewart, GA
0.7864
0.8483Liberty County, GALong County, GA26100
Holland-Grand Haven, MI
0.9066
0.9351Ottawa County, MI26180
Honolulu, HI
1.1289
1.0866Honolulu County, HI26300
Hot Springs, AR
0.9110
0.9382Garland County, AR26380
Houma-Bayou Cane-Thibodaux, LA
0.7980
0.8568Lafourche Parish, LATerrebonne Parish, LA26420
1
                                 Houston-Sugar Land-Baytown, TX
1.0048
1.0033Austin County, TXBrazoria County, TXChambers County, TXFort Bend County, TXGalveston County, TXHarris County, TXLiberty County, TXMontgomery County, TXSan Jacinto County, TXWaller County, TX26580
Huntington-Ashland, WV-KY-OH
0.8845
0.9194Boyd County, KYGreenup County, KYLawrence County, OHCabell County, WVWayne County, WV26620
Huntsville, AL
0.9175
0.9427Limestone County, ALMadison County, AL26820
Idaho Falls, ID
0.9352
0.9552Bonneville County, IDJefferson County, ID26900
1
                                 Indianapolis-Carmel, IN
0.9723
0.9809Boone County, INBrown County, INHamilton County, INHancock County, INHendricks County, INJohnson County, INMarion County, INMorgan County, INPutnam County, INShelby County, IN26980
Iowa City, IA
0.9428
0.9605Johnson County, IAWashington County, IA27060
Ithaca, NY
0.9715
0.9804Tompkins County, NY27100
Jackson, MI
0.9465
0.9630Jackson County, MI27140
Jackson, MS
0.8273
0.8782Copiah County, MSHinds County, MS( print page 24934)Madison County, MSRankin County, MSSimpson County, MS27180
Jackson, TN
0.8590
0.9012Chester County, TNMadison County, TN27260
1
                                 Jacksonville, FL
0.9129
0.9395Baker County, FLClay County, FLDuval County, FLNassau County, FLSt. Johns County, FL27340
2
                                 Jacksonville, NC
0.8608
0.9024Onslow County, NC27500
Janesville, WI
0.9813
0.9872Rock County, WI27620
Jefferson City, MO
0.8706
0.9095Callaway County, MOCole County, MOMoniteau County, MOOsage County, MO27740
2
                                 Johnson City, TN
0.7916
0.8521Carter County, TNUnicoi County, TNWashington County, TN27780
2
                                 Johnstown, PA
0.8366
0.8850Cambria County, PA27860
Jonesboro, AR
0.8507
0.8952Craighead County, ARPoinsett County, AR27900
Joplin, MO
0.9318
0.9528Jasper County, MONewton County, MO28020
Kalamazoo-Portage, MI
1.0505
1.0343Kalamazoo County, MIVan Buren County, MI28100
Kankakee-Bradley, IL
1.1678
1.1121Kankakee County, IL28140
1
                                 Kansas City, MO-KS
0.9321
0.9530Franklin County, KSJohnson County, KSLeavenworth County, KSLinn County, KSMiami County, KSWyandotte County, KSBates County, MOCaldwell County, MOCass County, MOClay County, MOClinton County, MOJackson County, MOLafayette County, MOPlatte County, MORay County, MO28420
2
                                 Kennewick-Richland-Pasco, WA
1.0565
1.0384Benton County, WAFranklin County, WA28660
Killeen-Temple-Fort Hood, TX
0.8308
0.8808Bell County, TXCoryell County, TXLampasas County, TX28700
2
                                 Kingsport-Bristol-Bristol, TN-VA (TN Hospitals)
0.7916
0.8521Hawkins County, TNSullivan County, TNBristol City, VAScott County, VAWashington County, VA28700
2
                                 Kingsport-Bristol-Bristol, TN-VA (VA  Hospitals)
0.8095
0.8653Hawkins County, TNSullivan County, TN( print page 24935)Bristol City, VAScott County, VAWashington County, VA28740
Kingston, NY
0.9518
0.9667Ulster County, NY28940
Knoxville, TN
0.8042
0.8614Anderson County, TNBlount County, TNKnox County, TNLoudon County, TNUnion County, TN29020
Kokomo, IN
0.9468
0.9633Howard County, INTipton County, IN29100
La Crosse, WI-MN
0.9704
0.9796Houston County, MNLa Crosse County, WI29140
Lafayette, IN
0.8682
0.9078Benton County, INCarroll County, INTippecanoe County, IN29180
Lafayette, LA
0.8323
0.8819Lafayette Parish, LASt. Martin Parish, LA29340
Lake Charles, LA
0.7787
0.8426Calcasieu Parish, LACameron Parish, LA29404
Lake County-Kenosha County, IL-WI
1.0287
1.0196Lake County, ILKenosha County, WI29420
2
                                 Lake Havasu City-Kingman, AZ
0.9386
0.9575Mohave County, AZ29460
Lakeland, FL
0.8839
0.9190Polk County, FL29540
Lancaster, PA
0.9589
0.9717Lancaster County, PA29620
Lansing-East Lansing, MI
1.0053
1.0036Clinton County, MIEaton County, MIIngham County, MI29700
Laredo, TX
0.8484
0.8935Webb County, TX29740
2
                                 Las Cruces, NM
0.8965
0.9279Dona Ana County, NM29820
1
                                 Las Vegas-Paradise, NV
1.1431
1.0959Clark County, NV29940
Lawrence, KS
0.8208
0.8735Douglas County, KS30020
Lawton, OK
0.8406
0.8879Comanche County, OK30140
2
                                 Lebanon, PA
0.8366
0.8850Lebanon County, PA30300
Lewiston, ID-WA (ID Hospitals)
0.9231
0.9467Nez Perce County, IDAsotin County, WA30300
2
                                 Lewiston, ID-WA (WA Hospitals)
1.0565
1.0384Nez Perce County, IDAsotin County, WA30340
Lewiston-Auburn, ME
0.9295
0.9512Androscoggin County, ME30460
Lexington-Fayette, KY
0.9027
0.9323Bourbon County, KYClark County, KYFayette County, KYJessamine County, KYScott County, KYWoodford County, KY30620
Lima, OH
0.9312
0.9524Allen County, OH30700
Lincoln, NE
0.9836
0.9887( print page 24936)Lancaster County, NESeward County, NE30780
Little Rock-North Little Rock-Conway, AR
0.8965
0.9279Faulkner County, ARGrant County, ARLonoke County, ARPerry County, ARPulaski County, ARSaline County, AR30860
Logan, UT-ID
0.9219
0.9458Franklin County, IDCache County, UT30980
Longview, TX
0.8875
0.9215Gregg County, TXRusk County, TXUpshur County, TX31020
Longview, WA
1.1033
1.0696Cowlitz County, WA31084
1
                                 Los Angeles-Long Beach-Glendale, CA
1.1633
1.1091Los Angeles County, CA31140
1
                                 Louisville-Jefferson County, KY-IN
0.9045
0.9336Clark County, INFloyd County, INHarrison County, INWashington County, INBullitt County, KYHenry County, KYJefferson County, KYMeade County, KYNelson County, KYOldham County, KYShelby County, KYSpencer County, KYTrimble County, KY31180
Lubbock, TX
0.8678
0.9075Crosby County, TXLubbock County, TX31340
Lynchburg, VA
0.8490
0.8940Amherst County, VAAppomattox County, VABedford County, VACampbell County, VABedford City, VALynchburg City, VA31420
Macon, GA
0.9752
0.9829Bibb County, GACrawford County, GAJones County, GAMonroe County, GATwiggs County, GA31460
2
                                 Madera, CA
1.1607
1.1074Madera County, CA31540
Madison, WI
1.1181
1.0794Columbia County, WIDane County, WIIowa County, WI31700
2
                                 Manchester-Nashua, NH
1.1266
1.0851Hillsborough County, NHMerrimack County, NH31900
Mansfield, OH
0.9214
0.9455Richland County, OH32420
Mayagüez, PR
0.3659
0.5023Hormigueros Municipio, PRMayagüez Municipio, PR32580
McAllen-Edinburg-Mission, TX
0.9140
0.9403Hidalgo County, TX32780
Medford, OR
1.0304
1.0207Jackson County, OR32820
1
                                 Memphis, TN-MS-AR
0.9291
0.9509Crittenden County, AR( print page 24937)DeSoto County, MSMarshall County, MSTate County, MSTunica County, MSFayette County, TNShelby County, TNTipton County, TN32900
Merced, CA
1.1961
1.1305Merced County, CA33124
1
                                 Miami-Miami Beach-Kendall, FL
1.0023
1.0016Miami-Dade County, FL33140
Michigan City-La Porte, IN
0.8791
0.9155LaPorte County, IN33260
Midland, TX
1.0016
1.0011Midland County, TX33340
1
                                 Milwaukee-Waukesha-West Allis, WI
1.0296
1.0202Milwaukee County, WIOzaukee County, WIWashington County, WIWaukesha County, WI33460
1
                                 Minneapolis-St. Paul-Bloomington, MN-WI
1.0961
1.0649Anoka County, MNCarver County, MNChisago County, MNDakota County, MNHennepin County, MNIsanti County, MNRamsey County, MNScott County, MNSherburne County, MNWashington County, MNWright County, MNPierce County, WISt. Croix County, WI33540
Missoula, MT
0.8737
0.9117Missoula County, MT33660
Mobile, AL
0.7950
0.8546Mobile County, AL33700
Modesto, CA
1.1989
1.1323Stanislaus County, CA33740
Monroe, LA
0.7872
0.8489Ouachita Parish, LAUnion Parish, LA33780
Monroe, MI
0.9475
0.9637Monroe County, MI33860
Montgomery, AL
0.8366
0.8850Autauga County, ALElmore County, ALLowndes County, ALMontgomery County, AL34060
Morgantown, WV
0.8411
0.8883Monongalia County, WVPreston County, WV34100
2
                                 Morristown, TN
0.7916
0.8521Grainger County, TNHamblen County, TNJefferson County, TN34580
2
                                 Mount Vernon-Anacortes, WA
1.0565
1.0384Skagit County, WA34620
2
                                 Muncie, IN
0.8599
0.9018Delaware County, IN34740
Muskegon-Norton Shores, MI
0.9935
0.9955Muskegon County, MI34820
2
                                 Myrtle Beach-Conway-North Myrtle Beach, SC
0.8791
0.9155Horry County, SC34900
Napa, CA
1.3825
1.2483Napa County, CA34940
Naples-Marco Island, FL
0.9756
0.9832Collier County, FL34980
1
                                 Nashville-Davidson-Murfreesboro-Franklin, TN
0.9675
0.9776( print page 24938)Cannon County, TNCheatham County, TNDavidson County, TNDickson County, TNHickman County, TNMacon County, TNRobertson County, TNRutherford County, TNSmith County, TNSumner County, TNTrousdale County, TNWilliamson County, TNWilson County, TN35004
1
                                 Nassau-Suffolk, NY
1.2791
1.1836Nassau County, NYSuffolk County, NY35084
1
                                 Newark-Union, NJ-PA
1.1681
1.1123Essex County, NJHunterdon County, NJMorris County, NJSussex County, NJUnion County, NJPike County, PA35300
2
                                 New Haven-Milford, CT
1.2439
1.1612New Haven County, CT35380
1
                                 New Orleans-Metairie-Kenner, LA
0.8732
0.9113Jefferson Parish, LAOrleans Parish, LAPlaquemines Parish, LASt. Bernard Parish, LASt. Charles Parish, LASt. John the Baptist Parish, LASt. Tammany Parish, LA35644
1
                                 New York-White Plains-Wayne, NY-NJ
1.3215
1.2103Bergen County, NJHudson County, NJPassaic County, NJBronx County, NYKings County, NYNew York County, NYPutnam County, NYQueens County, NYRichmond County, NYRockland County, NYWestchester County, NY35660
Niles-Benton Harbor, MI
0.9138
0.9401Berrien County, MI35980
2
                                 Norwich-New London, CT
1.2439
1.1612New London County, CT36084
1
                                 Oakland-Fremont-Hayward, CA
1.5299
1.3380Alameda County, CAContra Costa County, CA36100
2
                                 Ocala, FL
0.8749
0.9125Marion County, FL36140
Ocean City, NJ
1.0749
1.0507Cape May County, NJ36220
Odessa, TX
0.9959
0.9972Ector County, TX36260
Ogden-Clearfield, UT
0.9061
0.9347Davis County, UTMorgan County, UTWeber County, UT36420
1
                                 Oklahoma City, OK
0.8764
0.9136Canadian County, OKCleveland County, OKGrady County, OKLincoln County, OKLogan County, OKMcClain County, OKOklahoma County, OK( print page 24939)36500
Olympia, WA
1.1463
1.0980Thurston County, WA36540
Omaha-Council Bluffs, NE-IA
0.9419
0.9598Harrison County, IAMills County, IAPottawattamie County, IACass County, NEDouglas County, NESarpy County, NESaunders County, NEWashington County, NE36740
1
                                 Orlando-Kissimmee, FL
0.9383
0.9573Lake County, FLOrange County, FLOsceola County, FLSeminole County, FL36780
2
                                 Oshkosh-Neenah, WI
0.9635
0.9749Winnebago County, WI36980
Owensboro, KY
0.8801
0.9163Daviess County, KYHancock County, KYMcLean County, KY37100
2
                                 Oxnard-Thousand Oaks-Ventura, CA
1.1607
1.1074Ventura County, CA37340
Palm Bay-Melbourne-Titusville, FL
0.9385
0.9575Brevard County, FL37380
2
                                 Palm Coast, FL
0.8749
0.9125Flager County, FL37460
2
                                 Panama City-Lynn Haven, FL
0.8749
0.9125Bay County, FL37620
2
                                 Parkersburg-Marietta-Vienna, WV-OH  (OH Hospitals)
0.8701
0.9091Washington County, OHPleasants County, WVWirt County, WVWood County, WV37620
Parkersburg-Marietta-Vienna, WV-OH  (WV Hospitals)
0.8238
0.8757Washington County, OHPleasants County, WVWirt County, WVWood County, WV37700
Pascagoula, MS
0.8544
0.8978George County, MSJackson County, MS37764
Peabody, MA
1.0214
1.0146Essex County, MA37860
2
                                 Pensacola-Ferry Pass-Brent, FL
0.8749
0.9125Escambia County, FLSanta Rosa County, FL37900
Peoria, IL
0.9374
0.9567Marshall County, ILPeoria County, ILStark County, ILTazewell County, ILWoodford County, IL37964
1
                                 Philadelphia, PA
1.0906
1.0612Bucks County, PAChester County, PADelaware County, PAMontgomery County, PAPhiladelphia County, PA38060
1
                                 Phoenix-Mesa-Scottsdale, AZ
1.0115
1.0079Maricopa County, AZPinal County, AZ38220
Pine Bluff, AR
0.8155
0.8696Cleveland County, ARJefferson County, ARLincoln County, AR38300
1
                                 Pittsburgh, PA
0.8388
0.8866Allegheny County, PAArmstrong County, PA( print page 24940)Beaver County, PAButler County, PAFayette County, PAWashington County, PAWestmoreland County, PA38340
Pittsfield, MA
1.0071
1.0049Berkshire County, MA38540
Pocatello, ID
0.9158
0.9415Bannock County, IDPower County, ID38660
Ponce, PR
0.4161
0.5486Juana Díaz Municipio, PRPonce Municipio, PRVillalba Municipio, PR38860
Portland-South Portland-Biddeford, ME
1.0008
1.0005Cumberland County, MESagadahoc County, MEYork County, ME38900
1
                                 Portland-Vancouver-Beaverton, OR-WA
1.1233
1.0829Clackamas County, ORColumbia County, ORMultnomah County, ORWashington County, ORYamhill County, ORClark County, WASkamania County, WA38940
Port St. Lucie, FL
0.9990
0.9993Martin County, FLSt. Lucie County, FL39100
Poughkeepsie-Newburgh-Middletown, NY
1.0853
1.0577Dutchess County, NYOrange County, NY39140
Prescott, AZ
0.9913
0.9940Yavapai County, AZ39300
1
                                 Providence-New Bedford-Fall River,  RI-MA
1.0654
1.0443Bristol County, MABristol County, RIKent County, RINewport County, RIProvidence County, RIWashington County, RI39340
Provo-Orem, UT
0.9488
0.9646Juab County, UTUtah County, UT39380
2
                                 Pueblo, CO
0.9451
0.9621Pueblo County, CO39460
Punta Gorda, FL
0.9562
0.9698Charlotte County, FL39540
2
                                 Racine, WI
0.9635
0.9749Racine County, WI39580
Raleigh-Cary, NC
0.9373
0.9566Franklin County, NCJohnston County, NCWake County, NC39660
Rapid City, SD
0.8690
0.9083Meade County, SDPennington County, SD39740
Reading, PA
0.9419
0.9598Berks County, PA39820
Redding, CA
1.2826
1.1858Shasta County, CA39900
Reno-Sparks, NV
1.1062
1.0716Storey County, NVWashoe County, NV40060
1
                                 Richmond, VA
0.9238
0.9472Amelia County, VACaroline County, VACharles City County, VAChesterfield County, VACumberland County, VA( print page 24941)Dinwiddie County, VAGoochland County, VAHanover County, VAHenrico County, VAKing and Queen County, VAKing William County, VALouisa County, VANew Kent County, VAPowhatan County, VAPrince George County, VASussex County, VAColonial Heights City, VAHopewell City, VAPetersburg City, VARichmond City, VA40140
1, 2
                                 Riverside-San Bernardino-Ontario, CA
1.1607
1.1074Riverside County, CASan Bernardino County, CA40220
Roanoke, VA
0.9441
0.9614Botetourt County, VACraig County, VAFranklin County, VARoanoke County, VARoanoke City, VASalem City, VA40340
Rochester, MN
1.0761
1.0515Dodge County, MNOlmsted County, MNWabasha County, MN40380
1
                                 Rochester, NY
0.8899
0.9232Livingston County, NYMonroe County, NYOntario County, NYOrleans County, NYWayne County, NY40420
Rockford, IL
0.9659
0.9765Boone County, ILWinnebago County, IL40484
2
                                 Rockingham County-Strafford County,  NH
1.1266
1.0851Rockingham County, NHStrafford County, NH40580
Rocky Mount, NC
0.9017
0.9316Nash County, NC40660
Rome, GA
0.9549
0.9689Floyd County, GA40900
1
                                 Sacramento--Arden-Arcade--Roseville,  CA
1.2999
1.1968El Dorado County, CAPlacer County, CASacramento County, CAYolo County, CA40980
Saginaw-Saginaw Township North, MI
0.9127
0.9394Saginaw County, MI41060
St. Cloud, MN
1.1063
1.0716Benton County, MNStearns County, MN41100
St. George, UT
0.9546
0.9687Washington County, UT41140
St. Joseph, MO-KS
0.8831
0.9184Doniphan County, KSAndrew County, MOBuchanan County, MODeKalb County, MO41180
1
                                 St. Louis, MO-IL
0.8885
0.9222Bond County, ILCalhoun County, ILClinton County, ILJersey County, ILMacoupin County, ILMadison County, ILMonroe County, IL( print page 24942)St. Clair County, ILCrawford County, MOFranklin County, MOJefferson County, MOLincoln County, MOSt. Charles County, MOSt. Louis County, MOWarren County, MOWashington County, MOSt. Louis City, MO41420
Salem, OR
1.0404
1.0275Marion County, ORPolk County, OR41500
Salinas, CA
1.4408
1.2841Monterey County, CA41540
2
                                 Salisbury, MD
0.8917
0.9245Somerset County, MDWicomico County, MD41620
Salt Lake City, UT
0.9482
0.9642Salt Lake County, UTSummit County, UTTooele County, UT41660
San Angelo, TX
0.8663
0.9064Irion County, TXTom Green County, TX41700
1
                                 San Antonio, TX
0.8916
0.9244Atascosa County, TXBandera County, TXBexar County, TXComal County, TXGuadalupe County, TXKendall County, TXMedina County, TXWilson County, TX41740
1, 2
                                 San Diego-Carlsbad-San Marcos, CA
1.1607
1.1074San Diego County, CA41780
Sandusky, OH
0.8760
0.9133Erie County, OH41884
1
                                 San Francisco-San Mateo-Redwood  City, CA
1.4766
1.3059Marin County, CASan Francisco County, CASan Mateo County, CA41900
San Germán-Cabo Rojo, PR
0.4605
0.5880Cabo Rojo Municipio, PRLajas Municipio, PRSabana Grande Municipio, PRSan Germán Municipio, PR41940
1
                                 San Jose-Sunnyvale-Santa Clara, CA
1.5378
1.3427San Benito County, CASanta Clara County, CA41980
1
                                 San Juan-Caguas-Guaynabo, PR
0.4517
0.5803Aguas Buenas Municipio, PRAibonito Municipio, PRArecibo Municipio, PRBarceloneta Municipio, PRBarranquitas Municipio, PRBayamón Municipio, PRCaguas Municipio, PRCamuy Municipio, PRCanóvanas Municipio, PRCarolina Municipio, PRCataño Municipio, PRCayey Municipio, PRCiales Municipio, PRCidra Municipio, PRComerío Municipio, PRCorozal Municipio, PRDorado Municipio, PRFlorida Municipio, PRGuaynabo Municipio, PR( print page 24943)Gurabo Municipio, PRHatillo Municipio, PRHumacao Municipio, PRJuncos Municipio, PRLas Piedras Municipio, PRLoíza Municipio, PRManatí Municipio, PRMaunabo Municipio, PRMorovis Municipio, PRNaguabo Municipio, PRNaranjito Municipio, PROrocovis Municipio, PRQuebradillas Municipio, PRRío Grande Municipio, PRSan Juan Municipio, PRSan Lorenzo Municipio, PRToa Alta Municipio, PRToa Baja Municipio, PRTrujillo Alto Municipio, PRVega Alta Municipio, PRVega Baja Municipio, PRYabucoa Municipio, PR42020
San Luis Obispo-Paso Robles, CA
1.1912
1.1273San Luis Obispo County, CA42044
1, 2
                                 Santa Ana-Anaheim-Irvine, CA
1.1607
1.1074Orange County, CA42060
2
                                 Santa Barbara-Santa Maria-Goleta, CA
1.1607
1.1074Santa Barbara County, CA42100
Santa Cruz-Watsonville, CA
1.5667
1.3600Santa Cruz County, CA42140
Santa Fe, NM
1.0689
1.0467Santa Fe County, NM42220
Santa Rosa-Petaluma, CA
1.4266
1.2755Sonoma County, CA42260
Sarasota-Bradenton-Venice, FL
0.9758
0.9834Manatee County, FLSarasota County, FL42340
Savannah, GA
0.8987
0.9295Bryan County, GAChatham County, GAEffingham County, GA42540
2
                                 Scranton--Wilkes-Barre, PA
0.8366
0.8850Lackawanna County, PALuzerne County, PAWyoming County, PA42644
1
                                 Seattle-Bellevue-Everett, WA
1.1351
1.0907King County, WASnohomish County, WA42680
Sebastian-Vero Beach, FL
0.9708
0.9799Indian River County, FL43100
2
                                 Sheboygan, WI
0.9635
0.9749Sheboygan County, WI43300
Sherman-Denison, TX
0.8535
0.8972Grayson County, TX43340
Shreveport-Bossier City, LA
0.8615
0.9029Bossier Parish, LACaddo Parish, LADe Soto Parish, LA43580
Sioux City, IA-NE-SD
0.9220
0.9459Woodbury County, IADakota County, NEDixon County, NEUnion County, SD43620
Sioux Falls, SD
0.9558
0.9695Lincoln County, SDMcCook County, SDMinnehaha County, SDTurner County, SD43780
South Bend-Mishawaka, IN-MI
0.9649
0.9758St. Joseph County, IN( print page 24944)Cass County, MI43900
Spartanburg, SC
0.9334
0.9539Spartanburg County, SC44060
2
                                 Spokane, WA
1.0565
1.0384Spokane County, WA44100
Springfield, IL
0.8947
0.9266Menard County, ILSangamon County, IL44140
Springfield, MA
1.0236
1.0161Franklin County, MAHampden County, MAHampshire County, MA44180
Springfield, MO
0.9196
0.9442Christian County, MODallas County, MOGreene County, MOPolk County, MOWebster County, MO44220
2
                                 Springfield, OH
0.8701
0.9091Clark County, OH44300
State College, PA
0.8625
0.9037Centre County, PA44700
Stockton, CA
1.1735
1.1158San Joaquin County, CA44940
Sumter, SC
0.8875
0.9215Sumter County, SC45060
Syracuse, NY
0.9912
0.9940Madison County, NYOnondaga County, NYOswego County, NY45104
Tacoma, WA
1.1060
1.0714Pierce County, WA45220
Tallahassee, FL
0.9032
0.9327Gadsden County, FLJefferson County, FLLeon County, FLWakulla County, FL45300
1
                                 Tampa-St. Petersburg-Clearwater, FL
0.9174
0.9427Hernando County, FLHillsborough County, FLPasco County, FLPinellas County, FL45460
Terre Haute, IN
0.8828
0.9182Clay County, INSullivan County, INVermillion County, INVigo County, IN45500
Texarkana, TX-Texarkana, AR (AR Hospitals)
0.8131
0.8679Miller County, ARBowie County, TX45500
2
                                 Texarkana, TX-Texarkana, AR (TX  Hospitals)
0.8204
0.8732Miller County, ARBowie County, TX45780
Toledo, OH
0.9276
0.9498Fulton County, OHLucas County, OHOttawa County, OHWood County, OH45820
Topeka, KS
0.8561
0.8991Jackson County, KSJefferson County, KSOsage County, KSShawnee County, KSWabaunsee County, KS45940
Trenton-Ewing, NJ
1.0720
1.0488Mercer County, NJ46060
Tucson, AZ
0.9484
0.9644Pima County, AZ46140
Tulsa, OK
0.8504
0.8950Creek County, OK( print page 24945)Okmulgee County, OKOsage County, OKPawnee County, OKRogers County, OKTulsa County, OKWagoner County, OK46220
Tuscaloosa, AL
0.8534
0.8971Greene County, ALHale County, ALTuscaloosa County, AL46340
Tyler, TX
0.9190
0.9438Smith County, TX46540
Utica-Rome, NY
0.8774
0.9143Herkimer County, NYOneida County, NY46660
Valdosta, GA
0.8208
0.8735Brooks County, GAEchols County, GALanier County, GALowndes County, GA46700
Vallejo-Fairfield, CA
1.4400
1.2837Solano County, CA47020
2
                                 Victoria, TX
0.8204
0.8732Calhoun County, TXGoliad County, TXVictoria County, TX47220
Vineland-Millville-Bridgeton, NJ
1.0653
1.0443Cumberland County, NJ47260
1
                                 Virginia Beach-Norfolk-Newport News,  VA-NC
0.8785
0.9151Currituck County, NCGloucester County, VAIsle of Wight County, VAJames City County, VAMathews County, VASurry County, VAYork County, VAChesapeake City, VAHampton City, VANewport News City, VANorfolk City, VAPoquoson City, VAPortsmouth City, VASuffolk City, VAVirginia Beach City, VAWilliamsburg City, VA47300
2
                                 Visalia-Porterville, CA
1.1607
1.1074Tulare County, CA47380
Waco, TX
0.8598
0.9017McLennan County, TX47580
Warner Robins, GA
0.9619
0.9737Houston County, GA47644
1
                                 Warren-Troy-Farmington Hills, MI
1.0040
1.0027Lapeer County, MILivingston County, MIMacomb County, MIOakland County, MISt. Clair County, MI47894
1
                                 Washington-Arlington-Alexandria, DC-VA-MD-WV
1.0679
1.0460District of Columbia, DCCalvert County, MDCharles County, MDPrince George's County, MDArlington County, VAClarke County, VAFairfax County, VAFauquier County, VALoudoun County, VAPrince William County, VASpotsylvania County, VAStafford County, VA( print page 24946)Warren County, VAAlexandria City, VAFairfax City, VAFalls Church City, VAFredericksburg City, VAManassas City, VAManassas Park City, VAJefferson County, WV47940
Waterloo-Cedar Falls, IA
0.8891
0.9227Black Hawk County, IABremer County, IAGrundy County, IA48140
Wausau, WI
1.0011
1.0008Marathon County, WI48260
2
                                 Weirton-Steubenville, WV-OH (OH  Hospitals)
0.8701
0.9091Jefferson County, OHBrooke County, WVHancock County, WV48260
Weirton-Steubenville, WV-OH (WV  Hospitals)
0.7893
0.8504Jefferson County, OHBrooke County, WVHancock County, WV48300
Wenatchee, WA
1.1281
1.0860Chelan County, WADouglas County, WA48424
1
                                 West Palm Beach-Boca Raton-Boynton  Beach, FL
0.9587
0.9715Palm Beach County, FL48540
2
                                 Wheeling, WV-OH (OH Hospitals)
0.8701
0.9091Belmont County, OHMarshall County, WVOhio County, WV48540
2
                                 Wheeling, WV-OH (WV Hospitals)
0.7568
0.8263Belmont County, OHMarshall County, WVOhio County, WV48620
Wichita, KS
0.9009
0.9310Butler County, KSHarvey County, KSSedgwick County, KSSumner County, KS48660
Wichita Falls, TX
0.8488
0.8938Archer County, TXClay County, TXWichita County, TX48700
2
                                 Williamsport, PA
0.8366
0.8850Lycoming County, PA48864
Wilmington, DE-MD-NJ
1.0752
1.0509New Castle County, DECecil County, MDSalem County, NJ48900
Wilmington, NC
0.9338
0.9542Brunswick County, NCNew Hanover County, NCPender County, NC49020
Winchester, VA-WV
0.9850
0.9897Frederick County, VAWinchester City, VAHampshire County, WV49180
Winston-Salem, NC
0.9083
0.9363Davie County, NCForsyth County, NCStokes County, NCYadkin County, NC49340
Worcester, MA
1.1341
1.0900Worcester County, MA49420
2
                                 Yakima, WA
1.0565
1.0384Yakima County, WA49500
Yauco, PR
0.3203
0.4586Guánica Municipio, PRGuayanilla Municipio, PR( print page 24947)Peñuelas Municipio, PRYauco Municipio, PR49620
York-Hanover, PA
0.9307
0.9520York County, PA49660
Youngstown-Warren-Boardman, OH-PA
0.8996
0.9301Mahoning County, OHTrumbull County, OHMercer County, PA49700
2
                                 Yuba City, CA
1.1607
1.1074Sutter County, CAYuba County, CA49740
Yuma, AZ
0.9468
0.9633Yuma County, AZ1
                             Large urban area.2
                             Hospitals geographically located in the area are assigned the statewide rural wage index for FY 2008.
 Table 4B.—Wage Index and Capital Geographic Adjustment (GAF) for Rural Areas by CBSA—FY 2008
CBSA code
Nonurban area
Wage index
GAF01
Alabama
0.7598
0.828502
Alaska
1.1817
1.121103
Arizona
0.9386
0.957504
Arkansas
0.7519
0.822605
California
1.1607
1.107406
Colorado
0.9451
0.962107
Connecticut
1.2439
1.161208
Delaware
0.9825
0.988010
Florida
0.8749
0.912511
Georgia
0.7864
0.848312
Hawaii
1.0751
1.050813
Idaho
0.7879
0.849414
Illinois
0.8355
0.884215
Indiana
0.8599
0.901816
Iowa
0.8480
0.893217
Kansas
0.7989
0.857518
Kentucky
0.7812
0.844419
Louisiana
0.7591
0.828020
Maine
0.8412
0.888321
Maryland
0.8917
0.924522
Massachusetts
0.9739
0.982123
Michigan
0.8899
0.923224
Minnesota
0.9212
0.945325
Mississippi
0.7915
0.852026
Missouri
0.8145
0.868927
Montana
0.8337
0.882928
Nebraska
0.8848
0.919629
Nevada
0.9688
0.978530
New Hampshire
1.1266
1.085131
New Jersey 132
New Mexico
0.8965
0.927933
New York
0.8440
0.890334
North Carolina
0.8608
0.902435
North Dakota
0.7313
0.807136
Ohio
0.8701
0.909137
Oklahoma
0.7702
0.836338
Oregon
0.9950
0.996639
Pennsylvania
0.8366
0.885040
Puerto Rico 141
Rhode Island 142
South Carolina
0.8791
0.915543
South Dakota
0.8343
0.883344
Tennessee
0.7916
0.852145
Texas
0.8204
0.873246
Utah
0.8267
0.877847
Vermont
1.0401
1.027349
Virginia
0.8095
0.865350
Washington
1.0565
1.0384( print page 24948)51
West Virginia
0.7568
0.826352
Wisconsin
0.9635
0.974953
Wyoming
0.9214
0.94551
                             All counties in the State or Territory are classified as urban.
 Table 4C.—Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That Are Reclassified by CBSA—FY 2008
CBSA code
Area
Wage index
GAF10420
Akron, OH
0.8854
0.920010500
Albany, GA
0.8671
0.907010580
Albany-Schenectady-Troy, NY
0.8672
0.907010740
Albuquerque, NM
0.9740
0.982110780
Alexandria, LA
0.7982
0.857010900
Allentown-Bethlehem-Easton, PAN-J
1.0024
1.001611100
Amarillo, TX
0.9141
0.940311180
Ames, IA
0.9227
0.946411260
Anchorage, AK
1.1840
1.122611460
Ann Arbor, MI
1.0138
1.009411500
Anniston-Oxford, AL
0.8042
0.861412060
Atlanta-Sandy Springs-Marietta, GA
0.9845
0.989412420
Austin-Round Rock, TX
0.9518
0.966712580
Baltimore-Towson, MD
1.0108
1.007412620
Bangor, ME
0.9860
0.990412940
Baton Rouge, LA
0.8014
0.859313020
Bay City, MI
0.9399
0.958413644
Bethesda-Gaithersburg-Frederick, MD
1.0990
1.066813780
Binghamton, NY
0.8779
0.914713820
Birmingham-Hoover, AL
0.8737
0.911713900
Bismarck, ND
0.7329
0.808313980
Blacksburg-Christiansburg-Radford, VA
0.7744
0.839414020
Bloomington, IN
0.8828
0.918214484
Boston-Quincy, MA
1.1256
1.084414540
Bowling Green, KY
0.8089
0.864814740
Bremerton-Silverdale, WA
1.0826
1.055914860
Bridgeport-Stamford-Norwalk, CT
1.2380
1.157415380
Buffalo-Niagara Falls, NY
0.9586
0.971515540
Burlington-South Burlington, VT
0.9589
0.971715764
Cambridge-Newton-Framingham, MA
1.1266
1.085115940
Canton-Massillon, OH
0.8810
0.916916180
Carson City, NV
0.9688
0.978516620
Charleston, WV
0.8294
0.879816700
Charleston-North Charleston, SC
0.9144
0.940616740
Charlotte-Gastonia-Concord, NC-SC
0.9348
0.954916820
Charlottesville, VA
0.9353
0.955216860
Chattanooga, TN-GA
0.8967
0.928116974
Chicago-Naperville-Joliet, IL
1.0455
1.030917140
Cincinnati-Middletown, OH-KY-IN
0.9654
0.976217300
Clarksville, TN-KY
0.8116
0.866817460
Cleveland-Elyria-Mentor, OH
0.9238
0.947217780
College Station-Bryan, TX
0.9177
0.942917860
Columbia, MO
0.8545
0.897917980
Columbus, GA-AL
0.8594
0.901418140
Columbus, OH
0.9840
0.989018700
Corvallis, OR
1.0322
1.021919124
Dallas-Plano-Irving, TX
0.9681
0.978019340
Davenport-Moline-Rock Island, IA-IL
0.8898
0.923219380
Dayton, OH
0.9283
0.950319460
Decatur, AL
0.7927
0.852919740
Denver-Aurora, CO
1.0490
1.033319804
Detroit-Livonia-Dearborn, MI
1.0091
1.006220100
Dover, DE
1.0023
1.001620260
Duluth, MN-WI
1.0020
1.001420500
Durham, NC
0.9603
0.972620764
Edison, NJ
1.1131
1.076121060
Elizabethtown, KY
0.7983
0.857021500
Erie, PA
0.8440
0.8903( print page 24949)21660
Eugene-Springfield, OR
1.0713
1.048321780
Evansville, IN-KY (KY Hospitals)
0.8127
0.867621780
Evansville, IN-KY (IN Hospitals)
0.8599
0.901822020
Fargo, ND-MN (ND Hospitals)
0.8189
0.872122020
Fargo, ND-MN (SD Hospitals)
0.8343
0.883322180
Fayetteville, NC
0.9600
0.972422220
Fayetteville-Springdale-Rogers, AR-MO
0.8719
0.910422380
Flagstaff, AZ
1.1310
1.088022420
Flint, MI
1.0272
1.018522520
Florence-Muscle Shoals, AL
0.7971
0.856222540
Fond du Lac, WI
0.9721
0.980822660
Fort Collins-Loveland, CO
0.9577
0.970822744
Fort Lauderdale-Pompano Beach-Deerfield Beach, FL
1.0245
1.016723020
Fort Walton Beach-Crestview-Destin, FL
0.8749
0.912523060
Fort Wayne, IN
0.9046
0.933623104
Fort Worth-Arlington, TX
0.9646
0.975623540
Gainesville, FL
0.9306
0.951923844
Gary, IN
0.9246
0.947724300
Grand Junction, CO
1.0141
1.009624340
Grand Rapids-Wyoming, MI
0.9380
0.957124500
Great Falls, MT
0.8765
0.913724540
Greeley, CO
0.9746
0.982524580
Green Bay, WI (MI Hospitals)
0.9339
0.954224580
Green Bay, WI (WI Hospitals)
0.9635
0.974924660
Greensboro-High Point, NC
0.9111
0.938224780
Greenville, NC
0.9272
0.949624860
Greenville-Mauldin-Easley, SC
0.9386
0.957525060
Gulfport-Biloxi, MS
0.8223
0.874625420
Harrisburg-Carlisle, PA
0.9130
0.939625540
Hartford-West Hartford-East Hartford, CT (CT Hospitals)
1.2439
1.161225540
Hartford-West Hartford-East Hartford, CT (MA Hospitals)
1.0955
1.064525860
Hickory-Lenoir-Morganton, NC
0.8819
0.917526100
Holland-Grand Haven, MI
0.9066
0.935126180
Honolulu, HI
1.1289
1.086626420
Houston-Sugar Land-Baytown, TX
1.0048
1.003326580
Huntington-Ashland, WV-KY-OH
0.8706
0.909526620
Huntsville, AL
0.8760
0.913326820
Idaho Falls, ID
0.9352
0.955226900
Indianapolis-Carmel, IN
0.9723
0.980926980
Iowa City, IA
0.9142
0.940427060
Ithaca, NY
0.9715
0.980427140
Jackson, MS
0.8273
0.878227180
Jackson, TN
0.8432
0.889827260
Jacksonville, FL
0.9129
0.939527620
Jefferson City, MO
0.8706
0.909527780
Johnstown, PA
0.8366
0.885027860
Jonesboro, AR
0.8507
0.895227900
Joplin, MO
0.9040
0.933228020
Kalamazoo-Portage, MI
1.0151
1.010328100
Kankakee-Bradley, IL
1.1678
1.112128140
Kansas City, MO-KS
0.9321
0.953028420
Kennewick-Richland-Pasco, WA (ID Hospitals)
0.9620
0.973828420
Kennewick-Richland-Pasco, WA (WA Hospitals)
1.0565
1.038428700
Kingsport-Bristol-Bristol, TN-VA (KY Hospitals)
0.7840
0.846528700
Kingsport-Bristol-Bristol, TN-VA (TN Hospitals)
0.7916
0.852128700
Kingsport-Bristol-Bristol, TN-VA (VA Hospitals)
0.8095
0.865328740
Kingston, NY
0.9231
0.946728940
Knoxville, TN
0.8042
0.861429180
Lafayette, LA
0.8323
0.881929404
Lake County-Kenosha County, IL-WI
1.0287
1.019629460
Lakeland, FL
0.8839
0.919029540
Lancaster, PA
0.9589
0.971729620
Lansing-East Lansing, MI
0.9933
0.995429740
Las Cruces, NM
0.8965
0.927929820
Las Vegas-Paradise, NV
1.1205
1.081030020
Lawton, OK
0.8071
0.863530460
Lexington-Fayette, KY
0.8815
0.917330620
Lima, OH
0.9312
0.952430700
Lincoln, NE
0.9603
0.972630780
Little Rock-North Little Rock-Conway, AR
0.8720
0.9105( print page 24950)30860
Logan, UT-ID
0.9219
0.945830980
Longview, TX
0.8875
0.921531084
Los Angeles-Long Beach-Santa Ana, CA
1.1607
1.107431140
Louisville-Jefferson County, KY-IN
0.9045
0.933631340
Lynchburg, VA
0.8490
0.894031420
Macon, GA
0.9571
0.970431540
Madison, WI
1.1002
1.067631700
Manchester-Nashua, NH
1.1266
1.085132780
Medford, OR
1.0151
1.010332820
Memphis, TN-MS-AR
0.8951
0.926933124
Miami-Miami Beach-Kendall, FL
1.0023
1.001633340
Milwaukee-Waukesha-West Allis, WI
1.0296
1.020233460
Minneapolis-St. Paul-Bloomington, MN-WI
1.0961
1.064933540
Missoula, MT
0.8737
0.911733660
Mobile, AL
0.7950
0.854633700
Modesto, CA
1.1989
1.132333740
Monroe, LA
0.7766
0.841033860
Montgomery, AL
0.8366
0.885034060
Morgantown, WV
0.8244
0.876134740
Muskegon-Norton Shores, MI
0.9472
0.963534820
Myrtle Beach-Conway-North Myrtle Beach, SC
0.8791
0.915534980
Nashville-Davidson-Murfreesboro-Franklin, TN
0.9407
0.959035004
Nassau-Suffolk, NY
1.2565
1.169235084
Newark-Union, NJPA
1.1578
1.105535300
New Haven-Milford, CT
1.2439
1.161235380
New Orleans-Metairie-Kenner, LA
0.8732
0.911335644
New York-White Plains-Wayne, NY-NJ
1.2993
1.196435980
Norwich-New London, CT
1.1794
1.119636084
Oakland-Fremont-Hayward, CA
1.5299
1.338036140
Ocean City, NJ
1.0358
1.024436220
Odessa, TX
0.9527
0.967436420
Oklahoma City, OK
0.8764
0.913636500
Olympia, WA
1.1325
1.088936740
Orlando-Kissimmee, FL
0.9245
0.947737700
Pascagoula, MS
0.8544
0.897837860
Pensacola-Ferry Pass-Brent, FL
0.8127
0.867637900
Peoria, IL
0.9217
0.945737964
Philadelphia, PA
1.0777
1.052638220
Pine Bluff, AR
0.7959
0.855338300
Pittsburgh, PA (PA and WV Hospitals)
0.8388
0.886638300
Pittsburgh, PA (OH Hospitals)
0.8701
0.909138340
Pittsfield, MA
1.0401
1.027338540
Pocatello, ID
0.9158
0.941538860
Portland-South Portland-Biddeford, ME
0.9601
0.972538900
Portland-Vancouver-Beaverton, OR-WA
1.1233
1.082938940
Port St. Lucie, FL
0.9990
0.999339100
Poughkeepsie-Newburgh-Middletown, NY
1.0644
1.043739140
Prescott, AZ
0.9534
0.967839340
Provo-Orem, UT
0.9388
0.957739580
Raleigh-Cary, NC
0.9373
0.956639740
Reading, PA
0.9419
0.959839820
Redding, CA
1.2666
1.175739900
Reno-Sparks, NV
1.0851
1.057540060
Richmond, VA
0.9238
0.947240220
Roanoke, VA
0.9190
0.943840340
Rochester, MN
1.0761
1.051540380
Rochester, NY
0.8899
0.923240420
Rockford, IL
0.9659
0.976540484
Rockingham County, NH
1.0179
1.012240660
Rome, GA
0.9391
0.957940900
Sacramento-Arden-Arcade-Roseville, CA
1.2853
1.187540980
Saginaw-Saginaw Township North, MI
0.8979
0.928941060
St. Cloud, MN
1.0390
1.026541100
St. George, UT
0.9546
0.968741140
St. Joseph, MO-KS
0.8831
0.918441180
St. Louis, MO-IL
0.8885
0.922241620
Salt Lake City, UT (UT Hospitals)
0.9482
0.964241620
Salt Lake City, UT (NV Hospitals)
0.9688
0.978541700
San Antonio, TX
0.8916
0.924441884
San Francisco-San Mateo-Redwood City, CA
1.4766
1.3059( print page 24951)41940
San Jose-Sunnyvale-Santa Clara, CA
1.5378
1.342741980
San Juan-Caguas-Guaynabo, PR
0.4517
0.580342044
Santa Ana-Anaheim-Irvine, CA
1.1607
1.107442140
Santa Fe, NM
1.0376
1.025642220
Santa Rosa-Petaluma, CA
1.3959
1.256642260
Sarasota-Bradenton-Venice, FL
0.9758
0.983442340
Savannah, GA
0.8987
0.929542644
Seattle-Bellevue-Everett, WA
1.1202
1.080842680
Sebastian-Vero Beach, FL
0.9482
0.964243300
Sherman-Denison, TX
0.8535
0.897243340
Shreveport-Bossier City, LA
0.8615
0.902943580
Sioux City, IA-NE-SD
0.8848
0.919643620
Sioux Falls, SD
0.9395
0.958243780
South Bend-Mishawaka, IN-MI
0.9488
0.964643900
Spartanburg, SC
0.9334
0.953944060
Spokane, WA
1.0220
1.015044180
Springfield, MO
0.8943
0.926444940
Sumter, SC
0.8791
0.915545060
Syracuse, NY
0.9577
0.970845104
Tacoma, WA
1.1060
1.071445220
Tallahassee, FL
0.8458
0.891645300
Tampa-St. Petersburg-Clearwater, FL
0.9174
0.942745500
Texarkana, TX-Texarkana, AR
0.8131
0.867945780
Toledo, OH
0.9276
0.949845820
Topeka, KS
0.8455
0.891446140
Tulsa, OK
0.8504
0.895046220
Tuscaloosa, AL
0.8166
0.870546340
Tyler, TX
0.9190
0.943846700
Vallejo-Fairfield, CA
1.4200
1.271447260
Virginia Beach-Norfolk-Newport News, VA
0.8785
0.915147894
Washington-Arlington-Alexandria DC-VA
1.0679
1.046047940
Waterloo-Cedar Falls, IA
0.8891
0.922748140
Wausau, WI
1.0011
1.000848620
Wichita, KS
0.8761
0.913448700
Williamsport, PA
0.8366
0.885048864
Wilmington, DE-MD-NJ
1.0752
1.050948900
Wilmington, NC
0.9172
0.942549180
Winston-Salem, NC
0.9083
0.936349660
Youngstown-Warren-Boardman, OH-PA
0.8775
0.914403
Rural Arizona
0.9386
0.957504
Rural Arkansas
0.7591
0.828005
Rural California
1.1607
1.107407
Rural Connecticut
1.2439
1.161210
Rural Florida
0.8749
0.912514
Rural Illinois
0.8355
0.884216
Rural Iowa
0.8480
0.893217
Rural Kansas
0.7989
0.857522
Rural Massachusetts
0.9739
0.982123
Rural Michigan
0.8899
0.923225
Rural Mississippi
0.7915
0.852026
Rural Missouri
0.8145
0.868929
Rural Nevada
0.8780
0.914830
Rural New Hampshire
1.0782
1.052933
Rural New York
0.8440
0.890334
Rural North Carolina
0.8608
0.902436
Rural Ohio
0.8701
0.909137
Rural Oklahoma
0.7702
0.836338
Rural Oregon
0.9950
0.996639
Rural Pennsylvania (PA Hospitals)
0.8366
0.885039
Rural Pennsylvania (NY Hospitals)
0.8440
0.890344
Rural Tennessee
0.7916
0.852145
Rural Texas
0.8204
0.873247
Rural Vermont
0.9431
0.960749
Rural Virginia
0.8095
0.865350
Rural Washington
1.0565
1.038452
Rural Wisconsin
0.9635
0.974953
Rural Wyoming
0.9049
0.9339
 
 
 Table 4F.—Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF) by CBSA—FY 2008
CBSA code
Area
Wage index
GAF
Wage index—reclassified hospitals
GAF—reclassified hospitals10380
Aguadilla-Isabela-San Sebastián, PR
0.7690
0.835421940
Fajardo, PR
0.9543
0.968525020
Guayama, PR
0.6904
0.775932420
Mayagüez, PR
0.8532
0.897038660
Ponce, PR
0.9692
0.978841900
San Germán-Cabo Rojo, PR
1.0616
1.041841980
San Juan-Caguas-Guaynabo, PR
1.0437
1.0297
1.0437
1.029749500
Yauco, PR
0.7478
0.8195
 The following list represents all hospitals that are eligible to have their wage index increased by the outmigration adjustment listed in this table. Hospitals cannot receive the outmigration adjustment if they are reclassified under section 1886(d)(10) of the Act or redesignated under section 1886(d)(8) of the Act. Hospitals that have already been reclassified under section 1886(d)(10) of the Act or redesignated under section 1886(d)(8(B)) of the Act are designated with an asterisk. We will automatically assume that hospitals that have already been reclassified under section 1886(d)(10) of the Act or redesignated under section 1886(d)(8) of the Act wish to retain their reclassification/redesignation status and waive the application of the outmigration adjustment. Section 1886(d)(10) hospitals that wish to receive the outmigration adjustment, rather than their reclassification, should follow the termination/withdrawal procedures specified in 42 CFR 412.273 and section III.I.3. of the preamble of this proposed rule. Otherwise, they will be deemed to have waived the outmigration adjustment. Hospitals redesignated under section 1886(d)(8) of the Act will be deemed to have waived the outmigration adjustment, unless they explicitly notify CMS that they elect to receive the outmigration adjustment instead within 45 days from the publication of this proposed rule. These notifications should be sent to the following address: Centers for Medicare and Medicaid Services, Center for Medicare Management, Attention: Wage Index Adjustment Waivers, Division of Acute Care, Room C40806, 7500 Security Boulevard, Baltimore, MD 21244-1850. Table 4J.—Out-Migration Adjustment—FY 2008
Provider No.
Reclassified for FY 2008
Out-migration Adjustment
Qualifying county name
County code010005
*
0.0322
MARSHALL
01470010008

0.0245
CRENSHAW
01200010009
*
0.0177
MORGAN
01510010010
*
0.0322
MARSHALL
01470010012
*
0.0182
DE KALB
01240010015

0.0043
CLARKE
01120010022
*
0.1106
CHEROKEE
01090010025
*
0.0188
CHAMBERS
01080010029
*
0.0281
LEE
01400010032

0.0320
RANDOLPH
01550010035
*
0.0263
CULLMAN
01210010038

0.0038
CALHOUN
01070010045
*
0.0216
FAYETTE
01280010047

0.0179
BUTLER
01060010052

0.0124
TALLAPOOSA
01610010054
*
0.0177
MORGAN
01510010061

0.0566
JACKSON
01350010065
*
0.0124
TALLAPOOSA
01610010078

0.0038
CALHOUN
01070010083
*
0.0125
BALDWIN
01010010085
*
0.0177
MORGAN
01510010091

0.0043
CLARKE
01120010100
*
0.0125
BALDWIN
01010010101
*
0.0209
TALLADEGA
01600010109

0.0369
PICKENS
01530010110

0.0303
BULLOCK
01050010125

0.0471
WINSTON
01660010128

0.0043
CLARKE
01120010129

0.0125
BALDWIN
01010010138

0.0113
SUMTER
01590010143
*
0.0263
CULLMAN
01210010146

0.0038
CALHOUN
01070010150
*
0.0179
BUTLER
01060010158
*
0.0067
FRANKLIN
01290010164
*
0.0209
TALLADEGA
01600( print page 24953)030040

0.0012
SANTA CRUZ
03110030067

0.0230
LAPAZ
03055040014
*
0.0163
WHITE
04720040019
*
0.0254
ST. FRANCIS
04610040039
*
0.0172
GREENE
04270040047

0.0117
RANDOLPH
04600040067

0.0008
COLUMBIA
04130040071
*
0.0149
JEFFERSON
04340040076
*
0.1001
HOT SPRING
04290040081

0.0358
PIKE
04540040100
*
0.0163
WHITE
04720050002

0.0009
ALAMEDA
05000050007

0.0140
SAN MATEO
05510050009
*
0.0196
NAPA
05380050013
*
0.0196
NAPA
05380050014
*
0.0147
AMADOR
05020050042
*
0.0184
TEHAMA
05620050043

0.0009
ALAMEDA
05000050069
*
0.0006
ORANGE
05400050070

0.0140
SAN MATEO
05510050073
*
0.0169
SOLANO
05580050075

0.0009
ALAMEDA
05000050084

0.0135
SAN JOAQUIN
05490050089
*
0.0005
SAN BERNARDINO
05460050090
*
0.0085
SONOMA
05590050099
*
0.0005
SAN BERNARDINO
05460050101
*
0.0169
SOLANO
05580050113

0.0140
SAN MATEO
05510050118
*
0.0135
SAN JOAQUIN
05490050122

0.0135
SAN JOAQUIN
05490050129
*
0.0005
SAN BERNARDINO
05460050133
*
0.0186
YUBA
05680050136
*
0.0085
SONOMA
05590050140
*
0.0005
SAN BERNARDINO
05460050150
*
0.0357
NEVADA
05390050167

0.0135
SAN JOAQUIN
05490050168
*
0.0006
ORANGE
05400050173
*
0.0006
ORANGE
05400050174
*
0.0085
SONOMA
05590050193
*
0.0006
ORANGE
05400050195

0.0009
ALAMEDA
05000050197
*
0.0140
SAN MATEO
05510050211

0.0009
ALAMEDA
05000050224
*
0.0006
ORANGE
05400050226
*
0.0006
ORANGE
05400050230
*
0.0006
ORANGE
05400050245
*
0.0005
SAN BERNARDINO
05460050264

0.0009
ALAMEDA
05000050272
*
0.0005
SAN BERNARDINO
05460050279
*
0.0005
SAN BERNARDINO
05460050283

0.0009
ALAMEDA
05000050289

0.0140
SAN MATEO
05510050291
*
0.0085
SONOMA
05590050298
*
0.0005
SAN BERNARDINO
05460050300
*
0.0005
SAN BERNARDINO
05460050305

0.0009
ALAMEDA
05000050313

0.0135
SAN JOAQUIN
05490050320

0.0009
ALAMEDA
05000050325

0.0046
TUOLUMNE
05650050327
*
0.0005
SAN BERNARDINO
05460050335

0.0046
TUOLUMNE
05650050336

0.0135
SAN JOAQUIN
05490050348
*
0.0006
ORANGE
05400050366

0.0025
CALAVERAS
05040050367
*
0.0169
SOLANO
05580050385
*
0.0085
SONOMA
05590050426
*
0.0006
ORANGE
05400050444

0.0229
MERCED
05340050476
*
0.0275
LAKE
05160050488

0.0009
ALAMEDA
05000( print page 24954)050494
*
0.0357
NEVADA
05390050512

0.0009
ALAMEDA
05000050517
*
0.0005
SAN BERNARDINO
05460050526
*
0.0006
ORANGE
05400050528
*
0.0229
MERCED
05340050541
*
0.0140
SAN MATEO
05510050543
*
0.0006
ORANGE
05400050547
*
0.0085
SONOMA
05590050548
*
0.0006
ORANGE
05400050551
*
0.0006
ORANGE
05400050567
*
0.0006
ORANGE
05400050570
*
0.0006
ORANGE
05400050580
*
0.0006
ORANGE
05400050584
*
0.0005
SAN BERNARDINO
05460050586
*
0.0005
SAN BERNARDINO
05460050589
*
0.0006
ORANGE
05400050603
*
0.0006
ORANGE
05400050609
*
0.0006
ORANGE
05400050618
*
0.0005
SAN BERNARDINO
05460050667
*
0.0196
NAPA
05380050678
*
0.0006
ORANGE
05400050680
*
0.0169
SOLANO
05580050690
*
0.0085
SONOMA
05590050693
*
0.0006
ORANGE
05400050707

0.0140
SAN MATEO
05510050720
*
0.0006
ORANGE
05400050744

0.0006
ORANGE
05400050745

0.0006
ORANGE
05400050746

0.0006
ORANGE
05400050747

0.0006
ORANGE
05400050748

0.0135
SAN JOAQUIN
05490050754

0.0140
SAN MATEO
05510050756

0.0005
SAN BERNARDINO
05460060001
*
0.0045
WELD
06610060003
*
0.0075
BOULDER
06060060010

0.0087
LARIMER
06340060027
*
0.0075
BOULDER
06060060030

0.0087
LARIMER
06340060103
*
0.0075
BOULDER
06060060116
*
0.0075
BOULDER
06060080001
*
0.0018
NEW CASTLE
08010080003
*
0.0018
NEW CASTLE
08010100014
*
0.0059
VOLUSIA
10630100017
*
0.0059
VOLUSIA
10630100045
*
0.0059
VOLUSIA
10630100047
*
0.0026
CHARLOTTE
10070100068
*
0.0059
VOLUSIA
10630100072
*
0.0059
VOLUSIA
10630100077
*
0.0026
CHARLOTTE
10070100118
*
0.0179
FLAGLER
10170100232
*
0.0057
PUTNAM
10530100236
*
0.0026
CHARLOTTE
10070100252
*
0.0146
OKEECHOBEE
10460100290

0.0390
SUMTER
10590110023
*
0.0416
GORDON
11500110029
*
0.0056
HALL
11550110040
*
0.1727
JACKSON
11610110041
*
0.0624
HABERSHAM
11540110100

0.0789
JEFFERSON
11620110101

0.0067
COOK
11311110142

0.0202
EVANS
11441110146
*
0.0438
CAMDEN
11170110150
*
0.0227
BALDWIN
11030110187
*
0.0643
LUMPKIN
11701110190

0.0242
MACON
11710110205

0.0514
GILMER
11471130024

0.0422
BONNER
13080130049
*
0.0319
KOOTENAI
13270130066

0.0319
KOOTENAI
13270130067
*
0.0697
BINGHAM
13050( print page 24955)130068

0.0319
KOOTENAI
13270140001

0.0362
FULTON
14370140026

0.0288
LA SALLE
14580140043
*
0.0055
WHITESIDE
14988140058
*
0.0125
MORGAN
14770140110
*
0.0288
LA SALLE
14580140160
*
0.0302
STEPHENSON
14970140161
*
0.0193
LIVINGSTON
14610140167
*
0.1054
IROQUOIS
14460140234

0.0288
LA SALLE
14580150006
*
0.0085
LA PORTE
15450150015

0.0085
LA PORTE
15450150022

0.0151
MONTGOMERY
15530150030
*
0.0186
HENRY
15320150072

0.0101
CASS
15080150076
*
0.0210
MARSHALL
15490150088
*
0.0111
MADISON
15470150091
*
0.0047
HUNTINGTON
15340150102
*
0.0103
STARKE
15740150113
*
0.0111
MADISON
15470150133
*
0.0167
KOSCIUSKO
15420150146
*
0.0081
NOBLE
15560160013

0.0179
MUSCATINE
16690160032

0.0235
JASPER
16490160080
*
0.0066
CLINTON
16220170137
*
0.0387
DOUGLAS
17220170150

0.0176
COWLEY
17170180012
*
0.0081
HARDIN
18460180017
*
0.0035
BARREN
18040180049
*
0.0497
MADISON
18750180064

0.0320
MONTGOMERY
18860180066
*
0.0450
LOGAN
18700180070

0.0240
GRAYSON
18420180079

0.0264
HARRISON
18480190003
*
0.0085
IBERIA
19220190015
*
0.0231
TANGIPAHOA
19520190017
*
0.0184
ST. LANDRY
19480190034

0.0188
VERMILION
19560190044

0.0259
ACADIA
19000190050

0.0044
BEAUREGARD
19050190053

0.0100
JEFFRSON DAVIS
19260190054

0.0085
IBERIA
19220190078

0.0184
ST. LANDRY
19480190086
*
0.0050
LINCOLN
19300190088
*
0.0410
WEBSTER
19590190099
*
0.0189
AVOYELLES
19040190106
*
0.0101
ALLEN
19010190116

0.0084
MOREHOUSE
19330190133

0.0101
ALLEN
19010190140

0.0034
FRANKLIN
19200190144
*
0.0410
WEBSTER
19590190145

0.0090
LA SALLE
19290190184
*
0.0075
CALDWELL
19100190190

0.0075
CALDWELL
19100190191
*
0.0184
ST. LANDRY
19480190246

0.0075
CALDWELL
19100190257

0.0050
LINCOLN
19300200024
*
0.0092
ANDROSCOGGIN
20000200032

0.0316
OXFORD
20080200034
*
0.0092
ANDROSCOGGIN
20000200050
*
0.0223
HANCOCK
20040210001

0.0184
WASHINGTON
21210210023

0.0070
ANNE ARUNDEL
21010210028

0.0356
ST. MARYS
21180210043

0.0070
ANNE ARUNDEL
21010220002
*
0.0235
MIDDLESEX
22090220010
*
0.0461
ESSEX
22040220011
*
0.0235
MIDDLESEX
22090220029
*
0.0461
ESSEX
22040220033
*
0.0461
ESSEX
22040( print page 24956)220035
*
0.0461
ESSEX
22040220049
*
0.0235
MIDDLESEX
22090220063
*
0.0235
MIDDLESEX
22090220070
*
0.0235
MIDDLESEX
22090220080
*
0.0461
ESSEX
22040220082
*
0.0235
MIDDLESEX
22090220084
*
0.0235
MIDDLESEX
22090220098
*
0.0235
MIDDLESEX
22090220101
*
0.0235
MIDDLESEX
22090220105
*
0.0235
MIDDLESEX
22090220171
*
0.0235
MIDDLESEX
22090220174
*
0.0461
ESSEX
22040230003
*
0.0217
OTTAWA
23690230005

0.0473
LENAWEE
23450230013
*
0.0023
OAKLAND
23620230015

0.0297
ST. JOSEPH
23740230019
*
0.0023
OAKLAND
23620230021
*
0.0099
BERRIEN
23100230022
*
0.0212
BRANCH
23110230029
*
0.0023
OAKLAND
23620230035
*
0.0096
MONTCALM
23580230037
*
0.0211
HILLSDALE
23290230047
*
0.0018
MACOMB
23490230069
*
0.0208
LIVINGSTON
23460230071
*
0.0023
OAKLAND
23620230072
*
0.0217
OTTAWA
23690230075

0.0048
CALHOUN
23120230078
*
0.0099
BERRIEN
23100230092
*
0.0221
JACKSON
23370230093

0.0060
MECOSTA
23530230096
*
0.0297
ST. JOSEPH
23740230099
*
0.0230
MONROE
23570230121
*
0.0695
SHIAWASSEE
23770230130
*
0.0023
OAKLAND
23620230151
*
0.0023
OAKLAND
23620230174
*
0.0217
OTTAWA
23690230195
*
0.0018
MACOMB
23490230204
*
0.0018
MACOMB
23490230207
*
0.0023
OAKLAND
23620230208
*
0.0096
MONTCALM
23580230217
*
0.0048
CALHOUN
23120230222
*
0.0037
MIDLAND
23550230223
*
0.0023
OAKLAND
23620230227
*
0.0018
MACOMB
23490230254
*
0.0023
OAKLAND
23620230257
*
0.0018
MACOMB
23490230264
*
0.0018
MACOMB
23490230269
*
0.0023
OAKLAND
23620230277
*
0.0023
OAKLAND
23620230279
*
0.0208
LIVINGSTON
23460240018

0.0873
GOODHUE
24240240044

0.0671
WINONA
24840240064
*
0.0130
ITASCA
24300240069
*
0.0301
STEELE
24730240071
*
0.0377
RICE
24650240117

0.0593
MOWER
24490240211

0.0386
PINE
24570250023
*
0.0430
PEARL RIVER
25540250040
*
0.0022
JACKSON
25290250117
*
0.0430
PEARL RIVER
25540250128

0.0393
PANOLA
25530250160

0.0393
PANOLA
25530260059

0.0127
LACLEDE
26520260064
*
0.0092
AUDRAIN
26030260097

0.0295
JOHNSON
26500270081

0.0236
MUSSELSHELL
27320280077

0.0057
DODGE
28260280123

0.0118
GAGE
28330290002
*
0.0280
LYON
29090310002
*
0.0264
ESSEX
31200( print page 24957)310009
*
0.0264
ESSEX
31200310010
*
0.0159
MERCER
31260310013
*
0.0264
ESSEX
31200310018
*
0.0264
ESSEX
31200310021

0.0159
MERCER
31260310031
*
0.0130
BURLINGTON
31150310032
*
0.0027
CUMBERLAND
31190310038
*
0.0368
MIDDLESEX
31270310039
*
0.0368
MIDDLESEX
31270310044
*
0.0159
MERCER
31260310054
*
0.0264
ESSEX
31200310057

0.0130
BURLINGTON
31150310061

0.0130
BURLINGTON
31150310070
*
0.0368
MIDDLESEX
31270310076
*
0.0264
ESSEX
31200310083
*
0.0264
ESSEX
31200310092
*
0.0159
MERCER
31260310093
*
0.0264
ESSEX
31200310096
*
0.0264
ESSEX
31200310108
*
0.0368
MIDDLESEX
31270310110

0.0159
MERCER
31260310119
*
0.0264
ESSEX
31200310127

0.0130
BURLINGTON
31150320003
*
0.0480
SAN MIGUEL
32230320011

0.0337
RIO ARRIBA
32190320018

0.0025
DONA ANA
32060320085

0.0025
DONA ANA
32060330004
*
0.0615
ULSTER
33740330008
*
0.0102
WYOMING
33900330010

0.0042
MONTGOMERY
33380330027
*
0.0148
NASSAU
33400330033

0.0205
CHENANGO
33080330047

0.0042
MONTGOMERY
33380330073
*
0.0122
GENESEE
33290330094
*
0.0463
COLUMBIA
33200330103

0.0121
CATTARAUGUS
33040330106
*
0.0148
NASSAU
33400330126
*
0.0675
ORANGE
33540330132
*
0.0121
CATTARAUGUS
33040330135
*
0.0675
ORANGE
33540330167
*
0.0148
NASSAU
33400330175

0.0241
CORTLAND
33210330181
*
0.0148
NASSAU
33400330182
*
0.0148
NASSAU
33400330191
*
0.0017
WARREN
33750330198
*
0.0148
NASSAU
33400330205
*
0.0675
ORANGE
33540330224
*
0.0615
ULSTER
33740330225
*
0.0148
NASSAU
33400330235
*
0.0281
CAYUGA
33050330259
*
0.0148
NASSAU
33400330264
*
0.0675
ORANGE
33540330331
*
0.0148
NASSAU
33400330332
*
0.0148
NASSAU
33400330372
*
0.0148
NASSAU
33400330386
*
0.0687
SULLIVAN
33710340020

0.0143
LEE
34520340021
*
0.0162
CLEVELAND
34220340024

0.0171
SAMPSON
34810340027
*
0.0125
LENOIR
34530340037

0.0162
CLEVELAND
34220340038
*
0.0253
BEAUFORT
34060340039
*
0.0101
IREDELL
34480340068
*
0.0094
COLUMBUS
34230340069
*
0.0083
WAKE
34910340070
*
0.0417
ALAMANCE
34000340071
*
0.0168
HARNETT
34420340073
*
0.0083
WAKE
34910340085

0.0250
DAVIDSON
34280340096

0.0250
DAVIDSON
34280( print page 24958)340104
*
0.0162
CLEVELAND
34220340114
*
0.0083
WAKE
34910340124
*
0.0168
HARNETT
34420340126
*
0.0084
WILSON
34970340129
*
0.0101
IREDELL
34480340133

0.0242
MARTIN
34580340138
*
0.0083
WAKE
34910340144
*
0.0101
IREDELL
34480340145
*
0.0337
LINCOLN
34540340151

0.0053
HALIFAX
34410340173
*
0.0083
WAKE
34910360002

0.0142
ASHLAND
36020360010
*
0.0075
TUSCARAWAS
36800360013
*
0.0135
SHELBY
36760360025
*
0.0073
ERIE
36220360036
*
0.0168
WAYNE
36860360040

0.0392
KNOX
36430360044

0.0123
DARKE
36190360065
*
0.0077
HURON
36400360071

0.0035
VAN WERT
36820360086
*
0.0187
CLARK
36110360096
*
0.0071
COLUMBIANA
36140360107
*
0.0095
SANDUSKY
36730360125
*
0.0137
ASHTABULA
36030360156

0.0095
SANDUSKY
36730360175
*
0.0175
CLINTON
36130360185
*
0.0071
COLUMBIANA
36140360187
*
0.0187
CLARK
36110360245
*
0.0137
ASHTABULA
36030370014
*
0.0363
BRYAN
37060370015
*
0.0369
MAYES
37480370023

0.0090
STEPHENS
37680370065

0.0097
CRAIG
37170370072

0.0260
LATIMER
37380370083

0.0051
PUSHMATAHA
37630370100

0.0101
CHOCTAW
37110370149
*
0.0292
POTTAWATOMIE
37620370156

0.0122
GARVIN
37240370169

0.0164
MCINTOSH
37450370172

0.0260
LATIMER
37380370214

0.0122
GARVIN
37240380022
*
0.0069
LINN
38210390008

0.0055
LAWRENCE
39450390016
*
0.0055
LAWRENCE
39450390030
*
0.0163
SCHUYLKILL
39650390031
*
0.0163
SCHUYLKILL
39650390044
*
0.0191
BERKS
39110390052

0.0044
CLEARFIELD
39230390065
*
0.0489
ADAMS
39000390066
*
0.0364
LEBANON
39460390086
*
0.0044
CLEARFIELD
39230390096
*
0.0191
BERKS
39110390113
*
0.0049
CRAWFORD
39260390122

0.0049
CRAWFORD
39260390138
*
0.0212
FRANKLIN
39350390146

0.0019
WARREN
39740390150
*
0.0019
GREENE
39370390151
*
0.0212
FRANKLIN
39350390181
*
0.0163
SCHUYLKILL
39650390183
*
0.0163
SCHUYLKILL
39650390201
*
0.1091
MONROE
39550390313
*
0.0163
SCHUYLKILL
39650420007
*
0.0037
SPARTANBURG
42410420019

0.0142
CHESTER
42110420027
*
0.0145
ANDERSON
42030420030
*
0.0051
COLLETON
42140420039
*
0.0148
UNION
42430420043

0.0132
CHEROKEE
42100420062
*
0.0096
CHESTERFIELD
42120420069
*
0.0023
CLARENDON
42130( print page 24959)420083
*
0.0037
SPARTANBURG
42410430008

0.0537
BROOKINGS
43050430048
*
0.0055
LAWRENCE
43400430094

0.0055
LAWRENCE
43400440007

0.0226
COFFEE
44150440008
*
0.0449
HENDERSON
44380440016

0.0144
CARROLL
44080440024
*
0.0230
BRADLEY
44050440030

0.0015
HAMBLEN
44310440031

0.0025
ROANE
44720440033

0.0036
CAMPBELL
44060440035
*
0.0309
MONTGOMERY
44620440047

0.0338
GIBSON
44260440051

0.0071
MCNAIRY
44540440057

0.0028
CLAIBORNE
44120440060
*
0.0338
GIBSON
44260440067
*
0.0015
HAMBLEN
44310440070

0.0109
DECATUR
44190440081

0.0069
SEVIER
44770440084

0.0034
MONROE
44610440109

0.0070
HARDIN
44350440115

0.0338
GIBSON
44260440137

0.0763
BEDFORD
44010440144
*
0.0226
COFFEE
44150440148
*
0.0306
DE KALB
44200440174

0.0310
HAYWOOD
44370440180

0.0036
CAMPBELL
44060440181

0.0361
HARDEMAN
44340440182

0.0144
CARROLL
44080440185
*
0.0230
BRADLEY
44050450032
*
0.0253
HARRISON
45620450039
*
0.0024
TARRANT
45910450052
*
0.0276
BOSQUE
45160450059
*
0.0074
COMAL
45320450064
*
0.0024
TARRANT
45910450087
*
0.0024
TARRANT
45910450090

0.0651
COOKE
45340450099
*
0.0143
GRAY
45563450135
*
0.0024
TARRANT
45910450137
*
0.0024
TARRANT
45910450144

0.0558
ANDREWS
45010450163

0.0053
KLEBERG
45743450192

0.0271
HILL
45651450194

0.0213
CHEROKEE
45281450210

0.0150
PANOLA
45842450224
*
0.0195
WOOD
45974450236

0.0389
HOPKINS
45654450270

0.0271
HILL
45651450283
*
0.0655
VAN ZANDT
45947450347
*
0.0379
WALKER
45949450348
*
0.0058
FALLS
45500450370

0.0241
COLORADO
45312450389
*
0.0619
HENDERSON
45640450395
*
0.0452
POLK
45850450419
*
0.0024
TARRANT
45910450438
*
0.0241
COLORADO
45312450451

0.0537
SOMERVELL
45893450460

0.0048
TYLER
45942450497

0.0395
MONTAGUE
45800450539

0.0071
HALE
45582450547

0.0195
WOOD
45974450563
*
0.0024
TARRANT
45910450565

0.0481
PALO PINTO
45841450573

0.0115
JASPER
45690450596
*
0.0744
HOOD
45653450639
*
0.0024
TARRANT
45910450641

0.0395
MONTAGUE
45800450672
*
0.0024
TARRANT
45910450675
*
0.0024
TARRANT
45910450677
*
0.0024
TARRANT
45910( print page 24960)450698

0.0135
LAMB
45751450747
*
0.0127
ANDERSON
45000450755

0.0295
HOCKLEY
45652450770
*
0.0182
MILAM
45795450779
*
0.0024
TARRANT
45910450813
*
0.0127
ANDERSON
45000450838

0.0115
JASPER
45690450872
*
0.0024
TARRANT
45910450880
*
0.0024
TARRANT
45910450884

0.0050
UPSHUR
45943450886

0.0024
TARRANT
45910450888

0.0024
TARRANT
45910460017

0.0364
BOX ELDER
46010460039
*
0.0364
BOX ELDER
46010490019
*
0.1081
CULPEPER
49230490084

0.0145
ESSEX
49280490110

0.0327
MONTGOMERY
49600500003
*
0.0164
SKAGIT
50280500007
*
0.0164
SKAGIT
50280500019

0.0140
LEWIS
50200500039
*
0.0101
KITSAP
50170500041
*
0.0020
COWLITZ
50070510018
*
0.0187
JACKSON
51170510047
*
0.0270
MARION
51240520028
*
0.0297
GREEN
52220520035

0.0083
SHEBOYGAN
52580520044

0.0083
SHEBOYGAN
52580520057

0.0184
SAUK
52550520059
*
0.0189
RACINE
52500520060
*
0.0048
GREEN LAKE
52230520071
*
0.0174
JEFFERSON
52270520076
*
0.0159
DODGE
52130520095
*
0.0184
SAUK
52550520096

0.0189
RACINE
52500520102
*
0.0242
WALWORTH
52630520116
*
0.0174
JEFFERSON
52270
 Table 5.—List of Proposed Medicare Severity-Diagnosis Related Groups (MS-DRGs), Relative Weighting Factors, and Geometric and Arithmetic Mean Length of Stay
MS-DRG
FY 2008 proposed rule post-acute DRG
FY 2008 proposed rule special pay DRG
MDC
TYPE
MS-DRG title
Weights
Geometric mean length of stay
Arithmetic mean length of stay1
NO
NO
PRE
SURG
Heart transplant or implant of heart assist system w MCC
23.6378
30.5
44.22
NO
NO
PRE
SURG
Heart transplant or implant of heart assist system w/o MCC
11.2998
16.0
22.83
YES
NO
PRE
SURG
ECMO or trach w MV 96+ hrs or PDX exc face, mouth & neck w maj O.R
18.6118
36.2
43.24
YES
NO
PRE
SURG
Trach w MV 96+ hrs or PDX exc face, mouth & neck w/o maj O.R
11.5312
26.2
31.35
NO
NO
PRE
SURG
Liver transplant w MCC or intestinal transplant
10.3032
17.0
22.66
NO
NO
PRE
SURG
Liver transplant w/o MCC
4.7075
8.7
10.07
NO
NO
PRE
SURG
Lung transplant
7.6379
14.6
17.38
NO
NO
PRE
SURG
Simultaneous pancreas/kidney transplant
5.0633
10.2
11.99
NO
NO
PRE
SURG
Bone marrow transplant
6.1059
18.1
21.610
NO
NO
PRE
SURG
Pancreas transplant
3.6839
9.1
10.211
NO
NO
PRE
SURG
Tracheostomy for face, mouth & neck diagnoses w MCC
4.8010
13.0
16.312
NO
NO
PRE
SURG
Tracheostomy for face, mouth & neck diagnoses w CC
2.9948
9.0
10.913
NO
NO
PRE
SURG
Tracheostomy for face, mouth & neck diagnoses w/o CC/MCC
1.8882
6.1
7.320
NO
NO
01
SURG
Intracranial vascular procedures w PDX hemorrhage w MCC
8.2109
15.4
19.2( print page 24961)21
NO
NO
01
SURG
Intracranial vascular procedures w PDX hemorrhage w CC
6.1724
13.4
15.622
NO
NO
01
SURG
Intracranial vascular procedures w PDX hemorrhage w/o CC/MCC
4.1017
7.9
9.723
NO
NO
01
SURG
Craniotomy w major device implant or acute complex CNS PDX w MCC
5.1123
9.8
13.724
NO
NO
01
SURG
Craniotomy w major device implant or acute complex CNS PDX w/o MCC
3.4316
6.1
8.725
YES
NO
01
SURG
Craniotomy & endovascular intracranial procedures w MCC
4.9933
10.7
13.826
YES
NO
01
SURG
Craniotomy & endovascular intracranial procedures w CC
2.9515
6.7
8.427
YES
NO
01
SURG
Craniotomy & endovascular intracranial procedures w/o CC/MCC
2.0380
3.6
4.728
NO
NO
01
SURG
Spinal procedures w MCC
4.9251
10.9
14.729
NO
NO
01
SURG
Spinal procedures w CC
2.5965
5.7
7.730
NO
NO
01
SURG
Spinal procedures w/o CC/MCC
1.5278
2.7
3.731
NO
NO
01
SURG
Ventricular shunt procedures w MCC
3.8505
9.2
13.232
NO
NO
01
SURG
Ventricular shunt procedures w CC
1.7502
3.9
5.833
NO
NO
01
SURG
Ventricular shunt procedures w/o CC/MCC
1.2661
2.3
3.134
NO
NO
01
SURG
Carotid artery stent procedure w MCC
3.2158
4.8
7.335
NO
NO
01
SURG
Carotid artery stent procedure w CC
2.0186
2.0
3.036
NO
NO
01
SURG
Carotid artery stent procedure w/o CC/MCC
1.5746
1.3
1.637
NO
NO
01
SURG
Extracranial procedures w MCC
3.0383
6.0
8.738
NO
NO
01
SURG
Extracranial procedures w CC
1.5518
2.6
3.839
NO
NO
01
SURG
Extracranial procedures w/o CC/MCC
1.0172
1.5
1.940
YES
YES
01
SURG
Periph & cranial nerve & other nerv syst proc w MCC
3.8181
10.4
14.041
YES
YES
01
SURG
Periph & cranial nerve & other nerv syst proc w CC
2.1436
5.6
7.542
YES
YES
01
SURG
Periph & cranial nerve & other nerv syst proc w/o CC/MCC
1.6878
2.5
3.752
NO
NO
01
MED
Spinal disorders & injuries w CC/MCC
1.5118
4.9
6.853
NO
NO
01
MED
Spinal disorders & injuries w/o CC/MCC
0.9105
3.2
4.054
YES
NO
01
MED
Nervous system neoplasms w MCC
1.6182
5.5
7.455
YES
NO
01
MED
Nervous system neoplasms w/o MCC
1.0567
3.9
5.156
YES
NO
01
MED
Degenerative nervous system disorders w MCC
1.6121
6.2
8.257
YES
NO
01
MED
Degenerative nervous system disorders w/o MCC
0.8403
4.0
5.058
NO
NO
01
MED
Multiple sclerosis & cerebellar ataxia w MCC
1.6022
5.8
8.059
NO
NO
01
MED
Multiple sclerosis & cerebellar ataxia w CC
0.9288
4.3
5.260
NO
NO
01
MED
Multiple sclerosis & cerebellar ataxia w/o CC/MCC
0.7126
3.4
4.161
NO
NO
01
MED
Acute ischemic stroke w use of thrombolytic agent w MCC
2.9195
7.4
9.862
NO
NO
01
MED
Acute ischemic stroke w use of thrombolytic agent w CC
1.9977
5.4
6.463
NO
NO
01
MED
Acute ischemic stroke w use of thrombolytic agent w/o CC/MCC
1.5581
4.0
4.664
YES
NO
01
MED
Intracranial hemorrhage or cerebral infarction w MCC
1.9072
5.9
7.965
YES
NO
01
MED
Intracranial hemorrhage or cerebral infarction w CC
1.1841
4.5
5.466
YES
NO
01
MED
Intracranial hemorrhage or cerebral infarction w/o CC/MCC
0.8588
3.2
3.867
NO
NO
01
MED
Nonspecific cva & precerebral occlusion w/o infarct w MCC
1.5069
4.8
6.268
NO
NO
01
MED
Nonspecific cva & precerebral occlusion w/o infarct w/o MCC
0.8855
2.8
3.669
NO
NO
01
MED
Transient ischemia
0.7372
2.5
3.170
YES
NO
01
MED
Nonspecific cerebrovascular disorders w MCC
1.8674
6.3
8.271
YES
NO
01
MED
Nonspecific cerebrovascular disorders w CC
1.1698
4.6
5.8( print page 24962)72
YES
NO
01
MED
Nonspecific cerebrovascular disorders w/o CC/MCC
0.8275
3.0
3.873
NO
NO
01
MED
Cranial & peripheral nerve disorders w MCC
1.3298
4.8
6.474
NO
NO
01
MED
Cranial & peripheral nerve disorders w/o MCC
0.8482
3.4
4.475
NO
NO
01
MED
Viral meningitis w CC/MCC
1.7156
6.1
7.776
NO
NO
01
MED
Viral meningitis w/o CC/MCC
0.9367
3.5
4.277
NO
NO
01
MED
Hypertensive encephalopathy w MCC
1.7374
5.6
7.278
NO
NO
01
MED
Hypertensive encephalopathy w CC
1.0221
3.8
4.679
NO
NO
01
MED
Hypertensive encephalopathy w/o CC/MCC
0.8041
2.9
3.580
NO
NO
01
MED
Nontraumatic stupor & coma w MCC
1.0699
3.6
4.981
NO
NO
01
MED
Nontraumatic stupor & coma w/o MCC
0.6932
2.7
3.482
NO
NO
01
MED
Traumatic stupor & coma, coma >1 hr w MCC
2.0060
3.9
6.483
NO
NO
01
MED
Traumatic stupor & coma, coma >1 hr w CC
1.3451
3.8
5.384
NO
NO
01
MED
Traumatic stupor & coma, coma >1 hr w/o CC/MCC
0.8999
2.3
3.185
YES
NO
01
MED
Traumatic stupor & coma, coma <1 hr w MCC
2.0578
6.0
8.286
YES
NO
01
MED
Traumatic stupor & coma, coma <1 hr w CC
1.1911
4.1
5.387
YES
NO
01
MED
Traumatic stupor & coma, coma <1 hr w/o CC/MCC
0.8097
2.7
3.488
NO
NO
01
MED
Concussion w MCC
1.5966
4.3
6.189
NO
NO
01
MED
Concussion w CC
0.9494
3.0
3.890
NO
NO
01
MED
Concussion w/o CC/MCC
0.6755
2.0
2.591
YES
NO
01
MED
Other disorders of nervous system w MCC
1.6189
4.9
6.892
YES
NO
01
MED
Other disorders of nervous system w CC
0.9082
3.6
4.593
YES
NO
01
MED
Other disorders of nervous system w/o CC/MCC
0.6805
2.6
3.294
NO
NO
01
MED
Bacterial & tuberculous infections of nervous system w MCC
3.5061
10.3
12.995
NO
NO
01
MED
Bacterial & tuberculous infections of nervous system w CC
2.3341
7.7
9.496
NO
NO
01
MED
Bacterial & tuberculous infections of nervous system w/o CC/MCC
1.9369
5.1
6.397
NO
NO
01
MED
Non-bacterial infect of nervous sys exc viral meningitis w MCC
3.0776
9.6
12.098
NO
NO
01
MED
Non-bacterial infect of nervous sys exc viral meningitis w CC
1.8380
7.0
8.799
NO
NO
01
MED
Non-bacterial infect of nervous sys exc viral meningitis w/o CC/MCC
1.3644
5.2
6.4100
YES
NO
01
MED
Seizures w MCC
1.5034
4.8
6.4101
YES
NO
01
MED
Seizures w/o MCC
0.7674
3.0
3.7102
NO
NO
01
MED
Headaches w MCC
1.0425
3.6
5.1103
NO
NO
01
MED
Headaches w/o MCC
0.6534
2.5
3.2113
NO
NO
02
SURG
Orbital procedures w CC/MCC
1.6088
3.9
5.6114
NO
NO
02
SURG
Orbital procedures w/o CC/MCC
0.8349
2.0
2.715
NO
NO
02
SURG
Extraocular procedures except orbit
1.0782
3.3
4.5116
NO
NO
02
SURG
Intraocular procedures w CC/MCC
1.0167
2.2
3.5117
NO
NO
02
SURG
Intraocular procedures w/o CC/MCC
0.6329
1.5
2.0121
NO
NO
02
MED
Acute major eye infections w CC/MCC
1.0166
4.7
5.9122
NO
NO
02
MED
Acute major eye infections w/o CC/MCC
0.5585
3.4
4.1123
NO
NO
02
MED
Neurological eye disorders
0.7168
2.4
2.9124
NO
NO
02
MED
Other disorders of the eye w MCC
1.1057
4.0
5.3125
NO
NO
02
MED
Other disorders of the eye w/o MCC
0.6561
2.7
3.5129
NO
NO
03
SURG
Major head & neck procedures w CC/MCC or major device
1.9117
3.6
5.1130
NO
NO
03
SURG
Major head & neck procedures w/o CC/MCC
1.1754
2.5
3.2131
NO
NO
03
SURG
Cranial/facial procedures w CC/MCC
1.8374
3.9
5.6132
NO
NO
03
SURG
Cranial/facial procedures w/o CC/MCC
1.0808
2.1
2.6133
NO
NO
03
SURG
Other ear, nose, mouth & throat O.R. procedures w CC/MCC
1.7401
4.1
6.4( print page 24963)134
NO
NO
03
SURG
Other ear, nose, mouth & throat O.R. procedures w/o CC/MCC
0.7834
1.8
2.3135
NO
NO
03
SURG
Sinus & mastoid procedures w CC/MCC
1.8091
4.0
6.1136
NO
NO
03
SURG
Sinus & mastoid procedures w/o CC/MCC
0.9299
1.7
2.3137
NO
NO
03
SURG
Mouth procedures w CC/MCC
1.3963
3.7
5.4138
NO
NO
03
SURG
Mouth procedures w/o CC/MCC
0.7922
1.9
2.4139
NO
NO
03
SURG
Salivary gland procedures
0.8585
1.5
1.9146
NO
NO
03
MED
Ear, nose, mouth & throat malignancy w MCC
2.2573
7.1
10.2147
NO
NO
03
MED
Ear, nose, mouth & throat malignancy w CC
1.1662
4.2
5.8148
NO
NO
03
MED
Ear, nose, mouth & throat malignancy w/o CC/MCC
0.7281
2.5
3.5149
NO
NO
03
MED
Dysequilibrium
0.6154
2.2
2.7150
NO
NO
03
MED
Epistaxis w MCC
1.3003
4.0
5.5151
NO
NO
03
MED
Epistaxis w/o MCC
0.5760
2.3
2.9152
NO
NO
03
MED
Otitis media & URI w MCC
0.9462
3.7
4.7153
NO
NO
03
MED
Otitis media & URI w/o MCC
0.6048
2.8
3.4154
NO
NO
03
MED
Nasal trauma & deformity w MCC
1.3989
4.9
6.5155
NO
NO
03
MED
Nasal trauma & deformity w CC
0.8749
3.6
4.6156
NO
NO
03
MED
Nasal trauma & deformity w/o CC/MCC
0.6360
2.5
3.2157
NO
NO
03
MED
Dental & Oral Diseases w MCC
1.4922
5.0
6.9158
NO
NO
03
MED
Dental & Oral Diseases w CC
0.8634
3.4
4.5159
NO
NO
03
MED
Dental & Oral Diseases w/o CC/MCC
0.6046
2.4
3.1163
YES
NO
04
SURG
Major chest procedures w MCC
5.0199
12.7
15.4164
YES
NO
04
SURG
Major chest procedures w CC
2.5482
7.0
8.5165
YES
NO
04
SURG
Major chest procedures w/o CC/MCC
1.7780
4.5
5.4166
YES
NO
04
SURG
Other resp system O.R. procedures w MCC
3.7734
10.6
13.4167
YES
NO
04
SURG
Other resp system O.R. procedures w CC
2.0778
6.7
8.3168
YES
NO
04
SURG
Other resp system O.R. procedures w/o CC/MCC
1.3566
4.1
5.5175
YES
NO
04
MED
Pulmonary embolism w MCC
1.6160
6.4
7.6176
YES
NO
04
MED
Pulmonary embolism w/o MCC
1.0969
4.9
5.6177
YES
NO
04
MED
Respiratory infections & inflammations w MCC
2.0518
7.6
9.5178
YES
NO
04
MED
Respiratory infections & inflammations w CC
1.5058
6.3
7.7179
YES
NO
04
MED
Respiratory infections & inflammations w/o CC/MCC
1.0484
4.8
5.8180
NO
NO
04
MED
Respiratory neoplasms w MCC
1.7205
6.1
8.0181
NO
NO
04
MED
Respiratory neoplasms w CC
1.2288
4.6
6.0182
NO
NO
04
MED
Respiratory neoplasms w/o CC/MCC
0.8973
3.3
4.3183
NO
NO
04
MED
Major chest trauma w MCC
1.5059
5.7
7.2184
NO
NO
04
MED
Major chest trauma w CC
0.9082
3.8
4.7185
NO
NO
04
MED
Major chest trauma w/o CC/MCC
0.6322
2.7
3.3186
YES
NO
04
MED
Pleural effusion w MCC
1.6338
6.0
7.7187
YES
NO
04
MED
Pleural effusion w CC
1.1228
4.4
5.6188
YES
NO
04
MED
Pleural effusion w/o CC/MCC
0.8350
3.3
4.2189
NO
NO
04
MED
Pulmonary edema & respiratory failure
1.3833
4.9
6.3190
YES
NO
04
MED
Chronic obstructive pulmonary disease w MCC
1.3448
5.3
6.6191
YES
NO
04
MED
Chronic obstructive pulmonary disease w CC
1.0024
4.3
5.2192
YES
NO
04
MED
Chronic obstructive pulmonary disease w/o CC/MCC
0.7484
3.4
4.1193
YES
NO
04
MED
Simple pneumonia & pleurisy w MCC
1.4737
5.7
7.0194
YES
NO
04
MED
Simple pneumonia & pleurisy w CC
1.0280
4.5
5.4195
YES
NO
04
MED
Simple pneumonia & pleurisy w/o CC/MCC
0.7461
3.6
4.2196
YES
NO
04
MED
Interstitial lung disease w MCC
1.5597
6.0
7.5197
YES
NO
04
MED
Interstitial lung disease w CC
1.1041
4.5
5.5198
YES
NO
04
MED
Interstitial lung disease w/o CC/MCC
0.8423
3.5
4.3199
NO
NO
04
MED
Pneumothorax w MCC
1.7928
6.7
8.5200
NO
NO
04
MED
Pneumothorax w CC
1.0158
4.0
5.2201
NO
NO
04
MED
Pneumothorax w/o CC/MCC
0.7356
3.2
4.1202
NO
NO
04
MED
Bronchitis & asthma w CC/MCC
0.8324
3.6
4.5203
NO
NO
04
MED
Bronchitis & asthma w/o CC/MCC
0.6040
2.9
3.5204
NO
NO
04
MED
Respiratory signs & symptoms
0.6685
2.2
2.9( print page 24964)205
YES
NO
04
MED
Other respiratory system diagnoses w MCC
1.2260
4.4
5.8206
YES
NO
04
MED
Other respiratory system diagnoses w/o MCC
0.7438
2.7
3.5207
YES
NO
04
MED
Respiratory system diagnosis w ventilator support 96+ hours
5.1817
13.0
15.3208
NO
NO
04
MED
Respiratory system diagnosis w ventilator support <96 hours
2.2694
5.3
7.4215
NO
NO
05
SURG
Other heart assist system implant
11.3007
6.3
12.2216
YES
NO
05
SURG
Cardiac valve & oth maj cardiothoracic proc w card cath w MCC
10.1554
16.5
19.3217
YES
NO
05
SURG
Cardiac valve & oth maj cardiothoracic proc w card cath w CC
6.7770
11.2
12.6218
YES
NO
05
SURG
Cardiac valve & oth maj cardiothoracic proc w card cath w/o CC/MCC
5.3817
8.5
9.2219
YES
YES
05
SURG
Cardiac valve & oth maj cardiothoracic proc w/o card cath w MCC
8.0521
12.0
14.7220
YES
YES
05
SURG
Cardiac valve & oth maj cardiothoracic proc w/o card cath w CC
5.2148
7.7
8.8221
YES
YES
05
SURG
Cardiac valve & oth maj cardiothoracic proc w/o card cath w/o CC/MCC
4.2664
6.1
6.5222
NO
NO
05
SURG
Cardiac defib implant w cardiac cath w AMI/HF/shock w MCC
8.7087
10.8
13.3223
NO
NO
05
SURG
Cardiac defib implant w cardiac cath w AMI/HF/shock w/o MCC
6.4941
5.0
6.6224
NO
NO
05
SURG
Cardiac defib implant w cardiac cath w/o AMI/HF/shock w MCC
8.0293
9.2
11.5225
NO
NO
05
SURG
Cardiac defib implant w cardiac cath w/o AMI/HF/shock w/o MCC
6.0000
4.6
5.8226
NO
NO
05
SURG
Cardiac defibrillator implant w/o cardiac cath w MCC
6.6475
6.2
9.4227
NO
NO
05
SURG
Cardiac defibrillator implant w/o cardiac cath w/o MCC
4.9179
1.8
2.8228
YES
NO
05
SURG
Other cardiothoracic procedures w MCC
7.6611
12.4
15.1229
YES
NO
05
SURG
Other cardiothoracic procedures w CC
4.9100
8.1
9.3230
YES
NO
05
SURG
Other cardiothoracic procedures w/o CC/MCC
3.8738
5.8
6.7231
NO
NO
05
SURG
Coronary bypass w PTCA w MCC
7.8839
10.8
13.2232
NO
NO
05
SURG
Coronary bypass w PTCA w/o MCC
5.7100
8.1
9.0233
YES
NO
05
SURG
Coronary bypass w cardiac cath w MCC
7.1576
12.9
14.7234
YES
NO
05
SURG
Coronary bypass w cardiac cath w/o MCC
4.6250
8.3
9.0235
YES
NO
05
SURG
Coronary bypass w/o cardiac cath w MCC
5.8085
10.0
11.9236
YES
NO
05
SURG
Coronary bypass w/o cardiac cath w/o MCC
3.5360
6.1
6.7237
NO
NO
05
SURG
Major cardiovascular procedures w MCC
5.1414
8.3
11.6238
NO
NO
05
SURG
Major cardiovascular procedures w/o MCC
2.8491
3.4
4.9239
YES
NO
05
SURG
Amputation for circ sys disorders exc upper limb & toe w MCC
4.4948
13.6
16.9240
YES
NO
05
SURG
Amputation for circ sys disorders exc upper limb & toe w CC
2.6343
9.4
11.4241
YES
NO
05
SURG
Amputation for circ sys disorders exc upper limb & toe w/o CC/MCC
1.6041
6.2
7.4242
YES
NO
05
SURG
Permanent cardiac pacemaker implant w MCC
3.7363
7.1
9.1243
YES
NO
05
SURG
Permanent cardiac pacemaker implant w CC
2.5922
3.9
5.2244
YES
NO
05
SURG
Permanent cardiac pacemaker implant w/o CC/MCC
2.0181
2.2
3.0245
NO
NO
05
SURG
AICD lead & generator procedures
3.1597
2.1
3.3246
NO
NO
05
SURG
PercutAneous cardiovascular proc w drugeluting stent w MCC
3.3910
4.4
6.3247
NO
NO
05
SURG
PercutAneous cardiovascular proc w drugeluting stent w/o MCC
2.0829
1.7
2.2248
NO
NO
05
SURG
PercutAneous cardiovasc proc w non drugeluting stent w MCC
2.9777
4.7
6.5249
NO
NO
05
SURG
PercutAneous cardiovasc proc w non drugeluting stent w/o MCC
1.7813
1.9
2.5250
NO
NO
05
SURG
Perc cardiovasc proc w/o coronary artery stent or AMI w MCC
2.8561
5.3
7.5( print page 24965)251
NO
NO
05
SURG
Perc cardiovasc proc w/o coronary artery stent or AMI w/o MCC
1.6341
2.1
3.0252
NO
NO
05
SURG
Other vascular procedures w MCC
2.9234
5.7
8.8253
NO
NO
05
SURG
Other vascular procedures w CC
2.2669
4.3
6.3254
NO
NO
05
SURG
Other vascular procedures w/o CC/MCC
1.5412
2.1
2.9255
YES
NO
05
SURG
Upper limb & toe amputation for circ system disorders w MCC
2.4736
8.0
10.5256
YES
NO
05
SURG
Upper limb & toe amputation for circ system disorders w CC
1.5502
6.2
7.9257
YES
NO
05
SURG
Upper limb & toe amputation for circ system disorders w/o CC/MCC
0.9882
3.9
5.2258
NO
NO
05
SURG
Cardiac pacemaker device replacement w MCC
2.9077
5.5
7.6259
NO
NO
05
SURG
Cardiac pacemaker device replacement w/o MCC
1.6063
1.9
2.6260
NO
NO
05
SURG
Cardiac pacemaker revision except device replacement w MCC
2.9653
7.3
10.3261
NO
NO
05
SURG
Cardiac pacemaker revision except device replacement w CC
1.3133
2.8
4.0262
NO
NO
05
SURG
Cardiac pacemaker revision except device replacement w/o CC/MCC
0.9197
1.9
2.5263
NO
NO
05
SURG
Vein ligation & stripping
1.5146
3.5
5.5264
YES
NO
05
SURG
Other circulatory system O.R. procedures
2.4755
6.1
9.2280
YES
NO
05
MED
Acute myocardial infarction, discharged alive w MCC
1.9690
6.4
7.8281
YES
NO
05
MED
Acute myocardial infarction, discharged alive w CC
1.2675
4.2
5.1282
YES
NO
05
MED
Acute myocardial infarction, discharged alive w/o CC/MCC
0.9121
2.7
3.4283
NO
NO
05
MED
Acute myocardial infarction, expired w MCC
1.7404
3.4
5.5284
NO
NO
05
MED
Acute myocardial infarction, expired w CC
1.0037
2.3
3.5285
NO
NO
05
MED
Acute myocardial infarction, expired w/o CC/MCC
0.6679
1.7
2.3286
NO
NO
05
MED
Circulatory disorders except AMI, w card cath w MCC
2.0464
5.3
7.1287
NO
NO
05
MED
Circulatory disorders except AMI, w card cath w/o MCC
1.0939
2.5
3.2288
YES
NO
05
MED
Acute & subacute endocarditis w MCC
3.1146
10.4
12.8289
YES
NO
05
MED
Acute & subacute endocarditis w CC
1.9306
7.7
9.2290
YES
NO
05
MED
Acute & subacute endocarditis w/o CC/MCC
1.2534
5.6
6.9291
YES
NO
05
MED
Heart failure & shock w MCC
1.4850
5.3
6.8292
YES
NO
05
MED
Heart failure & shock w CC
1.0216
4.3
5.2293
YES
NO
05
MED
Heart failure & shock w/o CC/MCC
0.7317
3.1
3.8294
NO
NO
05
MED
Deep vein thrombophlebitis w CC/MCC
0.9403
4.6
5.6295
NO
NO
05
MED
Deep vein thrombophlebitis w/o CC/MCC
0.5995
3.8
4.4296
NO
NO
05
MED
Cardiac arrest, unexplained w MCC
1.3021
2.0
3.3297
NO
NO
05
MED
Cardiac arrest, unexplained w CC
0.7673
1.5
2.0298
NO
NO
05
MED
Cardiac arrest, unexplained w/o CC/MCC
0.4932
1.2
1.5299
YES
NO
05
MED
Peripheral vascular disorders w MCC
1.4537
5.4
7.1300
YES
NO
05
MED
Peripheral vascular disorders w CC
0.9234
4.3
5.3301
YES
NO
05
MED
Peripheral vascular disorders w/o CC/MCC
0.6535
3.1
3.8302
NO
NO
05
MED
Atherosclerosis w MCC
1.0240
3.3
4.4303
NO
NO
05
MED
Atherosclerosis w/o MCC
0.5972
2.1
2.6304
NO
NO
05
MED
Hypertension w MCC
1.0693
4.0
5.3305
NO
NO
05
MED
Hypertension w/o MCC
0.5937
2.3
2.9306
NO
NO
05
MED
Cardiac congenital & valvular disorders w MCC
1.4448
4.7
6.5307
NO
NO
05
MED
Cardiac congenital & valvular disorders w/o MCC
0.7582
2.8
3.5308
NO
NO
05
MED
Cardiac arrhythmia & conduction disorders w MCC
1.3406
4.3
5.8309
NO
NO
05
MED
Cardiac arrhythmia & conduction disorders w CC
0.8421
3.2
4.0310
NO
NO
05
MED
Cardiac arrhythmia & conduction disorders w/o CC/MCC
0.5917
2.3
2.8311
NO
NO
05
MED
Angina pectoris
0.5209
1.9
2.3( print page 24966)312
NO
NO
05
MED
Syncope & collapse
0.7198
2.5
3.2313
NO
NO
05
MED
Chest pain
0.5588
1.7
2.1314
YES
NO
05
MED
Other circulatory system diagnoses w MCC
1.7436
5.3
7.3315
YES
NO
05
MED
Other circulatory system diagnoses w CC
0.9947
3.7
4.8316
YES
NO
05
MED
Other circulatory system diagnoses w/o CC/MCC
0.6650
2.4
3.1326
YES
NO
06
SURG
Stomach, esophageal & duodenal proc w MCC
5.9079
13.9
17.7327
YES
NO
06
SURG
Stomach, esophageal & duodenal proc w CC
2.8426
8.2
10.5328
YES
NO
06
SURG
Stomach, esophageal & duodenal proc w/o CC/MCC
1.4776
3.4
4.6329
YES
NO
06
SURG
Major small & large bowel procedures w MCC
5.1551
13.3
16.4330
YES
NO
06
SURG
Major small & large bowel procedures w CC
2.5597
8.6
10.0331
YES
NO
06
SURG
Major small & large bowel procedures w/o CC/MCC
1.6155
5.5
6.1332
YES
NO
06
SURG
Rectal resection w MCC
4.6624
12.7
15.2333
YES
NO
06
SURG
Rectal resection w CC
2.4296
8.0
9.1334
YES
NO
06
SURG
Rectal resection w/o CC/MCC
1.5965
5.0
5.7335
YES
NO
06
SURG
Peritoneal adhesiolysis w MCC
4.2165
12.2
14.7336
YES
NO
06
SURG
Peritoneal adhesiolysis w CC
2.2499
7.8
9.4337
YES
NO
06
SURG
Peritoneal adhesiolysis w/o CC/MCC
1.4712
4.5
5.7338
NO
NO
06
SURG
Appendectomy w complicated principal diag w MCC
3.3316
9.1
10.9339
NO
NO
06
SURG
Appendectomy w complicated principal diag w CC
1.8705
6.2
7.2340
NO
NO
06
SURG
Appendectomy w complicated principal diag w/o CC/MCC
1.2680
3.6
4.3341
NO
NO
06
SURG
Appendectomy w/o complicated principal diag w MCC
2.3828
5.4
7.3342
NO
NO
06
SURG
Appendectomy w/o complicated principal diag w CC
1.3623
3.4
4.4343
NO
NO
06
SURG
Appendectomy w/o complicated principal diag w/o CC/MCC
0.9442
1.9
2.3344
NO
NO
06
SURG
Minor small & large bowel procedures w MCC
3.1864
9.4
12.1345
NO
NO
06
SURG
Minor small & large bowel procedures w CC
1.6018
6.3
7.3346
NO
NO
06
SURG
Minor small & large bowel procedures w/o CC/MCC
1.1496
4.5
5.0347
NO
NO
06
SURG
Anal & stomal procedures w MCC
2.1945
6.2
8.4348
NO
NO
06
SURG
Anal & stomal procedures w CC
1.2723
4.2
5.6349
NO
NO
06
SURG
Anal & stomal procedures w/o CC/MCC
0.7728
2.4
3.1350
NO
NO
06
SURG
Inguinal & femoral hernia procedures w MCC
2.3797
5.9
8.1351
NO
NO
06
SURG
Inguinal & femoral hernia procedures w CC
1.2299
3.5
4.7352
NO
NO
06
SURG
Inguinal & femoral hernia procedures w/o CC/MCC
0.7910
1.9
2.5353
NO
NO
06
SURG
Hernia procedures except inguinal & femoral w MCC
2.5720
6.6
8.7354
NO
NO
06
SURG
Hernia procedures except inguinal & femoral w CC
1.3793
4.0
5.1355
NO
NO
06
SURG
Hernia procedures except inguinal & femoral w/o CC/MCC
0.9375
2.3
2.9356
YES
NO
06
SURG
Other digestive system O.R. procedures w MCC
3.8336
10.0
13.7357
YES
NO
06
SURG
Other digestive system O.R. procedures w CC
2.1324
6.3
8.3358
YES
NO
06
SURG
Other digestive system O.R. procedures w/o CC/MCC
1.4045
3.6
4.7368
NO
NO
06
MED
Major esophageal disorders w MCC
1.6379
5.1
6.7369
NO
NO
06
MED
Major esophageal disorders w CC
1.0821
3.9
4.8370
NO
NO
06
MED
Major esophageal disorders w/o CC/MCC
0.8138
2.9
3.4371
YES
NO
06
MED
Major gastrointestinal disorders & peritoneal infections w MCC
1.8831
6.9
9.0( print page 24967)372
YES
NO
06
MED
Major gastrointestinal disorders & peritoneal infections w CC
1.2657
5.8
7.0373
YES
NO
06
MED
Major gastrointestinal disorders & peritoneal infections w/o CC/MCC
0.8644
4.3
5.1374
YES
NO
06
MED
Digestive malignancy w MCC
2.0243
6.7
9.0375
YES
NO
06
MED
Digestive malignancy w CC
1.2489
4.7
6.1376
YES
NO
06
MED
Digestive malignancy w/o CC/MCC
0.8688
3.2
4.1377
YES
NO
06
MED
G.I. hemorrhage w MCC
1.6119
5.2
6.6378
YES
NO
06
MED
G.I. hemorrhage w CC
1.0451
3.9
4.8379
YES
NO
06
MED
G.I. hemorrhage w/o CC/MCC
0.7745
3.0
3.5380
YES
NO
06
MED
Complicated peptic ulcer w MCC
1.7245
5.7
7.4381
YES
NO
06
MED
Complicated peptic ulcer w CC
1.1612
4.4
5.4382
YES
NO
06
MED
Complicated peptic ulcer w/o CC/MCC
0.8139
3.1
3.7383
NO
NO
06
MED
Uncomplicated peptic ulcer w MCC
1.2971
4.6
5.9384
NO
NO
06
MED
Uncomplicated peptic ulcer w/o MCC
0.8274
3.2
3.9385
NO
NO
06
MED
Inflammatory bowel disease w MCC
1.8700
6.7
9.0386
NO
NO
06
MED
Inflammatory bowel disease w CC
1.0592
4.6
5.8387
NO
NO
06
MED
Inflammatory bowel disease w/o CC/MCC
0.8063
3.6
4.4388
YES
NO
06
MED
G.I. obstruction w MCC
1.5834
5.7
7.6389
YES
NO
06
MED
G.I. obstruction w CC
0.9405
4.1
5.1390
YES
NO
06
MED
G.I. obstruction w/o CC/MCC
0.6490
3.0
3.6391
NO
NO
06
MED
Esophagitis, gastroent & misc digest disorders w MCC
1.1256
4.1
5.5392
NO
NO
06
MED
Esophagitis, gastroent & misc digest disorders w/o MCC
0.6920
2.8
3.6393
NO
NO
06
MED
Other digestive system diagnoses w MCC
1.5389
5.0
7.0394
NO
NO
06
MED
Other digestive system diagnoses w CC
0.9667
3.9
5.0395
NO
NO
06
MED
Other digestive system diagnoses w/o CC/MCC
0.6878
2.7
3.4405
YES
NO
07
SURG
Pancreas, liver & shunt procedures w MCC
5.7069
13.3
17.8406
YES
NO
07
SURG
Pancreas, liver & shunt procedures w CC
2.7512
7.2
9.6407
YES
NO
07
SURG
Pancreas, liver & shunt procedures w/o CC/MCC
1.7634
4.3
5.6408
NO
NO
07
SURG
Biliary tract proc except only cholecyst w or w/o c.d.e. w MCC
4.2285
12.1
14.9409
NO
NO
07
SURG
Biliary tract proc except only cholecyst w or w/o c.d.e. w CC
2.4974
8.3
10.0410
NO
NO
07
SURG
Biliary tract proc except only cholecyst w or w/o c.d.e. w/o CC/MCC
1.7031
5.8
6.8411
NO
NO
07
SURG
Cholecystectomy w c.d.e. w MCC
3.9469
10.9
13.1412
NO
NO
07
SURG
Cholecystectomy w c.d.e. w CC
2.4190
7.6
8.9413
NO
NO
07
SURG
Cholecystectomy w c.d.e. w/o CC/MCC
1.7392
5.2
6.1414
YES
NO
07
SURG
Cholecystectomy except by laparoscope w/o c.d.e. w MCC
3.6536
10.0
12.1415
YES
NO
07
SURG
Cholecystectomy except by laparoscope w/o c.d.e. w CC
2.0589
6.7
7.8416
YES
NO
07
SURG
Cholecystectomy except by laparoscope w/o c.d.e. w/o CC/MCC
1.3309
4.2
4.9417
NO
NO
07
SURG
Laparoscopic cholecystectomy w/o c.d.e. w MCC
2.5133
6.6
8.4418
NO
NO
07
SURG
Laparoscopic cholecystectomy w/o c.d.e. w CC
1.6868
4.5
5.7419
NO
NO
07
SURG
Laparoscopic cholecystectomy w/o c.d.e. w/o CC/MCC
1.1458
2.5
3.2420
NO
NO
07
SURG
Hepatobiliary diagnostic procedures w MCC
4.1023
10.1
14.1421
NO
NO
07
SURG
Hepatobiliary diagnostic procedures w CC
1.9241
5.6
7.9422
NO
NO
07
SURG
Hepatobiliary diagnostic procedures w/o CC/MCC
1.1906
3.4
4.5423
NO
NO
07
SURG
Other hepatobiliary or pancreas O.R. procedures w MCC
4.2038
11.4
15.4424
NO
NO
07
SURG
Other hepatobiliary or pancreas O.R. procedures w CC
2.4168
7.8
10.3425
NO
NO
07
SURG
Other hepatobiliary or pancreas O.R. procedures w/o CC/MCC
1.6595
4.7
5.9432
NO
NO
07
MED
Cirrhosis & alcoholic hepatitis w MCC
1.6308
5.2
6.9433
NO
NO
07
MED
Cirrhosis & alcoholic hepatitis w CC
0.9191
3.8
4.9434
NO
NO
07
MED
Cirrhosis & alcoholic hepatitis w/o CC/MCC
0.6679
2.8
3.6( print page 24968)435
NO
NO
07
MED
Malignancy of hepatobiliary system or pancreas w MCC
1.7244
5.8
7.7436
NO
NO
07
MED
Malignancy of hepatobiliary system or pancreas w CC
1.1881
4.6
5.9437
NO
NO
07
MED
Malignancy of hepatobiliary system or pancreas w/o CC/MCC
0.9486
3.3
4.4438
NO
NO
07
MED
Disorders of pancreas except malignancy w MCC
1.7775
5.7
7.8439
NO
NO
07
MED
Disorders of pancreas except malignancy w CC
1.0709
4.3
5.5440
NO
NO
07
MED
Disorders of pancreas except malignancy w/o CC/MCC
0.7280
3.2
3.9441
YES
NO
07
MED
Disorders of liver except malig,cirr,alc hepa w MCC
1.5813
5.2
7.1442
YES
NO
07
MED
Disorders of liver except malig,cirr,alc hepa w CC
0.9918
4.1
5.2443
YES
NO
07
MED
Disorders of liver except malig,cirr,alc hepa w/o CC/MCC
0.7215
3.1
3.9444
NO
NO
07
MED
Disorders of the biliary tract w MCC
1.5675
5.2
6.7445
NO
NO
07
MED
Disorders of the biliary tract w CC
1.0589
3.9
4.9446
NO
NO
07
MED
Disorders of the biliary tract w/o CC/MCC
0.7631
2.7
3.3453
NO
NO
08
SURG
Combined anterior/posterior spinal fusion w MCC
10.1153
12.7
15.9454
NO
NO
08
SURG
Combined anterior/posterior spinal fusion w CC
6.5111
7.0
8.7455
NO
NO
08
SURG
Combined anterior/posterior spinal fusion w/o CC/MCC
4.8831
4.2
4.9456
NO
NO
08
SURG
Spinal fusion exc cerv w spinal curv, malig or 9+ fusions w MCC
8.2061
12.2
15.7457
NO
NO
08
SURG
Spinal fusion exc cerv w spinal curv, malig or 9+ fusions w CC
5.5526
6.8
8.3458
NO
NO
08
SURG
Spinal fusion exc cerv w spinal curv, malig or 9+ fusions w/o CC/MCC
4.5646
4.2
4.8459
YES
NO
08
SURG
Spinal fusion except cervical w MCC
5.8259
8.2
10.0460
YES
NO
08
SURG
Spinal fusion except cervical w/o MCC
3.4246
3.8
4.4461
NO
NO
08
SURG
Bilateral or multiple major joint procs of lower extremity w MCC
4.4292
7.0
8.4462
NO
NO
08
SURG
Bilateral or multiple major joint procs of lower extremity w/o MCC
3.0007
3.9
4.3463
YES
NO
08
SURG
Wnd debrid & skn grft exc hand, for musculoconn tiss dis w MCC
4.6953
14.0
18.3464
YES
NO
08
SURG
Wnd debrid & skn grft exc hand, for musculoconn tiss dis w CC
2.5929
8.4
11.0465
YES
NO
08
SURG
Wnd debrid & skn grft exc hand, for musculo-conn tiss dis w/o CC/MCC
1.5985
4.9
6.5466
YES
NO
08
SURG
Revision of hip or knee replacement w MCC
4.3570
8.2
10.2467
YES
NO
08
SURG
Revision of hip or knee replacement w CC
2.9233
5.3
6.3468
YES
NO
08
SURG
Revision of hip or knee replacement w/o CC/MCC
2.2405
3.7
4.1469
YES
NO
08
SURG
Major joint replacement or reattachment of lower extremity w MCC
3.2932
7.5
8.9470
YES
NO
08
SURG
Major joint replacement or reattachment of lower extremity w/o MCC
1.9422
3.8
4.0471
NO
NO
08
SURG
Cervical spinal fusion w MCC
4.3150
7.0
10.1472
NO
NO
08
SURG
Cervical spinal fusion w CC
2.5303
2.9
4.4473
NO
NO
08
SURG
Cervical spinal fusion w/o CC/MCC
1.8721
1.6
2.0474
YES
NO
08
SURG
Amputation for musculoskeletal sys & conn tissue dis w MCC
3.3888
10.6
13.5475
YES
NO
08
SURG
Amputation for musculoskeletal sys & conn tissue dis w CC
1.9833
7.2
9.2476
YES
NO
08
SURG
Amputation for musculoskeletal sys & conn tissue dis w/o CC/MCC
1.1111
4.0
5.2477
YES
YES
08
SURG
Biopsies of musculoskeletal system & connective tissue w MCC
3.3833
9.9
12.8478
YES
YES
08
SURG
Biopsies of musculoskeletal system & connective tissue w CC
2.0553
4.9
7.0( print page 24969)479
YES
YES
08
SURG
Biopsies of musculoskeletal system & connective tissue w/o CC/MCC
1.4543
1.9
2.9480
YES
YES
08
SURG
Hip & femur procedures except major joint w MCC
2.8506
8.2
9.7481
YES
YES
08
SURG
Hip & femur procedures except major joint w CC
1.8267
5.7
6.3482
YES
YES
08
SURG
Hip & femur procedures except major joint w/o CC/MCC
1.4721
4.6
5.0483
NO
NO
08
SURG
Major joint & limb reattachment proc of upper extremity w CC/MCC
2.1725
3.6
4.6484
NO
NO
08
SURG
Major joint & limb reattachment proc of upper extremity w/o CC/MCC
1.6673
2.2
2.5485
NO
NO
08
SURG
Knee procedures w pdx of infection w MCC
3.2946
10.4
12.7486
NO
NO
08
SURG
Knee procedures w pdx of infection w CC
2.1122
7.0
8.4487
NO
NO
08
SURG
Knee procedures w pdx of infection w/o CC/MCC
1.5140
5.1
5.8488
NO
NO
08
SURG
Knee procedures w/o pdx of infection w CC/MCC
1.6962
4.3
5.7489
NO
NO
08
SURG
Knee procedures w/o pdx of infection w/o CC/MCC
1.0796
2.6
3.1490
NO
NO
08
SURG
Back & neck procedures except spinal fusion w CC/MCC or disc devices
1.6543
3.4
4.9491
NO
NO
08
SURG
Back & neck procedures except spinal fusion w/o CC/MCC
0.9538
1.8
2.3492
YES
YES
08
SURG
Lower extrem & humer proc except hip,foot,femur w MCC
2.7254
7.1
8.9493
YES
YES
08
SURG
Lower extrem & humer proc except hip, foot, femur w CC
1.7402
4.5
5.5494
YES
YES
08
SURG
Lower extrem & humer proc except hip, foot, femur w/o CC/MCC
1.2067
2.9
3.4495
YES
NO
08
SURG
Local excision & removal int fix devices exc hip & femur w MCC
3.2333
9.0
11.7496
YES
NO
08
SURG
Local excision & removal int fix devices exc hip & femur w CC
1.7033
4.7
6.2497
YES
NO
08
SURG
Local excision & removal int fix devices exc hip & femur w/o CC/MCC
1.1384
2.4
3.3498
NO
NO
08
SURG
Local excision & removal int fix devices of hip & femur w CC/MCC
2.0669
6.0
8.4499
NO
NO
08
SURG
Local excision & removal int fix devices of hip & femur w/o CC/MCC
0.9152
2.4
3.3500
YES
YES
08
SURG
Soft tissue procedures w MCC
3.0695
8.4
11.5501
YES
YES
08
SURG
Soft tissue procedures w CC
1.4828
4.6
6.1502
YES
YES
08
SURG
Soft tissue procedures w/o CC/MCC
0.9295
2.3
3.0503
NO
NO
08
SURG
Foot procedures w MCC
2.1343
6.9
8.9504
NO
NO
08
SURG
Foot procedures w CC
1.4821
5.1
6.5505
NO
NO
08
SURG
Foot procedures w/o CC/MCC
0.9794
2.6
3.4506
NO
NO
08
SURG
Major thumb or joint procedures
0.9900
2.3
3.2507
NO
NO
08
SURG
Major shoulder or elbow joint procedures w CC/MCC
1.6307
3.8
5.3508
NO
NO
08
SURG
Major shoulder or elbow joint procedures w/o CC/MCC
1.0467
1.7
2.1509
NO
NO
08
SURG
Arthroscopy
1.0441
2.0
2.9510
NO
NO
08
SURG
Shoulder, elbow or forearm proc, exc major joint proc w MCC
2.0281
5.0
6.6511
NO
NO
08
SURG
Shoulder, elbow or forearm proc, exc major joint proc w CC
1.2889
3.1
3.9512
NO
NO
08
SURG
Shoulder, elbow or forearm proc, exc major joint proc w/o CC/MCC
0.9269
1.7
2.1513
NO
NO
08
SURG
Hand or wrist proc, except major thumb or joint proc w CC/MCC
1.3544
3.7
5.1514
NO
NO
08
SURG
Hand or wrist proc, except major thumb or joint proc w/o CC/MCC
0.8233
2.0
2.6515
YES
YES
08
SURG
Other musculoskelet sys & conn tiss O.R. proc w MCC
3.0667
8.4
11.1516
YES
YES
08
SURG
Other musculoskelet sys & conn tiss O.R. proc w CC
1.8221
4.5
6.1( print page 24970)517
YES
YES
08
SURG
Other musculoskelet sys & conn tiss O.R. proc w/o CC/MCC
1.3195
2.1
2.9533
YES
NO
08
MED
Fractures of femur w MCC
1.4317
5.5
7.2534
YES
NO
08
MED
Fractures of femur w/o MCC
0.6905
3.4
4.2535
YES
NO
08
MED
Fractures of hip & pelvis w MCC
1.3683
5.1
6.6536
YES
NO
08
MED
Fractures of hip & pelvis w/o MCC
0.6743
3.5
4.1537
NO
NO
08
MED
Sprains, strains, & dislocations of hip, pelvis & thigh w CC/MCC
0.8451
3.9
4.7538
NO
NO
08
MED
Sprains, strains, & dislocations of hip, pelvis & thigh w/o CC/MCC
0.5424
2.6
3.1539
YES
NO
08
MED
Osteomyelitis w MCC
2.0095
8.4
10.8540
YES
NO
08
MED
Osteomyelitis w CC
1.3085
6.2
7.6541
YES
NO
08
MED
Osteomyelitis w/o CC/MCC
0.9229
4.6
5.8542
YES
NO
08
MED
Pathological fractures & musculoskelet & conn tiss malig w MCC
1.8245
7.1
9.0543
YES
NO
08
MED
Pathological fractures & musculoskelet & conn tiss malig w CC
1.1004
5.0
6.2544
YES
NO
08
MED
Pathological fractures & musculoskelet & conn tiss malig w/o CC/MCC
0.7580
3.9
4.6545
YES
NO
08
MED
Connective tissue disorders w MCC
2.2353
6.7
9.2546
YES
NO
08
MED
Connective tissue disorders w CC
1.0595
4.4
5.6547
YES
NO
08
MED
Connective tissue disorders w/o CC/MCC
0.7387
3.2
4.0548
NO
NO
08
MED
Septic arthritis w MCC
1.8774
7.2
9.5549
NO
NO
08
MED
Septic arthritis w CC
1.1402
5.2
6.4550
NO
NO
08
MED
Septic arthritis w/o CC/MCC
0.7637
3.7
4.6551
YES
NO
08
MED
Medical back problems w MCC
1.5024
5.8
7.5552
YES
NO
08
MED
Medical back problems w/o MCC
0.7526
3.5
4.2553
NO
NO
08
MED
Bone diseases & arthropathies w MCC
1.0922
4.8
6.1554
NO
NO
08
MED
Bone diseases & arthropathies w/o MCC
0.6166
3.0
3.7555
NO
NO
08
MED
Signs & symptoms of musculoskeletal system & conn tissue w MCC
0.9488
3.6
4.9556
NO
NO
08
MED
Signs & symptoms of musculoskeletal system & conn tissue w/o MCC
0.5771
2.5
3.2557
YES
NO
08
MED
Tendonitis, myositis & bursitis w MCC
1.5172
5.7
7.2558
YES
NO
08
MED
Tendonitis, myositis & bursitis w/o MCC
0.7900
3.6
4.3559
YES
NO
08
MED
Aftercare, musculoskeletal system & connective tissue w MCC
1.6221
5.6
7.7560
YES
NO
08
MED
Aftercare, musculoskeletal system & connective tissue w CC
0.9149
3.8
4.9561
YES
NO
08
MED
Aftercare, musculoskeletal system & connective tissue w/o CC/MCC
0.5701
2.2
2.8562
YES
NO
08
MED
Fx, sprn, strn & disl except femur, hip, pelvis & thigh w MCC
1.3859
5.3
6.8563
YES
NO
08
MED
Fx, sprn, strn & disl except femur, hip, pelvis & thigh w/o MCC
0.6597
3.2
3.8564
NO
NO
08
MED
Other musculoskeletal sys & connective tissue diagnoses w MCC
1.4031
5.4
7.2565
NO
NO
08
MED
Other musculoskeletal sys & connective tissue diagnoses w CC
0.8829
4.0
5.1566
NO
NO
08
MED
Other musculoskeletal sys & connective tissue diagnoses w/o CC/MCC
0.6423
3.0
3.8573
YES
NO
09
SURG
Skin graft &/or debrid for skn ulcer or cellulitis w MCC
3.2955
11.3
14.9574
YES
NO
09
SURG
Skin graft &/or debrid for skn ulcer or cellulitis w CC
1.9279
7.9
10.1575
YES
NO
09
SURG
Skin graft &/or debrid for skn ulcer or cellulitis w/o CC/MCC
1.1628
5.0
6.2576
NO
NO
09
SURG
Skin graft &/or debrid exc for skin ulcer or cellulitis w MCC
3.2274
7.8
12.2577
NO
NO
09
SURG
Skin graft &/or debrid exc for skin ulcer or cellulitis w CC
1.5681
4.1
6.0578
NO
NO
09
SURG
Skin graft &/or debrid exc for skin ulcer or cellulitis w/o CC/MCC
0.9412
2.5
3.5579
YES
NO
09
SURG
Other skin, subcut tiss & breast proc w MCC
2.9032
9.1
12.0580
YES
NO
09
SURG
Other skin, subcut tiss & breast proc w CC
1.6213
5.7
7.5( print page 24971)581
YES
NO
09
SURG
Other skin, subcut tiss & breast proc w/o CC/MCC
0.9588
3.0
4.1582
NO
NO
09
SURG
Mastectomy for malignancy w CC/MCC
0.9881
2.1
2.8583
NO
NO
09
SURG
Mastectomy for malignancy w/o CC/MCC
0.7441
1.5
1.8584
NO
NO
09
SURG
Breast biopsy, local excision & other breast procedures w CC/MCC
1.2819
2.7
4.5585
NO
NO
09
SURG
Breast biopsy, local excision & other breast procedures w/o CC/MCC
0.7975
1.5
1.9592
YES
NO
09
MED
Skin ulcers w MCC
1.7628
7.1
9.3593
YES
NO
09
MED
Skin ulcers w CC
1.0687
5.5
6.7594
YES
NO
09
MED
Skin ulcers w/o CC/MCC
0.7221
4.1
5.0595
NO
NO
09
MED
Major skin disorders w MCC
1.7504
6.1
8.3596
NO
NO
09
MED
Major skin disorders w/o MCC
0.8037
3.8
4.8597
NO
NO
09
MED
Malignant breast disorders w MCC
1.6544
5.9
8.1598
NO
NO
09
MED
Malignant breast disorders w CC
1.0084
4.3
5.6599
NO
NO
09
MED
Malignant breast disorders w/o CC/MCC
0.6089
2.6
3.6600
NO
NO
09
MED
Non-malignant breast disorders w CC/MCC
0.9421
4.2
5.4601
NO
NO
09
MED
Non-malignant breast disorders w/o CC/MCC
0.6207
3.1
3.8602
YES
NO
09
MED
Cellulitis w MCC
1.3689
5.7
7.2603
YES
NO
09
MED
Cellulitis w/o MCC
0.7698
4.0
4.8604
NO
NO
09
MED
Trauma to the skin, subcut tiss & breast w MCC
1.1521
4.2
5.4605
NO
NO
09
MED
Trauma to the skin, subcut tiss & breast w/o MCC
0.6584
2.8
3.5606
NO
NO
09
MED
Minor skin disorders w MCC
1.0928
4.2
5.9607
NO
NO
09
MED
Minor skin disorders w/o MCC
0.6163
2.9
3.8614
NO
NO
10
SURG
Adrenal & pituitary procedures w CC/MCC
2.4677
5.3
7.4615
NO
NO
10
SURG
Adrenal & pituitary procedures w/o CC/MCC
1.3907
2.8
3.4616
YES
NO
10
SURG
Amputat of lower limb for endocrine, nutrit, & metabol dis w MCC
3.9552
13.8
16.6617
YES
NO
10
SURG
Amputat of lower limb for endocrine, nutrit, & metabol dis w CC
2.0973
7.7
9.4618
YES
NO
10
SURG
Amputat of lower limb for endocrine, nutrit, & metabol dis w/o CC/MCC
1.3024
5.4
6.7619
NO
NO
10
SURG
O.R. procedures for obesity w MCC
3.7048
6.4
9.3620
NO
NO
10
SURG
O.R. procedures for obesity w CC
2.0768
3.4
4.3621
NO
NO
10
SURG
O.R. procedures for obesity w/o CC/MCC
1.5791
2.1
2.4622
YES
NO
10
SURG
Skin grafts & wound debrid for endoc, nutrit & metab dis w MCC
3.2426
10.8
14.2623
YES
NO
10
SURG
Skin grafts & wound debrid for endoc, nutrit & metab dis w CC
1.8784
7.3
9.2624
YES
NO
10
SURG
Skin grafts & wound debrid for endoc, nutrit & metab dis w/o CC/MCC
1.1114
4.8
6.1625
NO
NO
10
SURG
Thyroid, parathyroid & thyroglossal procedures w MCC
2.2742
5.0
7.5626
NO
NO
10
SURG
Thyroid, parathyroid & thyroglossal procedures w CC
1.1509
2.2
3.3627
NO
NO
10
SURG
Thyroid, parathyroid & thyroglossal procedures w/o CC/MCC
0.7404
1.3
1.6628
YES
NO
10
SURG
Other endocrine, nutrit & metab O.R. proc w MCC
3.3711
8.0
12.0629
YES
NO
10
SURG
Other endocrine, nutrit & metab O.R. proc w CC
2.2663
7.4
9.2630
YES
NO
10
SURG
Other endocrine, nutrit & metab O.R. proc w/o CC/MCC
1.5036
4.0
5.5637
YES
NO
10
MED
Diabetes w MCC
1.3914
4.8
6.3638
YES
NO
10
MED
Diabetes w CC
0.8349
3.5
4.5639
YES
NO
10
MED
Diabetes w/o CC/MCC
0.5768
2.5
3.1640
YES
NO
10
MED
Nutritional & misc metabolic disorders w MCC
1.1366
4.2
5.7641
YES
NO
10
MED
Nutritional & misc metabolic disorders w/o MCC
0.6856
3.1
3.9642
NO
NO
10
MED
Inborn errors of metabolism
1.0612
3.8
5.2643
YES
NO
10
MED
Endocrine disorders w MCC
1.6611
6.2
8.0644
YES
NO
10
MED
Endocrine disorders w CC
1.0256
4.5
5.5( print page 24972)645
YES
NO
10
MED
Endocrine disorders w/o CC/MCC
0.7361
3.2
3.9652
NO
NO
11
SURG
Kidney transplant
2.9875
6.7
7.9653
YES
NO
11
SURG
Major bladder procedures w MCC
5.6554
14.1
17.5654
YES
NO
11
SURG
Major bladder procedures w CC
2.9409
9.0
10.3655
YES
NO
11
SURG
Major bladder procedures w/o CC/MCC
1.9932
6.0
6.7656
NO
NO
11
SURG
Kidney & ureter procedures for neoplasm w MCC
3.3280
8.4
10.8657
NO
NO
11
SURG
Kidney & ureter procedures forneoplasm w CC
1.8514
5.2
6.2658
NO
NO
11
SURG
Kidney & ureter procedures for neoplasm w/o CC/MCC
1.3628
3.4
3.9659
YES
NO
11
SURG
Kidney & ureter procedures for non-neoplasm w MCC
3.2759
8.5
11.6660
YES
NO
11
SURG
Kidney & ureter procedures for non-neoplasm w CC
1.8525
5.0
6.7661
YES
NO
11
SURG
Kidney & ureter procedures for non-neoplasm w/o CC/MCC
1.2497
2.8
3.6662
NO
NO
11
SURG
Minor bladder procedures w MCC
2.5929
7.3
10.5663
NO
NO
11
SURG
Minor bladder procedures w CC
1.3800
3.6
5.2664
NO
NO
11
SURG
Minor bladder procedures w/o CC/MCC
0.9462
1.7
2.2665
NO
NO
11
SURG
Prostatectomy w MCC
2.8312
9.3
12.2666
NO
NO
11
SURG
Prostatectomy w CC
1.5177
4.2
6.4667
NO
NO
11
SURG
Prostatectomy w/o CC/MCC
0.8075
2.1
2.9668
NO
NO
11
SURG
Transurethral procedures w MCC
2.1963
6.3
8.6669
NO
NO
11
SURG
Transurethral procedures w CC
1.1980
3.1
4.4670
NO
NO
11
SURG
Transurethral procedures w/o CC/MCC
0.7731
1.9
2.6671
NO
NO
11
SURG
Urethral procedures w CC/MCC
1.4041
4.0
5.8672
NO
NO
11
SURG
Urethral procedures w/o CC/MCC
0.7515
1.9
2.6673
NO
NO
11
SURG
Other kidney & urinary tract procedures w MCC
2.8645
6.0
10.1674
NO
NO
11
SURG
Other kidney & urinary tract procedures w CC
2.1903
4.5
7.3675
NO
NO
11
SURG
Other kidney & urinary tract procedures w/o CC/MCC
1.3402
1.7
2.6682
YES
NO
11
MED
Renal failure w MCC
1.6772
5.5
7.4683
YES
NO
11
MED
Renal failure w CC
1.1655
4.8
6.0684
YES
NO
11
MED
Renal failure w/o CC/MCC
0.7764
3.3
4.1685
NO
NO
11
MED
Admit for renal dialysis
0.8496
2.4
3.5686
NO
NO
11
MED
Kidney & urinary tract neoplasms w MCC
1.7101
6.0
8.1687
NO
NO
11
MED
Kidney & urinary tract neoplasms w CC
1.0483
4.0
5.3688
NO
NO
11
MED
Kidney & urinary tract neoplasms w/o CC/MCC
0.7032
2.6
3.3689
YES
NO
11
MED
Kidney & urinary tract infections w MCC
1.2389
5.2
6.6690
YES
NO
11
MED
Kidney & urinary tract infections w/o MCC
0.7621
3.6
4.4691
NO
NO
11
MED
Urinary stones w esw lithotripsy w CC/MCC
1.4666
3.0
4.2692
NO
NO
11
MED
Urinary stones w esw lithotripsy w/o CC/MCC
1.0647
1.8
2.3693
NO
NO
11
MED
Urinary stones w/o esw lithotripsy w MCC
1.2714
3.9
5.2694
NO
NO
11
MED
Urinary stones w/o esw lithotripsy w/o MCC
0.6729
2.0
2.6695
NO
NO
11
MED
Kidney & urinary tract signs & symptoms w MCC
1.1689
4.3
5.7696
NO
NO
11
MED
Kidney & urinary tract signs & symptoms w/o MCC
0.6054
2.6
3.2697
NO
NO
11
MED
Urethral stricture
0.7231
2.4
3.3698
YES
NO
11
MED
Other kidney & urinary tract diagnoses w MCC
1.4706
5.3
6.9699
YES
NO
11
MED
Other kidney & urinary tract diagnoses w CC
0.9845
4.0
5.1700
YES
NO
11
MED
Other kidney & urinary tract diagnoses w/o CC/MCC
0.7059
2.9
3.6707
NO
NO
12
SURG
Major male pelvic procedures w CC/MCC
1.7114
3.8
4.9708
NO
NO
12
SURG
Major male pelvic procedures w/o CC/MCC
1.1515
2.1
2.4709
NO
NO
12
SURG
Penis procedures w CC/MCC
1.9087
3.8
6.7710
NO
NO
12
SURG
Penis procedures w/o CC/MCC
1.2258
1.5
1.9711
NO
NO
12
SURG
Testes procedures w CC/MCC
1.9149
5.4
8.0712
NO
NO
12
SURG
Testes procedures w/o CC/MCC
0.8141
2.2
3.0713
NO
NO
12
SURG
Transurethral prostatectomy w CC/MCC
1.1007
2.9
4.1( print page 24973)714
NO
NO
12
SURG
Transurethral prostatectomy w/o CC/MCC
0.6342
1.7
2.0715
NO
NO
12
SURG
Other male reproductive system O.R. proc for malignancy w CC/MCC
1.8234
3.9
6.2716
NO
NO
12
SURG
Other male reproductive system O.R. proc for malignancy w/o CC/MCC
1.0017
1.3
1.5717
NO
NO
12
SURG
Other male reproductive system O.R. proc exc malignancy w CC/MCC
1.8454
5.2
7.7718
NO
NO
12
SURG
Other male reproductive system O.R. proc exc malignancy w/o CC/MCC
0.7902
2.1
2.8722
NO
NO
12
MED
Malignancy, male reproductive system w MCC
1.4829
5.6
7.5723
NO
NO
12
MED
Malignancy, male reproductive system w CC
1.0428
4.2
5.5724
NO
NO
12
MED
Malignancy, male reproductive system w/o CC/MCC
0.6146
2.5
3.4725
NO
NO
12
MED
Benign prostatic hypertrophy w MCC
1.0622
4.3
5.6726
NO
NO
12
MED
Benign prostatic hypertrophy w/o MCC
0.6648
2.8
3.5727
NO
NO
12
MED
Inflammation of the male reproductive system w MCC
1.2681
5.1
6.6728
NO
NO
12
MED
Inflammation of the male reproductive system w/o MCC
0.6875
3.3
4.1729
NO
NO
12
MED
Other male reproductive system diagnoses w CC/MCC
1.0808
3.8
5.2730
NO
NO
12
MED
Other male reproductive system diagnoses w/o CC/MCC
0.5860
2.5
3.3734
NO
NO
13
SURG
Pelvic evisceration, rad hysterectomy & rad vulvectomy w CC/MCC
2.2946
5.9
7.7735
NO
NO
13
SURG
Pelvic evisceration, rad hysterectomy & rad vulvectomy w/o CC/MCC
1.0226
3.0
3.5736
NO
NO
13
SURG
Uterine & adnexa proc for ovarian or adnexal malignancy w MCC
4.1656
11.6
13.9737
NO
NO
13
SURG
Uterine & adnexa proc for ovarian or adnexal malignancy w CC
1.9738
6.3
7.4738
NO
NO
13
SURG
Uterine & adnexa proc for ovarian or adnexal malignancy w/o CC/MCC
1.1607
3.6
4.0739
NO
NO
13
SURG
Uterine, adnexa proc for non-ovarian/adnexal malig w MCC
2.8464
7.9
10.2740
NO
NO
13
SURG
Uterine, adnexa proc for non-ovarian/adnexal malig w CC
1.3873
4.4
5.2741
NO
NO
13
SURG
Uterine, adnexa proc for non-ovarian/adnexal malig w/o CC/MCC
0.9624
2.8
3.2742
NO
NO
13
SURG
Uterine & adnexa proc for non-malignancy w CC/MCC
1.3758
3.6
4.7743
NO
NO
13
SURG
Uterine & adnexa proc for non-malignancy w/o CC/MCC
0.8461
2.1
2.4744
NO
NO
13
SURG
D&C, conization, laparascopy & tubal interruption w CC/MCC
1.4153
4.1
5.9745
NO
NO
13
SURG
D&C, conization, laparascopy & tubal interruption w/o CC/MCC
0.7416
2.1
2.6746
NO
NO
13
SURG
Vagina, cervix & vulva procedures w CC/MCC
1.2205
3.0
4.2747
NO
NO
13
SURG
Vagina, cervix & vulva procedures w/o CC/MCC
0.8192
1.7
1.9748
NO
NO
13
SURG
Female reproductive system reconstructive procedures
0.7966
1.5
1.8749
NO
NO
13
SURG
Other female reproductive system O.R. procedures w CC/MCC
2.5201
7.1
9.9750
NO
NO
13
SURG
Other female reproductive system O.R. procedures w/o CC/MCC
0.9713
2.6
3.3754
NO
NO
13
MED
Malignancy, female reproductive system w MCC
1.8553
6.4
8.9755
NO
NO
13
MED
Malignancy, female reproductive system w CC
1.0847
4.2
5.7756
NO
NO
13
MED
Malignancy, female reproductive system w/o CC/MCC
0.6339
2.5
3.3757
NO
NO
13
MED
Infections, female reproductive system w MCC
1.6992
6.8
8.9( print page 24974)758
NO
NO
13
MED
Infections, female reproductive system w CC
1.0758
4.9
6.2759
NO
NO
13
MED
Infections, female reproductive system w/o CC/MCC
0.7668
3.8
4.6760
NO
NO
13
MED
Menstrual & other female reproductive system disorders w CC/MCC
0.7794
3.0
3.8761
NO
NO
13
MED
Menstrual & other female reproductive system disorders w/o CC/MCC
0.5041
2.0
2.5765
NO
NO
14
SURG
Cesarean section w CC/MCC
0.9644
4.1
5.3766
NO
NO
14
SURG
Cesarean section w/o CC/MCC
0.6422
3.0
3.2767
NO
NO
14
SURG
Vaginal delivery w sterilization &/or D&C
0.6419
2.5
2.9768
NO
NO
14
SURG
Vaginal delivery w O.R. proc except steril &/or D&C
1.6334
4.7
5.8769
NO
NO
14
SURG
Postpartum & post abortion diagnoses w O.R. procedure
1.9655
3.3
5.7770
NO
NO
14
SURG
Abortion w D&C, aspiration curettage or hysterotomy
0.7598
1.6
2.7774
NO
NO
14
MED
Vaginal delivery w complicating diagnoses
0.5412
2.6
3.2775
NO
NO
14
MED
Vaginal delivery w/o complicating diagnoses
0.3953
2.1
2.3776
NO
NO
14
MED
Postpartum & post abortion diagnoses w/o O.R. procedure
0.6480
2.6
3.6777
NO
NO
14
MED
Ectopic pregnancy
0.7237
1.8
2.1778
NO
NO
14
MED
Threatened abortion
0.3775
2.0
2.8779
NO
NO
14
MED
Abortion w/o D&C
0.6006
1.7
2.6780
NO
NO
14
MED
False labor
0.2935
1.3
2.7781
NO
NO
14
MED
Other antepartum diagnoses w medical complications
0.5771
2.7
3.8782
NO
NO
14
MED
Other antepartum diagnoses w/o medical complications
0.4359
1.7
2.8789
NO
NO
15
MED
Neonates, died or transferred to another acute care facility
1.4246
*
*790
NO
NO
15
MED
Extreme immaturity or respiratory distress syndrome, neonate
4.6977
*
*791
NO
NO
15
MED
Prematurity w major problems
3.2084
*
*792
NO
NO
15
MED
Prematurity w/o major problems
1.9359
*
*793
NO
NO
15
MED
Full term neonate w major problems
3.2957
*
*794
NO
NO
15
MED
Neonate w other significant problems
1.1665
*
*795
NO
NO
15
MED
Normal newborn
0.1579
*
*799
NO
NO
16
SURG
Splenectomy w MCC
4.8444
10.8
14.3800
NO
NO
16
SURG
Splenectomy w CC
2.5219
6.5
8.4801
NO
NO
16
SURG
Splenectomy w/o CC/MCC
1.6365
3.8
4.9802
NO
NO
16
SURG
Other O.R. proc of the blood & blood forming organs w MCC
3.6564
9.2
12.8803
NO
NO
16
SURG
Other O.R. proc of the blood & blood forming organs w CC
1.6759
4.8
6.6804
NO
NO
16
SURG
Other O.R. proc of the blood & blood forming organs w/o CC/MCC
0.9952
2.4
3.3808
YES
NO
16
MED
Major hematol/immun diag exc sickle cell crisis & coagul w MCC
1.9239
6.2
8.1809
YES
NO
16
MED
Major hematol/immun diag exc sickle cell crisis & coagul w CC
1.0868
4.0
5.1810
YES
NO
16
MED
Major hematol/immun diag exc sickle cell crisis & coagul w/o CC/MCC
0.8426
3.1
4.0811
NO
NO
16
MED
Red blood cell disorders w MCC
1.1761
4.0
5.6812
NO
NO
16
MED
Red blood cell disorders w/o MCC
0.7332
2.8
3.7813
NO
NO
16
MED
Coagulation disorders
1.3307
3.8
5.2814
NO
NO
16
MED
Reticuloendothelial & immunity disorders w MCC
1.5585
5.4
7.2815
NO
NO
16
MED
Reticuloendothelial & immunity disorders w CC
0.9778
3.9
4.9816
NO
NO
16
MED
Reticuloendothelial & immunity disorders w/o CC/MCC
0.7021
2.7
3.4820
NO
NO
17
SURG
Lymphoma & leukemia w major O.R. procedure w MCC
5.6599
13.8
18.4821
NO
NO
17
SURG
Lymphoma & leukemia w major O.R. procedure w CC
2.2223
5.4
7.8( print page 24975)822
NO
NO
17
SURG
Lymphoma & leukemia w major O.R. procedure w/o CC/MCC
1.2363
2.7
3.7823
NO
NO
17
SURG
Lymphoma & non-acute leukemia w other O.R. proc w MCC
4.0550
12.1
15.4824
NO
NO
17
SURG
Lymphoma & non-acute leukemia w other O.R. proc w CC
2.1337
6.6
8.9825
NO
NO
17
SURG
Lymphoma & non-acute leukemia w other O.R. proc w/o CC/MCC
1.3321
3.3
4.8826
NO
NO
17
SURG
Myeloprolif disord or poorly diff neopl w maj O.R. proc w MCC
5.0473
13.2
17.4827
NO
NO
17
SURG
Myeloprolif disord or poorly diff neopl w maj O.R. proc w CC
2.0842
5.8
7.6828
NO
NO
17
SURG
Myeloprolif disord or poorly diff neopl w maj O.R. proc w/o CC/MCC
1.2241
3.0
3.8829
NO
NO
17
SURG
Myeloprolif disord or poorly diff neopl w other O.R. proc w CC/MCC
2.6852
6.9
10.5830
NO
NO
17
SURG
Myeloprolif disord or poorly diff neopl w other O.R. proc w/o CC/MCC
1.0340
2.5
3.7834
NO
NO
17
MED
Acute leukemia w/o major O.R. procedure w MCC
3.9520
9.2
15.0835
NO
NO
17
MED
Acute leukemia w/o major O.R. procedure w CC
1.8790
5.4
8.4836
NO
NO
17
MED
Acute leukemia w/o major O.R. procedure w/o CC/MCC
1.1326
3.4
5.1837
NO
NO
17
MED
Chemo w acute leukemia as sdx or w high dose chemo agent w MCC
5.7668
17.2
22.7838
NO
NO
17
MED
Chemo w acute leukemia as sdx or w high dose chemo agent w CC
2.3625
6.3
9.2839
NO
NO
17
MED
Chemo w acute leukemia as sdx or w high dose chemo agent w/o CC/MCC
1.2331
4.8
6.0840
YES
NO
17
MED
Lymphoma & non-acute leukemia w MCC
2.3808
7.1
9.8841
YES
NO
17
MED
Lymphoma & non-acute leukemia w CC
1.4326
5.1
6.7842
YES
NO
17
MED
Lymphoma & non-acute leukemia w/o CC/MCC
0.9558
3.3
4.3843
NO
NO
17
MED
Other myeloprolif dis or poorly diff neopl diag w MCC
1.9072
6.3
8.8844
NO
NO
17
MED
Other myeloprolif dis or poorly diff neopl diag w CC
1.1252
4.5
6.0845
NO
NO
17
MED
Other myeloprolif dis or poorly diff neopl diag w/o CC/MCC
0.8433
3.3
4.3846
NO
NO
17
MED
Chemotherapy w/o acute leukemia as secondary diagnosis w MCC
2.1956
5.8
8.5847
NO
NO
17
MED
Chemotherapy w/o acute leukemia as secondary diagnosis w CC
0.9758
2.7
3.3848
NO
NO
17
MED
Chemotherapy w/o acute leukemia as secondary diagnosis w/o CC/MCC
0.7495
2.3
2.9849
NO
NO
17
MED
Radiotherapy
1.2491
4.3
6.0853
YES
NO
18
SURG
Infectious & parasitic diseases w O.R. procedure w MCC
5.4321
13.4
17.4854
YES
NO
18
SURG
Infectious & parasitic diseases w O.R. procedure w CC
2.9346
9.5
11.5855
YES
NO
18
SURG
Infectious & parasitic diseases w O.R. procedure w/o CC/MCC
1.8472
5.8
7.6856
YES
NO
18
SURG
Postoperative or post-traumatic infections w O.R. proc w MCC
4.9141
13.4
17.4857
YES
NO
18
SURG
Postoperative or post-traumatic infections w O.R. proc w CC
2.0895
7.3
9.3858
YES
NO
18
SURG
Postoperative or post-traumatic infections w O.R. proc w/o CC/MCC
1.3418
5.0
6.3862
YES
NO
18
MED
Postoperative & post-traumatic infections w MCC
1.8740
6.6
8.6863
YES
NO
18
MED
Postoperative & post-traumatic infections w/o MCC
0.9224
4.4
5.4864
NO
NO
18
MED
Fever of unknown origin
0.8171
3.2
4.1865
NO
NO
18
MED
Viral illness w MCC
1.5687
4.9
6.8866
NO
NO
18
MED
Viral illness w/o MCC
0.6691
2.8
3.5( print page 24976)867
YES
NO
18
MED
Other infectious & parasitic diseases diagnoses w MCC
2.5039
7.5
10.2868
YES
NO
18
MED
Other infectious & parasitic diseases diagnoses w CC
1.1589
4.7
6.1869
YES
NO
18
MED
Other infectious & parasitic diseases diagnoses w/o CC/MCC
0.8295
3.6
4.4870
YES
NO
18
MED
Septicemia w MV 96+ hours
5.8269
13.0
15.7871
YES
NO
18
MED
Septicemia w/o MV 96+ hours w MCC
1.8811
5.8
7.8872
YES
NO
18
MED
Septicemia w/o MV 96+ hours w/o MCC
1.1304
4.8
5.9876
NO
NO
19
SURG
O.R. procedure w principal diagnoses of mental illness
2.4818
6.8
11.2880
NO
NO
19
MED
Acute adjustment reaction & psychosocial dysfunction
0.6104
2.4
3.2881
NO
NO
19
MED
Depressive neuroses
0.5320
3.1
4.2882
NO
NO
19
MED
Neuroses except depressive
0.5791
3.1
4.5883
NO
NO
19
MED
Disorders of personality & impulse control
0.8908
4.6
7.4884
YES
NO
19
MED
Organic disturbances & mental retardation
0.8407
4.2
5.5885
NO
NO
19
MED
Psychoses
0.8183
5.6
7.6886
NO
NO
19
MED
Behavioral & developmental disorders
0.7095
4.0
5.9887
NO
NO
19
MED
Other mental disorder diagnoses
0.8075
3.1
4.6894
NO
NO
20
MED
Alcohol/drug abuse or dependence, left ama
0.3712
2.1
2.9895
NO
NO
20
MED
Alcohol/drug abuse or dependence w rehabilitation therapy
.7771
8.2
10.5896
YES
NO
20
MED
Alcohol/drug abuse or dependence w/o rehabilitation therapy w MCC
1.2975
5.0
6.8897
YES
NO
20
MED
Alcohol/drug abuse or dependence w/o rehabilitation therapy w/o MCC
0.5935
3.3
4.1901
NO
NO
21
SURG
Wound debridements for injuries w MCC
3.6765
9.3
14.5902
NO
NO
21
SURG
Wound debridements for injuries w CC
1.7433
5.7
8.0903
NO
NO
21
SURG
Wound debridements for injuries w/o CC/MCC
1.0239
3.5
4.9904
NO
NO
21
SURG
Skin grafts for injuries w CC/MCC
2.9545
7.3
12.4905
NO
NO
21
SURG
Skin grafts for injuries w/o CC/MCC
1.0711
3.6
4.8906
NO
NO
21
SURG
Hand procedures for injuries
0.9899
2.2
3.3907
YES
NO
21
SURG
Other O.R. procedures for injuries w MCC
3.6201
8.4
12.0908
YES
NO
21
SURG
Other O.R. procedures for injuries w CC
1.8922
5.3
7.2909
YES
NO
21
SURG
Other O.R. procedures for injuries w/o CC/MCC
1.1253
2.8
3.7913
NO
NO
21
MED
Traumatic injury w MCC
1.3122
4.5
6.1914
NO
NO
21
MED
Traumatic injury w/o MCC
0.6590
2.7
3.4915
NO
NO
21
MED
Allergic reactions w MCC
1.1882
3.3
4.6916
NO
NO
21
MED
Allergic reactions w/o MCC
0.4531
1.7
2.1917
YES
NO
21
MED
Poisoning & toxic effects of drugs w MCC
1.4901
3.9
5.4918
YES
NO
21
MED
Poisoning & toxic effects of drugs w/o MCC
0.5940
2.1
2.7919
NO
NO
21
MED
Complications of treatment w MCC
1.4806
4.5
6.3920
NO
NO
21
MED
Complications of treatment w CC
0.9200
3.4
4.5921
NO
NO
21
MED
Complications of treatment w/o CC/MCC
0.6150
2.4
3.0922
NO
NO
21
MED
Other injury, poisoning & toxic effect diag w MCC
1.4653
4.2
6.1923
NO
NO
21
MED
Other injury, poisoning & toxic effect diag w/o MCC
0.6493
2.4
3.3927
NO
NO
22
SURG
Extensive burns or full thickness burns w MV 96+ hrs w skin graft
12.7968
23.1
29.0928
NO
NO
22
SURG
Full thickness burn w skin graft or inhal inj w CC/MCC
4.7844
12.2
16.2929
NO
NO
22
SURG
Full thickness burn w skin graft or inhal inj w/o CC/MCC
1.8538
5.6
7.8933
NO
NO
22
MED
Extensive burns or full thickness burns w MV 96+ hrs w/o skin graft
2.6367
2.7
5.9934
NO
NO
22
MED
Full thickness burn w/o skin grft or inhal inj
1.3929
4.8
7.0935
NO
NO
22
MED
Non-extensive burns
1.2000
3.7
5.6939
NO
NO
23
SURG
O.R. proc w diagnoses of other contact w health services w MCC
2.6958
7.5
11.0940
NO
NO
23
SURG
O.R. proc w diagnoses of other contact w health services w CC
1.7409
4.5
6.5( print page 24977)941
NO
NO
23
SURG
O.R. proc w diagnoses of other contact w health services w/o CC/MCC
1.0979
2.4
3.1945
YES
NO
23
MED
Rehabilitation w CC/MCC
1.1456
9.3
11.1946
YES
NO
23
MED
Rehabilitation w/o CC/MCC
0.9009
7.3
8.1947
YES
NO
23
MED
Signs & symptoms w MCC
1.0303
3.9
5.1948
YES
NO
23
MED
Signs & symptoms w/o MCC
0.6298
2.8
3.4949
NO
NO
23
MED
Aftercare w CC/MCC
0.7746
2.5
4.2950
NO
NO
23
MED
Aftercare w/o CC/MCC
0.5018
2.4
3.4951
NO
NO
23
MED
Other factors influencing health status
0.6104
2.1
3.7955
NO
NO
24
SURG
Craniotomy for multiple significant trauma
5.1127
8.6
12.3956
YES
YES
24
SURG
Limb reattachment, hip & femur proc for multiple significant trauma
3.3955
7.9
9.7957
NO
NO
24
SURG
Other O.R. procedures for multiple significant trauma w MCC
6.8026
11.6
16.9958
NO
NO
24
SURG
Other O.R. procedures for multiple significant trauma w CC
4.3582
8.8
11.6959
NO
NO
24
SURG
Other O.R. procedures for multiple significant trauma w/o CC/MCC
3.1511
5.8
7.8963
NO
NO
24
MED
Other multiple significant trauma w MCC
2.7874
6.7
9.6964
NO
NO
24
MED
Other multiple significant trauma w CC
1.6288
5.5
6.9965
NO
NO
24
MED
Other multiple significant trauma w/o CC/MCC
1.2426
3.8
4.7969
NO
NO
25
SURG
HIV w extensive O.R. procedure w MCC
5.6577
13.6
19.0970
NO
NO
25
SURG
HIV w extensive O.R. procedure w/o MCC
3.0430
8.2
11.8974
NO
NO
25
MED
HIV w major related condition w MCC
2.2553
6.5
9.4975
NO
NO
25
MED
HIV w major related condition w CC
1.5844
5.8
8.0976
NO
NO
25
MED
HIV w major related condition w/o CC/MCC
1.0710
4.2
5.6977
NO
NO
25
MED
HIV w or w/o other related condition
1.0477
3.8
5.2981
YES
NO

SURG
Extensive O.R. procedure unrelated to principal diagnosis w MCC
5.0683
12.5
15.8982
YES
NO

SURG
Extensive O.R. procedure unrelated to principal diagnosis w CC
3.1457
8.2
10.3983
YES
NO

SURG
Extensive O.R. procedure unrelated to principal diagnosis w/o CC/MCC
2.0435
4.1
5.6984
NO
NO

SURG
Prostatic O.R. procedure unrelated to principal diagnosis w MCC
3.3812
11.8
14.6985
NO
NO

SURG
Prostatic O.R. procedure unrelated to principal diagnosis w CC
2.1002
7.5
9.9986
NO
NO

SURG
Prostatic O.R. procedure unrelated to principal diagnosis w/o CC/MCC
1.2417
3.6
5.2987
YES
NO

SURG
Non-extensive O.R. proc unrelated to principal diagnosis w MCC
3.5163
10.4
13.6988
YES
NO

SURG
Non-extensive O.R. proc unrelated to principal diagnosis w CC
1.8823
6.1
8.1989
YES
NO

SURG
Non-extensive O.R. proc unrelated to principal diagnosis w/o CC/MCC
1.1151
3.0
4.3998
NO
NO

**
Principal diagnosis invalid as discharge diagnosis
0.0000
0.0
0.0999
NO
NO

**
Ungroupable
0.0000
0.0
0.0MS-DRGs 998 and 999 contain cases that could not be assigned to valid DRGs.**Note:**
                             If there is no value or asterisk in either the geometric mean length of stay or the arithmetic mean length of stay columns, the volume of cases is insufficient to determine a meaningful computation of these statistics.
 Table 6A.—New Diagnosis Codes
Diagnosis code
Description
CC
MDC
MS-DRG040.41
Infant botulism
Y
15
791 1
                                , 793 1CC
18
867, 868, 869040.42
Wound botulism
Y
18
867, 868, 869CC058.10
Roseola infantum, unspecified
N
15
791 1
                                , 793 118
865, 866058.11
Roseola infantum due to human herpes virus 6
N
15
791 1
                                , 793 118
865, 866058.12
Roseola infantum due to human herpes virus 7
N
15
791 1
                                , 793 1( print page 24978)18
865, 866058.21
Human herpes virus 6 encephalitis
Y
                                 MCC
1
23, 24, 97, 98, 
                                 9915
791 1
                                , 793 125
974, 975, 976058.29
Other human herpes virus encephalitis
Y
                                 MCC
1
23, 24,97, 98, 9915
791 1
                                , 793 125
974, 975, 976058.81
Human herpes virus 6 infection
N
9
606, 607058.82
Human herpes virus 7 infection
N
9
606, 607058.89
Other human herpes virus infection
N
9
606, 607079.83
Parvovirus B19
Y
                                 CC
18
865, 866200.30
Marginal zone lymphoma, unspecified site, extranodal and solid organ sites
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.31
Marginal zone lymphoma, lymph nodes of head, face, and neck
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.32
Marginal zone lymphoma, intrathoracic lymph nodes
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.33
Marginal zone lymphoma, intraabdominal lymph nodes
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.34
Marginal zone lymphoma, lymph nodes of axilla and upper limb
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.35
Marginal zone lymphoma, lymph nodes of inguinal region and lower limb
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.36
Marginal zone lymphoma, intrapelvic lymph nodes
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.37
Marginal zone lymphoma, spleen
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.38
Marginal zone lymphoma, lymph nodes of multiple sites
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.40
Mantle cell lymphoma, unspecified site, extranodal and solid organ sites
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.41
Mantle cell lymphoma, lymph nodes of head, face, and neck
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.42
Mantle cell lymphoma, intrathoracic lymph nodes
Y
                                 CC
17
820, 821,822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.43
Mantle cell lymphoma, intra-abdominal lymph nodes
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.44
Mantle cell lymphoma, lymph nodes of axilla and upper limb
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976( print page 24979)200.45
Mantle cell lymphoma, lymph nodes of inguinal region and lower limb
Y
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.46
Mantle cell lymphoma,  intrapelvic lymph nodes
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.47
Mantle cell lymphoma, spleen
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.48
Mantle cell lymphoma, lymph nodes of multiple sites
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.50
Primary central nervous system lymphoma, unspecified site,  extranodal and solid organ sites
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.51
Primary central nervous system lymphoma, lymph nodes of head, face, and neck
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.52
Primary central nervous system lymphoma, intrathoracic lymph nodes
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.53
Primary central nervous system lymphoma, intra-abdominal lymph nodes
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.54
Primary central nervous system lymphoma, lymph nodes of axilla and upper limb
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.55
Primary central nervous system lymphoma, lymph nodes of inguinal region and lower limb
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.56
Primary central nervous system lymphoma, intrapelvic lymph nodes
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.57
Primary central nervous system lymphoma, spleen
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.58
Primary central nervous system lymphoma, lymph nodes of multiple sites
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.60
Anaplastic large cell lymphoma, unspecified site, extranodal and solid organ sites
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.61
Anaplastic large cell lymphoma, lymph nodes of head, face, and neck
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.62
Anaplastic large cell lymphoma, intrathoracic lymph nodes
Y
                                 CC
17
820, 821,  822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.63
Anaplastic large cell lymphoma,  intra-abdominal lymph nodes
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.64
Anaplastic large cell lymphoma, lymph nodes of axilla and upper limb
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 842( print page 24980)25
974, 975, 976200.65
Anaplastic large cell lymphoma, lymph nodes of inguinal region and lower limb
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.66
Anaplastic large cell lymphoma,  intrapelvic lymph nodes
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.67
Anaplastic large cell lymphoma, spleen
Y 
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.68
Anaplastic large cell lymphoma, lymph nodes of multiple sites
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.70
Large cell lymphoma, unspecified site, extranodal and solid organ sites
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.71
Large cell lymphoma, lymph nodes of head, face, and neck
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.72
Large cell lymphoma, intrathoracic lymph nodes
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.73
Large cell lymphoma, intra- abdominal lymph nodes
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.74
Large cell lymphoma, lymph nodes of axilla and upper limb
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.75
Large cell lymphoma, lymph nodes of inguinal region and lower limb
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.76
Large cell lymphoma, intrapelvic lymph nodes
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.77
Large cell lymphoma, spleen
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976200.78
Large cell lymphoma, lymph nodes of multiple sites
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976202.70
Peripheral T cell lymphoma, unspecified site, extranodal and solid organ sites
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976202.71
Peripheral T cell lymphoma, lymph nodes of head, face, and neck
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976202.72
Peripheral T cell lymphoma, intrathoracic lymph nodes
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976202.73
Peripheral T cell lymphoma, intra-abdominal lymph nodes
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976( print page 24981)202.74
Peripheral T cell lymphoma, lymph nodes of axilla and upper limb
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976202.75
Peripheral T cell lymphoma, lymph nodes of inguinal region and lower limb
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976202.76
Peripheral T cell lymphoma, intrapelvic lymph nodes
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976202.77
Peripheral T cell lymphoma, spleen
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976202.78
Peripheral T cell lymphoma, lymph nodes of multiple sites
Y
                                 CC
17
820, 821, 822, 
                                 823, 824, 825,  
                                 840, 841, 84225
974, 975, 976233.30
Carcinoma in situ, unspecified female genital organ
N
13
739, 740, 741, 
                                 744, 745, 754,  
                                 755, 756233.31
Carcinoma in situ,vagina
N
13
739, 740, 741, 
                                 744, 745, 754,  
                                 755, 756233.32
Carcinoma in situ,vulva
N
13
739, 740, 741, 
                                 744, 745, 754,  
                                 755, 756233.39
Carcinoma in situ, other female genital organ
N
13
739, 740, 741, 
                                 744, 745, 754,  
                                 755, 756255.41
Glucocorticoid deficiency
Y
10
643, 644, 645CC255.42
Mineralocorticoid deficiency
Y
10
643, 644, 645CC258.01
Multiple endocrine neoplasia [MEN] type I
N
10
643, 644, 645258.02
Multiple endocrine neoplasia [MEN] type IIA
N
10
643, 644, 645258.03
Multiple endocrine neoplasia [MEN] type IIB
N
10
643, 644, 645284.81
Red cell aplasia (acquired)(adult)(with thymoma)
Y
16
808, 809, 810MCC
25
977284.89
Other specified aplastic anemias
Y
16
808, 809, 810MCC
25
977288.66
Bandemia
N
16
814, 815, 816315.34
Speech and language developmental delay due to hearing loss
N
19
886331.5
Idiopathic normal pressure hydrocephalus (INPH)
Y
                                 CC
1
56, 57359.21
Myotonic muscular dystrophy
N
1
91, 92, 93359.22
Myotonia congenital
N
1
91, 92, 93359.23
Myotonic chondrodystrophy
N
1
91, 92, 93359.24
Drug induced myotonia
N
1
91, 92, 93359.29
Other specified myotonic disorder
N
1
91, 92, 93364.81
Floppy iris syndrome
N
2
124, 125364.89
Other disorders of iris and ciliary body
N
2
124, 125388.45
Acquired auditory processing disorder
N
19
886389.05
Conductive hearing loss, unilateral
N
3
154, 155, 156389.06
Conductive hearing loss, bilateral
N
3
154, 155, 156389.13
Neural hearing loss, unilateral
N
3
154, 155, 156389.17
Sensory hearing loss, unilateral
N
3
154, 155, 156389.20
Mixed hearing loss, unspecified
N
3
154, 155, 156389.21
Mixed hearing loss, unilateral
N
3
154, 155, 156389.22
Mixed hearing loss, bilateral
N
3
154, 155, 156414.2
Chronic total occlusion of coronary artery
N
5
302, 303415.12
Septic pulmonary embolism
Y
4
175,176MCC
15
791 1
                                , 793 1423.3
Cardiac tamponade
Y
                                 CC
5
314, 315, 316440.4
Chronic total occlusion of artery of the extremities
N
5
299, 300, 301449
Septic arterial embolism
Y
5
299, 300, 301CC
15
791 1
                                , 793 1488
Influenza due to identified avian influenza virus
N
3
152, 153( print page 24982)525.71
Osseointegration failure of dental implant
N
PRE3
11, 12, 13, 
                                 157, 158, 159525.72
Post-osseointegration biological failure of dental implant
N
PRE3
11, 12, 13, 
                                 157, 158, 159525.73
Post-osseointegration mechanical failure of dental implant
N
PRE3
11, 12, 13, 
                                 157, 158, 159525.79
Other endosseous dental implant failure
N
PRE3
11, 12, 13, 
                                 157, 158, 159569.43
Anal sphincter tear (healed) (old)
N
6
393, 394, 395624.01
Vulvar intraepithelial neoplasia I [VIN I]
N
13
742, 743, 760, 
                                 761624.02
Vulvar intraepithelial neoplasia II [VIN II]
N
13
742, 743, 760, 
                                 761624.09
Other dystrophy of vulva
N
13
742, 743, 760, 
                                 761629.82
Acquired absence of both uterus and cervix
N
13
742, 743, 760, 
                                 761629.83
Acquired absence of uterus, with remaining cervical stump
N
13
742, 743, 760, 
                                 761629.84
Acquired absence of cervix with remaining uterus
N
13
742, 743, 760, 
                                 761664.60
Anal sphincter tear complicating delivery, not associated with third-degree perineal laceration, unspecified as to episode of care or not applicable
N
14
765, 766, 767, 
                                 768, 774, 775664.61
Anal sphincter tear complicating delivery, not associated with third-degree perineal laceration, delivered, with or without mention of antepartum condition
Y
                                 CC
14
765, 766, 767, 
                                 768, 774, 775664.64
Anal sphincter tear complicating delivery, not associated with third-degree perineal laceration, postpartum condition or complication
Y
                                 CC
14
769, 776733.45
Aseptic necrosis of bone, jaw
Y
8
553, 554CC787.20
Dysphagia, unspecified
N
6
391, 392787.21
Dysphagia, oral phase
N
6
391, 392787.22
Dysphagia, oropharyngeal phase
N
6
391, 392787.23
Dysphagia, pharyngeal phase
N
6
391, 392787.24
Dysphagia, pharyngoesophageal phase
N
6
391, 392787.29
Other dysphagia
N
6
391, 392789.51
Malignant ascites
Y
23
947, 948789.59
Other ascites
Y
23
947, 948CCV12.53
Personal history of sudden cardiac arrest
N
23
951V12.54
Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
N
23
951V13.22
Personal history of cervical dysplasia
N
17
843, 844, 845V16.52
Family history of malignant neoplasm, bladder
N
23
951V17.40
Family history of cardiovascular diseases, unspecified
N
23
951V17.41
Family history of sudden cardiac death (SCD)
N
23
951V17.49
Family history of other cardiovascular diseases
N
23
951V18.11
Family history of multiple endocrine neoplasia [MEN] syndrome
N
23
951V18.19
Family history of other endocrine and metabolic diseases
N
23
951V25.04
Counseling and instruction in natural family planning to avoid pregnancy
N
23
951V26.41
Procreative counseling and advice using natural family planning
N
23
951V26.49
Other procreative management, counseling and advice
N
23
951V26.81
Encounter for assisted reproductive fertility procedure cycle
N
23
951V26.89
Other specified procreative management
N
23
951V49.85
Dual sensory impairment
N
23
951V68.01
Disability examination
N
23
951V68.09
Other issue of medical certificates
N
23
951V72.12
Encounter for hearing conservation and treatment
N
15
795 223
951V73.81
Special screening examination, Human papilloma virus (HPV)
N
23
951V84.81
Genetic susceptibility to multiple endocrine neoplasia  [MEN]
N
23
951V84.89
Genetic susceptibility to other disease
N
23
951MCC—Major Complication or Comorbidity in MS-DRGs.1
                             Secondary diagnosis of major problem.2
                             On “Only secondary diagnosis” list.
 Table 6B.—New Procedure Codes
Procedure code
Description
O.R.
MDC
MS-DRG00.19
Disruption of blood brain barrier via infusion [BBBD]
N( print page 24983)01.10
Intracranial pressure monitoring
N01.16
Intracranial oxygen monitoring
N01.17
Brain temperature monitoring
N32.41
Thoracoscopic lobectomy of lung
Y
4
163, 164, 16521
907, 908, 90924
957, 958, 95932.49
Other lobectomy of lung
Y
4
163, 164, 16521
907, 908, 90924
957, 958, 95933.20
Thoracoscopic lung biopsy
Y
4
166, 167, 1685
2648
515, 516, 51711
673, 674, 67517
823, 824, 825, 829, 83034.06
Thoracoscopic drainage of pleural cavity
Y
4
166, 167, 16834.20
Thoracoscopic pleural biopsy
Y
4
166, 167, 16834.52
Thoracoscopic decortication of lung
Y
4
163, 164, 16517
820, 821, 822, 
                                 826, 827, 82821
907, 908, 90924
957, 958, 95970.53
Repair of cystocele and rectocele with graft or prosthesis
Y
6
329, 330, 33111
653, 654, 65513
74870.54
Repair of cystocele with graft or prosthesis
Y
11
662, 663, 66413
74870.55
Repair of rectocele with graft or prosthesis
Y
6
329, 330, 33113
74870.63
Vaginal construction with graft or prosthesis
Y
13
74870.64
Vaginal reconstruction with graft or prosthesis
Y
13
74821
907, 908, 90924
957, 958, 95970.78
Vaginal suspension and fixation with graft or prosthesis
Y
11
662, 663, 66413
74870.93
Other operations on cul-de-sac with graft or prosthesis
Y
13
746, 74770.94
Insertion of biological graft
N70.95
Insertion of synthetic graft or prosthesis
N88.59
Intra-operative fluorescence vascular angiography
N
 Table 6C.—Invalid Diagnosis Codes
Diagnosis code
Description
CC
MDC
CMS DRG233.3
Carcinoma in situ,other and unspecified female genital organs
N
13
354, 355, 363, 366, 367255.4
Corticoadrenal insufficiency
Y
10
300, 301258.0
Polyglandular activity in multiple endocrine adenomatosis
N
10
300, 301284.8
Other specified aplastic anemias
Y
16
57425
490359.2
Myotonic disorders
N
1
34, 35364.8
Other disorders of iris and ciliary body
N
2
46, 47, 48389.2
Mixed conductive and sensorineural hearing loss
N
3
73, 74624.0
Dystrophy of vulva
N
13
358, 359, 369787.2
Dysphagia
N
6
182, 183, 184789.5
Ascites
Y
23
463, 464V17.4
Family history of other cardiovascular diseases
N
23
467V18.1
Family history of other endocrine and metabolic diseases
N
23
467V26.4
Procreative management, general counseling and advice
N
23
467V26.8
Other specified procreative management
N
23
467V68.0
Issue of medical certificates
N
23
467V84.8
Genetic susceptibility to other disease
N
23
467
 The DRG assignments listed are based on the current code assignment in the CMS DRGs. 
                        ( print page 24984) Table 6D.—Invalid Procedure Codes
Procedure code
Description
OR
MDC
CMS DRG32.4
Lobectomy of lung
Y
4 
                                 21  
                                 24
75 
                                 442,443  
                                 486
 The DRG assignments listed are based on the current code assignment in the CMS DRGs. Table 6E.—Revised Diagnosis Code Titles
Diagnosis  code
Description
CC
MDC
MS-DRG005.1
Botulism food poisoning
Y 
                                 CC
18
867, 868, 869359.3
Periodic paralysis
N
1
91, 92, 93389.14
Central hearing loss
N
3
154, 155, 156389.18
Sensorineural hearing loss, bilateral
N
3
154, 155,156389.7
Deaf, nonspeaking, not elsewhere classifiable
N
3
154, 155, 156
 Table 6F.—Revised Procedure Code Titles
Procedure code
Description
OR
MDC
MS-DRG00.74
Hip bearing surface, metal-on-polyethylene
N00.75
Hip bearing surface, metal-on-metal
N00.76
Hip bearing surface, ceramic-on-ceramic
N00.77
Hip bearing surface, ceramic-on-polyethylene
N34.24
Other pleural biopsy
N53.41
Repair of umbilical hernia with graft or prosthesis
Y
6
353, 354, 355 987, 988, 98953.61
Incisional hernia repair with graft or prosthesis
Y
6 
                                 21  
                                 24
353, 354, 355 
                                 907, 908, 909  
                                 957, 958, 959  
                                 987, 988, 98953.69
Repair of other hernia of anterior abdominal wall with graft or prosthesis
Y
06
353, 354, 355 
                                 987, 988, 98999.14
Injection or infusion of gamma globulin
N
 Note: Diagnoses codes 42741 (Ventricular fibrillation), 4275 (Cardiac arrest), 78551 (Cardiogenic shock), 78559 (Other shock without mention of trauma) and 7991 (Respiratory arrest) are assigned as a major CC only for patients discharged alive, otherwise they will be assigned as a non CC. TABLE 6J.—Major Complication and Comorbidity (Major CC) List
Diagnosis code
Code title0031
Salmonella septicemia.00321
Salmonella meningitis.00322
Salmonella pneumonia.0063
Amebic liver abscess.0064
Amebic lung abscess.0065
Amebic brain abscess.01160
Tuberculous pneumonia (any form), unspecified examination.01161
Tuberculous pneumonia (any form), bacteriological or histological examination not done.01162
Tuberculous pneumonia (any form), bacteriological or histological examination results unknown (at present).01163
Tuberculous pneumonia (any form), tubercle bacilli found (in sputum) by microscopy.01164
Tuberculous pneumonia (any form), tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01165
Tuberculous pneumonia (any form), tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01166
Tuberculous pneumonia (any form), tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01300
Tuberculous meningitis, unspecified examination.01301
Tuberculous meningitis, bacteriological or histological examination not done.( print page 24985)01302
Tuberculous meningitis, bacteriological or histological examination results unknown (at present).01303
Tuberculous meningitis, tubercle bacilli found (in sputum) by microscopy.01304
Tuberculous meningitis, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01305
Tuberculous meningitis, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01306
Tuberculous meningitis, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01310
Tuberculoma of meninges, unspecified examination.01311
Tuberculoma of meninges, bacteriological or histological examination not done.01312
Tuberculoma of meninges, bacteriological or histological examination results unknown (at present).01313
Tuberculoma of meninges, tubercle bacilli found (in sputum) by microscopy.01314
Tuberculoma of meninges, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01315
Tuberculoma of meninges, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01316
Tuberculoma of meninges, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01320
Tuberculoma of brain, unspecified examination.01321
Tuberculoma of brain, bacteriological or histological examination not done.01322
Tuberculoma of brain, bacteriological or histological examination results unknown (at present).01323
Tuberculoma of brain, tubercle bacilli found (in sputum) by microscopy.01324
Tuberculoma of brain, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01325
Tuberculoma of brain, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01326
Tuberculoma of brain, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01330
Tuberculous abscess of brain, unspecified examination.01331
Tuberculous abscess of brain, bacteriological or histological examination not done.01332
Tuberculous abscess of brain, bacteriological or histological examination results unknown (at present).01333
Tuberculous abscess of brain, tubercle bacilli found (in sputum) by microscopy.01334
Tuberculous abscess of brain, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01335
Tuberculous abscess of brain, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01336
Tuberculous abscess of brain, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01340
Tuberculoma of spinal cord, unspecified examination.01341
Tuberculoma of spinal cord, bacteriological or histological examination not done.01342
Tuberculoma of spinal cord, bacteriological or histological examination results unknown (at present).01343
Tuberculoma of spinal cord, tubercle bacilli found (in sputum) by microscopy.01344
Tuberculoma of spinal cord, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01345
Tuberculoma of spinal cord, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01346
Tuberculoma of spinal cord, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01350
Tuberculous abscess of spinal cord, unspecified examination.01351
Tuberculous abscess of spinal cord, bacteriological or histological examination not done.01352
Tuberculous abscess of spinal cord, bacteriological or histological examination results unknown (at present).01353
Tuberculous abscess of spinal cord, tubercle bacilli found (in sputum) by microscopy.01354
Tuberculous abscess of spinal cord, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01355
Tuberculous abscess of spinal cord, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01356
Tuberculous abscess of spinal cord, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01360
Tuberculous encephalitis or myelitis, unspecified examination.01361
Tuberculous encephalitis or myelitis, bacteriological or histological examination not done.01362
Tuberculous encephalitis or myelitis, bacteriological or histological examination results unknown (at present).01363
Tuberculous encephalitis or myelitis, tubercle bacilli found (in sputum) by microscopy.01364
Tuberculous encephalitis or myelitis, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01365
Tuberculous encephalitis or myelitis, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01366
Tuberculous encephalitis or myelitis, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01380
Other specified tuberculosis of central nervous system, unspecified examination.01381
Other specified tuberculosis of central nervous system, bacteriological or histological examination not done.01382
Other specified tuberculosis of central nervous system, bacteriological or histological examination results unknown (at present).01383
Other specified tuberculosis of central nervous system, tubercle bacilli found (in sputum) by microscopy.01384
Other specified tuberculosis of central nervous system, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.( print page 24986)01385
Other specified tuberculosis of central nervous system, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01386
Other specified tuberculosis of central nervous system, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01390
Unspecified tuberculosis of central nervous system, unspecified examination.01391
Unspecified tuberculosis of central nervous system, bacteriological or histological examination not done.01392
Unspecified tuberculosis of central nervous system, bacteriological or histological examination results unknown (at present).01393
Unspecified tuberculosis of central nervous system, tubercle bacilli found (in sputum) by microscopy.01394
Unspecified tuberculosis of central nervous system, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01395
Unspecified tuberculosis of central nervous system, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01396
Unspecified tuberculosis of central nervous system, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01400
Tuberculous peritonitis, unspecified examination.01401
Tuberculous peritonitis, bacteriological or histological examination not done.01402
Tuberculous peritonitis, bacteriological or histological examination results unknown (at present).01403
Tuberculous peritonitis, tubercle bacilli found (in sputum) by microscopy.01404
Tuberculous peritonitis, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01405
Tuberculous peritonitis, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01406
Tuberculous peritonitis, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01800
Acute miliary tuberculosis, unspecified examination.01801
Acute miliary tuberculosis, bacteriological or histological examination not done.01802
Acute miliary tuberculosis, bacteriological or histological examination results unknown (at present).01803
Acute miliary tuberculosis, tubercle bacilli found (in sputum) by microscopy.01804
Acute miliary tuberculosis, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01805
Acute miliary tuberculosis, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01806
Acute miliary tuberculosis, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01880
Other specified miliary tuberculosis, unspecified examination.01881
Other specified miliary tuberculosis, bacteriological or histological examination not done.01882
Other specified miliary tuberculosis, bacteriological or histological examination results unknown (at present).01883
Other specified miliary tuberculosis, tubercle bacilli found (in sputum) by microscopy.01884
Other specified miliary tuberculosis, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01885
Other specified miliary tuberculosis, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01886
Other specified miliary tuberculosis, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01890
Unspecified miliary tuberculosis, unspecified examination.01891
Unspecified miliary tuberculosis, bacteriological or histological examination not done.01892
Unspecified miliary tuberculosis, bacteriological or histological examination results unknown (at present).01893
Unspecified miliary tuberculosis, tubercle bacilli found (in sputum) by microscopy.01894
Unspecified miliary tuberculosis, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01895
Unspecified miliary tuberculosis, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01896
Unspecified miliary tuberculosis, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).0200
Bubonic plague.0201
Cellulocutaneous plague.0202
Septicemic plague.0203
Primary pneumonic plague.0204
Secondary pneumonic plague.0205
Pneumonic plague, unspecified.0208
Other specified types of plague.0209
Plague, unspecified.0221
Pulmonary anthrax.0223
Anthrax septicemia.0360
Meningococcal meningitis.0361
Meningococcal encephalitis.0362
Meningococcemia.0363
Waterhouse-friderichsen syndrome, meningococcal.03640
Meningococcal carditis, unspecified.03641
Meningococcal pericarditis.03642
Meningococcal endocarditis.03643
Meningococcal myocarditis.037
Tetanus.( print page 24987)0380
Streptococcal septicemia.03810
Staphylococcal septicemia, unspecified.03811
Staphylococcus aureus septicemia.03819
Other staphylococcal septicemia.0382
Pneumococcal septicemia.0383
Septicemia due to anaerobes.03840
Septicemia due to gram-negative organism, unspecified.03841
Septicemia due to hemophilus influenzae (h. influenzae).03842
Septicemia due to escherichia coli (e. coli).03843
Septicemia due to pseudomonas.03844
Septicemia due to serratia.03849
Other septicemia due to gram-negative organisms.0388
Other specified septicemias.0389
Unspecified septicemia.0400
Gas gangrene.04082
Toxic shock syndrome.042
Human immunodeficiency virus (hiv) disease.04500
Acute paralytic poliomyelitis specified as bulbar, unspecified type of poliovirus.04501
Acute paralytic poliomyelitis specified as bulbar, poliovirus type i.04502
Acute paralytic poliomyelitis specified as bulbar, poliovirus type ii.04503
Acute paralytic poliomyelitis specified as bulbar, poliovirus type iii.04510
Acute poliomyelitis with other paralysis, unspecified type of poliovirus.04511
Acute poliomyelitis with other paralysis, poliovirus type i.04512
Acute poliomyelitis with other paralysis, poliovirus type ii.04513
Acute poliomyelitis with other paralysis, poliovirus type iii.0520
Postvaricella encephalitis.0521
Varicella (hemorrhagic) pneumonitis.0522
Postvaricella myelitis.0530
Herpes zoster with meningitis.05314
Herpes zoster myelitis.0543
Herpetic meningoencephalitis.0545
Herpetic septicemia.05472
Herpes simplex meningitis.05474
Herpes simplex myelitis.0550
Postmeasles encephalitis.0551
Postmeasles pneumonia.05601
Encephalomyelitis due to rubella.05821
Human herpes virus 6 encephalitis.05829
Other human herpes virus encephalitis.0620
Japanese encephalitis.0621
Western equine encephalitis.0622
Eastern equine encephalitis.0623
St. Louis encephalitis.0624
Australian encephalitis.0625
California virus encephalitis.0628
Other specified mosquito-borne viral encephalitis.0629
Mosquito-borne viral encephalitis, unspecified.0630
Russian spring-summer (taiga) encephalitis.0631
Louping ill.0632
Central european encephalitis.0638
Other specified tick-borne viral encephalitis.0639
Tick-borne viral encephalitis, unspecified.064
Viral encephalitis transmitted by other and unspecified arthropods.06640
West Nile Fever, unspecified.06641
West Nile Fever with encephalitis.06642
West Nile Fever with other neurologic manifestation.06649
West Nile Fever with other complications.0700
Viral hepatitis a with hepatic coma.07020
Viral hepatitis b with hepatic coma, acute or unspecified, without mention of hepatitis delta.07021
Viral hepatitis b with hepatic coma, acute or unspecified, with hepatitis delta.07022
Chronic viral hepatitis b with hepatic coma without hepatitis delta.07023
Chronic viral hepatitis b with hepatic coma with hepatitis delta.07041
Acute hepatitis C with hepatic coma.07042
Hepatitis delta without mention of active hepatitis b disease, with hepatic coma, hepatitis delta with hepatitis b carrier state.07043
Hepatitis e with hepatic coma.07044
Chronic hepatitis c with hepatic coma.07049
Other specified viral hepatitis with hepatic coma.0706
Unspecified viral hepatitis with hepatic coma.07071
Unspecified viral hepatitis C with hepatic coma.0721
Mumps meningitis.0722
Mumps encephalitis.( print page 24988)0730
Ornithosis with pneumonia.0840
Falciparum malaria (malignant tertian).09041
Congenital syphilitic encephalitis.09042
Congenital syphilitic meningitis.09181
Acute syphilitic meningitis (secondary).0942
Syphilitic meningitis.09481
Syphilitic encephalitis.09487
Syphilitic ruptured cerebral aneurysm.09882
Gonococcal meningitis.09883
Gonococcal pericarditis.09884
Gonococcal endocarditis.10081
Leptospiral meningitis (aseptic).1124
Candidiasis of lung.1125
Disseminated candidiasis.11281
Candidal endocarditis.11283
Candidal meningitis.1142
Coccidioidal meningitis.11501
Histoplasma capsulatum meningitis.11503
Histoplasma capsulatum pericarditis.11504
Histoplasma capsulatum endocarditis.11505
Histoplasma capsulatum pneumonia.11511
Histoplasma duboisii meningitis.11513
Histoplasma duboisii pericarditis.11514
Histoplasma duboisii endocarditis.11515
Histoplasma duboisii pneumonia.11591
Histoplasmosis meningitis, unspecified.11593
Histoplasmosis pericarditis, unspecified.11594
Histoplasmosis endocarditis.11595
Histoplasmosis pneumonia, unspecified.1177
Zygomycosis (phycomycosis or mucormycosis).1300
Meningoencephalitis due to toxoplasmosis.1303
Myocarditis due to toxoplasmosis.1304
Pneumonitis due to toxoplasmosis.1308
Multisystemic disseminated toxoplasmosis.1362
Specific infections by free-living amebae.1363
Pneumocystosis.24201
Toxic diffuse goiter with mention of thyrotoxic crisis or storm.24211
Toxic uninodular goiter with mention of thyrotoxic crisis or storm.24221
Toxic multinodular goiter with mention of thyrotoxic crisis or storm.24231
Toxic nodular goiter, unspecified type, with mention of thyrotoxic crisis or storm.24241
Thyrotoxicosis from ectopic thyroid nodule with mention of thyrotoxic crisis or storm.24281
Thyrotoxicosis of other specified origin with mention of thyrotoxic crisis or storm.24291
Thyrotoxicosis without mention of goiter or other cause, with mention of thyrotoxic crisis or storm.25010
Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled.25011
Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled.25012
Diabetes with ketoacidosis, type II or unspecified type, uncontrolled.25013
Diabetes with ketoacidosis, type I [juvenile type], uncontrolled.25020
Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled.25021
Diabetes with hyperosmolarity, type I [juvenile type], not stated as uncontrolled.25022
Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled.25023
Diabetes with hyperosmolarity, type I [juvenile type], uncontrolled.25030
Diabetes with other coma, type II or unspecified type, not stated as uncontrolled.25031
Diabetes with other coma, type I [juvenile type], not stated as uncontrolled.25032
Diabetes with other coma, type II or unspecified type, uncontrolled.25033
Diabetes with other coma, type I [juvenile type], uncontrolled.260
Kwashiorkor.261
Nutritional marasmus.262
Other severe protein-calorie malnutrition.27701
Cystic fibrosis with meconium ileus.27702
Cystic fibrosis with pulmonary manifestations.28242
Sickle-Cell thalassemia with crisis.28262
Hb-ss disease with crisis.28264
Sickle-Cell/Hb-C disease with crisis.28311
Hemolytic-uremic syndrome.28481
Red cell aplasia (acquired)(adult)(with thymoma).28489
Other specified aplastic anemias.2860
Congenital factor viii disorder.2861
Congenital factor ix disorder.2866
Defibrination syndrome.3200
Hemophilus meningitis.3201
Pneumococcal meningitis.3202
Streptococcal meningitis.( print page 24989)3203
Staphylococcal meningitis.3207
Meningitis in other bacterial diseases classified elsewhere.32081
Anaerobic meningitis.32082
Meningitis due to gram-negative bacteria, not elsewhere classified.32089
Meningitis due to other specified bacteria.3209
Meningitis due to unspecified bacterium.3210
Cryptococcal meningitis.3211
Meningitis in other fungal diseases.3212
Meningitis due to viruses not elsewhere classified.3213
Meningitis due to trypanosomiasis.3214
Meningitis in sarcoidosis.3218
Meningitis due to other nonbacterial organisms classified elsewhere.3220
Nonpyogenic meningitis.3221
Eosinophilic meningitis.3229
Meningitis, unspecified.32301
Encephalitis and encephalomyelitis in viral diseases classified elsewhere.32302
Myelitis in viral diseases classified elsewhere.3231
Encephalitis, myelitis, and encephalomyelitis in rickettsial diseases classified elsewhere.3232
Encephalitis, myelitis, and encephalomyelitis in protozoal diseases classified elsewhere.32341
Other encephalitis and encephalomyelitis due to infection classified elsewhere.32342
Other myelitis due to infection classified elsewhere.32351
Encephalitis and encephalomyelitis following immunization procedures.32352
Myelitis following immunization procedures.32361
Infectious acute disseminated encephalomyelitis (ADEM).32362
Other postinfectious encephalitis and encephalomyelitis.32363
Postinfectious myelitis.32371
Toxic encephalitis and encephalomyelitis.32372
Toxic myelitis.32381
Other causes of encephalitis and encephalomyelitis.32382
Other causes of myelitis.3239
Unspecified causes of encephalitis, myelitis, and encephalomyelitis.3240
Intracranial abscess.3241
Intraspinal abscess.3249
Intracranial and intraspinal abscess of unspecified site.325
Phlebitis and thrombophlebitis of intracranial venous sinuses.33181
Reye's syndrome.33392
Neuroleptic malignant syndrome.3361
Vascular myelopathies.3432
Congenital quadriplegia.34400
Quadriplegia, unspecified.34401
Quadriplegia, C1-C4, complete.34402
Quadriplegia, C1-C4, incomplete.34403
Quadriplegia, C5-C7, complete.34404
Quadriplegia, C5-C7, incomplete.34409
Other quadriplegia.34481
Locked-in state.3453
Grand mal status, epileptic.34830
Encephalopathy, unspecified.34831
Metabolic encephalopathy.34839
Other encephalopathy.3484
Compression of brain.3485
Cerebral edema.34982
Toxic encephalopathy.35801
Myasthenia gravis with (acute) exacerbation.41001
Acute myocardial infarction of anterolateral wall, initial episode of care.41011
Acute myocardial infarction of other anterior wall, initial episode of care.41021
Acute myocardial infarction of inferolateral wall, initial episode of care.41031
Acute myocardial infarction of inferoposterior wall, initial episode of care.41041
Acute myocardial infarction of other inferior wall, initial episode of care.41051
Acute myocardial infarction of other lateral wall, initial episode of care.41061
True posterior wall infarction, initial episode of care.41071
Subendocardial infarction, initial episode of care.41081
Acute myocardial infarction of other specified sites, initial episode of care.41091
Acute myocardial infarction of unspecified site, initial episode of care.41412
Dissection of coronary artery.4150
Acute cor pulmonale.41511
Iatrogenic pulmonary embolism and infarction.41512
Septic pulmonary embolism.41519
Other pulmonary embolism and infarction.4210
Acute and subacute bacterial endocarditis.4211
Acute and subacute infective endocarditis in diseases classified elsewhere.4219
Acute endocarditis, unspecified.( print page 24990)4220
Acute myocarditis in diseases classified elsewhere.42290
Acute myocarditis, unspecified.42291
Idiopathic myocarditis.42292
Septic myocarditis.42293
Toxic myocarditis.42299
Other acute myocarditis.42741
Ventricular fibrillation.42742
Ventricular flutter.4275
Cardiac arrest.42821
Acute systolic heart failure.42823
Acute on chronic systolic heart failure.42831
Acute diastolic heart failure.42833
Acute on chronic diastolic heart failure.42841
Acute combined systolic and diastolic heart failure.42843
Acute on chronic combined systolic and diastolic heart failure.4295
Rupture of chordae tendineae.4296
Rupture of papillary muscle.430
Subarachnoid hemorrhage.431
Intracerebral hemorrhage.4320
Nontraumatic extradural hemorrhage.4321
Subdural hemorrhage.43301
Occlusion and stenosis of basilar artery with cerebral infarction.43311
Occlusion and stenosis of carotid artery with cerebral infarction.43321
Occlusion and stenosis of vertebral artery with cerebral infarction.43331
Occlusion and stenosis of multiple and bilateral precerebral arteries with cerebral infarction.43381
Occlusion and stenosis of other specified precerebral artery with cerebral infarction.43391
Occlusion and stenosis of unspecified precerebral artery with cerebral infarction.43401
Cerebral thrombosis with cerebral infarction.43411
Cerebral embolism with cerebral infarction.43491
Cerebral artery occlusion, unspecified with cerebral infarction.44100
Dissection of aorta, unspecified site.44101
Dissection of aorta, thoracic.44102
Dissection of aorta, abdominal.44103
Dissection of aorta, thoracoabdominal.4411
Thoracic aneurysm, ruptured.4413
Abdominal aneurysm, ruptured.4415
Aortic aneurysm of unspecified site, ruptured.4416
Thoracoabdominal aneurysm, ruptured.44321
Dissection of carotid artery.44322
Dissection of iliac artery.44323
Dissection of renal artery.44324
Dissection of vertebral artery.44329
Dissection of other artery.4466
Thrombotic microangiopathy.452
Portal vein thrombosis.4530
Budd-chiari syndrome.4532
Embolism and thrombosis of vena cava.4560
Esophageal varices with bleeding.45620
Esophageal varices in diseases classified elsewhere, with bleeding.46401
Acute laryngitis with obstruction.46411
Acute tracheitis with obstruction.46421
Acute laryngotracheitis with obstruction.46431
Acute epiglottitis with obstruction.46451
Supraglottitis unspecified with obstruction.4800
Pneumonia due to adenovirus.4801
Pneumonia due to respiratory syncytial virus.4802
Pneumonia due to parainfluenza virus.4803
Pneumonia due to sars-associated coronavirus.4808
Pneumonia due to other virus not elsewhere classified.4809
Viral pneumonia, unspecified.481
Pneumococcal pneumonia [streptococcus pneumoniae pneumonia].4820
Pneumonia due to klebsiella pneumoniae.4821
Pneumonia due to pseudomonas.4822
Pneumonia due to hemophilus influenzae (h. influenzae).48230
Pneumonia due to streptococcus, unspecified.48231
Pneumonia due to streptococcus, group a.48232
Pneumonia due to streptococcus, group b.48239
Pneumonia due to other streptococcus.48240
Pneumonia due to staphylococcus, unspecified.48241
Pneumonia due to staphylococcus aureus.48249
Other staphylococcus pneumonia.48281
Pneumonia due to anaerobes.( print page 24991)48282
Pneumonia due to escherichia coli [e.coli].48283
Pneumonia due to other gram-negative bacteria.48284
Pneumonia due to legionnaires' disease.48289
Pneumonia due to other specified bacteria.4829
Bacterial pneumonia, unspecified.4830
Pneumonia due to mycoplasma pneumoniae.4831
Pneumonia due to chlamydia.4838
Pneumonia due to other specified organism.4841
Pneumonia in cytomegalic inclusion disease.4843
Pneumonia in whooping cough.4845
Pneumonia in anthrax.4846
Pneumonia in aspergillosis.4847
Pneumonia in other systemic mycoses.4848
Pneumonia in other infectious diseases classified elsewhere.485
Bronchopneumonia, organism unspecified.486
Pneumonia, organism unspecified.4870
Influenza with pneumonia.5061
Acute pulmonary edema due to fumes and vapors.5070
Pneumonitis due to inhalation of food or vomitus.5071
Pneumonitis due to inhalation of oils and essences.5078
Pneumonitis due to other solids and liquids.5100
Empyema with fistula.5109
Empyema without mention of fistula.5111
Pleurisy with effusion, with mention of a bacterial cause other than tuberculosis.5118
Other specified forms of pleural effusion, except tuberculous.5120
Spontaneous tension pneumothorax.5130
Abscess of lung.5131
Abscess of mediastinum.5184
Acute edema of lung, unspecified.5185
Pulmonary insufficiency following trauma and surgery.51881
Acute respiratory failure.51884
Acute and chronic respiratory failure.5192
Mediastinitis.53021
Ulcer of esophagus with bleeding.5304
Perforation of esophagus.5307
Gastroesophageal laceration-hemorrhage syndrome.53082
Esophageal hemorrhage.53084
Tracheoesophageal fistula.53100
Acute gastric ulcer with hemorrhage, without mention of obstruction.53101
Acute gastric ulcer with hemorrhage, with obstruction.53110
Acute gastric ulcer with perforation, without mention of obstruction.53111
Acute gastric ulcer with perforation, with obstruction.53120
Acute gastric ulcer with hemorrhage and perforation, without mention of obstruction.53121
Acute gastric ulcer with hemorrhage and perforation, with obstruction.53131
Acute gastric ulcer without mention of hemorrhage or perforation, with obstruction.53140
Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction.53141
Chronic or unspecified gastric ulcer with hemorrhage, with obstruction.53150
Chronic or unspecified gastric ulcer with perforation, without mention of obstruction.53151
Chronic or unspecified gastric ulcer with perforation, with obstruction.53160
Chronic or unspecified gastric ulcer with hemorrhage and perforation, without mention of obstruction.53161
Chronic or unspecified gastric ulcer with hemorrhage and perforation, with obstruction.53171
Chronic gastric ulcer without mention of hemorrhage or perforation, with obstruction.53191
Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, with obstruction.53200
Acute duodenal ulcer with hemorrhage, without mention of obstruction.53201
Acute duodenal ulcer with hemorrhage, with obstruction.53210
Acute duodenal ulcer with perforation, without mention of obstruction.53211
Acute duodenal ulcer with perforation, with obstruction.53220
Acute duodenal ulcer with hemorrhage and perforation, without mention of obstruction.53221
Acute duodenal ulcer with hemorrhage and perforation, with obstruction.53231
Acute duodenal ulcer without mention of hemorrhage or perforation, with obstruction.53240
Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction.53241
Chronic or unspecified duodenal ulcer with hemorrhage, with obstruction.53250
Chronic or unspecified duodenal ulcer with perforation, without mention of obstruction.53251
Chronic or unspecified duodenal ulcer with perforation, with obstruction.53260
Chronic or unspecified duodenal ulcer with hemorrhage and perforation, without mention of obstruction.53261
Chronic or unspecified duodenal ulcer with hemorrhage and perforation, with obstruction.53271
Chronic duodenal ulcer without mention of hemorrhage or perforation, with obstruction.53291
Duodenal ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, with obstruction.53300
Acute peptic ulcer of unspecified site with hemorrhage, without mention of obstruction.53301
Acute peptic ulcer of unspecified site with hemorrhage, with obstruction.53310
Acute peptic ulcer of unspecified site with perforation, without mention of obstruction.( print page 24992)53311
Acute peptic ulcer of unspecified site with perforation, with obstruction.53320
Acute peptic ulcer of unspecified site with hemorrhage and perforation, without mention of obstruction.53321
Acute peptic ulcer of unspecified site with hemorrhage and perforation, with obstruction.53331
Acute peptic ulcer of unspecified site without mention of hemorrhage and perforation, with obstruction.53340
Chronic or unspecified peptic ulcer of unspecified site with hemorrhage, without mention of obstruction.53341
Chronic or unspecified peptic ulcer of unspecified site with hemorrhage, with obstruction.53350
Chronic or unspecified peptic ulcer of unspecified site with perforation, without mention of obstruction.53351
Chronic or unspecified peptic ulcer of unspecified site with perforation, with obstruction.53360
Chronic or unspecified peptic ulcer of unspecified site with hemorrhage and perforation, without mention of obstruction.53361
Chronic or unspecified peptic ulcer of unspecified site with hemorrhage and perforation, with obstruction.53371
Chronic peptic ulcer of unspecified site without mention of hemorrhage or perforation, with obstruction.53391
Peptic ulcer of unspecified site, unspecified as acute or chronic, without mention of hemorrhage or perforation, with obstruction.53400
Acute gastrojejunal ulcer with hemorrhage, without mention of obstruction.53401
Acute gastrojejunal ulcer, with hemorrhage, with obstruction.53410
Acute gastrojejunal ulcer with perforation, without mention of obstruction.53411
Acute gastrojejunal ulcer with perforation, with obstruction.53420
Acute gastrojejunal ulcer with hemorrhage and perforation, without mention of obstruction.53421
Acute gastrojejunal ulcer with hemorrhage and perforation, with obstruction.53431
Acute gastrojejunal ulcer without mention of hemorrhage or perforation, with obstruction.53440
Chronic or unspecified gastrojejunal ulcer with hemorrhage, without mention of obstruction.53441
Chronic or unspecified gastrojejunal ulcer, with hemorrhage, with obstruction.53450
Chronic or unspecified gastrojejunal ulcer with perforation, without mention of obstruction.53451
Chronic or unspecified gastrojejunal ulcer with perforation, with obstruction.53460
Chronic or unspecified gastrojejunal ulcer with hemorrhage and perforation, without mention of obstruction.53461
Chronic or unspecified gastrojejunal ulcer with hemorrhage and perforation, with obstruction.53471
Chronic gastrojejunal ulcer without mention of hemorrhage or perforation, with obstruction.53491
Gastrojejunal ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, with obstruction.53501
Acute gastritis with hemorrhage.53511
Atrophic gastritis with hemorrhage.53521
Gastric mucosal hypertrophy with hemorrhage.53531
Alcoholic gastritis with hemorrhage.53541
Other specified gastritis with hemorrhage.53551
Unspecified gastritis and gastroduodenitis with hemorrhage.53561
Duodenitis with hemorrhage.53783
Angiodysplasia of stomach and duodenum with hemorrhage.53784
Dielulafoy lesion (hemorrhagic) of stomach and duodenum.5400
Acute appendicitis with generalized peritonitis.5401
Acute appendicitis with peritoneal abscess.55000
Unilateral or unspecified inguinal hernia, with gangrene.55001
Recurrent unilateral or unspecified inguinal hernia, with gangrene.55002
Bilateral inguinal hernia, with gangrene.55003
Recurrent bilateral inguinal hernia, with gangrene.55100
Unilateral or unspecified femoral hernia with gangrene.55101
Recurrent unilateral or unspecified femoral hernia with gangrene.55102
Bilateral femoral hernia with gangrene.55103
Recurrent bilateral femoral hernia with gangrene.5511
Umbilical hernia with gangrene.55120
Unspecified ventral hernia with gangrene.55121
Incisional ventral hernia, with gangrene.55129
Other ventral hernia with gangrene.5513
Diaphragmatic hernia with gangrene.5518
Hernia of other specified sites, with gangrene.5519
Hernia of unspecified site, with gangrene.5570
Acute vascular insufficiency of intestine.5602
Volvulus.56202
Diverticulosis of small intestine with hemorrhage.56203
Diverticulitis of small intestine with hemorrhage.56212
Diverticulosis of colon with hemorrhage.56213
Diverticulitis of colon with hemorrhage.5670
Peritonitis in infectious diseases classified elsewhere.5671
Pneumococcal peritonitis.56721
Peritonitis (acute) generalized.56722
Peritoneal abscess.56723
Spontaneous bacterial peritonitis.56729
Other suppurative peritonitis.56731
Psoas muscle abscess.56738
Other retroperitoneal abscess.56739
Other retroperitoneal infections.56781
Choleperitonitis.( print page 24993)56789
Other specified peritonitis.5679
Unspecified peritonitis.56881
Hemoperitoneum (nontraumatic).56983
Perforation of intestine.56985
Angiodysplasia of intestine with hemorrhage.56986
Dieulafoy lesion (hemorrhagic) of intestine.570
Acute and subacute necrosis of liver.5720
Abscess of liver.5721
Portal pyemia.5722
Hepatic coma.5724
Hepatorenal syndrome.5734
Hepatic infarction.57481
Calculus of gallbladder and bile duct with acute and chronic cholecystitis, with obstruction.5754
Perforation of gallbladder.5762
Obstruction of bile duct.5763
Perforation of bile duct.5770
Acute pancreatitis.5800
Acute glomerulonephritis with lesion of proliferative glomerulonephritis.5804
Acute glomerulonephritis with lesion of rapidly progressive glomerulonephritis.58081
Acute glomerulonephritis in diseases classified elsewhere.58089
Acute glomerulonephritis with other specified pathological lesion in kidney.5809
Acute glomerulonephritis with unspecified pathological lesion in kidney.5834
Nephritis and nephropathy, not specified as acute or chronic, with lesion of rapidly progressive glomerulonephritis.5836
Nephritis and nephropathy, not specified as acute or chronic, with lesion of renal cortical necrosis.5845
Acute renal failure with lesion of tubular necrosis.5846
Acute renal failure with lesion of renal cortical necrosis.5847
Acute renal failure with lesion of renal medullary (papillary) necrosis.5848
Acute renal failure with other specified pathological lesion in kidney.5849
Acute renal failure, unspecified.5856
End stage renal disease.59011
Acute pyelonephritis with lesion of renal medullary necrosis.5902
Renal and perinephric abscess.5966
Rupture of bladder, nontraumatic.6145
Acute or unspecified pelvic peritonitis, female.63430
Spontaneous abortion, unspecified, complicated by renal failure.63431
Spontaneous abortion, incomplete, complicated by renal failure.63432
Spontaneous abortion, complete, complicated by renal failure.63450
Spontaneous abortion, unspecified, complicated by shock.63451
Spontaneous abortion, incomplete, complicated by shock.63452
Spontaneous abortion, complete, complicated by shock.63461
Spontaneous abortion, incomplete, complicated by embolism.63462
Spontaneous abortion, complete, complicated by embolism.63530
Legally induced abortion, unspecified, complicated by renal failure.63531
Legally induced abortion, incomplete, complicated by renal failure.63532
Legally induced abortion, complete, complicated by renal failure.63550
Legally induced abortion, unspecified, complicated by shock.63551
Legally induced abortion, incomplete, complicated by shock.63552
Legally induced abortion, complete, complicated by shock.63560
Legally induced abortion, unspecified, complicated by embolism.63561
Legally induced abortion, incomplete, complicated by embolism.63562
Legally induced abortion, complete, complicated by embolism.63630
Illegal abortion, unspecified, complicated by renal failure.63631
Illegal abortion, incomplete, complicated by renal failure.63632
Illegal abortion, complete, complicated by renal failure.63650
Illegal abortion, unspecified, complicated by shock.63651
Illegal abortion, incomplete, complicated by shock.63652
Illegal abortion, complete, complicated by shock.63660
Illegal abortion, unspecified, complicated by embolism.63661
Illegal abortion, incomplete, complicated by embolism.63662
Illegal abortion, complete, complicated by embolism.63730
Legally unspecified type of abortion, unspecified, complicated by renal failure.63731
Legally unspecified abortion, incomplete, complicated by renal failure.63732
Legally unspecified abortion, complete, complicated by renal failure.63750
Legally unspecified type of abortion, unspecified, complicated by shock.63751
Legally unspecified abortion, incomplete, complicated by shock.63752
Legally unspecified abortion, complete, complicated by shock.63760
Legally unspecified type of abortion, unspecified, complicated by embolism.63761
Legally unspecified abortion, incomplete, complicated by embolism.63762
Legally unspecified abortion, complete, complicated by embolism.6383
Failed attempted abortion complicated by renal failure.6385
Failed attempted abortion complicated by shock.( print page 24994)6386
Failed attempted abortion complicated by embolism.6393
Renal failure following abortion or ectopic and molar pregnancies.6395
Shock following abortion or ectopic and molar pregnancies.6396
Embolism following abortion or ectopic and molar pregnancies.64111
Hemorrhage from placenta previa, with delivery.64113
Hemorrhage from placenta previa, antepartum.64121
Premature separation of placenta, with delivery.64131
Antepartum hemorrhage associated with coagulation defects, with delivery.64133
Antepartum hemorrhage associated with coagulation defects.64211
Hypertension secondary to renal disease, with delivery.64212
Hypertension secondary to renal disease, with delivery, with mention of postpartum complication.64242
Mild or unspecified pre-eclampsia, with delivery, with mention of postpartum complication.64251
Severe pre-eclampsia, with delivery.64252
Severe pre-eclampsia, with delivery, with mention of postpartum complication.64253
Severe pre-eclampsia, antepartum.64254
Severe pre-eclampsia, postpartum.64261
Eclampsia, with delivery.64262
Eclampsia, with delivery, with mention of postpartum complication.64263
Eclampsia, antepartum.64264
Eclampsia, postpartum.64271
Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, with delivery.64272
Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, with delivery, with mention of postpartum complication.64273
Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, antepartum.64274
Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, postpartum.64403
Threatened premature labor, antepartum.64421
Early onset of delivery, delivered, with or without mention of antepartum condition.64801
Diabetes mellitus of mother, with delivery.64802
Diabetes mellitus of mother, with delivery, with mention of postpartum complication.65451
Cervical incompetence, with delivery.65452
Cervical incompetence, delivered, with mention of postpartum complication.65453
Cervical incompetence, antepartum condition or complication.65454
Cervical incompetence, postpartum condition or complication.65841
Infection of amniotic cavity, delivered.65843
Infection of amniotic cavity, antepartum.65931
Generalized infection during labor, delivered.65933
Generalized infection during labor, antepartum.66501
Rupture of uterus before onset of labor, with delivery.66503
Rupture of uterus before onset of labor, antepartum.66511
Rupture of uterus, with delivery.66911
Obstetric shock, with delivery, with or without mention of antepartum condition.66912
Obstetric shock, with delivery, with mention of postpartum complication.66913
Antepartum obstetric shock.66914
Postpartum obstetric shock.66921
Maternal hypotension syndrome, with delivery, with or without mention of antepartum condition.66922
Maternal hypotension syndrome, with delivery, with mention of postpartum complication.66932
Acute renal failure with delivery, with mention of postpartum complication.66934
Acute renal failure following labor and delivery, postpartum condition or complication.67002
Major puerperal infection, delivered, with mention of postpartum complication.67004
Major puerperal infection, postpartum.67131
Deep phlebothrombosis, antepartum, with delivery.67133
Deep phlebothrombosis, antepartum.67142
Deep phlebothrombosis, postpartum, with delivery.67144
Deep phlebothrombosis, postpartum.67301
Obstetrical air embolism, with delivery, with or without mention of antepartum condition.67302
Obstetrical air embolism, with delivery, with mention of postpartum complication.67303
Obstetrical air embolism, antepartum condition or complication.67304
Obstetrical air embolism, postpartum condition or complication.67311
Amniotic fluid embolism, with delivery, with or without mention of antepartum condition.67312
Amniotic fluid embolism, with delivery, with mention of postpartum complication.67313
Amniotic fluid embolism, antepartum condition or complication.67314
Amniotic fluid embolism, postpartum condition or complication.67321
Obstetrical blood-clot embolism, with delivery, with or without mention of antepartum condition.67322
Obstetrical blood-clot embolism, with mention of postpartum complication.67323
Obstetrical blood-clot embolism, antepartum.67324
Obstetrical blood-clot embolism, postpartum.67331
Obstetrical pyemic and septic embolism, with delivery, with or without mention of antepartum condition.67332
Obstetrical pyemic and septic embolism, with delivery, with mention of postpartum complicaton.67333
Obstetrical pyemic and septic embolism, antepartum.67334
Obstetrical pyemic and septic embolism, postpartum.67381
Other obstetrical pulmonary embolism, with delivery, with or without mention of antepartum condition.67382
Other obstetrical pulmonary embolism, with delivery, with mention of postpartum complication.( print page 24995)67383
Other obstetrical pulmonary embolism, antepartum.67384
Other obstetrical pulmonary embolism, postpartum.67401
Cerebrovascular disorders, with delivery, with or without mention of antepartum condition.67450
Peripartum cardiomyopathy, unspecified as to episode of care or not applicable.67451
Peripartum cardiomyopathy, delivered, with or without mention of antepartum condition.67452
Peripartum cardiomyopathy, delivered, with mention of postpartum condition.67453
Peripartum cardiomyopathy, antepartum condition or complication.67454
Peripartum cardiomyopathy, postpartum condition or complication.70702
Decubitus ulcer, upper back.70703
Decubitus ulcer, lower back.70704
Decubitus ulcer, hip.70705
Decubitus ulcer, buttock.70706
Decubitus ulcer, ankle.70707
Decubitus ulcer, heel.72886
Necrotizing fasciitis.7400
Anencephalus.7401
Craniorachischisis.7402
Iniencephaly.7422
Congenital reduction deformities of brain.7450
Common truncus.74510
Complete transposition of great vessels.74511
Double outlet right ventricle.74519
Other transposition of great vessels.7452
Tetralogy of fallot.7453
Common ventricle.7457
Cor biloculare.74601
Atresia of pulmonary valve, congenital.7461
Tricuspid atresia and stenosis, congenital.7462
Ebstein's anomaly.7467
Hypoplastic left heart syndrome.74681
Subaortic stenosis, congenital.74682
Cor triatriatum.74684
Congenital obstructive anomalies of heart, not elsewhere classified.74686
Congenital heart block.74711
Interruption of aortic arch.7473
Congenital anomalies of pulmonary artery.74781
Congenital anomalies of cerebrovascular system.74783
Persistent fetal circulation.7485
Congenital agenesis, hypoplasia, and dysplasia of lung.7503
Congenital tracheoesophageal fistula, esophageal atresia and stenosis.75161
Biliary atresia, congenital.75555
Acrocephalosyndactyly.7566
Congenital anomalies of diaphragm.75670
Anomaly of abdominal wall, unspecified.75671
Prune belly syndrome.75679
Other congenital anomalies of abdominal wall.75832
Velo-cardio-facial syndrome.7594
Conjoined twins.7670
Subdural and cerebral hemorrhage due to birth trauma.7685
Severe birth asphyxia.7687
Hypoxic-ischemic encephalopathy (HIE).769
Respiratory distress syndrome in newborn.7700
Congenital pneumonia.77012
Meconium aspiration with respiratory symptoms.77014
Aspiration of clear amniotic fluid with respiratory symptoms.77016
Aspiration of blood with respiratory symptoms.77018
Other fetal and newborn aspiration with respiratory symptoms.7702
Interstitial emphysema and related conditions of newborn.7703
Pulmonary hemorrhage of fetus or newborn.7707
Chronic respiratory disease arising in the perinatal period.77084
Respiratory failure of newborn.77086
Aspiration of postnatal stomach contents with respiratory symptoms.77087
Respiratory arrest of newborn.7711
Congenital cytomegalovirus infection.7712
Other congenital infections specific to the perinatal period.7713
Tetanus neonatorum.77181
Septicemia [sepsis] of newborn.77213
Intraventricular hemorrhage grade iii.77214
Intraventricular hemorrhage grade iv.7722
Subarachnoid hemorrhage of newborn.7724
Gastrointestinal hemorrhage of fetus or newborn.7733
Hydrops fetalis due to isoimmunization.( print page 24996)7734
Kernicterus of fetus or newborn due to isoimmunization.7744
Perinatal jaundice due to hepatocellular damage.7747
Kernicterus of fetus or newborn not due to isoimmunization.7757
Late metabolic acidosis of newborn.7761
Transient neonatal thrombocytopenia.7762
Disseminated intravascular coagulation in newborn.7767
Transient neonatal neutropenia.7775
Necrotizing enterocolitis in fetus or newborn.7776
Perinatal intestinal perforation.7780
Hydrops fetalis not due to isoimmunization.7790
Convulsions in newborn.7792
Cerebral depression, coma, and other abnormal cerebral signs in fetus or newborn.7797
Preventricular leukomalacia.77985
Cardiac arrest of newborn.78551
Cardiogenic shock.78552
Septic shock.78559
Other shock without mention of trauma.7991
Respiratory arrest.80003
Closed fracture of vault of skull without mention of intracranial injury, with moderate (1-24 hours) loss of consciousness.80004
Closed fracture of vault of skull without mention of intracranial injury, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80005
Closed fracture of vault of skull without mention of intracranial injury, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80010
Closed fracture of vault of skull with cerebral laceration and contusion, with state of consciousness unspecified.80011
Closed fracture of vault of skull with cerebral laceration and contusion, with no loss of consciousness.80012
Closed fracture of vault of skull with cerebral laceration and contusion, with brief (less than one hour) loss of consciousness.80013
Closed fracture of vault of skull with cerebral laceration and contusion, with moderate (1-24 hours) loss of consciousness.80014
Closed fracture of vault of skull with cerebral laceration and contusion, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80015
Closed fracture of vault of skull with cerebral laceration and contusion, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80016
Closed fracture of vault of skull with cerebral laceration and contusion, with loss of consciousness of unspecified duration.80019
Closed fracture of vault of skull with cerebral laceration and contusion, with concussion, unspecified.80020
Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with state of consciousness unspecified.80021
Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness.80022
Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with brief (less than one hour) loss of consciousness.80023
Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with moderate (1-24 hours) loss of consciousness.80024
Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80025
Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80026
Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration.80029
Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with concussion, unspecified.80030
Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with state of consciousness unspecified.80031
Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with no loss of consciousness.80032
Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with brief (less than one hour) loss of consciousness.80033
Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with moderate (1-24 hours) loss of consciousness.80034
Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80035
Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80036
Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with loss of consciousness of unspecified duration.80039
Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with concussion, unspecified.80043
Closed fracture of vault of skull with intracranial injury of other and unspecified nature, with moderate (1-24 hours) loss of consciousness.( print page 24997)80044
Closed fracture of vault of skull with intracranial injury of other and unspecified nature, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80045
Closed fracture of vault of skull with intracranial injury of other and unspecified nature, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80050
Open fracture of vault of skull without mention of intracranial injury, with state of consciousness unspecified.80051
Open fracture of vault of skull without mention of intracranial injury, with no loss of consciousness.80052
Open fracture of vault of skull without mention of intracranial injury, with brief (less than one hour) loss of consciousness.80053
Open fracture of vault of skull without mention of intracranial injury, with moderate (1-24 hours) loss of consciousness.80054
Open fracture of vault of skull without mention of intracranial injury, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80055
Open fracture of vault of skull without mention of intracranial injury, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80056
Open fracture of vault of skull without mention of intracranial injury, with loss of consciousness of unspecified duration.80059
Open fracture of vault of skull without mention of intracranial injury, with concussion, unspecified.80060
Open fracture of vault of skull with cerebral laceration and contusion, with state of consciousness unspecified.80061
Open fracture of vault of skull with cerebral laceration and contusion, with no loss of consciousness.80062
Open fracture of vault of skull with cerebral laceration and contusion, with brief (less than one hour) loss of consciousness.80063
Open fracture of vault of skull with cerebral laceration and contusion, with moderate (1-24 hours) loss of consciousness.80064
Open fracture of vault of skull with cerebral laceration and contusion, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80065
Open fracture of vault of skull with cerebral laceration and contusion, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80066
Open fracture of vault of skull with cerebral laceration and contusion, with loss of consciousness of unspecified duration.80069
Open fracture of vault of skull with cerebral laceration and contusion, with concussion, unspecified.80070
Open fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with state of consciousness unspecified.80071
Open fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness.80072
Open fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with brief (less than one hour) loss of consciousness.80073
Open fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with moderate (1-24 hours) loss of consciousness.80074
Open fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80075
Open fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80076
Open fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration.80079
Open fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with concussion, unspecified.80080
Open fracture of vault of skull with other and unspecified intracranial hemorrhage, with state of consciousness unspecified.80081
Open fracture of vault of skull with other and unspecified intracranial hemorrhage, with no loss of consciousness.80082
Open fracture of vault of skull with other and unspecified intracranial hemorrhage, with brief (less than one hour) loss of consciousness.80083
Open fracture of vault of skull with other and unspecified intracranial hemorrhage, with moderate (1-24 hours) loss of consciousness.80084
Open fracture of vault of skull with other and unspecified intracranial hemorrhage, with prolonged (more than 24 hours)loss of consciousness and return to pre-existing conscious level.80085
Open fracture of vault of skull with other and unspecified intracranial hemorrhage, with prolonged (more than 24 hours)loss of consciousness, without return to pre-existing conscious level.80086
Open fracture of vault of skull with other and unspecified intracranial hemorrhage, with loss of consciousness of unspecified duration.80089
Open fracture of vault of skull with other and unspecified intracranial hemorrhage, with concussion, unspecified.80090
Open fracture of vault of skull with intracranial injury of other and unspecified nature, with state of consciousness unspecified.80091
Open fracture of vault of skull with intracranial injury of other and unspecified nature, with no loss of consciousness.80092
Open fracture of vault of skull with intracranial injury of other and unspecified nature, with brief (less than one hour) loss of consciousness.80093
Open fracture of vault of skull with intracranial injury of other and unspecified nature, with moderate (1-24 hours) loss of consciousness.80094
Open fracture of vault of skull with intracranial injury of other and unspecified nature, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.( print page 24998)80095
Open fracture of vault of skull with intracranial injury of other and unspecified nature, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80096
Open fracture of vault of skull with intracranial injury of other and unspecified nature, with loss of consciousness of unspecified duration.80099
Open fracture of vault of skull with intracranial injury of other and unspecified nature, with concussion, unspecified.80103
Closed fracture of base of skull without mention of intra cranial injury, with moderate (1-24 hours) loss of consciousness.80104
Closed fracture of base of skull without mention of intra cranial injury, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80105
Closed fracture of base of skull without mention of intra cranial injury, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80110
Closed fracture of base of skull with cerebral laceration and contusion, with state of consciousness unspecified.80111
Closed fracture of base of skull with cerebral laceration and contusion, with no loss of consciousness.80112
Closed fracture of base of skull with cerebral laceration and contusion, with brief (less than one hour) loss of consciousness.80113
Closed fracture of base of skull with cerebral laceration and contusion, with moderate (1-24 hours) loss of consciousness.80114
Closed fracture of base of skull with cerebral laceration and contusion, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80115
Closed fracture of base of skull with cerebral laceration and contusion, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80116
Closed fracture of base of skull with cerebral laceration and contusion, with loss of consciousness of unspecified duration.80119
Closed fracture of base of skull with cerebral laceration and contusion, with concussion, unspecified.80120
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with state of consciousness unspecified.80121
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness.80122
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with brief (less than one hour) loss of consciousness.80123
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with moderate (1-24 hours) loss of consciousness.80124
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80125
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80126
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration.80129
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with concussion, unspecified.80130
Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with state of consciousness unspecified.80131
Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with no loss of consciousness.80132
Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with brief (less than one hour) loss of consciousness.80133
Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with moderate (1-24 hours) loss of consciousness.80134
Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80135
Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80136
Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with loss of consciousness of unspecified duration.80139
Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with concussion, unspecified.80143
Closed fracture of base of skull with intracranial injury of other and unspecified nature, with moderate (1-24 hours) loss of consciousness.80144
Closed fracture of base of skull with intracranial injury of other and unspecified nature, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80145
Closed fracture of base of skull with intracranial injury of other and unspecified nature, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80150
Open fracture of base of skull without mention of intracranial injury, with state of consciousness unspecified.80151
Open fracture of base of skull without mention of intracranial injury, with no loss of consciousness.80152
Open fracture of base of skull without mention of intracranial injury, with brief (less than one hour) loss of consciousness.80153
Open fracture of base of skull without mention of intracranial injury, with moderate (1-24 hours) loss of consciousness.80154
Open fracture of base of skull without mention of intracranial injury, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.( print page 24999)80155
Open fracture of base of skull without mention of intracranial injury, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80156
Open fracture of base of skull without mention of intracranial injury, with loss of consciousness of unspecified duration.80159
Open fracture of base of skull without mention of intracranial injury, with concussion, unspecified.80160
Open fracture of base of skull with cerebral laceration and contusion, with state of consciousness unspecified.80161
Open fracture of base of skull with cerebral laceration and contusion, with no loss of consciousness.80162
Open fracture of base of skull with cerebral laceration and contusion, with brief (less than one hour) loss of consciousness.80163
Open fracture of base of skull with cerebral laceration and contusion, with moderate (1-24 hours) loss of consciousness.80164
Open fracture of base of skull with cerebral laceration and contusion, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80165
Open fracture of base of skull with cerebral laceration and contusion, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80166
Open fracture of base of skull with cerebral laceration and contusion, with loss of consciousness of unspecified duration.80169
Open fracture of base of skull with cerebral laceration and contusion, with concussion, unspecified.80170
Open fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with state of consciousness unspecified.80171
Open fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness.80172
Open fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with brief (less than one hour) loss of consciousness.80173
Open fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with moderate (1-24 hours) loss of consciousness.80174
Open fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80175
Open fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80176
Open fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration.80179
Open fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with concussion, unspecified.80180
Open fracture of base of skull with other and unspecified intracranial hemorrhage, with state of consciousness unspecified.80181
Open fracture of base of skull with other and unspecified intracranial hemorrhage, with no loss of consciousness.80182
Open fracture of base of skull with other and unspecified intracranial hemorrhage, with brief (less than one hour) loss of consciousness.80183
Open fracture of base of skull with other and unspecified intracranial hemorrhage, with moderate (1-24 hours) loss of consciousness.80184
Open fracture of base of skull with other and unspecified intracranial hemorrhage, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80185
Open fracture of base of skull with other and unspecified intracranial hemorrhage, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80186
Open fracture of base of skull with other and unspecified intracranial hemorrhage, with loss of consciousness of unspecified duration.80189
Open fracture of base of skull with other and unspecified intracranial hemorrhage, with concussion, unspecified.80190
Open fracture of base of skull with intracranial injury of other and unspecified nature, with state of consciousness unspecified.80191
Open fracture of base of skull with intracranial injury of other and unspecified nature, with no loss of consciousness.80192
Open fracture of base of skull with intracranial injury of other and unspecified nature, with brief (less than one hour) loss of consciousness.80193
Open fracture of base of skull with intracranial injury of other and unspecified nature, with moderate (1-24 hours) loss of consciousness.80194
Open fracture of base of skull with intracranial injury of other and unspecified nature, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80195
Open fracture of base of skull with intracranial injury of other and unspecified nature, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80196
Open fracture of base of skull with intracranial injury of other and unspecified nature, with loss of consciousness of unspecified duration.80199
Open fracture of base of skull with intracranial injury of other and unspecified nature, with concussion, unspecified.80303
Other closed skull fracture without mention of intracranial injury, with moderate (1-24 hours) loss of consciousness.80304
Other closed skull fracture without mention of intracranial injury, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80305
Other closed skull fracture without mention of intracranial injury, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.( print page 25000)80310
Other closed skull fracture with cerebral laceration and contusion, with state of consciousness unspecified.80311
Other closed skull fracture with cerebral laceration and contusion, with no loss of consciousness.80312
Other closed skull fracture with cerebral laceration and contusion, with brief (less than one hour) loss of consciousness.80313
Other closed skull fracture with cerebral laceration and contusion, with moderate (1-24 hours) loss of consciousness.80314
Other closed skull fracture with cerebral laceration and contusion, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80315
Other closed skull fracture with cerebral laceration and contusion, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80316
Other closed skull fracture with cerebral laceration and contusion, with loss of consciousness of unspecified duration.80319
Other closed skull fracture with cerebral laceration and contusion, with concussion, unspecified.80320
Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, with state of consciousness unspecified.80321
Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness.80322
Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, with brief (less than one hour) loss of consciousness.80323
Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, with moderate (1-24 hours) loss of consciousness.80324
Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80325
Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80326
Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration.80329
Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, with concussion, unspecified.80330
Other closed skull fracture with other and unspecified intracranial hemorrhage, with state of unconsciousness unspecified.80331
Other closed skull fracture with other and unspecified intracranial hemorrhage, with no loss of consciousness.80332
Other closed skull fracture with other and unspecified intracranial hemorrhage, with brief (less than one hour) loss of consciousness.80333
Other closed skull fracture with other and unspecified intracranial hemorrhage, with moderate (1-24 hours) loss of consciousness.80334
Other closed skull fracture with other and unspecified intracranial hemorrhage, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80335
Other closed skull fracture with other and unspecified intracranial hemorrhage, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80336
Other closed skull fracture with other and unspecified intracranial hemorrhage, with loss of consciousness of unspecified duration.80339
Other closed skull fracture with other and unspecified intracranial hemorrhage, with concussion, unspecified.80343
Other closed skull fracture with intracranial injury of other and unspecified nature, with moderate (1-24 hours) loss of consciousness.80344
Other closed skull fracture with intracranial injury of other and unspecified nature, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80345
Other site of closed skull fracture with intracranial injury of other and unspecified nature, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80350
Other open skull fracture without mention of injury, with state of consciousness unspecified.80351
Other open skull fracture without mention of intracranial injury, with no loss of consciousness.80352
Other open skull fracture without mention of intracranial injury, with brief (less than one hour) loss of consciousness.80353
Other open skull fracture without mention of intracranial injury, with moderate (1-24 hours) loss of consciousness.80354
Other open skull fracture without mention of intracranial injury, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80355
Other open skull fracture without mention of intracranial injury, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80356
Other open skull fracture without mention of intracranial injury, with loss of consciousness of unspecified duration.80359
Other open skull fracture without mention of intracranial injury, with concussion, unspecified.80360
Other open skull fracture with cerebral laceration and contusion, with state of consciousness unspecified.80361
Other open skull fracture with cerebral laceration and contusion, with no loss of consciousness.80362
Other open skull fracture with cerebral laceration and contusion, with brief (less than one hour) loss of consciousness.80363
Other open skull fracture with cerebral laceration and contusion, with moderate (1-24 hours) loss of consciousness.80364
Other open skull fracture with cerebral laceration and contusion, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80365
Other open skull fracture with cerebral laceration and contusion, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.( print page 25001)80366
Other open skull fracture with cerebral laceration and contusion, with loss of consciousness of unspecified duration.80369
Other open skull fracture with cerebral laceration and contusion, with concussion, unspecified.80370
Other open skull fracture with subarachnoid, subdural, and extradural hemorrhage, with state of consciousness unspecified.80371
Other open skull fracture with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness.80372
Other open skull fracture with subarachnoid, subdural, and extradural hemorrhage, with brief (less than one hour) loss of consciousness.80373
Other open skull fracture with subarachnoid, subdural, and extradural hemorrhage, with moderate (1-24 hours) loss of consciousness.80374
Other open skull fracture with subarachnoid, subdural, and extradural hemorrhage, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80375
Other open skull fracture with subarachnoid, subdural, and extradural hemorrhage, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80376
Other open skull fracture with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration.80379
Other open skull fracture with subarachnoid, subdural, and extradural hemorrhage, with concussion, unspecified.80380
Other open skull fracture with other and unspecified intracranial hemorrhage, with state of consciousness unspecified.80381
Other open skull fracture with other and unspecified intracranial hemorrhage, with no loss of consciousness.80382
Other open skull fracture with other and unspecified intracranial hemorrhage, with brief (less than one hour) loss of consciousness.80383
Other open skull fracture with other and unspecified intracranial hemorrhage, with moderate (1-24 hours) loss of consciousness.80384
Other open skull fracture with other and unspecified intracranial hemorrhage, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80385
Other open skull fracture with other and unspecified intracranial hemorrhage, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80386
Other open skull fracture with other and unspecified intracranial hemorrhage, with loss of consciousness of unspecified duration.80389
Other open skull fracture with other and unspecified intracranial hemorrhage, with concussion, unspecified.80390
Other open skull fracture with intracranial injury of other and unspecified nature, with state of consciousness unspecified.80391
Other open skull fracture with intracranial injury of other and unspecified nature, with no loss of consciousness.80392
Other open skull fracture with intracranial injury of other and unspecified nature, with brief (less than one hour) loss of consciousness.80393
Other open skull fracture with intracranial injury of other and unspecified nature, with moderate (1-24 hours) loss of consciousness.80394
Other open skull fracture with intracranial injury of other and unspecified nature, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80395
Other open skull fracture with intracranial injury of other and unspecified nature, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80396
Other open skull fracture with intracranial injury of other and unspecified nature, with loss of consciousness of unspecified duration.80399
Other open skull fracture with intracranial injury of other and unspecified nature, with concussion, unspecified.80403
Closed fractures involving skull or face with other bones, without mention of intracranial injury, with moderate (1-24 hours) loss of consciousness.80404
Closed fractures involving skull or face with other bones, without mention or intracranial injury, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80405
Closed fractures involving skull of face with other bones, without mention of intracranial injury, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80410
Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, with state of consciousness unspecified.80411
Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, with no loss of consciousness.80412
Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, with brief (less than one hour) loss of consciousness.80413
Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, with moderate (1-24 hours) loss of consciousness.80414
Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80415
Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80416
Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, with loss of consciousness of unspecified duration.80419
Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, with concussion, unspecified.80420
Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with state of consciousness unspecified.( print page 25002)80421
Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness.80422
Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with brief (less than one hour) loss of consciousness.80423
Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with moderate (1-24 hours) loss of consciousness.80424
Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80425
Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80426
Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration.80429
Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with concussion, unspecified.80430
Closed fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with state of consciousness unspecified.80431
Closed fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with no loss of consciousness.80432
Closed fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with brief (less than one hour) loss of consciousness.80433
Closed fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with moderate (1-24 hours) loss of consciousness.80434
Closed fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80435
Closed fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80436
Closed fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with loss of consciousness of unspecified duration.80439
Closed fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with concussion, unspecified.80443
Closed fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with moderate (1-24 hours) loss of consciousness.80444
Closed fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80445
Closed fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80453
Open fractures involving skull or face with other bones, without mention of intracranial injury, with moderate (1-24 hours) loss of consciousness.80454
Open fractures involving skull or face with other bones, without mention of intracranial injury, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80455
Open fractures involving skull or face with other bones, without mention of intracranial injury, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80460
Open fractures involving skull or face with other bones, with cerebral laceration and contusion, with state of consciousness unspecified.80461
Open fractures involving skull or face with other bones, with cerebral laceration and contusion, with no loss of consciousness.80462
Open fractures involving skull or face with other bones, with cerebral laceration and contusion, with brief (less than one hour) loss of consciousness.80463
Open fractures involving skull or face with other bones, with cerebral laceration and contusion, with moderate (1-24 hours) loss of consciousness.80464
Open fractures involving skull or face with other bones, with cerebral laceration and contusion, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80465
Open fractures involving skull or face with other bones, with cerebral laceration and contusion, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80466
Open fractures involving skull or face with other bones, with cerebral laceration and contusion, with loss of consciousness of unspecified duration.80469
Open fractures involving skull or face with other bones, with cerebral laceration and contusion, with concussion, unspecified.80470
Open fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with state of consciousness unspecified.80471
Open fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness.80472
Open fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with brief (less than one hour) loss of consciousness.80473
Open fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with moderate (1-24 hours) loss of consciousness.80474
Open fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.( print page 25003)80475
Open fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.80476
Open fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration.80479
Open fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with concussion, unspecified.80480
Open fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with state of consciousness unspecified.80481
Open fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with no loss of consciousness.80482
Open fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with brief (less than one hour) loss of consciousness.80483
Open fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with moderate (1-24 hours) loss of consciousness.80484
Open fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80485
Open fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with prolonged (more than 24 hours) loss consciousness, without return to pre-existing conscious level.80486
Open fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with loss of consciousness of unspecified duration.80489
Open fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with concussion, unspecified.80493
Open fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with moderate (1-24 hours) loss of consciousness.80494
Open fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.80495
Open fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with prolonged (more than 24 hours) loss of consciousness without return to pre-existing conscious level.80510
Open fracture of cervical vertebra, unspecified level.80511
Open fracture of first cervical vertebra.80512
Open fracture of second cervical vertebra.80513
Open fracture of third cervical vertebra.80514
Open fracture of fourth cervical vertebra.80515
Open fracture of fifth cervical vertebra.80516
Open fracture of sixth cervical vertebra.80517
Open fracture of seventh cervical vertebra.80518
Open fracture of multiple cervical vertebrae.8053
Open fracture of dorsal (thoracic) vertebra without mention of spinal cord injury.8055
Open fracture of lumbar vertebra without mention of spinal cord injury.8057
Open fracture of sacrum and coccyx without mention of spinal cord injury.8059
Open fracture of unspecified part of vertebral column without mention of spinal cord injury.80600
Closed fracture of C1-C4 level with unspecified spinal cord injury.80601
Closed fracture of C1-C4 level with complete lesion of cord.80602
Closed fracture of C1-C4 level with anterior cord syndrome.80603
Closed fracture of C1-C4 level with central cord syndrome.80604
Closed fracture of C1-C4 level with other specified spinal cord injury.80605
Closed fracture of C5-C7 level with unspecified spinal cord injury.80606
Closed fracture of C5-C7 level with complete lesion of cord.80607
Closed fracture of C5-C7 level with anterior cord syndrome.80608
Closed fracture of C5-C7 level with central cord syndrome.80609
Closed fracture of C5-C7 level with other specified spinal cord injury.80610
Open fracture of C1-C4 level with unspecified spinal cord injury.80611
Open fracture of C1-C4 level with complete lesion of cord.80612
Open fracture of C1-C4 level with anterior cord syndrome.80613
Open fracture of C1-C4 level with central cord syndrome.80614
Open fracture of C1-C4 level with other specified spinal cord injury.80615
Open fracture of C5-C7 level with unspecified spinal cord injury.80616
Open fracture of C5-C7 level with complete lesion of cord.80617
Open fracture of C5-C7 level with anterior cord syndrome.80618
Open fracture of C5-C7 level with central cord syndrome.80619
Open fracture of C5-C7 level with other specified spinal cord injury.80620
Closed fracture of T1-T6 level with unspecified spinal cord injury.80621
Closed fracture of T1-T6 level with complete lesion of cord.80622
Closed fracture of T1-T6 level with anterior cord syndrome.80623
Closed fracture of T1-T6 level with central cord syndrome.80624
Closed fracture of T1-T6 level with other specified spinal cord injury.80625
Closed fracture of T7-T12 level with unspecified spinal cord injury.80626
Closed fracture of T7-T12 level with complete lesion of cord.80627
Closed fracture of T7-T12 level with anterior cord syndrome.80628
Closed fracture of T7-T12 level with central cord syndrome.80629
Closed fracture of T7-T12 level with other specified spinal cord injury.( print page 25004)80630
Open fracture of T1-T6 level with unspecified spinal cord injury.80631
Open fracture of T1-T6 level with complete lesion of cord.80632
Open fracture of T1-T6 level with anterior cord syndrome.80633
Open fracture of T1-T6 level with central cord syndrome.80634
Open fracture of T1-T6 level with other specified spinal cord injury.80635
Open fracture of T7-T12 level with unspecified spinal cord injury.80636
Open fracture of T7-T12 level with complete lesion of cord.80637
Open fracture of T7-T12 level with anterior cord syndrome.80638
Open fracture of T7-T12 level with central cord syndrome.80639
Open fracture of T7-T-12 level with other specified spinal cord injury.8064
Closed fracture of lumbar spine with spinal cord injury.8065
Open fracture of lumbar spine with spinal cord injury.80660
Closed fracture of sacrum and coccyx with unspecified spinal cord injury.80661
Closed fracture of sacrum and coccyx with complete cauda equina lesion.80662
Closed fracture of sacrum and coccyx with other cauda equina injury.80669
Closed fracture of sacrum and coccyx with other spinal cord injury.80670
Open fracture of sacrum and coccyx with unspecified spinal cord injury.80671
Open fracture of sacrum and coccyx with complete cauda equina lesion.80672
Open fracture of sacrum and coccyx with other cauda equina injury.80679
Open fracture of sacrum and coccyx with other spinal cord injury.8068
Closed fracture of unspecified vertebra with spinal cord injury.8069
Open fracture of unspecified vertebra with spinal cord injury.80710
Open fracture of rib(s), unspecified.80711
Open fracture of one rib.80712
Open fracture of two ribs.80713
Open fracture of three ribs.80714
Open fracture of four ribs.80715
Open fracture of five ribs.80716
Open fracture of six ribs.80717
Open fracture of seven ribs.80718
Open fracture of eight or more ribs.80719
Open fracture of multiple ribs, unspecified.8073
Open fracture of sternum.8074
Flail chest.8075
Closed fracture of larynx and trachea.8076
Open fracture of larynx and trachea.8080
Closed fracture of acetabulum.8081
Open fracture of acetabulum.8083
Open fracture of pubis.80851
Open fracture of ilium.80852
Open fracture of ischium.80853
Multiple open pelvic fractures with disruption of pelvic circle.80859
Open fracture of other specified part of pelvis.8089
Unspecified open fracture of pelvis.8091
Fracture of bones of trunk, open.81210
Fracture of unspecified part of upper end of humerus, open.81211
Fracture of surgical neck of humerus, open.81212
Fracture of anatomical neck of humerus, open.81213
Fracture of greater tuberosity of humerus, open.81219
Other open fracture of upper end of humerus.81230
Fracture of unspecified part of humerus, open.81231
Fracture of shaft of humerus, open.81250
Fracture of unspecified part of lower end of humerus, open.81251
Supracondylar fracture of humerus, open.81252
Fracture of lateral condyle of humerus, open.81253
Fracture of medial condyle of humerus, open.81254
Fracture of unspecified condyle(s) of humerus, open.81259
Other fracture of lower end of humerus, open.81310
Open fracture of upper end of forearm, unspecified.81311
Fracture of olecranon process of ulna, open.81312
Fracture of coronoid process of ulna, open.81313
Monteggia's fracture, open.81314
Other and unspecified open fractures of proximal end of ulna (alone).81315
Fracture of head of radius, open.81316
Fracture of neck of radius, open.81317
Other and unspecified open fractures of proximal end of radius (alone).81318
Fracture of radius with ulna, upper end (any part), open.81330
Fracture of shaft of radius or ulna, unspecified, open.81331
Fracture of shaft of radius (alone), open.81332
Fracture of shaft of ulna (alone), open.81333
Fracture of shaft of radius with ulna, open.81350
Open fracture of lower end of forearm, unspecified.( print page 25005)81351
Colles' fracture, open.81352
Other open fractures of distal end of radius (alone).81353
Fracture of distal end of ulna (alone), open.81354
Fracture of lower end of radius with ulna, open.81390
Fracture of unspecified part of forearm, open.81391
Fracture of unspecified part of radius (alone), open.81392
Fracture of unspecified part of ulna (alone), open.81393
Fracture of unspecified part of radius with ulna, open.82000
Fracture of unspecified intracapsular section of neck of femur, closed.82001
Fracture of epiphysis (separation) (upper) of neck of femur, closed.82002
Fracture of midcervical section of femur, closed.82003
Fracture of base of neck of femur, closed.82009
Other transcervical fracture of femur, closed.82010
Fracture of unspecified intracapsular section of neck of femur, open.82011
Fracture of epiphysis (separation) (upper) of neck of femur, open.82012
Fracture of midcervical section of femur, open.82013
Fracture of base of neck of femur, open.82019
Other transcervical fracture of femur, open.82020
Fracture of unspecified trochanteric section of femur, closed.82021
Fracture of intertrochanteric section of femur, closed.82022
Fracture of subtrochanteric section of femur, closed.82030
Fracture of unspecified trochanteric section of femur, open.82031
Fracture of intertrochanteric section of femur, open.82032
Fracture of subtrochanteric section of femur, open.8208
Fracture of unspecified part of neck of femur, closed.8209
Fracture of unspecified part of neck of femur, open.82100
Fracture of unspecified part of femur, closed.82101
Fracture of shaft of femur, closed.82110
Fracture of unspecified part of femur, open.82111
Fracture of shaft of femur, open.82130
Fracture of lower end of femur, unspecified part, open.82131
Fracture of femoral condyle, open.82132
Fracture of lower epiphysis of femur, open.82133
Supracondylar fracture of femur, open.82139
Other fracture of lower end of femur, open.82310
Open fracture of upper end of tibia.82311
Open fracture of upper end of fibula.82312
Open fracture of upper end of fibula with tibia.82330
Open fracture of shaft of tibia.82331
Open fracture of shaft of fibula.82332
Open fracture of shaft of fibula with tibia.82390
Open fracture of unspecified part of tibia.82391
Open fracture of unspecified part of fibula.82392
Open fracture of unspecified part of fibula with tibia.8280
Multiple fractures involving both lower limbs, lower with upper limb, and lower limb(s) with rib(s) and sternum, closed.8281
Multiple fractures involving both lower limbs, lower with upper limb, and lower limb(s) with rib(s) and sternum, open.83510
Open dislocation of hip, unspecified site.83511
Open posterior dislocation of hip.83512
Open obturator dislocation of hip.83513
Other open anterior dislocation of hip.83910
Open dislocation, cervical vertebra, unspecified.83911
Open dislocation, first cervical vertebra.83912
Open dislocation, second cervical vertebra.83913
Open dislocation, third cervical vertebra.83914
Open dislocation, fourth cervical vertebra.83915
Open dislocation, fifth cervical vertebra.83916
Open dislocation, sixth cervical vertebra.83917
Open dislocation, seventh cervical vertebra.83918
Open dislocation, multiple cervical vertebrae.83930
Open dislocation, lumbar vertebra.83931
Open dislocation, thoracic vertebra.83950
Open dislocation, vertebra, unspecified site.83959
Open dislocation, other vertebra.83971
Open dislocation, sternum.8504
Concussion with prolonged loss of consciousness, without return to pre-existing conscious level.85105
Cortex (cerebral) contusion without mention of open intracranial wound, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.85110
Cortex (cerebral) contusion with open intracranial wound, without mention of specific state of consciousness.85111
Cortex (cerebral) contusion with open intracranial wound, with no loss of consciousness.85112
Cortex (cerebral) contusion with open intracranial wound, with brief (less than one hour) loss of consciousness.( print page 25006)85113
Cortex (cerebral) contusion with open intracranial wound, with moderate (1-24 hours) loss of consciousness.85114
Cortex (cerebral) contusion with open intracranial wound, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.85115
Cortex (cerebral) contusion with open intracranial wound, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.85116
Cortex (cerebral) contusion with open intracranial wound, with loss of consciousness of unspecified duration.85119
Cortex (cerebral) contusion with open intracranial wound, with concussion, unspecified.85120
Cortex (cerebral) laceration without mention of open intracranial wound, with state of consciousness unspecified.85121
Cortex (cerebral) laceration without mention of open intracranial wound, with no loss of consciousness.85122
Cortex (cerebral) laceration without mention of open intracranial wound, with brief (less than one hour) loss of consciousness.85123
Cortex (cerebral) laceration without mention of open intracranial wound, with moderate (1-24 hours) loss of consciousness.85124
Cortex (cerebral) laceration without mention of open intracranial wound, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.85125
Cortex (cerebral) laceration without mention of open intracranial wound, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.85126
Cortex (cerebral) laceration without mention of open intracranial wound, with loss of consciousness of unspecified duration.85129
Cortex (cerebral) laceration without mention of open intracranial wound, with concussion, unspecified.85130
Cortex (cerebral) laceration with open intracranial wound, with state of consciousness unspecified.85131
Cortex (cerebral) laceration with open intracranial wound, with no loss of consciousness.85132
Cortex (cerebral) laceration with open intracranial wound, with brief (less than one hour) loss of consciousness.85133
Cortex (cerebral) laceration with open intracranial wound, with moderate (1-24 hours) loss of consciousness.85134
Cortex (cerebral) laceration with open intracranial wound, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.85135
Cortex (cerebral) laceration with open intracranial wound, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.85136
Cortex (cerebral) laceration with open intracranial wound, with loss of consciousness of unspecified duration.85139
Cortex (cerebral) laceration with open intracranial wound, with concussion, unspecified.85145
Cerebellar or brain stem contusion without mention of open intracranial wound, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.85150
Cerebellar or brain stem contusion with open intracranial wound, with state of consciousness unspecified.85151
Cerebellar or brain stem contusion with open intracranial wound, with no loss of consciousness.85152
Cerebellar or brain stem contusion with open intracranial wound, with brief (less than one hour) loss of consciousness.85153
Cerebellar or brain stem contusion with open intracranial wound, with moderate (1-24 hours) loss of consciousness.85154
Cerebellar or brain stem contusion with open intracranial wound, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.85155
Cerebellar or brain stem contusion with open intracranial wound, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.85156
Cerebellar or brain stem contusion with open intracranial wound, with loss of consciousness of unspecified duration.85159
Cerebellar or brain stem contusion with open intracranial wound, with concussion, unspecified.85160
Cerebellar or brain stem laceration without mention of open intracranial wound, with state of consciousness unspecified.85161
Cerebellar or brain stem laceration without mention of open intracranial wound, with no loss of consciousness.85162
Cerebellar or brain stem laceration without mention of open intracranial wound, with brief (less than 1 hour) loss of consciousness.85163
Cerebellar or brain stem laceration without mention of open intracranial wound, with moderate (1-24 hours) loss of consciousness.85164
Cerebellar or brain stem laceration without mention of open intracranial wound, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.85165
Cerebellar or brain stem laceration without mention of open intracranial wound, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.85166
Cerebellar or brain stem laceration without mention of open intracranial wound, with loss of consciousness of unspecified duration.85169
Cerebellar or brain stem laceration without mention of open intracranial wound, with concussion, unspecified.85170
Cerebellar or brain stem laceration with open intracranial wound, with state of consciousness unspecified.85171
Cerebellar or brain stem laceration with open intracranial wound, with no loss of consciousness.85172
Cerebellar or brain stem laceration with open intracranial wound, with brief (less than one hour) loss of consciousness.85173
Cerebellar or brain stem laceration with open intracranial wound, with moderate (1-24 hours) loss of consciousness.85174
Cerebellar or brain stem laceration with open intracranial wound, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.85175
Cerebellar or brain stem laceration with open intracranial wound, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.( print page 25007)85176
Cerebellar or brain stem laceration with open intracranial wound, with loss of consciousness of unspecified duration.85179
Cerebellar or brain stem laceration with open intracranial wound, with concussion, unspecified.85180
Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with state of consciousness unspecified.85181
Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness.85182
Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with brief (less than one hour) loss of consciousness.85183
Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with moderate (1-24 hours) loss of consciousness.85184
Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.85185
Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.85186
Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with loss of consciousness of unspecified duration.85189
Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with concussion, unspecified.85190
Other and unspecified cerebral laceration and contusion, with open intracranial wound, with state of consciousness unspecified.85191
Other and unspecified cerebral laceration and contusion, with open intracranial wound, with no loss of consciousness.85192
Other and unspecified cerebral laceration and contusion, with open intracranial wound, with brief (less than one hour) loss of consciousness.85193
Other and unspecified cerebral laceration and contusion, with open intracranial wound, with moderate (1-24 hours) loss of consciousness.85194
Other and unspecified cerebral laceration and contusion, with open intracranial wound, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.85195
Other and unspecified cerebral laceration and contusion, with open intracranial wound, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.85196
Other and unspecified cerebral laceration and contusion, with open intracranial wound, with loss of consciousness of unspecified duration.85199
Other and unspecified cerebral laceration and contusion, with open intracranial wound, with concussion, unspecified.85200
Subarachnoid hemorrhage following injury, without mention of open intracranial wound, with state of consciousness unspecified.85201
Subarachnoid hemorrhage following injury, without mention of open intracranial wound, with no loss of consciousness.85202
Subarachnoid hemorrhage following injury, without mention of open intracranial wound, with brief (less than one hour) loss of consciousness.85203
Subarachnoid hemorrhage following injury, without mention of open intracranial wound, with moderate (1-24 hours) loss of consciousness.85204
Subarachnoid hemorrhage following injury, without mention of open intracranial wound, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.85205
Subarachnoid hemorrhage following injury, without mention of open intracranial wound, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.85206
Subarachnoid hemorrhage following injury, without mention of open intracranial wound, with loss of consciousness of unspecified duration.85209
Subarachnoid hemorrhage following injury, without mention of open intracranial wound, with concussion, unspecified.85210
Subarachnoid hemorrhage following injury, with open intracranial wound, with state of consciousness unspecified.85211
Subarachnoid hemorrhage following injury, with open intracranial wound, with no loss of consciousness.85212
Subarachnoid hemorrhage following injury, with open intracranial wound, with brief (less than one hour) loss of consciousness.85213
Subarachnoid hemorrhage following injury, with open intracranial wound, with moderate (1-24 hours) loss of consciousness.85214
Subarachnoid hemorrhage following injury, with open intracranial wound, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.85215
Subarachnoid hemorrhage following injury, with open intracranial wound, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.85216
Subarachnoid hemorrhage following injury, with open intracranial wound, with loss of consciousness of unspecified duration.85219
Subarachnoid hemorrhage following injury, with open intracranial wound, with concussion, unspecified.85220
Subdural hemorrhage following injury, without mention of open intracranial wound, with state of consciousness unspecified.85221
Subdural hemorrhage following injury, without mention of open intracranial wound, with no loss of consciousness.85222
Subdural hemorrhage following injury, without mention of open intracranial wound, with brief (less than one hour) loss of consciousness.( print page 25008)85223
Subdural hemorrhage following injury, without mention of open intracranial wound, with moderate (1-24 hours) loss of consciousness.85224
Subdural hemorrhage following injury, without mention of open intracranial wound, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.85225
Subdural hemorrhage following injury, without mention of open intracranial wound, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.85226
Subdural hemorrhage following injury, without mention of open intracranial wound, with loss of consciousness of unspecified duration.85229
Subdural hemorrhage following injury, without mention of open intracranial wound, with concussion, unspecified.85230
Subdural hemorrhage following injury, with open intracranial wound, with state of consciousness unspecified.85231
Subdural hemorrhage following injury, with open intracranial wound, with no loss of consciousness.85232
Subdural hemorrhage following injury, with open intracranial wound, with brief (less than one hour) loss of consciousness.85233
Subdural hemorrhage following injury, with open intracranial wound, with moderate (1-24 hours) loss of consciousness.85234
Subdural hemorrhage following injury, with open intracranial wound, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.85235
Subdural hemorrhage following injury, with open intracranial wound, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.85236
Subdural hemorrhage following injury, with open intracranial wound, with loss of consciousness of unspecified duration.85239
Subdural hemorrhage following injury, with open intracranial wound, with concussion, unspecified.85240
Extradural hemorrhage following injury, without mention of open intracranial wound, with state of consciousness unspecified.85241
Extradural hemorrhage following injury, without mention of open intracranial wound, with no loss of consciousness.85242
Extradural hemorrhage following injury, without mention of open intracranial wound, with brief (less than 1 hour) loss of consciousness.85243
Extradural hemorrhage following injury, without mention of open intracranial wound, with moderate (1-24 hours) loss of consciousness.85244
Extradural hemorrhage following injury, without mention of open intracranial wound, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.85245
Extradural hemorrhage following injury, without mention of open intracranial wound, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.85246
Extradural hemorrhage following injury, without mention of open intracranial wound, with loss of consciousness of unspecified duration.85249
Extradural hemorrhage following injury, without mention of open intracranial wound, with concussion, unspecified.85250
Extradural hemorrhage following injury, with open intracranial wound, with state of consciousness unspecified.85251
Extradural hemorrhage following injury, with open intracranial wound, with no loss of consciousness.85252
Extradural hemorrhage following injury, with open intracranial wound, with brief (less than one hour) loss of consciousness.85253
Extradural hemorrhage following injury, with open intracranial wound, with moderate (1-24 hours) loss of consciousness.85254
Extradural hemorrhage following injury, with open intracranial wound, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.85255
Extradural hemorrhage following injury, with open intracranial wound, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.85256
Extradural hemorrhage following injury, with open intracranial wound, with loss of consciousness of unspecified duration.85259
Extradural hemorrhage following injury, with open intracranial wound, with concussion, unspecified.85300
Other and unspecified intracranial hemorrhage following injury, without mention of open intracranial wound, with state of consciousness unspecified.85301
Other and unspecified intracranial hemorrhage following injury, without mention of open intracranial wound, with no loss of consciousness.85302
Other and unspecified intracranial hemorrhage following injury, without mention of open intracranial wound, with brief (less than one hour) loss of consciousness.85303
Other and unspecified intracranial hemorrhage following injury, without mention of open intracranial wound, with moderate (1-24 hours) loss of consciousness.85304
Other and unspecified intracranial hemorrhage following injury, without mention of open intracranial wound, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.85305
Other and unspecified intracranial hemorrhage following injury. without mention of open intracranial wound, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.85306
Other and unspecified intracranial hemorrhage following injury, without mention of open intracranial wound, with loss of consciousness of unspecified duration.85309
Other and unspecified intracranial hemorrhage following injury, without mention of open intracranial wound, with concussion, unspecified.85310
Other and unspecified intracranial hemorrhage following injury, with open intracranial wound, with state of consciousness unspecified.85311
Other and unspecified intracranial hemorrhage following injury, with open intracranial wound, with no loss of consciousness.( print page 25009)85312
Other and unspecified intracranial hemorrhage following injury, with open intracranial wound, with brief (less than one hour) loss of consciousness.85313
Other and unspecified intracranial hemorrhage following injury, with open intracranial wound, with moderate (1-24 hours) loss of consciousness.85314
Other and unspecified intracranial hemorrhage following injury, with open intracranial wound, with prolonged( more than 24 hours) loss of consciousness and return to pre-existing conscious level.85315
Other and unspecified intracranial hemorrhage following injury, with open intracranial wound, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.85316
Other and unspecified intracranial hemorrhage following injury, with open intracranial wound, with loss of consciousness of unspecified duration.85319
Other and unspecified intracranial hemorrhage following injury, with open intracranial wound, with concussion, unspecified.85405
Intracranial injury of other and unspecified nature, without mention of open intracranial wound, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.85410
Intracranial injury of other and unspecified nature, with open intracranial wound, with state of consciousness unspecified.85411
Intracranial injury of other and unspecified nature, with open intracranial wound, with no loss of consciousness.85412
Intracranial injury of other and unspecified nature, with open intracranial wound, with brief (less than one hour) loss of consciousness.85413
Intracranial injury of other and unspecified nature, with open intracranial wound, with moderate (1-24 hours) loss of consciousness.85414
Intracranial injury of other and unspecified nature, with open intracranial wound, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.85415
Intracranial injury of other and unspecified nature, with open intracranial wound, with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level.85416
Intracranial injury of other and unspecified nature, with open intracranial wound, with loss of consciousness of unspecified duration.85419
Intracranial injury of other and unspecified nature, with open intracranial wound, with concussion, unspecified.8601
Traumatic pneumothorax with open wound into thorax.8602
Traumatic hemothorax without mention of open wound into thorax.8603
Traumatic hemothorax with open wound into thorax.8604
Traumatic pneumohemothorax without mention of open wound into thorax.8605
Traumatic pneumohemothorax with open wound into thorax.86102
Laceration of heart without penetration of heart chambers or open wound into thorax.86103
Laceration of heart with penetration of heart chambers, without mention of open wound into thorax.86110
Unspecified injury of heart with open wound into thorax.86111
Contusion of heart with open wound into thorax.86112
Laceration of heart without penetration of heart chambers, with open wound into thorax.86113
Laceration of heart with penetration of heart chambers and open wound into thorax.86122
Laceration of lung without open wound into thorax.86130
Unspecified injury of lung with open wound into thorax.86131
Contusion of lung with open wound into thorax.86132
Laceration of lung with open wound into thorax.8621
Injury to diaphragm with open wound into cavity.86221
Injury to bronchus without open wound into cavity.86222
Injury to esophagus without mention of open wound into cavity.86231
Injury to bronchus with open wound into cavity.86232
Injury to esophagus with open wound into cavity.86239
Injury to other specified intrathoracic organs with open wound into cavity.8629
Injury to multiple and unspecified intrathoracic organs with open wound into cavity.8631
Injury to stomach with open wound into cavity.86330
Injury to small intestine, unspecified site, with open wound into cavity.86331
Injury to duodenum with open wound into cavity.86339
Other injury to small intestine with open wound into cavity.86350
Injury to colon, unspecified site, with open wound into cavity.86351
Injury to ascending (right) colon with open wound into cavity.86352
Injury to transverse colon with open wound into cavity.86353
Injury to descending (left) colon with open wound into cavity.86354
Injury to sigmoid colon with open wound into cavity.86355
Injury to rectum with open wound into cavity.86356
Injury to multiple sites in colon and rectum with open wound into cavity.86359
Other injury to colon and rectum with open wound into cavity.86390
Injury to gastrointestinal tract, unspecified site, with open wound into cavity.86391
Injury to pancreas head with open wound into cavity.86392
Injury to pancreas body with open wound into cavity.86393
Injury to pancreas tail with open wound into cavity.86394
Injury to pancreas, multiple and unspecified sites, with open wound into cavity.86395
Injury to appendix with open wound into cavity.86399
Injury to other and unspecified gastrointestinal sites with open wound into cavity.86403
Laceration of liver, moderate, without mention of open wound into cavity.86404
Laceration of liver, major, without mention of open wound into cavity.( print page 25010)86410
Unspecified injury to liver with open wound into cavity.86411
Hematoma and contusion of liver with open wound into cavity.86412
Laceration of liver, minor, with open wound into cavity.86413
Laceration of liver, moderate, with open wound into cavity.86414
Laceration of liver, major, with open wound into cavity.86415
Laceration of liver, unspecified, with open wound into cavity.86419
Other injury to liver with open wound into cavity.86503
Laceration of spleen extending into parenchyma without mention of open wound into cavity.86504
Massive parenchymal disruption of spleen without mention of open wound into cavity.86510
Unspecified injury to spleen with open wound into cavity.86511
Hematoma of spleen, without rupture of capsule, with open wound into cavity.86512
Capsular tears to spleen, without major disruption of parenchyma, with open wound into cavity.86513
Laceration of spleen extending into parenchyma, with open wound into cavity.86514
Massive parenchyma disruption of spleen with open wound into cavity.86519
Other injury to spleen with open wound into cavity.86603
Complete disruption of kidney parenchyma, without mention of open wound into cavity.86610
Unspecified injury to kidney with open wound into cavity.86611
Hematoma of kidney, without rupture of capsule, with open wound into cavity.86612
Laceration of kidney with open wound into cavity.86613
Complete disruption of kidney parenchyma, with open wound into cavity.8671
Injury to bladder and urethra with open wound into cavity.8673
Injury to ureter with open wound into cavity.8675
Injury to uterus with open wound into cavity.8677
Injury to other specified pelvic organs with open wound into cavity.8679
Injury to unspecified pelvic organ with open wound into cavity.86810
Injury to unspecified intra-abdominal organ, with open wound into cavity.86811
Injury to adrenal gland, with open wound into cavity.86812
Injury to bile duct and gallbladder, with open wound into cavity.86813
Injury to peritoneum with open wound into cavity.86814
Injury to retroperitoneum with open wound into cavity.86819
Injury to other and multiple intra-abdominal organs, with open wound into cavity.8691
Internal injury to unspecified or ill-defined organs with open wound into cavity.87400
Open wound of larynx with trachea, uncomplicated.87401
Open wound of larynx, uncomplicated.87402
Open wound of trachea, uncomplicated.87410
Open wound of larynx with trachea, complicated.87411
Open wound of larynx, complicated.87412
Open wound of trachea, complicated.8876
Traumatic amputation of arm and hand (complete) (partial), bilateral (any level), without mention of complication.8877
Traumatic amputation of arm and hand (complete) (partial), bilateral (any level), complicated.8962
Traumatic amputation of foot (complete) (partial), bilateral, without mention of complication.8963
Traumatic amputation of foot (complete) (partial), bilateral, complicated.8976
Traumatic amputation of leg(s) (complete) (partial), bilateral (any level), without mention of complication.8977
Traumatic amputation of leg(s) (complete) (partial), bilateral (any level), complicated.9010
Injury to thoracic aorta.9011
Injury to innominate and subclavian arteries.9012
Injury to superior vena cava.9013
Injury to innominate and subclavian veins.90140
Injury to pulmonary vessel(s), unspecified.90141
Injury to pulmonary artery.90142
Injury to pulmonary vein.90183
Injury to multiple blood vessels of thorax.9020
Injury to abdominal aorta.90210
Injury to inferior vena cava, unspecified.90211
Injury to hepatic veins.90219
Injury to other specified branches of inferior vena cava.90220
Injury to celiac and mesenteric arteries, unspecified.90221
Injury to gastric artery.90222
Injury to hepatic artery.90223
Injury to splenic artery.90224
Injury to other specified branches of celiac axis.90225
Injury to superior mesenteric artery (trunk).90226
Injury to primary branches of superior mesenteric artery.90227
Injury to inferior mesenteric artery.90229
Injury to other celiac and mesenteric arteries.90231
Injury to superior mesenteric vein and primary subdivisions.90232
Injury to inferior mesenteric vein.90233
Injury to portal vein.90234
Injury to splenic vein.90239
Injury to other portal and splenic veins.90240
Injury to renal vessel(s), unspecified.( print page 25011)90241
Injury to renal artery.90242
Injury to renal vein.90249
Injury to other renal blood vessels.90250
Injury to iliac vessel(s), unspecified.90251
Injury to hypogastric artery.90252
Injury to hypogastric vein.90253
Injury to iliac artery.90254
Injury to iliac vein.90259
Injury to other iliac blood vessels.90287
Injury to multiple blood vessels of abdomen and pelvis.90300
Injury to axillary vessel(s), unspecified.90301
Injury to axillary artery.90302
Injury to axillary vein.9040
Injury to common femoral artery.9041
Injury to superficial femoral artery.9042
Injury to femoral veins.90440
Injury to popliteal vessel(s), unspecified.90441
Injury to popliteal artery.90442
Injury to popliteal vein.94821
Burn (any degree) involving 20-29 percent of body surface with third degree burn of 10-19%.94822
Burn (any degree) involving 20-29 percent of body surface with third degree burn of 20-29%.94831
Burn (any degree) involving 30-39 percent of body surface with third degree burn of 10-19%.94832
Burn (any degree) involving 30-39 percent of body surface with third degree burn of 20-29%.94833
Burn (any degree) involving 30-39 percent of body surface with third degree burn of 30-39%.94841
Burn (any degree) involving 40-49 percent of body surface with third degree burn of 10-19%.94842
Burn (any degree) involving 40-49 percent of body surface with third degree burn of 20-29%.94843
Burn (any degree) involving 40-49 percent of body surface with third degree burn of 30-39%.94844
Burn (any degree) involving 40-49 percent of body surface with third degree burn of 40-49%.94851
Burn (any degree) involving 50-59 percent of body surface with third degree burn of 10-19%.94852
Burn (any degree) involving 50-59 percent of body surface with third degree burn of 20-29%.94853
Burn (any degree) involving 50-59 percent of body surface with third degree burn of 30-39%.94854
Burn (any degree) involving 50-59 percent of body surface with third degree burn of 40-49%.94855
Burn (any degree) involving 50-59 percent of body surface with third degree burn of 50-59%.94861
Burn (any degree) involving 60-69 percent of body surface with third degree burn of 10-19%.94862
Burn (any degree) involving 60-69 percent of body surface with third degree burn of 20-29%.94863
Burn (any degree) involving 60-69 percent of body surface with third degree burn of 30-39%.94864
Burn (any degree) involving 60-69 percent of body surface with third degree burn of 40-49%.94865
Burn (any degree) involving 60-69 percent of body surface with third degree burn of 50-59%.94866
Burn (any degree) involving 60-69 percent of body surface with third degree burn of 60-69%.94871
Burn (any degree) involving 70-79 percent of body surface with third degree burn of 10-19%.94872
Burn (any degree) involving 70-79 percent of body surface with third degree burn of 20-29%.94873
Burn (any degree) involving 70-79 percent of body surface with third degree burn of 30-39%.94874
Burn (any degree) involving 70-79 percent of body surface with third degree burn of 40-49%.94875
Burn (any degree) involving 70-79 percent of body surface with third degree burn of 50-59%.94876
Burn (any degree) involving 70-79 percent of body surface with third degree burn of 60-69%.94877
Burn (any degree) involving 70-79 percent of body surface with third degree burn of 70-79%.94881
Burn (any degree) involving 80-89 percent of body surface with third degree burn of 10-19%.94882
Burn (any degree) involving 80-89 percent of body surface with third degree burn of 20-29%.94883
Burn (any degree) involving 80-89 percent of body surface with third degree burn of 30-39%.94884
Burn (any degree) involving 80-89 percent of body surface with third degree burn of 40-49%.94885
Burn (any degree) involving 80-89 percent of body surface with third degree burn of 50-59%.94886
Burn (any degree) involving 80-89 percent of body surface with third degree burn of 60-69%.94887
Burn (any degree) involving 80-89 percent of body surface with third degree burn of 70-79%.94888
Burn (any degree) involving 80-89 percent of body surface with third degree burn of 80-89%.94891
Burn (any degree) involving 90 percent or more of body surface with third degree burn of 10-19%.94892
Burn (any degree) involving 90 percent or more of body surface with third degree burn of 20-29%.94893
Burn (any degree) involving 90 percent or more of body surface with third degree burn of 30-39%.94894
Burn (any degree) involving 90 percent or more of body surface with third degree burn of 40-49%.94895
Burn (any degree) involving 90 percent or more of body surface with third degree burn of 50-59%.94896
Burn (any degree) involving 90 percent or more of body surface with third degree burn of 60-69%.94897
Burn (any degree) involving 90 percent or more of body surface with third degree burn of 70-79%.94898
Burn (any degree) involving 90 percent or more of body surface with third degree burn of 80-89%.94899
Burn (any degree) involving 90 percent or more of body surface with third degree burn of 90% or more of body surface.95200
C1-C4 level spinal cord injury, unspecified.95201
C1-C4 level with complete lesion of spinal cord.95202
C1-C4 level with anterior cord syndrome.95203
C1-C4 level with central cord syndrome.95204
C1-C4 level with other specified spinal cord injury.95205
C5-C7 level spinal cord injury, unspecified.95206
C5-C7 level with complete lesion of spinal cord.95207
C5-C7 level with anterior cord syndrome.( print page 25012)95208
C5-C7 level with central cord syndrome.95209
C5-C7 level with other specified spinal cord injury.95210
T1-T6 level spinal cord injury, unspecified.95211
T1-T6 level with complete lesion of spinal cord.95212
T1-T6 level with anterior cord syndrome.95213
T1-T6 level with central cord syndrome.95214
T1-T6 level with other specified spinal cord injury.95215
T7-T12 level spinal cord injury, unspecified.95216
T7-T12 level with complete lesion of spinal cord.95217
T7-T12 level with anterior cord syndrome.95218
T7-T12 level with central cord syndrome.95219
T7-T12 level with other specified spinal cord injury.9522
Lumbar spinal cord injury without spinal bone injury.9523
Sacral spinal cord injury without spinal bone injury.9524
Cauda equina spinal cord injury without spinal bone injury.9528
Multiple sites of spinal cord injury without spinal bone injury.9580
Air embolism as an early complication of trauma.9581
Fat embolism as an early complication of trauma.9584
Traumatic shock.9585
Traumatic anuria.99591
Sepsis.99592
Severe sepsis.99594
Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction.9991
Air embolism as a complication of medical care, not elsewhere classified.
 Table 6K.—Complication and Comorbidity List
Diagnosis code
Code title0010
Cholera due to vibrio cholerae.0011
Cholera due to vibrio cholerae el tor.0019
Cholera, unspecified.0020
Typhoid fever.0021
Paratyphoid fever A.0022
Paratyphoid fever B.0023
Paratyphoid fever C.0029
Paratyphoid fever, unspecified.0030
Salmonella gastroenteritis.00323
Salmonella arthritis.00324
Salmonella osteomyelitis.00329
Other localized salmonella infections.0038
Other specified salmonella infections.0039
Salmonella infection, unspecified.0040
Shigella dysenteriae.0050
Staphylococcal food poisoning.0051
Botulism food poisoning.0052
Food poisoning due to clostridium perfringens (c. welchii).0053
Food poisoning due to other clostridia.0054
Food poisoning due to vibrio parahaemolyticus.00581
Food poisoning due to vibrio vulnificus.00589
Other bacterial food poisoning.0060
Acute amebic dysentery without mention of abscess.0061
Chronic intestinal amebiasis without mention of abscess.0062
Amebic nondysenteric colitis.0068
Amebic infection of other sites.0071
Giardiasis.0072
Coccidiosis.0074
Cryptosporidiosis.0075
Cyclosporiasis.0078
Other specified protozoal intestinal diseases.0079
Unspecified protozoal intestinal disease.00800
Intestinal infection due to e. coli, unspecified.00801
Intestinal infection due to enteropathogenic e. coli.00802
Intestinal infection due to enterotoxigenic e. coli.00803
Intestinal infection due to enteroinvasive e. coli.00804
Intestinal infection due to enterohemorrhagic e. coli.00809
Intestinal infection due to other intestinal e. coli infections.0081
Intestinal infection due to arizona group of paracolon bacilli.0082
Intestinal infection due to aerobacter aerogenes.0083
Intestinal infection due to proteus (mirabilis) (morganii).00841
Intestinal infection due to staphylococcus.( print page 25013)00842
Intestinal infection due to pseudomonas.00843
Intestinal infection due to campylobacter.00844
Intestinal infection due to yersinia enterocolitica.00845
Intestinal infection due to clostridium difficile.00846
Intestinal infection due to other anaerobes.00847
Intestinal infection due to other gram-negative bacteria.00849
Intestinal infection due to other organisms.0085
Bacterial enteritis, unspecified.00861
Enteritis due to rotavirus.00862
Enteritis due to adenovirus.00863
Enteritis due to norwalk virus.00864
Enteritis due to other small round viruses [srv's].00865
Enteritis due to calcivirus.00866
Enteritis due to astrovirus.00867
Enteritis due to enterovirus nec.00869
Enteritis due to other viral enteritis.0090
Infectious colitis, enteritis, and gastroenteritis.0091
Colitis, enteritis, and gastroenteritis of presumed infectious origin.0092
Infectious diarrhea.0093
Diarrhea of presumed infectious origin.01000
Primary tuberculous complex, unspecified examination.01001
Primary tuberculous complex, bacteriological or histological examination not done.01002
Primary tuberculous complex, bacteriological or histological examination results unknown (at present).01003
Primary tuberculous complex, tubercle bacilli found (in sputum) by microscopy.01004
Primary tuberculous complex, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01005
Primary tuberculous complex, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01006
Primary tuberculous complex, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01010
Tuberculous pleurisy in primary progressive tuberculosis, confirmation unspecified.01011
Tuberculous pleurisy in primary progressive tuberculosis, bacteriological or histological examination not done.01012
Tuberculous pleurisy in primary progressive tuberculosis, bacteriological or histological examination results unknown (at present).01013
Tuberculous pleurisy in primary progressive tuberculosis, tubercle bacilli found (in sputum) by microscopy.01014
Tuberculous pleurisy in primary progressive tuberculosis, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01015
Tuberculous pleurisy in primary progressive tuberculosis, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01016
Tuberculous pleurisy in primary progressive tuberculosis, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01080
Other primary progressive tuberculosis, confirmation unspecified.01081
Other primary progressive tuberculosis, bacteriological or histological examination not done.01082
Other primary progressive tuberculosis, bacteriological or histological examination results unknown (at present).01083
Other primary progressive tuberculosis, tubercle bacilli found (in sputum) by microscopy.01084
Other primary progressive tuberculosis, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01085
Other primary progressive tuberculosis, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01086
Other primary progressive tuberculosis, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01090
Primary tuberculous infection, unspecified type, confirmation unspecified.01091
Primary tuberculous infection, unspecified type, bacteriological or histological examination not done.01092
Primary tuberculous infection, unspecified type, bacteriological or histological examination results unknown (at present).01093
Primary tuberculous infection, unspecified type, tubercle bacilli found (in sputum) by microscopy.01094
Primary tuberculous infection, unspecified type, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01095
Primary tuberculous infection, unspecified type, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01096
Primary tuberculous infection, unspecified type, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01100
Tuberculosis of lung, infiltrative, confirmation unspecified.01101
Tuberculosis of lung, infiltrative, bacteriological or histological examination not done.01102
Tuberculosis of lung, infiltrative, bacteriological or histological examination results unknown (at present).01103
Tuberculosis of lung, infiltrative, tubercle bacilli found (in sputum) by microscopy.01104
Tuberculosis of lung, infiltrative, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01105
Tuberculosis of lung, infiltrative, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.( print page 25014)01106
Tuberculosis of lung, infiltrative, tubercle bacilli not found bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01110
Tuberculosis of lung, nodular, unspecified examination.01111
Tuberculosis of lung, nodular, bacteriological or histological examination not done.01112
Tuberculosis of lung, nodular, bacteriological or histological examination results unknown (at present).01113
Tuberculosis of lung, nodular, tubercle bacilli found (in sputum) by microscopy.01114
Tuberculosis of lung, nodular, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01115
Tuberculosis of lung, nodular, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01116
Tuberculosis of lung, nodular, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01120
Tuberculosis of lung with cavitation, unspecified examination.01121
Tuberculosis of lung with cavitation, bacteriological or histological examination not done.01122
Tuberculosis of lung with cavitation, bacteriological or histological examination results unknown (at present).01123
Tuberculosis of lung with cavitation, tubercle bacilli found (in sputum) by microscopy.01124
Tuberculosis of lung with cavitation, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01125
Tuberculosis of lung with cavitation, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01126
Tuberculosis of lung with cavitation, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01130
Tuberculosis of bronchus, unspecified examination.01131
Tuberculosis of bronchus, bacteriological or histological examination not done.01132
Tuberculosis of bronchus, bacteriological or histological examination results unknown (at present).01133
Tuberculosis of bronchus, tubercle bacilli found (in sputum) by microscopy.01134
Tuberculosis of bronchus, tubercle bacilli not found (in sputum) by microscopy, but found in bacterial culture.01135
Tuberculosis of bronchus, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01136
Tuberculosis of bronchus, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01140
Tuberculous fibrosis of lung, unspecified examination.01141
Tuberculous fibrosis of lung, bacteriological or histological examination not done.01142
Tuberculous fibrosis of lung, bacteriological or histological examination unknown (at present).01143
Tuberculous fibrosis of lung, tubercle bacilli found (in sputum) by microscopy.01144
Tuberculous fibrosis of lung, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01145
Tuberculous fibrosis of lung, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01146
Tuberculous fibrosis of lung, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01150
Tuberculous bronchiectasis, unspecified examination.01151
Tuberculous bronchiectasis, bacteriological or histological examination not done.01152
Tuberculous bronchiectasis, bacteriological or histological examination results unknown (at present).01153
Tuberculous bronchiectasis, tubercle bacilli found (in sputum) by microscopy.01154
Tuberculous bronchiectasis, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01155
Tuberculous bronchiectasis, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01156
Tuberculous bronchiectasis, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01170
Tuberculous pneumothorax, unspecified examination.01171
Tuberculous pneumothorax, bacteriological or histological examination not done.01172
Tuberculous pneumothorax, bacteriological or histological examination results unknown (at present).01173
Tuberculous pneumothorax, tubercle bacilli found (in sputum) by microscopy.01174
Tuberculous pneumothorax, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01175
Tuberculous pneumothorax, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01176
Tuberculous pneumothorax, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01180
Other specified pulmonary tuberculosis, unspecified confirmation.01181
Other specified pulmonary tuberculosis, bacteriological or histological examination not done.01182
Other specified pulmonary tuberculosis, bacteriological or histological examination results unknown (at present).01183
Other specified pulmonary tuberculosis, tubercle bacilli found (in sputum) by microscopy.01184
Other specified pulmonary tuberculosis, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01185
Other specified pulmonary tuberculosis, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01186
Other specified pulmonary tuberculosis, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).( print page 25015)01190
Unspecified pulmonary tuberculosis, confirmation unspecified.01191
Unspecified pulmonary tuberculosis, bacteriological or histological examination not done.01192
Unspecified pulmonary tuberculosis, bacteriological or histological examination results unknown (at present).01193
Unspecified pulmonary tuberculosis, tubercle bacilli found (in sputum) by microscopy.01194
Unspecified pulmonary tuberculosis, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01195
Unspecified pulmonary tuberculosis, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01196
Unspecified pulmonary tuberculosis, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01200
Tuberculous pleurisy, confirmation unspecified.01201
Tuberculous pleurisy, bacteriological or histological examination not done.01202
Tuberculous pleurisy, bacteriological or histological examination results unknown (at present).01203
Tuberculous pleurisy, tubercle bacilli found (in sputum) by microscopy.01204
Tuberculous pleurisy, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01205
Tuberculous pleurisy, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01206
Tuberculous pleurisy, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01210
Tuberculosis of intrathoracic lymph nodes, confirmation unspecified.01211
Tuberculosis of intrathoracic lymph nodes, bacteriological or histological examination not done.01212
Tuberculosis of intrathoracic lymph nodes, bacteriological or histological examination results unknown (at present).01213
Tuberculosis of intrathoracic lymph nodes, tubercle bacilli found (in sputum) by microscopy.01214
Tuberculosis of intrathoracic lymph nodes, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01215
Tuberculosis of intrathoracic lymph nodes, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01216
Tuberculosis of intrathoracic lymph nodes, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01220
Isolated tracheal or bronchial tuberculosis, unspecified examination.01221
Isolated tracheal or bronchial tuberculosis, bacteriological or histological examination not done.01222
Isolated tracheal or bronchial tuberculosis, bacteriological or histological examination results unknown (at present).01223
Isolated tracheal or bronchial tuberculosis, tubercle bacilli found (in sputum) by microscopy.01224
Isolated tracheal or bronchial tuberculosis, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01225
Isolated tracheal or bronchial tuberculosis, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01226
Isolated tracheal or bronchial tuberculosis, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01230
Tuberculous laryngitis, unspecified examination.01231
Tuberculous laryngitis, bacteriological or histological examination not done.01232
Tuberculous laryngitis, bacteriological or histological examination results unknown (at present).01233
Tuberculous laryngitis, tubercle bacilli found (in sputum) by microscopy.01234
Tuberculous laryngitis, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01235
Tuberculous laryngitis, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01236
Tuberculous laryngitis, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01280
Other specified respiratory tuberculosis, unspecified examination.01281
Other specified respiratory tuberculosis, bacteriological or histological examination not done.01282
Other specified respiratory tuberculosis, bacteriological or histological examination results unknown (at present).01283
Other specified respiratory tuberculosis, tubercle bacilli found (in sputum) by microscopy.01284
Other specified respiratory tuberculosis, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01285
Other specified respiratory tuberculosis, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01286
Other specified respiratory tuberculosis, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01480
Other tuberculosis of intestines and mesenteric glands, unspecified examination.01481
Other tuberculosis of intestines and mesenteric glands, bacteriological or histological examination not done.01482
Other tuberculosis of intestines and mesenteric glands, bacteriological or histological examination results unknown (at present).01483
Other tuberculosis of intestines and mesenteric glands, tubercle bacilli found (in sputum) by microscopy.01484
Other tuberculosis of intestines and mesenteric glands, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01485
Other tuberculosis of intestines and mesenteric glands, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01486
Other tuberculosis of intestines and mesenteric glands, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).( print page 25016)01500
Tuberculosis of vertebral column, unspecified examination.01501
Tuberculosis of vertebral column, bacteriological or histological examination not done.01502
Tuberculosis of vertebral column, bacteriological or histological examination results unknown (at present).01503
Tuberculosis of vertebral column, tubercle bacilli found (in sputum) by microscopy.01504
Tuberculosis of vertebral column, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01505
Tuberculosis of vertebral column, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01506
Tuberculosis of vertebral column, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01510
Tuberculosis of hip, unspecified examination.01511
Tuberculosis of hip, bacteriological or histological examination not done.01512
Tuberculosis of hip, bacteriological or histological examination results unknown (at present).01513
Tuberculosis of hip, tubercle bacilli found (in sputum) by microscopy.01514
Tuberculosis of hip, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01515
Tuberculosis of hip, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01516
Tuberculosis of hip, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01520
Tuberculosis of knee, unspecified examination.01521
Tuberculosis of knee, bacteriological or histological examination not done.01522
Tuberculosis of knee, bacteriological or histological examination results unknown (at present).01523
Tuberculosis of knee, tubercle bacilli found (in sputum) by microscopy.01524
Tuberculosis of knee, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01525
Tuberculosis of knee, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01526
Tuberculosis of knee, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01550
Tuberculosis of limb bones, unspecified examination.01551
Tuberculosis of limb bones, bacteriological or histological examination not done.01552
Tuberculosis of limb bones, bacteriological or histological examination results unknown (at present).01553
Tuberculosis of limb bones, tubercle bacilli found (in sputum) by microscopy.01554
Tuberculosis of limb bones, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01555
Tuberculosis of limb bones, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01556
Tuberculosis of limb bones, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01560
Tuberculosis of mastoid, unspecified examination.01561
Tuberculosis of mastoid, bacteriological or histological examination not done.01562
Tuberculosis of mastoid, bacteriological or histological examination results unknown (at present).01563
Tuberculosis of mastoid, tubercle bacilli found (in sputum) by microscopy.01564
Tuberculosis of mastoid, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01565
Tuberculosis of mastoid, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01566
Tuberculosis of mastoid, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01570
Tuberculosis of other specified bone, unspecified examination.01571
Tuberculosis of other specified bone, bacteriological or histological examination not done.01572
Tuberculosis of other specified bone, bacteriological or histological examination results unknown (at present).01573
Tuberculosis of other specified bone, tubercle bacilli found (in sputum) by microscopy.01574
Tuberculosis of other specified bone, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01575
Tuberculosis of other specified bone, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01576
Tuberculosis of other specified bone, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01580
Tuberculosis of other specified joint, unspecified examination.01581
Tuberculosis of other specified joint, bacteriological or histological examination not done.01582
Tuberculosis of other specified joint, bacteriological or histological examination results unknown (at present).01583
Tuberculosis of other specified joint, tubercle bacilli found (in sputum) by microscopy.01584
Tuberculosis of other specified joint, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01585
Tuberculosis of other specified joint, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01586
Tuberculosis of other specified joint, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01590
Tuberculosis of unspecified bones and joints, unspecified examination.01591
Tuberculosis of unspecified bones and joints, bacteriological or histological examination not done.01592
Tuberculosis of unspecified bones and joints, bacteriological or histological examination results unknown (at present).01593
Tuberculosis of unspecified bones and joints, tubercle bacilli found (in sputum) by microscopy.( print page 25017)01594
Tuberculosis of unspecified bones and joints, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01595
Tuberculosis of unspecified bones and joints, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01596
Tuberculosis of unspecified bones and joints, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01600
Tuberculosis of kidney, unspecified examination.01601
Tuberculosis of kidney, bacteriological or histological examination not done.01602
Tuberculosis of kidney, bacteriological or histological examination results unknown (at present).01603
Tuberculosis of kidney, tubercle bacilli found (in sputum) by microscopy.01604
Tuberculosis of kidney, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01605
Tuberculosis of kidney, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01606
Tuberculosis of kidney, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01610
Tuberculosis of bladder, unspecified examination.01611
Tuberculosis of bladder, bacteriological or histological examination not done.01612
Tuberculosis of bladder, bacteriological or histological examination results unknown (at present).01613
Tuberculosis of bladder, tubercle bacilli found (in sputum) by microscopy.01614
Tuberculosis of bladder, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01615
Tuberculosis of bladder, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01616
Tuberculosis of bladder, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01620
Tuberculosis of ureter, unspecified examination.01621
Tuberculosis of ureter, bacteriological or histological examination not done.01622
Tuberculosis of ureter, bacteriological or histological examination results unknown (at present).01623
Tuberculosis of ureter, tubercle bacilli found (in sputum) by microscopy.01624
Tuberculosis of ureter, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01625
Tuberculosis of ureter, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01626
Tuberculosis of ureter, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01630
Tuberculosis of other urinary organs, unspecified examination.01631
Tuberculosis of other urinary organs, bacteriological or histological examination not done.01632
Tuberculosis of other urinary organs, bacteriological or histological examination results unknown (at present).01633
Tuberculosis of other urinary organs, tubercle bacilli found (in sputum) by microscopy.01634
Tuberculosis of other urinary organs, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01635
Tuberculosis of other urinary organs, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01636
Tuberculosis of other urinary organs, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01640
Tuberculosis of epididymis, unspecified examination.01641
Tuberculosis of epididymis, bacteriological or histological examination not done.01642
Tuberculosis of epididymis, bacteriological or histological examination results unknown (at present).01643
Tuberculosis of epididymis, tubercle bacilli found (in sputum) by microscopy.01644
Tuberculosis of epididymis, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01645
Tuberculosis of epididymis, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01646
Tuberculosis of epididymis, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01650
Tuberculosis of other male genital organs, unspecified examination.01651
Tuberculosis of other male genital organs, bacteriological or histological examination not done.01652
Tuberculosis of other male genital organs, bacteriological or histological examination results unknown (at present).01653
Tuberculosis of other male genital organs, tubercle bacilli found (in sputum) by microscopy.01654
Tuberculosis of other male genital organs, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01655
Tuberculosis of other male genital organs, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01656
Tuberculosis of other male genital organs, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01660
Tuberculous oophoritis and salpingitis, unspecified examination.01661
Tuberculous oophoritis and salpingitis, bacteriological or histological examination not done.01662
Tuberculous oophoritis and salpingitis, bacteriological or histological examination results unknown (at present).01663
Tuberculous oophoritis and salpingitis, tubercle bacilli found (in sputum) by microscopy.01664
Tuberculous oophoritis and salpingitis, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01665
Tuberculous oophoritis and salpingitis, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.( print page 25018)01666
Tuberculous oophoritis and salpingitis, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01670
Tuberculosis of other female genital organs, unspecified examination.01671
Tuberculosis of other female genital organs, bacteriological or histological examination not done.01672
Tuberculosis of other female genital organs, bacteriological or histological examination results unknown (at present).01673
Tuberculosis of other female genital organs, tubercle bacilli found (in sputum) by microscopy.01674
Tuberculosis of other female genital organs, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01675
Tuberculosis of other female genital organs, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01676
Tuberculosis of other female genital organs, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01690
Unspecified genitourinary tuberculosis, unspecified examination.01691
Unspecified genitourinary tuberculosis, bacteriological or histological examination not done.01692
Unspecified genitourinary tuberculosis, bacteriological or histological examination results unknown (at present).01693
Unspecified genitourinary tuberculosis, tubercle bacilli found (in sputum) by microscopy.01694
Unspecified genitourinary tuberculosis, tubercle ba cilli not found (in sputum) by microscopy, but found by bacterial culture.01695
Unspecified genitourinary tuberculosis, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01696
Unspecified genitourinary tuberculosis, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01700
Tuberculosis of skin and subcutaneous cellular tissue, unspecified examination.01701
Tuberculosis of skin and subcutaneous cellular tissue, bacteriological or histological examination not done.01702
Tuberculosis of skin and subcutaneous cellular tissue, bacteriological or histological examination results unknown (at present).01703
Tuberculosis of skin and subcutaneous cellular tissue, tubercle bacilli found (in sputum) by microscopy.01704
Tuberculosis of skin and subcutaneous cellular tissue, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01705
Tuberculosis of skin and subcutaneous cellular tissue, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01706
Tuberculosis of skin and subcutaneous cellular tissue, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01720
Tuberculosis of peripheral lymph nodes, unspecified examination.01721
Tuberculosis of peripheral lymph nodes, bacteriological or histological examination not done.01722
Tuberculosis of peripheral lymph nodes, bacteriological or histological examination results unknown (at present).01723
Tuberculosis of peripheral lymph nodes, tubercle bacilli found (in sputum) by microscopy.01724
Tuberculosis of peripheral lymph nodes, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01725
Tuberculosis of peripheral lymph nodes, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01726
Tuberculosis of peripheral lymph nodes, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01730
Tuberculosis of eye, unspecified examination.01731
Tuberculosis of eye, bacteriological or histological examination not done.01732
Tuberculosis of eye, bacteriological or histological examination results unknown (at present).01733
Tuberculosis of eye, tubercle bacilli found (in sputum) by microscopy.01734
Tuberculosis of eye, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01735
Tuberculosis of eye, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01736
Tuberculosis of eye, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01740
Tuberculosis of ear, unspecified examination.01741
Tuberculosis of ear, bacteriological or histological examination not done.01742
Tuberculosis of ear, bacteriological or histological examination results unknown (at present).01743
Tuberculosis of ear, tubercle bacilli found (in sputum) by microscopy.01744
Tuberculosis of ear, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01745
Tuberculosis of ear, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01746
Tuberculosis of ear, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01750
Tuberculosis of thyroid gland, unspecified origin.01751
Tuberculosis of thyroid gland, bacteriological or histological examination not done.01752
Tuberculosis of thyroid gland, bacteriological or histological examination results unknown (at present).01753
Tuberculosis of thyroid gland, tubercle bacilli found (in sputum) by microscopy.01754
Tuberculosis of thyroid gland, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01755
Tuberculosis of thyroid gland, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.( print page 25019)01756
Tuberculosis of thyroid gland, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01760
Tuberculosis of adrenal glands, unspecified examination.01761
Tuberculosis of adrenal glands, bacteriological or histological examination not done.01762
Tuberculosis of adrenal glands, bacteriological or histological examination results unknown (at present).01763
Tuberculosis of adrenal glands, tubercle bacilli found (in sputum) by microscopy.01764
Tuberculosis of adrenal glands, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01765
Tuberculosis of adrenal glands, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01766
Tuberculosis of adrenal glands, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01770
Tuberculosis of spleen, unspecified examination.01771
Tuberculosis of spleen, bacteriological or histological examination not done.01772
Tuberculosis of spleen, bacteriological or histological examination results unknown (at present).01773
Tuberculosis of spleen, tubercle bacilli found (in sputum) by microscopy.01774
Tuberculosis of spleen, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01775
Tuberculosis of spleen, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01776
Tuberculosis of spleen, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01780
Tuberculosis of esophagus, unspecified examination.01781
Tuberculosis of esophagus, bacteriological or histological examination not done.01782
Tuberculosis of esophagus, bacteriological or histological examination results unknown (at present).01783
Tuberculosis of esophagus, tubercle bacilli found (in sputum) by microscopy.01784
Tuberculosis of esophagus, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01785
Tuberculosis of esophagus, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01786
Tuberculosis of esophagus, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).01790
Tuberculosis of other specified organs, unspecified examination.01791
Tuberculosis of other specified organs, bacteriological or histological examination not done.01792
Tuberculosis of other specified organs, bacteriological or histological examination results unknown (at present).01793
Tuberculosis of other specified organs, tubercle bacilli found (in sputum) by microscopy.01794
Tuberculosis of other specified organs, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture.01795
Tuberculosis of other specified organs, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically.01796
Tuberculosis of other specified organs, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals).0210
Ulceroglandular tularemia.0211
Enteric tularemia.0212
Pulmonary tularemia.0213
Oculoglandular tularemia.0218
Other specified tularemia.0219
Unspecified tularemia.0220
Cutaneous anthrax.0222
Gastrointestinal anthrax.0228
Other specified manifestations of anthrax.0229
Anthrax, unspecified.0238
Other brucellosis.0239
Brucellosis, unspecified.024
Glanders.025
Melioidosis.0260
Spirillary fever.0261
Streptobacillary fever.0269
Unspecified rat-bite fever.0270
Listeriosis.0272
Pasteurellosis.0278
Other specified zoonotic bacterial diseases.0279
Unspecified zoonotic bacterial disease.0300
Lepromatous leprosy (type L).0301
Tuberculoid leprosy (type T).0302
Indeterminate leprosy (group I).0303
Borderline leprosy (group B).0308
Other specified leprosy.0309
Leprosy, unspecified.0310
Pulmonary diseases due to other mycobacteria.0311
Cutaneous diseases due to other mycobacteria.0312
Disseminated mycobacterium.( print page 25020)0318
Other specified mycobacterial diseases.0319
Unspecified diseases due to mycobacteria.0320
Faucial diphtheria.0321
Nasopharyngeal diphtheria.0322
Anterior nasal diphtheria.0323
Laryngeal diphtheria.03281
Conjunctival diphtheria.03282
Diphtheritic myocarditis.03283
Diphtheritic peritonitis.03284
Diphtheritic cystitis.03285
Cutaneous diphtheria.03289
Other specified diphtheria.0329
Diphtheria, unspecified.0330
Whooping cough due to bordetella pertussis (b. pertussis).0331
Whooping cough due to bordetella parapertussis (b. parapertussis).0338
Whooping cough due to other specified organism.0339
Whooping cough, unspecified organism.0341
Scarlet fever.03681
Meningococcal optic neuritis.03682
Meningococcal arthropathy.03689
Other specified meningococcal infections.0369
Meningococcal infection, unspecified.0390
Cutaneous actinomycotic infection.0391
Pulmonary actinomycotic infection.0392
Abdominal actinomycotic infection.0393
Cervicofacial actinomycotic infection.0394
Madura foot.0398
Actinomycotic infection of other specified sites.0399
Actinomycotic infection of unspecified site.0402
Whipple's disease.0403
Necrobacillosis.04041
Infant botulism.04042
Wound botulism.04081
Tropical pyomyositis.0460
Kuru.0461
Jakob-creutzfeldt disease.0462
Subacute sclerosing panencephalitis.0463
Progressive multifocal leukoencephalopathy.0468
Other specified slow virus infection of central nervous system.0469
Unspecified slow virus infection of central nervous system.0470
Meningitis due to coxsackie virus.0471
Meningitis due to echo virus.0478
Other specified viral meningitis.0479
Unspecified viral meningitis.048
Other enterovirus diseases of central nervous system.0490
Non-arthopod borne lymphocytic choriomeningitis.0491
Non-arthopod borne meningitis due to adenovirus.0498
Other specified non-arthropod-borne viral diseases of central nervous system.0499
Unspecified non-arthropod-borne viral diseases of central nervous system.0500
Variola major.0501
Alastrim.0502
Modified smallpox.0509
Smallpox, unspecified.0527
Chickenpox with other specified complications.0528
Chickenpox with unspecified complication.0529
Varicella without mention of complication.05310
Herpes zoster with unspecified nervous system complication.05311
Geniculate herpes zoster.05312
Postherpetic trigeminal neuralgia.05313
Postherpetic polyneuropathy.05319
Herpes zoster with other nervous system complications.05320
Herpes zoster dermatitis of eyelid.05321
Herpes zoster keratoconjunctivitis.05322
Herpes zoster iridocyclitis.05329
Herpes zoster with other ophthalmic complications.05371
Otitis externa due to herpes zoster.05379
Herpes zoster with other specified complications.0538
Herpes zoster with unspecified complication.0542
Herpetic gingivostomatitis.05440
Herpes simplex with unspecified ophthalmic complication.05441
Herpes simplex dermatitis of eyelid.05442
Dendritic keratitis.( print page 25021)05443
Herpes simplex disciform keratitis.05444
Herpes simplex iridocyclitis.05449
Herpes simplex with other ophthalmic complications.05471
Visceral herpes simplex.05479
Herpes simplex with other specified complications.05571
Measles keratoconjunctivitis.05579
Measles with other specified complications.05600
Rubella with unspecified neurological complication.05609
Rubella with other neurological complications.05671
Arthritis due to rubella.05679
Rubella with other specified complications.0570
Erythema infectiosum (fifth disease).0600
Sylvatic yellow fever.0601
Urban yellow fever.0609
Yellow fever, unspecified.061
Dengue.0650
Crimean hemorrhagic fever (chf congo virus).0651
Omsk hemorrhagic fever.0652
Kyasanur forest disease.0653
Other tick-borne hemorrhagic fever.0654
Mosquito-borne hemorrhagic fever.0658
Other specified arthropod-borne hemorrhagic fever.0659
Arthropod-borne hemorrhagic fever, unspecified.0660
Phlebotomus fever.0661
Tick-borne fever.0662
Venezuelan equine fever.0663
Other mosquito-borne fever.0668
Other specified arthropod-borne viral diseases.0669
Arthropod-borne viral disease, unspecified.0701
Viral hepatitis a without mention of hepatic coma.07030
Viral hepatitis b without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta.07031
Viral hepatitis b without mention of hepatic coma, acute or unspecified, with hepatitis delta.07032
Chronic viral hepatitis b without mention of hepatic coma without mention of hepatitis delta.07033
Chronic viral hepatitis b without mention of hepatic coma with hepatitis delta.07051
Acute hepatitis C without mention of hepatic coma.07052
Hepatitis delta without mention of active hepatitis B disease or hepatic coma.07053
Hepatitis E without mention of hepatic coma.07059
Other specified viral hepatitis without mention of hepatic coma.0709
Unspecified viral hepatitis without mention of hepatic coma.071
Rabies.0720
Mumps orchitis.0723
Mumps pancreatitis.07271
Mumps hepatitis.07272
Mumps polyneuropathy.07279
Mumps with other specified complications.0728
Mumps with unspecified complication.0737
Ornithosis with other specified complications.0738
Ornithosis with unspecified complication.0739
Ornithosis, unspecified.07420
Coxsackie carditis, unspecified.07421
Coxsackie pericarditis.07422
Coxsackie endocarditis.07423
Coxsackie myocarditis.0783
Cat-scratch disease.0785
Cytomegaloviral disease.0786
Hemorrhagic nephrosonephritis.0787
Arenaviral hemorrhagic fever.07951
Human t-cell lymphotrophic virus, type i [HTLV-I].07952
Human t-cell lymphotrophic virus, type ii [HTLV-II].07953
Human immunodeficiency virus, type 2 [HIV-2].07981
Hantaviris infection.07982
Sars-assoc coronavirus.07983
Parvovirus B19.080
Louse-borne (epidemic) typhus.0810
Murine (endemic) typhus.0811
Brill's disease.0812
Scrub typhus.0819
Typhus, unspecified.0820
Spotted fevers.0821
Boutonneuse fever.0822
North asian tick fever.0823
Queensland tick typhus.( print page 25022)08240
Unspecified ehrlichiosis.08241
Ehrlichiosis chafeensis (e chafeensis).08249
Other ehrlichiosis.0828
Other specified tick-borne rickettsioses.0829
Tick-borne rickettsiosis, unspecified.0830
Q fever.0831
Trench fever.0832
Rickettsialpox.0838
Other specified rickettsioses.0839
Rickettsiosis, unspecified.0841
Vivax malaria (benign tertian).0842
Quartan malaria.0843
Ovale malaria.0844
Other malaria.0845
Mixed malaria.0846
Malaria, unspecified.0847
Induced malaria.0848
Blackwater fever.0849
Other pernicious complications of malaria.0850
Leishmaniasis visceral (kala-azar).0851
Cutaneous leishmaniasis, urban.0852
Cutaneous leishmaniasis, asian desert.0853
Cutaneous leishmaniasis, ethiopian.0854
Cutaneous leishmaniasis, american.0855
Mucocutaneous leishmaniasis, (american).0859
Leishmaniasis, unspecified.0860
Chagas' disease with heart involvement.0861
Chagas' disease with other organ involvement.0862
Chagas' disease without mention of organ involvement.0863
Gambian trypanosomiasis.0864
Rhodesian trypanosomiasis.0865
African trypanosomiasis, unspecified.0869
Trypanosomiasis, unspecified.0870
Relapsing fever, louse-borne.0871
Relapsing fever, tick-borne.0879
Relapsing fever, unspecified.0880
Bartonellosis.08881
Lyme disease.08882
Babesiosis.0900
Early congenital syphilis, symptomatic.0902
Early congenital syphilis, unspecified.0903
Syphilitic interstitial keratitis.09040
Juvenile neurosyphilis, unspecified.09049
Other juvenile neurosyphilis.0905
Other late congenital syphilis, symptomatic.0913
Secondary syphilis of skin or mucous membranes.0914
Adenopathy due to secondary syphilis.09150
Syphilitic uveitis, unspecified.09151
Syphilitic chorioretinitis (secondary).09152
Syphilitic iridocyclitis (secondary).09161
Secondary syphilitic periostitis.09162
Secondary syphilitic hepatitis.09169
Secondary syphilis of other viscera.0917
Secondary syphilis, relapse.09182
Syphilitic alopecia.09189
Other forms of secondary syphilis.0919
Unspecified secondary syphilis.0930
Aneurysm of aorta, specified as syphilitic.0931
Syphilitic aortitis.09320
Syphilitic endocarditis of valve, unspecified.09321
Syphilitic endocarditis of mitral valve.09322
Syphilitic endocarditis of aortic valve.09323
Syphilitic endocarditis of tricuspid valve.09324
Syphilitic endocarditis of pulmonary valve.09381
Syphilitic pericarditis.09382
Syphilitic myocarditis.09389
Other specified cardiovascular syphilis.0939
Cardiovascular syphilis, unspecified.0940
Tabes dorsalis.0941
General paresis.0943
Asymptomatic neurosyphilis.09482
Syphilitic parkinsonism.( print page 25023)09483
Syphilitic disseminated retinochoroiditis.09484
Syphilitic optic atrophy.09485
Syphilitic retrobulbar neuritis.09486
Syphilitic acoustic neuritis.09489
Other specified neurosyphilis.0949
Neurosyphilis, unspecified.0950
Syphilitic episcleritis.0951
Syphilis of lung.0952
Syphilitic peritonitis.0953
Syphilis of liver.0954
Syphilis of kidney.0955
Syphilis of bone.0956
Syphilis of muscle.0957
Syphilis of synovium, tendon, and bursa.0958
Other specified forms of late symptomatic syphilis.0959
Late symptomatic syphilis, unspecified.0980
Gonococcal infection (acute) of lower genitourinary tract.09810
Gonococcal infection (acute) of upper genitourinary tract, site unspecified.09811
Gonococcal cystitis (acute).09812
Gonococcal prostatitis (acute).09813
Gonococcal epididymo-orchitis (acute).09814
Gonococcal seminal vesiculitis (acute).09815
Gonococcal cervicitis (acute).09816
Gonococcal endometritis (acute).09817
Gonococcal salpingitis, specified as acute.09819
Other gonococcal infection (acute) of upper genitourinary tract.09840
Gonococcal conjunctivitis (neonatorum).09841
Gonococcal iridocyclitis.09842
Gonococcal endophthalmia.09843
Gonococcal keratitis.09849
Other gonococcal infection of eye.09850
Gonococcal arthritis.09851
Gonococcal synovitis and tenosynovitis.09852
Gonococcal bursitis.09853
Gonococcal spondylitis.09859
Other gonococcal infection of joint.09881
Gonococcal keratosis (blennorrhagica).09885
Other gonococcal heart disease.09886
Gonococcal peritonitis.09889
Gonococcal infection of other specified sites.09956
Other venereal diseases due to chlamydia trachomatis, peritoneum.1000
Leptospirosis icterohemorrhagica.10089
Other specified leptospiral infections.1009
Leptospirosis, unspecified.101
Vincent's angina.1120
Candidiasis of mouth.1122
Candidiasis of other urogenital sites.11282
Candidal otitis externa.11284
Candidal esophagitis.11285
Candidal enteritis.11289
Other candidiasis of other specified sites.1140
Primary coccidioidomycosis (pulmonary).1141
Primary extrapulmonary coccidioidomycosis.1143
Other forms of progressive coccidioidomycosis.1144
Chronic pulmonary coccidioidomycosis.1145
Pulmonary coccidioidomycosis, unspecified.1149
Coccidioidomycosis, unspecified.11502
Histoplasma capsulatum retinitis.11509
Infection by histoplasma capsulatum, with mention of other manifestation.11512
Histoplasma duboisii retinitis.11519
Infection by histoplasma duboisii with mention of other manifestation.11592
Histoplasmosis retinitis, unspecified.1160
Blastomycosis.1161
Paracoccidioidomycosis.1173
Aspergillosis.1174
Mycotic mycetomas.1175
Cryptococcosis.1176
Allescheriosis (petriellidosis).1178
Infection by dematiacious fungi, (phaehyphomycosis).1179
Other and unspecified mycoses.118
Opportunistic mycoses.1200
Schistosomiasis due to schistosoma haematobium.( print page 25024)1201
Schistosomiasis due to schistosoma mansoni.1202
Schistosomiasis due to schistosoma japonicum.1203
Cutaneous schistosomiasis.1208
Other specified schistosomiasis.1209
Schistosomiasis, unspecified.1210
Opisthorchiasis.1211
Clonorchiasis.1212
Paragonimiasis.1213
Fascioliasis.1214
Fasciolopsiasis.1215
Metagonimiasis.1216
Heterophyiasis.1218
Other specified trematode infections.1220
Echinococcus granulosus infection of liver.1221
Echinococcus granulosus infection of lung.1222
Echinococcus granulosus infection of thyroid.1223
Echinococcus granulosus infection, other.1224
Echinococcus granulosus infection, unspecified.1225
Echinococcus multilocularis infection of liver.1226
Echinococcus multilocularis infection, other.1227
Echinococcus multilocularis infection, unspecified.1228
Echinococcosis, unspecified, of liver.1229
Echinococcosis, other and unspecified.1230
Taenia solium infection, intestinal form.1231
Cysticercosis.1232
Taenia saginata infection.1233
Taeniasis, unspecified.1234
Diphyllobothriasis, intestinal.1235
Sparganosis (larval diphyllobothriasis).1236
Hymenolepiasis.1238
Other specified cestode infection.124
Trichinosis.1250
Bancroftian filariasis.1251
Malayan filariasis.1252
Loiasis.1253
Onchocerciasis.1254
Dipetalonemiasis.1255
Mansonella ozzardi infection.1256
Other specified filariasis.1257
Dracontiasis.1259
Unspecified filariasis.1260
Ancylostomiasis due to ancylostoma duodenale.1261
Necatoriasis due to necator americanus.1262
Ancylostomiasis due to ancylostoma braziliense.1263
Ancylostomiasis due to ancylostoma ceylanicum.1268
Other specified ancylostoma.1269
Ancylostomiasis and necatoriasis, unspecified.1270
Ascariasis.1271
Anisakiasis.1272
Strongyloidiasis.1273
Trichuriasis.1274
Enterobiasis.1275
Capillariasis.1276
Trichostrongyliasis.1277
Other specified intestinal helminthiasis.1278
Mixed intestinal helminthiasis.1279
Intestinal helminthiasis, unspecified.1301
Conjunctivitis due to toxoplasmosis.1302
Chorioretinitis due to toxoplasmosis.1305
Hepatitis due to toxoplasmosis.1307
Toxoplasmosis of other specified sites.1309
Toxoplasmosis, unspecified.1364
Psorospermiasis.1365
Sarcosporidiosis.1500
Malignant neoplasm of cervical esophagus.1501
Malignant neoplasm of thoracic esophagus.1502
Malignant neoplasm of abdominal esophagus.1503
Malignant neoplasm of upper third of esophagus.1504
Malignant neoplasm of middle third of esophagus.1505
Malignant neoplasm of lower third of esophagus.1508
Malignant neoplasm of other specified part of esophagus.1509
Malignant neoplasm of esophagus, unspecified site.( print page 25025)1510
Malignant neoplasm of cardia.1511
Malignant neoplasm of pylorus.1512
Malignant neoplasm of pyloric antrum.1513
Malignant neoplasm of fundus of stomach.1514
Malignant neoplasm of body of stomach.1515
Malignant neoplasm of lesser curvature of stomach, unspecified.1516
Malignant neoplasm of greater curvature of stomach, unspecified.1518
Malignant neoplasm of other specified sites of stomach.1519
Malignant neoplasm of stomach, unspecified site.1520
Malignant neoplasm of duodenum.1521
Malignant neoplasm of jejunum.1522
Malignant neoplasm of ileum.1523
Malignant neoplasm of meckel's diverticulum.1528
Malignant neoplasm of other specified sites of small intestine.1529
Malignant neoplasm of small intestine, unspecified site.1530
Malignant neoplasm of hepatic flexure.1531
Malignant neoplasm of transverse colon.1532
Malignant neoplasm of descending colon.1533
Malignant neoplasm of sigmoid colon.1534
Malignant neoplasm of cecum.1535
Malignant neoplasm of appendix vermiformis.1536
Malignant neoplasm of ascending colon.1537
Malignant neoplasm of splenic flexure.1538
Malignant neoplasm of other specified sites of large intestine.1539
Malignant neoplasm of colon, unspecified site.1540
Malignant neoplasm of rectosigmoid junction.1541
Malignant neoplasm of rectum.1542
Malignant neoplasm of anal canal.1543
Malignant neoplasm of anus, unspecified site.1548
Malignant neoplasm of other sites of rectum, rectosigmoid junction, and anus.1550
Malignant neoplasm of liver, primary.1551
Malignant neoplasm of intrahepatic bile ducts.1552
Malignant neoplasm of liver, not specified as primary or secondary.1560
Malignant neoplasm of gallbladder.1561
Malignant neoplasm of extrahepatic bile ducts.1562
Malignant neoplasm of ampulla of vater.1568
Malignant neoplasm of other specified sites of gallbladder and extrahepatic bile ducts.1569
Malignant neoplasm of biliary tract, part unspecified site.1570
Malignant neoplasm of head of pancreas.1571
Malignant neoplasm of body of pancreas.1572
Malignant neoplasm of tail of pancreas.1573
Malignant neoplasm of pancreatic duct.1574
Malignant neoplasm of islets of langerhans.1578
Malignant neoplasm of other specified sites of pancreas.1579
Malignant neoplasm of pancreas, part unspecified.1580
Malignant neoplasm of retroperitoneum.1588
Malignant neoplasm of specified parts of peritoneum.1589
Malignant neoplasm of peritoneum, unspecified.1620
Malignant neoplasm of trachea.1622
Malignant neoplasm of main bronchus.1623
Malignant neoplasm of upper lobe, bronchus or lung.1624
Malignant neoplasm of middle lobe, bronchus or lung.1625
Malignant neoplasm of lower lobe, bronchus or lung.1628
Malignant neoplasm of other parts of bronchus or lung.1629
Malignant neoplasm of bronchus and lung, unspecified.1630
Malignant neoplasm of parietal pleura.1631
Malignant neoplasm of visceral pleura.1638
Malignant neoplasm of other specified sites of pleura.1639
Malignant neoplasm of pleura, unspecified.1640
Malignant neoplasm of thymus.1641
Malignant neoplasm of heart.1642
Malignant neoplasm of anterior mediastinum.1643
Malignant neoplasm of posterior mediastinum.1648
Malignant neoplasm of other parts of mediastinum.1649
Malignant neoplasm of mediastinum, part unspecified.1700
Malignant neoplasm of bones of skull and face, except mandible.1701
Malignant neoplasm of mandible.1702
Malignant neoplasm of vertebral column, excluding sacrum and coccyx.1703
Malignant neoplasm of ribs, sternum, and clavicle.1704
Malignant neoplasm of scapula and long bones of upper limb.1705
Malignant neoplasm of short bones of upper limb.1706
Malignant neoplasm of pelvic bones, sacrum, and coccyx.( print page 25026)1707
Malignant neoplasm of long bones of lower limb.1708
Malignant neoplasm of short bones of lower limb.1709
Malignant neoplasm of bone and articular cartilage, site unspecified.1710
Malignant neoplasm of connective and other soft tissue of head, face, and neck.1712
Malignant neoplasm of connective and other soft tissue of upper limb, including shoulder.1713
Malignant neoplasm of connective and other soft tissue of lower limb, including hip.1714
Malignant neoplasm of connective and other soft tissue of thorax.1715
Malignant neoplasm of connective and other soft tissue of abdomen.1716
Malignant neoplasm of connective and other soft tissue of pelvis.1717
Malignant neoplasm of connective and other soft tissue of trunk, unspecified.1718
Malignant neoplasm of other specified sites of connective and other soft tissue.1719
Malignant neoplasm of connective and other soft tissue, site unspecified.1760
Kaposi's sarcoma, skin.1761
Kaposi's sarcoma, soft tissue.1762
Kaposi's sarcoma, palate.1763
Kaposi's sarcoma, gastrointestinal sites.1764
Kaposi's sarcoma, lung.1765
Kaposi's sarcoma, lymph nodes.1768
Kaposi's sarcoma, other specified sites.1769
Kaposi's sarcoma, unspecified site.1830
Malignant neoplasm of ovary.1890
Malignant neoplasm of kidney, except pelvis.1891
Malignant neoplasm of renal pelvis.1892
Malignant neoplasm of ureter.1893
Malignant neoplasm of urethra.1894
Malignant neoplasm of paraurethral glands.1898
Malignant neoplasm of other specified sites of urinary organs.1899
Malignant neoplasm of urinary organ, site unspecified.1910
Malignant neoplasm of cerebrum, except lobes and ventricles.1911
Malignant neoplasm of frontal lobe.1912
Malignant neoplasm of temporal lobe.1913
Malignant neoplasm of parietal lobe.1914
Malignant neoplasm of occipital lobe.1915
Malignant neoplasm of ventricles.1916
Malignant neoplasm of cerebellum nos.1917
Malignant neoplasm of brain stem.1918
Malignant neoplasm of other parts of brain.1919
Malignant neoplasm of brain, unspecified site.1920
Malignant neoplasm of cranial nerves.1921
Malignant neoplasm of cerebral meninges.1922
Malignant neoplasm of spinal cord.1923
Malignant neoplasm of spinal meninges.1928
Malignant neoplasm of other specified sites of nervous system.1929
Malignant neoplasm of nervous system, part unspecified.1940
Malignant neoplasm of adrenal gland.1941
Malignant neoplasm of parathyroid gland.1943
Malignant neoplasm of pituitary gland and craniopharyngeal duct.1944
Malignant neoplasm of pineal gland.1945
Malignant neoplasm of carotid body.1946
Malignant neoplasm of aortic body and other paraganglia.1948
Malignant neoplasm of other endocrine glands and related structures.1949
Malignant neoplasm of endocrine gland, site unspecified.1960
Secondary and unspecified malignant neoplasm of lymph nodes of head, face, and neck.1961
Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes.1962
Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes.1963
Secondary and unspecified malignant neoplasm of lymph nodes of axilla and upper limb.1965
Secondary and unspecified malignant neoplasm of lymph nodes of inguinal region and lower limb.1966
Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes.1968
Secondary and unspecified malignant neoplasm of lymph nodes of multiple sites.1969
Secondary and unspecified malignant neoplasm of lymph nodes, site unspecified.1970
Secondary malignant neoplasm of lung.1971
Secondary malignant neoplasm of mediastinum.1972
Secondary malignant neoplasm of pleura.1973
Secondary malignant neoplasm of other respiratory organs.1974
Secondary malignant neoplasm of small intestine including duodenum.1975
Secondary malignant neoplasm of large intestine and rectum.1976
Secondary malignant neoplasm of retroperitoneum and peritoneum.1977
Malignant neoplasm of liver, secondary.1978
Secondary malignant neoplasm of other digestive organs and spleen.1980
Secondary malignant neoplasm of kidney.1981
Secondary malignant neoplasm of other urinary organs.1982
Secondary malignant neoplasm of skin.( print page 25027)1983
Secondary malignant neoplasm of brain and spinal cord.1984
Secondary malignant neoplasm of other parts of nervous system.1985
Secondary malignant neoplasm of bone and bone marrow.1986
Secondary malignant neoplasm of ovary.1987
Secondary malignant neoplasm of adrenal gland.19881
Secondary malignant neoplasm of breast.19882
Secondary malignant neoplasm of genital organs.19889
Secondary malignant neoplasm of other specified sites.1990
Disseminated malignant neoplasm.20000
Reticulosarcoma, unspecified site.20001
Reticulosarcoma involving lymph nodes of head, face, and neck.20002
Reticulosarcoma involving intrathoracic lymph nodes.20003
Reticulosarcoma involving intra-abdominal lymph nodes.20004
Reticulosarcoma involving lymph nodes of axilla and upper limb.20005
Reticulosarcoma involving lymph nodes of inguinal region and lower limb.20006
Reticulosarcoma involving intrapelvic lymph nodes.20007
Reticulosarcoma involving spleen.20008
Reticulosarcoma involving lymph nodes of multiple sites.20010
Lymphosarcoma, unspecified site.20011
Lymphosarcoma involving lymph nodes of head, face, and neck.20012
Lymphosarcoma involving intrathoracic lymph nodes.20013
Lymphosarcoma involving intra-abdominal lymph nodes.20014
Lymphosarcoma involving lymph nodes of axilla and upper limb.20015
Lymphosarcoma involving lymph nodes of inguinal region and lower limb.20016
Lymphosarcoma involving intrapelvic lymph nodes.20017
Lymphosarcoma involving spleen.20018
Lymphosarcoma involving lymph nodes of multiple sites.20020
Burkitt's tumor or lymphoma, unspecified site.20021
Burkitt's tumor or lymphoma involving lymph nodes of head, face, and neck.20022
Burkitt's tumor or lymphoma involving intrathoracic lymph nodes.20023
Burkitt's tumor or lymphoma involving intra-abdominal lymph nodes.20024
Burkitt's tumor or lymphoma involving lymph nodes of axilla and upper limb.20025
Burkitt's tumor or lymphoma involving lymph nodes of inguinal region and lower limb.20026
Burkitt's tumor or lymphoma involving intrapelvic lymph nodes.20027
Burkitt's tumor or lymphoma involving spleen.20028
Burkitt's tumor or lymphoma involving lymph nodes of multiple sites.20030
Marginal zone lymphoma, unspecified site, extranodal and solid organ sites.20031
Marginal zone lymphoma, lymph nodes of head, face, and neck.20032
Marginal zone lymphoma, intrathoracic lymph nodes.20033
Marginal zone lymphoma, intraabdominal lymph nodes.20034
Marginal zone lymphoma, lymph nodes of axilla and upper limb.20035
Marginal zone lymphoma, lymph nodes of inguinal region and lower limb.20036
Marginal zone lymphoma, intrapelvic lymph nodes.20037
Marginal zone lymphoma, spleen.20038
Marginal zone lymphoma, lymph nodes of multiple sites.20040
Mantle cell lymphoma, unspecified site, extranodal and solid organ sites.20041
Mantle cell lymphoma, lymph nodes of head, face, and neck.20042
Mantle cell lymphoma, intrathoracic lymph nodes.20043
Mantle cell lymphoma, intra-abdominal lymph nodes.20044
Mantle cell lymphoma, lymph nodes of axilla and upper limb.20045
Mantle cell lymphoma,lymph nodes of inguinal region and lower limb.20046
Mantle cell lymphoma, intrapelvic lymph nodes.20047
Mantle cell lymphoma, spleen.20048
Mantle cell lymphoma, lymph nodes of multiple sites.20050
Primary central nervous system lymphoma, unspecified site, extranodal and solid organ sites.20051
Primary central nervous system lymphoma, lymph nodes of head, face, and neck.20052
Primary central nervous system lymphoma, intrathoracic lymph nodes.20053
Primary central nervous system lymphoma, intra-abdominal lymph nodes.20054
Primary central nervous system lymphoma, lymph nodes of axilla and upper limb.20055
Primary central nervous system lymphoma, lymph nodes of inguinal region and lower limb.20056
Primary central nervous system lymphoma, intrapelvic lymph nodes.20057
Primary central nervous system lymphoma, spleen.20058
Primary central nervous system lymphoma, lymph nodes of multiple sites.20060
Anaplastic large cell lymphoma, unspecified site, extranodal and solid organ sites.20061
Anaplastic large cell lymphoma, lymph nodes of head, face, and neck.20062
Anaplastic large cell lymphoma, intrathoracic lymph nodes.20063
Anaplastic large cell lymphoma, intra-abdominal lymph nodes.20064
Anaplastic large cell lymphoma, lymph nodes of axilla and upper limb.20065
Anaplastic large cell lymphoma, lymph nodes of inguinal region and lower limb.20066
Anaplastic large cell lymphoma, intrapelvic lymph nodes.20067
Anaplastic large cell lymphoma, spleen.20068
Anaplastic large cell lymphoma, lymph nodes of multiple sites.( print page 25028)20070
Large cell lymphoma, unspecified site, extranodal and solid organ sites.20071
Large cell lymphoma, lymph nodes of head, face, and neck.20072
Large cell lymphoma, intrathoracic lymph nodes.20073
Large cell lymphoma, intra-abdominal lymph nodes.20074
Large cell lymphoma, lymph nodes of axilla and upper limb.20075
Large cell lymphoma, lymph nodes of inguinal region and lower limb.20076
Large cell lymphoma, intrapelvic lymph nodes.20077
Large cell lymphoma, spleen.20078
Large cell lymphoma, lymph nodes of multiple sites.20080
Other named variants of lymphosarcoma and reticulosarcoma, unspecified site.20081
Other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of head, face, and neck.20082
Other named variants of lymphosarcoma and reticulosarcoma involving intrathoracic lymph nodes.20083
Other named variants of lymphosarcoma and reticulosarcoma involving intra-abdominal lymph nodes.20084
Other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of axilla and upper limb.20085
Other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of inguinal region and lower limb.20086
Other named variants of lymphosarcoma and reticulosarcoma involving intrapelvic lymph nodes.20087
Other named variants of lymphosarcoma and reticulosarcoma involving spleen.20088
Other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of multiple sites.20100
Hodgkin's paragranuloma, unspecified site.20101
Hodgkin's paragranuloma involving lymph nodes of head, face, and neck.20102
Hodgkin's paragranuloma involving intrathoracic lymph nodes.20103
Hodgkin's paragranuloma involving intra-abdominal lymph nodes.20104
Hodgkin's paragranuloma involving lymph nodes of axilla and upper limb.20105
Hodgkin's paragranuloma involving lymph nodes of inguinal region and lower limb.20106
Hodgkin's paragranuloma involving intrapelvic lymph nodes.20107
Hodgkin's paragranuloma involving spleen.20108
Hodgkin's paragranuloma involving lymph nodes of multiple sites.20110
Hodgkin's granuloma, unspecified site.20111
Hodgkin's granuloma involving lymph nodes of head, face, and neck.20112
Hodgkin's granuloma involving intrathoracic lymph nodes.20113
Hodgkin's granuloma involving intra-abdominal lymph nodes.20114
Hodgkin's granuloma involving lymph nodes of axilla and upper limb.20115
Hodgkin's granuloma involving lymph nodes of inguinal region and lower limb.20116
Hodgkin's granuloma involving intrapelvic lymph nodes.20117
Hodgkin's granuloma involving spleen.20118
Hodgkin's granuloma involving lymph nodes of multiple sites.20120
Hodgkin's sarcoma, unspecified site.20121
Hodgkin's sarcoma involving lymph nodes of head, face, and neck.20122
Hodgkin's sarcoma involving intrathoracic lymph nodes.20123
Hodgkin's sarcoma involving intra-abdominal lymph nodes.20124
Hodgkin's sarcoma involving lymph nodes of axilla and upper limb.20125
Hodgkin's sarcoma involving lymph nodes of inguinal region and lower limb.20126
Hodgkin's sarcoma involving intrapelvic lymph nodes.20127
Hodgkin's sarcoma involving spleen.20128
Hodgkin's sarcoma involving lymph nodes of multiple sites.20140
Hodgkin's disease, lymphocytic-histiocytic predominance, unspecified site.20141
Hodgkin's disease, lymphocytic-histiocytic predominance involving lymph nodes of head, face, and neck.20142
Hodgkin's disease, lymphocytic-histiocytic predominance involving intrathoracic lymph nodes.20143
Hodgkin's disease, lymphocytic-histiocytic predominance involving intra-abdominal lymph nodes.20144
Hodgkin's disease, lymphocytic-histiocytic predominance involving lymph nodes of axilla and upper limb.20145
Hodgkin's disease, lymphocytic-histiocytic predominance involving lymph nodes of inguinal region and lower limb.20146
Hodgkin's disease, lymphocytic-histiocytic predominance involving intrapelvic lymph nodes.20147
Hodgkin's disease, lymphocytic-histiocytic predominance involving spleen.20148
Hodgkin's disease, lymphocytic-histiocytic predominance involving lymph nodes of multiple sites.20150
Hodgkin's disease, nodular sclerosis, unspecified site.20151
Hodgkin's disease, nodular sclerosis, involving lymph nodes of head, face, and neck.20152
Hodgkin's disease, nodular sclerosis, involving intrathoracic lymph nodes.20153
Hodgkin's disease, nodular sclerosis, involving intra-abdominal lymph nodes.20154
Hodgkin's disease, nodular sclerosis, involving lymph nodes of axilla and upper limb.20155
Hodgkin's disease, nodular sclerosis, involving lymph nodes of inguinal region and lower limb.20156
Hodgkin's disease, nodular sclerosis, involving intrapelvic lymph nodes.20157
Hodgkin's disease, nodular sclerosis, involving spleen.20158
Hodgkin's disease, nodular sclerosis, involving lymph nodes of multiple sites.20160
Hodgkin's disease, mixed cellularity, unspecified site.20161
Hodgkin's disease, mixed cellularity, involving lymph nodes of head, face, and neck.20162
Hodgkin's disease, mixed cellularity, involving intrathoracic lymph nodes.20163
Hodgkin's disease, mixed cellularity, involving intra-abdominal lymph nodes.20164
Hodgkin's disease, mixed cellularity, involving lymph nodes of axilla and upper limb.20165
Hodgkin's disease, mixed cellularity, involving lymph nodes of inguinal region and lower limb.20166
Hodgkin's disease, mixed cellularity, involving intrapelvic lymph nodes.( print page 25029)20167
Hodgkin's disease, mixed cellularity, involving spleen.20168
Hodgkin's disease, mixed cellularity, involving lymph nodes of multiple sites.20170
Hodgkin's disease, lymphocytic depletion, unspecified site.20171
Hodgkin's disease, lymphocytic depletion, involving lymph nodes of head, face, and neck.20172
Hodgkin's disease, lymphocytic depletion, involving intrathoracic lymph nodes.20173
Hodgkin's disease, lymphocytic depletion, involving intra-abdominal lymph nodes.20174
Hodgkin's disease, lymphocytic depletion, involving lymph nodes of axilla and upper limb.20175
Hodgkin's disease, lymphocytic depletion, involving lymph nodes of inguinal region and lower limb.20176
Hodgkin's disease, lymphocytic depletion, involving intrapelvic lymph nodes.20177
Hodgkin's disease, lymphocytic depletion, involving spleen.20178
Hodgkin's disease, lymphocytic depletion, involving lymph nodes of multiple sites.20190
Hodgkin's disease, unspecified type, unspecified site.20191
Hodgkin's disease, unspecified type, involving lymph nodes of head, face, and neck.20192
Hodgkin's disease, unspecified type, involving intrathoracic lymph nodes.20193
Hodgkin's disease, unspecified type, involving intra-abdominal lymph nodes.20194
Hodgkin's disease, unspecified type, involving lymph nodes of axilla and upper limb.20195
Hodgkin's disease, unspecified type, involving lymph nodes of inguinal region and lower limb.20196
Hodgkin's disease, unspecified type, involving intrapelvic lymph nodes.20197
Hodgkin's disease, unspecified type, involving spleen.20198
Hodgkin's disease, unspecified type, involving lymph nodes of multiple sites.20200
Nodular lymphoma, unspecified site.20201
Nodular lymphoma involving lymph nodes of head, face, and neck.20202
Nodular lymphoma involving intrathoracic lymph nodes.20203
Nodular lymphoma involving intra-abdominal lymph nodes.20204
Nodular lymphoma involving lymph nodes of axilla and upper limb.20205
Nodular lymphoma involving lymph nodes of inguinal region and lower limb.20206
Nodular lymphoma involving intrapelvic lymph nodes.20207
Nodular lymphoma involving spleen.20208
Nodular lymphoma involving lymph nodes of multiple sites.20210
Mycosis fungoides, unspecified site.20211
Mycosis fungoides involving lymph nodes of head, face, and neck.20212
Mycosis fungoides involving intrathoracic lymph nodes.20213
Mycosis fungoides involving intra-abdominal lymph nodes.20214
Mycosis fungoides involving lymph nodes of axilla and upper limb.20215
Mycosis fungoides involving lymph nodes of inguinal region and lower limb.20216
Mycosis fungoides involving intrapelvic lymph nodes.20217
Mycosis fungoides involving spleen.20218
Mycosis fungoides involving lymph nodes of multiple sites.20220
Sezary's disease, unspecified site.20221
Sezary's disease involving lymph nodes of head, face, and neck.20222
Sezary's disease involving intrathoracic lymph nodes.20223
Sezary's disease involving intra-abdominal lymph nodes.20224
Sezary's disease involving lymph nodes of axilla and upper limb.20225
Sezary's disease involving lymph nodes of inguinal region and lower limb.20226
Sezary's disease involving intrapelvic lymph nodes.20227
Sezary's disease involving spleen.20228
Sezary's disease involving lymph nodes of multiple sites.20230
Malignant histiocytosis, unspecified site.20231
Malignant histiocytosis involving lymph nodes of head, face, and neck.20232
Malignant histiocytosis involving intrathoracic lymph nodes.20233
Malignant histiocytosis involving intra-abdominal lymph nodes.20234
Malignant histiocytosis involving lymph nodes of axilla and upper limb.20235
Malignant histiocytosis involving lymph nodes of inguinal region and lower limb.20236
Malignant histiocytosis involving intrapelvic lymph nodes.20237
Malignant histiocytosis involving spleen.20238
Malignant histiocytosis involving lymph nodes of multiple sites.20240
Leukemic reticuloendotheliosis, unspecified site.20241
Leukemic reticuloendotheliosis involving lymph nodes of head, face, and neck.20242
Leukemic reticuloendotheliosis involving intrathoracic lymph nodes.20243
Leukemic reticuloendotheliosis involving intra-abdominal lymph nodes.20244
Leukemic reticuloendotheliosis involving lymph nodes of axilla and upper arm.20245
Leukemic reticuloendotheliosis involving lymph nodes of inguinal region and lower limb.20246
Leukemic reticuloendotheliosis involving intrapelvic lymph nodes.20247
Leukemic reticuloendotheliosis involving spleen.20248
Leukemic reticuloendotheliosis involving lymph nodes of multipes sites.20250
Letterer-siwe disease, unspecified site.20251
Letterer-siwe disease involving lymph nodes of head, face, and neck.20252
Letterer-siwe disease involving intrathoracic lymph nodes.20253
Letterer-siwe disease involving intra-abdominal lymph nodes.20254
Letterer-siwe disease involving lymph nodes of axilla and upper limb.20255
Letterer-siwe disease involving lymph nodes of inguinal region and lower limb.20256
Letterer-siwe disease involving intrapelvic lymph nodes.( print page 25030)20257
Letterer-siwe disease involving spleen.20258
Letterer-siwe disease involving lymph nodes of multiple sites.20260
Malignant mast cell tumors, unspecified site.20261
Malignant mast cell tumors involving lymph nodes of head, face, and neck.20262
Malignant mast cell tumors involving intrathoracic lymph nodes.20263
Malignant mast cell tumors involving intra-abdominal lymph nodes.20264
Malignant mast cell tumors involving lymph nodes of axilla and upper limb.20265
Malignant mast cell tumors involving lymph nodes of inguinal region and lower limb.20266
Malignant mast cell tumors involving intrapelvic lymph nodes.20267
Malignant mast cell tumors involving spleen.20268
Malignant mast cell tumors involving lymph nodes of multiple sites.20270
Peripheral T cell lymphoma, unspecified site, extranodal and solid organ sites.20271
Peripheral T cell lymphoma, lymph nodes of head, face, and neck.20272
Peripheral T cell lymphoma, intrathoracic lymph nodes.20273
Peripheral T cell lymphoma, intra-abdominal lymph nodes.20274
Peripheral T cell lymphoma, lymph nodes of axilla and upper limb.20275
Peripheral T cell lymphoma, lymph nodes of inguinal region and lower limb.20276
Peripheral T cell lymphoma, intrapelvic lymph nodes.20277
Peripheral T cell lymphoma, spleen.20278
Peripheral T cell lymphoma, lymph nodes of multiple sites.20280
Other malignant lymphomas, unspecified site.20281
Other malignant lymphomas involving lymph nodes of head, face, and neck.20282
Other malignant lymphomas involving intrathoracic lymph nodes.20283
Other malignant lymphomas involving intra-abdominal lymph nodes.20284
Other malignant lymphomas involving lymph nodes of axilla and upper limb.20285
Other malignant lymphomas involving lymph nodes of inguinal region and lower limb.20286
Other malignant lymphomas involving intrapelvic lymph nodes.20287
Other malignant lymphomas involving spleen.20288
Other malignant lymphomas involving lymph nodes of multiple sites.290
Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue, unspecified site.20291
Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving lymph nodes of head, face, and neck.20292
Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving intrathoracic lymph nodes.20293
Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving intra-abdominal lymph nodes.20294
Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving lymph nodes of axilla and upper limb.20295
Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving lymph nodes of inguinal region and lower limb.20296
Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving intrapelvic lymph nodes.20297
Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving spleen.20298
Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving lymph nodes of multiple sites.20300
Multiple myeloma, without mention of remission.20301
Multiple myeloma, in remission.20310
Plasma cell leukemia, without mention of remission.20311
Plasma cell leukemia, in remission.20380
Other immunoproliferative neoplasms, without mention of remission.20381
Other immunoproliferative neoplasms, in remission.20400
Lymphoid leukemia, acute, without mention of remission.20401
Lymphoid leukemia, acute, in remission.20410
Lymphoid leukemia, chronic, without mention of remission.20411
Lymphoid leukemia, chronic, in remission.20420
Lymphoid leukemia, subacute, without mention of remission.20421
Lymphoid leukemia, subacute, in remission.20480
Other lymphoid leukemia, without mention of remission.20481
Other lymphoid leukemia, in remission.20490
Unspecified lymphoid leukemia, without mention of remission.20491
Unspecified lymphoid leukemia, in remission.20500
Myeloid leukemia, acute, without mention of remission.20501
Myeloid leukemia, acute, in remission.20510
Myeloid leukemia, chronic, without mention of remission.20511
Myeloid leukemia, chronic, in remission.20520
Myeloid leukemia, subacute, without mention of remission.20521
Myeloid leukemia, subacute, in remission.20530
Myeloid sarcoma, without mention of remission.20531
Myeloid sarcoma, in remission.20580
Other myeloid leukemia, without mention of remission.20581
Other myeloid leukemia, in remission.20590
Unspecified myeloid leukemia, without mention of remission.( print page 25031)20591
Unspecified myeloid leukemia, in remission.20600
Monocytic leukemia, acute, without mention of remission.20601
Monocytic leukemia, acute, in remission.20610
Monocytic leukemia, chronic without mention of remission.20611
Monocytic leukemia, chronic, in remission.20620
Monocytic leukemia, subacute, without mention of remission.20621
Monocytic leukemia, subacute, in remission.20680
Other monocytic leukemia, without mention of remission.20681
Other monocytic leukemia, in remission.20690
Unspecified monocytic leukemia, without mention of remission.20691
Unspecified monocytic leukemia, in remission.20700
Acute erythremia and erythroleukemia, without mention of remission.20701
Acute erythremia and erythroleukemia, in remission.20710
Chronic erythremia, without mention of remission.20711
Chronic erythremia, in remission.20720
Megakaryocytic leukemia, without mention of remission.20721
Megakaryocytic leukemia, in remission.20780
Other specified leukemia, without mention of remission.20781
Other specified leukemia, in remission.20800
Leukemia of unspecified cell type, acute, without mention of remission.20801
Leukemia of unspecified cell type, acute, in remission.20810
Leukemia of unspecified cell type, chronic, without mention of remission.20811
Leukemia of unspecified cell type, chronic, in remission.20820
Leukemia of unspecified cell type, subacute, without mention of remission.20821
Leukemia of unspecified cell type, subacute, in remission.20880
Other leukemia of unspecified cell type, without mention of remission.20881
Other leukemia of unspecified cell type, in remission.20890
Unspecified leukemia, without mention of remission.20891
Unspecified leukemia, in remission.2385
Neoplasm of uncertain behavior of histiocytic and mast cells.2386
Neoplasm of uncertain behavior of plasma cells.23873
High grade myelodysplastic syndrome lesions.23874
Myelodysplastic syndrome with 5q deletion.23876
Myelofibrosis with myeloid metaplasia.23879
Other lymphatic and hematopoietic tissues.2450
Acute thyroiditis.2463
Hemorrhage and infarction of thyroid.2510
Hypoglycemic coma.2513
Postsurgical hypoinsulinemia.2531
Other and unspecified anterior pituitary hyperfunction.2532
Panhypopituitarism.2535
Diabetes insipidus.2536
Other disorders of neurohypophysis.2541
Abscess of thymus.2550
Cushing's syndrome.2553
Other corticoadrenal overactivity.25541
Glucocorticoid deficiency.25542
Mineralocorticoid deficiency.2555
Other adrenal hypofunction.2556
Medulloadrenal hyperfunction.2592
Carcinoid syndrome.2632
Arrested development following protein-calorie malnutrition.2638
Other protein-calorie malnutrition.2639
Unspecified protein-calorie malnutrition.2650
Beriberi.2651
Other and unspecified manifestations of thiamine deficiency.2660
Ariboflavinosis.2680
Rickets, active.2700
Disturbances of amino-acid transport.2701
Phenylketonuria (PKU).2702
Other disturbances of aromatic amino-acid metabolism.2703
Disturbances of branched-chain amino-acid metabolism.2704
Disturbances of sulphur-bearing amino-acid metabolism.2705
Disturbances of histidine metabolism.2706
Disorders of urea cycle metabolism.2707
Other disturbances of straight-chain amino-acid metabolism.2708
Other specified disorders of amino-acid metabolism.2709
Unspecified disorder of amino-acid metabolism.2710
Glycogenosis.2711
Galactosemia.2718
Other specified disorders of carbohydrate transport and metabolism.27411
Uric acid nephrolithiasis.( print page 25032)2760
Hyperosmolality and/or hypernatremia.2761
Hyposmolality and/or hyponatremia.2762
Acidosis.2763
Alkalosis.2764
Mixed acid-base balance disorder.27700
Cystic fibrosis without mention of meconium ileus.27703
Cystic fibrosis with gastrointestinal manifestations.27709
Cystic fibrosis with other manifestations.2771
Disorders of porphyrin metabolism.2772
Other disorders of purine and pyrimidine metabolism.27730
Amyloidosis, unspecified.27731
Familial Mediterranean fever.27739
Other amyloidosis.2775
Mucopolysaccharidosis.27785
Disorders of fatty acid oxidation.27786
Peroxisomal disorders.27787
Disorders of mitochondrial metabolism.27789
Other specified disorders of metabolism.27900
Hypogammaglobulinemia, unspecified.27901
Selective iga immunodeficiency.27902
Selective igm immunodeficiency.27903
Other selective immunoglobulin deficiencies.27904
Congenital hypogammaglobulinemia.27905
Immunodeficiency with increased igm.27906
Common variable immunodeficiency.27909
Other deficiency of humoral immunity.27910
Immunodeficiency with predominant T-cell defect, unspecified.27911
Digeorge's syndrome.27912
Wiskott-aldrich syndrome.27913
Nezelof's syndrome.27919
Other deficiency of cell-mediated immunity.2792
Combined immunity deficiency.2793
Unspecified immunity deficiency.2828
Other specified hereditary hemolytic anemias.2829
Hereditary hemolytic anemia, unspecified.2830
Autoimmune hemolytic anemias.28310
Non-autoimmune hemolytic anemia, unspecified.28319
Other non-autoimmune hemolytic anemias.2839
Acquired hemolytic anemia, unspecified.28401
Constitutional red blood cell aplasia.28409
Other constitutional aplastic anemia.2841
Pancytopenia.2842
Myelophthisis.2849
Aplastic anemia, unspecified.2862
Congenital factor xi deficiency.2863
Congenital deficiency of other clotting factors.2864
Von willebrand's disease.2865
Hemorrhagic disorder due to intrinsic circulating anticoagulants.2867
Acquired coagulation factor deficiency.2869
Other and unspecified coagulation defects.2870
Allergic purpura.28731
Immune thrombocytopenic purpura.28732
Evans' syndrome.28733
Congenital and hereditary thrombocytopenic purpura.2884
Hemophagocytic syndromes.2897
Methemoglobinemia.28981
Primary hypercoagulable state.28982
Secondary hypercoagulable state.28983
Myelofibrosis.29011
Presenile dementia with delirium.29012
Presenile dementia with delusional features.29013
Presenile dementia with depressive features.29020
Senile dementia with delusional features.29021
Senile dementia with depressive features.2903
Senile dementia with delirium.29041
Vascular dementia, with delirium.29042
Vascular dementia, with delusions.29043
Vascular dementia, with depressed mood.2908
Other specified senile psychotic conditions.2909
Unspecified senile psychotic condition.2910
Alcohol withdrawal delirium.2912
Alcohol-induced persisting dementia.( print page 25033)2913
Alcohol-induced psychotic disorder with hallucinations.29181
Alcohol withdrawal.29189
Other alcohol-induced mental disorders.2919
Unspecified alcohol-induced mental disorders.2920
Drug withdrawal.29211
Drug-induced psychotic disorder with delusions.29212
Drug-induced psychotic disorder with hallucinations.29281
Drug-induced delirium.29282
Drug-induced persisting dementia.2930
Delirium due to conditions classified elsewhere.2931
Subacute delirium.29381
Psychotic disorder with delusions in conditions classified elsewhere.29382
Psychotic disorder with hallucinations in conditions classified elsewhere.2939
Unspecified transient mental disorder in conditions classified elsewhere.29411
Dementia in conditions classified elsewhere with behavioral disturbance.29500
Simple type schizophrenia, unspecified state.29501
Simple type schizophrenia, subchronic state.29502
Simple type schizophrenia, chronic state.29503
Simple type schizophrenia, subchronic state with acute exacerbation.29504
Simple type schizophrenia, chronic state with acute exacerbation.29510
Disorganized type schizophrenia, unspecified state.29511
Disorganized type schizophrenia, subchronic state.29512
Disorganized type schizophrenia, chronic state.29513
Disorganized type schizophrenia, subchronic state with acute exacerbation.29514
Disorganized type schizophrenia, chronic state with acute exacerbation.29520
Catatonic type schizophrenia, unspecified state.29521
Catatonic type schizophrenia, subchronic state.29522
Catatonic type schizophrenia, chronic state.29523
Catatonic type schizophrenia, subchronic state with acute exacerbation.29524
Catatonic type schizophrenia, chronic state with acute exacerbation.29530
Paranoid type schizophrenia, unspecified state.29531
Paranoid type schizophrenia, subchronic state.29532
Paranoid type schizophrenia, chronic state.29533
Paranoid type schizophrenia, subchronic state with acute exacerbation.29534
Paranoid type schizophrenia, chronic state with acute exacerbation.29540
Schizophreniform disorder, unspecified.29541
Schizophreniform disorder, subchronic.29542
Schizophreniform disorder, chronic.29543
Schizophreniform disorder, subchronic with acute exacerbation.29544
Schizophreniform disorder, chronic with acute exacerbation.29553
Latent schizophrenia, subchronic state with acute exacerbation.29554
Latent schizophrenia, chronic state with acute exacerbation.29560
Schizophrenic disorders, residual type, unspecified.29561
Schizophrenic disorders, residual type, subchronic.29562
Schizophrenic disorders, residual type, chronic.29563
Schizophrenic disorders, residual type, subchronic with acute exacerbation.29564
Schizophrenic disorders, residual type, chronic with acute exacerbation.29571
Schizoaffective disorder, subchronic.29572
Schizoaffective disorder, chronic.29573
Schizoaffective disorder, subchronic with acute exacerbation.29574
Schizoaffective disorder, chronic with acute exacerbation.29580
Other specified types of schizophrenia, unspecified state.29581
Other specified types of schizophrenia, subchronic state.29582
Other specified types of schizophrenia, chronic state.29583
Other specified types of schizophrenia, subchronic state with acute exacerbation.29584
Other specified types of schizophrenia, chronic state with acute exacerbation.29591
Unspecified type schizophrenia, subchronic state.29592
Unspecified type schizophrenia, chronic state.29593
Unspecified type schizophrenia, subchronic state with acute exacerbation.29594
Unspecified type schizophrenia, chronic state with acute exacerbation.29600
Bipolar I disorder, single manic episode, unspecified.29601
Bipolar I disorder, single manic episode, mild.29602
Bipolar I disorder, single manic episode, moderate.29603
Bipolar I disorder, single manic episode, severe, without mention of psychotic behavior.29604
Bipolar I disorder, single manic episode, severe, specified as with psychotic behavior.29610
Manic affective disorder, recurrent episode, unspecified degree.29611
Manic affective disorder, recurrent episode, mild degree.29612
Manic affective disorder, recurrent episode, moderate degree.29613
Manic affective disorder, recurrent episode, severe degree, without mention of psychotic behavior.29614
Manic affective disorder, recurrent episode, severe degree, specified as with psychotic behavior.29620
Major depressive affective disorder, single episode, unspecified degree.29621
Major depressive affective disorder, single episode, mild degree.( print page 25034)29622
Major depressive affective disorder, single episode, moderate degree.29623
Major depressive affective disorder, single episode, severe degree, without mention of psychotic behavior.29624
Major depressive affective disorder, single episode, severe degree, specified as with psychotic behavior.29630
Major depressive affective disorder, recurrent episode, unspecified degree.29631
Major depressive affective disorder, recurrent episode, mild degree.29632
Major depressive affective disorder, recurrent episode, moderate degree.29633
Major depressive affective disorder, recurrent episode, severe degree, without mention of psychotic behavior.29634
Major depressive affective disorder, recurrent episode, severe degree, specified as with psychotic behavior.29640
Bipolar I disorder, most recent episode (or current) manic, unspecified.29641
Bipolar I disorder, most recent episode (or current) manic, mild.29642
Bipolar I disorder, most recent episode (or current) manic, moderate.29643
Bipolar I disorder, most recent episode (or current) manic, severe, without mention of psychotic behavior.29644
Bipolar I disorder, most recent episode (or current) manic, severe, specified as with psychotic behavior.29650
Bipolar I disorder, most recent episode (or current) depressed, unspecified.29651
Bipolar I disorder, most recent episode (or current) depressed, mild.29652
Bipolar I disorder, most recent episode (or current) depressed, moderate.29653
Bipolar I disorder, most recent episode (or current) depressed, severe, without mention of psychotic behavior.29654
Bipolar I disorder, most recent episode (or current) depressed, severe, specified as with psychotic behavior.29660
Bipolar I disorder, most recent episode (or current) mixed, unspecified.29661
Bipolar I disorder, most recent episode (or current) mixed, mild.29662
Bipolar I disorder, most recent episode (or current) mixed, moderate.29663
Bipolar I disorder, most recent episode (or current) mixed, severe, without mention of psychotic behavior.29664
Bipolar I disorder, most recent episode (or current) mixed, severe, specified as with psychotic behavior.29689
Other and unspecified bipolar disorders, other.29699
Other specified episodic mood disorder.2980
Depressive type psychosis.2981
Excitative type psychosis.2983
Acute paranoid reaction.2984
Psychogenic paranoid psychosis.29900
Autistic disorder, current or active state.29901
Autistic disorder, residual state.29910
Childhood disintegrative disorder, current or active state.29911
Childhood disintegrative disorder, residual state.29980
Other specified pervasive developmental disorders, current or active state.29981
Other specified pervasive developmental disorders, residual state.29990
Unspecified pervasive developmental disorder, current or active state.29991
Unspecified pervasive developmental disorder, residual state.30151
Chronic factitious illness with physical symptoms.30401
Opioid type dependence, continuous use.30411
Sedative, hypnotic or anxiolytic dependence, continuous.30421
Cocaine dependence, continuous use.30441
Amphetamine and other psychostimulant dependence, continuous use.30451
Hallucinogen dependence, continuous use.30461
Other specified drug dependence, continuous use.30471
Combinations of opioid type drug with any other drug dependence, continuous use.30481
Combinations of drug dependence excluding opioid type drug, continuous use.30491
Unspecified drug dependence, continuous use.3071
Anorexia nervosa.30751
Bulimia nervosa.3181
Severe mental retardation.3182
Profound mental retardation.3222
Chronic meningitis.3300
Leukodystrophy.3301
Cerebral lipidoses.3302
Cerebral degeneration in generalized lipidoses.3303
Cerebral degeneration of childhood in other diseases classified elsewhere.3308
Other specified cerebral degenerations in childhood.3309
Unspecified cerebral degeneration in childhood.3313
Communicating hydrocephalus.3314
Obstructive hydrocephalus.3315
Idiopathic normal pressure hydrocephalus (INPH).3321
Secondary parkinsonism.3330
Other degenerative diseases of the basal ganglia.3334
Huntington's chorea.33371
Athetoid cerebral palsy.33372
Acute dystonia due to drugs.33379
Other acquired torsion dystonia.33390
Unspecified extrapyramidal disease and abnormal movement disorder.33391
Stiff-man syndrome.3340
Friedreich's ataxia.3341
Hereditary spastic paraplegia.3342
Primary cerebellar degeneration.( print page 25035)3343
Other cerebellar ataxia.3344
Cerebellar ataxia in diseases classified elsewhere.3348
Other spinocerebellar diseases.3349
Spinocerebellar disease, unspecified.3350
Werdnig-hoffmann disease.33510
Spinal muscular atrophy, unspecified.33511
Kugelberg-welander disease.33519
Other spinal muscular atrophy.33520
Amyotrophic lateral sclerosis.33521
Progressive muscular atrophy.33522
Progressive bulbar palsy.33523
Pseudobulbar palsy.33524
Primary lateral sclerosis.33529
Other motor neuron diseases.3358
Other anterior horn cell diseases.3359
Anterior horn cell disease, unspecified.3360
Syringomyelia and syringobulbia.3362
Subacute combined degeneration of spinal cord in diseases classified elsewhere.3363
Myelopathy in other diseases classified elsewhere.3368
Other myelopathy.3369
Unspecified disease of spinal cord.3370
Idiopathic peripheral autonomic neuropathy.3371
Peripheral autonomic neuropathy in disorders classified elsewhere.33720
Reflex sympathetic dystrophy, unspecified.33721
Reflex sympathetic dystrophy of the upper limb.33722
Reflex sympathetic dystrophy of the lower limb.33729
Reflex sympathetic dystrophy of other specified site.3410
Neuromyelitis optica.3411
Schilder's disease.34120
Acute (transverse) myelitis NOS.34121
Acute (transverse) myelitis in conditions classified elsewhere.34122
Idiopathic transverse myelitis.3418
Other demyelinating diseases of central nervous system.3419
Demyelinating disease of central nervous system, unspecified.34200
Flaccid hemiplegia and hemiparesis affecting unspecified side.34201
Flaccid hemiplegia and hemiparesis affecting dominant side.34202
Flaccid hemiplegia and hemiparesis affecting nondominant side.34210
Spastic hemiplegia and hemiparesis affecting unspecified side.34211
Spastic hemiplegia and hemiparesis affecting dominant side.34212
Spastic hemiplegia and hemiparesis affecting nondominant side.34280
Other specified hemiplegia and hemiparesis affecting unspecified side.34281
Other specified hemiplegia and hemiparesis affecting dominant side.34282
Other specified hemiplegia and hemiparesis affecting nondominant side.34290
Unspecified hemiplegia and hemiparesis affecting unspecified side.34291
Unspecified hemiplegia and hemiparesis affecting dominant side.34292
Unspecified hemiplegia and hemiparesis affecting nondominant side.3430
Congenital diplegia.3431
Congenital hemiplegia.3434
Infantile hemiplegia.3441
Paraplegia.3442
Diplegia of upper limbs.34460
Cauda equina syndrome without mention of neurogenic bladder.34461
Cauda equina syndrome with neurogenic bladder.34501
Generalized nonconvulsive epilepsy, with intractable epilepsy.34511
Generalized convulsive epilepsy, with intractable epilepsy.3452
Petit mal status, epileptic.34540
Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, without mention of intractable epilepsy.34541
Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, with intractable epilepsy.34550
Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy.34551
Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, with intractable epilepsy.34560
Infantile spasms, without mention of intractable epilepsy.34561
Infantile spasms, with intractable epilepsy.34570
Epilepsia partialis continua, without mention of intractable epilepsy.34571
Epilepsia partialis continua, with intractable epilepsy.34580
Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy.34581
Other forms of epilepsy and recurrent seizures, with intractable epilepsy.34591
Epilepsy, unspecified, with intractable epilepsy.3481
Anoxic brain damage.( print page 25036)3491
Nervous system complications from surgically implanted device.34981
Cerebrospinal fluid rhinorrhea.3563
Refsum's disease.3570
Acute infective polyneuritis.35781
Chronic inflammatory demyelinating polyneuritis.35782
Critical illness polyneuropathy.3581
Myasthenic syndromes in diseases classified elsewhere.3590
Congenital hereditary muscular dystrophy.3591
Hereditary progressive muscular dystrophy.3594
Toxic myopathy.3596
Symptomatic inflammatory myopathy in diseases classified elsewhere.35981
Critical illness myopathy.36000
Purulent endophthalmitis, unspecified.36001
Acute endophthalmitis.36002
Panophthalmitis.36004
Vitreous abscess.36011
Sympathetic uveitis.36012
Panuveitis.36013
Parasitic endophthalmitis nos.36019
Other endophthalmitis.3612
Serous retinal detachment.36181
Traction detachment of retina.36189
Other forms of retinal detachment.3619
Unspecified retinal detachment.36230
Retinal vascular occlusion, unspecified.36231
Central retinal artery occlusion.36232
Retinal arterial branch occlusion.36233
Partial retinal arterial occlusion.36234
Transient retinal arterial occlusion.36235
Central retinal vein occlusion.36240
Retinal layer separation, unspecified.36242
Serous detachment of retinal pigment epithelium.36243
Hemorrhagic detachment of retinal pigment epithelium.36284
Retinal ischemia.36310
Disseminated chorioretinitis, unspecified.36311
Disseminated choroiditis and chorioretinitis, posterior pole.36312
Disseminated choroiditis and chorioretinitis, peripheral.36313
Disseminated choroiditis and chorioretinitis, generalized.36314
Disseminated retinitis and retinochoroiditis, metastatic.36315
Disseminated retinitis and retinochoroiditis, pigment epitheliopathy.36320
Chorioretinitis, unspecified.36363
Choroidal rupture.36370
Choroidal detachment, unspecified.36371
Serous choroidal detachment.36372
Hemorrhagic choroidal detachment.36400
Acute and subacute iridocyclitis, unspecified.36401
Primary iridocyclitis.36402
Recurrent iridocyclitis.36403
Secondary iridocyclitis, infectious.36422
Glaucomatocyclitic crises.3643
Unspecified iridocyclitis.36522
Acute angle-closure glaucoma.36811
Sudden visual loss.36812
Transient visual loss.37601
Orbital cellulitis.37602
Orbital periostitis.37603
Orbital osteomyelitis.37700
Papilledema, unspecified.37701
Papilledema associated with increased intracranial pressure.37730
Optic neuritis, unspecified.37731
Optic papillitis.37732
Retrobulbar neuritis (acute).37739
Other optic neuritis.37751
Disorders of optic chiasm associated with pituitary neoplasms and disorders.37752
Disorders of optic chiasm associated with other neoplasms.37753
Disorders of optic chiasm associated with vascular disorders.37754
Disorders of optic chiasm associated with inflammatory disorders.37761
Disorders of other visual pathways associated with neoplasms.37762
Disorders of other visual pathways associated with vascular disorders.37763
Disorders of other visual pathways associated with inflammatory disorders.37771
Disorders of visual cortex associated with neoplasms.37772
Disorders of visual cortex associated with vascular disorders.( print page 25037)37773
Disorders of visual cortex associated with inflammatory disorders.38014
Malignant otitis externa.38300
Acute mastoiditis without complications.38301
Subperiosteal abscess of mastoid.38302
Acute mastoiditis with other complications.38861
Cerebrospinal fluid otorrhea.3910
Acute rheumatic pericarditis.3911
Acute rheumatic endocarditis.3912
Acute rheumatic myocarditis.3918
Other acute rheumatic heart disease.3919
Acute rheumatic heart disease, unspecified.3920
Rheumatic chorea with heart involvement.3929
Rheumatic chorea without mention of heart involvement.393
Chronic rheumatic pericarditis.3980
Rheumatic myocarditis.39891
Rheumatic heart failure (congestive).4010
Malignant essential hypertension.40200
Malignant hypertensive heart disease without congestive heart failure.40201
Malignant hypertensive heart disease with congestive heart failure.40211
Benign hypertensive heart disease with congestive heart failure.40291
Unspecified hypertensive heart disease with congestive heart failure.40300
Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage I through stage IV, or unspecified.40301
Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease.40311
Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end stage renal disease.40400
Hypertensive heart and chronic kidney disease, malignant, without heart failure and with chronic kidney disease stage I through stage IV, or unspecified.40401
Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified.40402
Hypertensive heart and chronic kidney disease, malignant, without heart failure and with chronic kidney disease stage V or end stage renal disease.40403
Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage V or end stage renal disease.40411
Hypertensive heart and chronic kidney disease, benign, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified.40412
Hypertensive heart and chronic kidney disease, benign, without heart failure and with chronic kidney disease stage V or end stage renal disease.40413
Hypertensive heart and chronic kidney disease, benign, with heart failure and chronic kidney disease stage V or end stage renal disease.40491
Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified.40492
Hypertensive heart and chronic kidney disease, unspecified, without heart failure and with chronic kidney disease stage V or end stage renal disease.40493
Hypertensive heart and chronic kidney disease, unspecified, with heart failure and chronic kidney disease stage V or end stage renal disease.40501
Malignant renovascular hypertension.40509
Other malignant secondary hypertension.4110
Postmyocardial infarction syndrome.4111
Intermediate coronary syndrome.41181
Other acute and subacute forms of ischemic heart disease, acute ischemic heart disease without myocardial infarction.41189
Other acute and subacute forms of ischemic heart disease, other.4130
Angina decubitus.4131
Prinzmetal angina.41402
Coronary atherosclerosis of autologous vein bypass graft.41403
Coronary atherosclerosis of nonautologous biological bypass graft.41404
Coronary atherosclerosis of artery bypass graft.41406
Coronary atherosclerosis of native coronary artery of transplanted heart.41407
Coronary atherosclerosis, of bypass graft (artery) (vein) of transplanted heart.41410
Aneurysm of heart (wall).41419
Other aneurysm of heart.4160
Primary pulmonary hypertension.4161
Kyphoscoliotic heart disease.4170
Arteriovenous fistula of pulmonary vessels.4171
Aneurysm of pulmonary artery.4200
Acute pericarditis in diseases classified elsewhere.42090
Acute pericarditis, unspecified.42091
Acute idiopathic pericarditis.42099
Other acute pericarditis.4230
Hemopericardium.4231
Adhesive pericarditis.( print page 25038)4232
Constrictive pericarditis.4233
Cardiac tamponade.4238
Other specified diseases of pericardium.4239
Unspecified disease of pericardium.42490
Endocarditis, valve unspecified, unspecified cause.42491
Endocarditis in diseases classified elsewhere.42499
Other endocarditis, valve unspecified.4250
Endomyocardial fibrosis.4251
Hypertrophic obstructive cardiomyopathy.4252
Obscure cardiomyopathy of africa.4253
Endocardial fibroelastosis.4254
Other primary cardiomyopathies.4255
Alcoholic cardiomyopathy.4257
Nutritional and metabolic cardiomyopathy.4258
Cardiomyopathy in other diseases classified elsewhere.4259
Secondary cardiomyopathy, unspecified.4260
Atrioventricular block, complete.42612
Mobitz (type) ii atrioventricular block.42689
Other specified conduction disorders.4270
Paroxysmal supraventricular tachycardia.4271
Paroxysmal ventricular tachycardia.42732
Atrial flutter.4281
Left heart failure.42820
Unspecified systolic heart failure.42822
Chronic systolic heart failure.42830
Unspecified diastolic heart failure.42832
Chronic diastolic heart failure.42840
Unspecified combined systolic and diastolic heart failure.42842
Chronic combined systolic and diastolic heart failure.42971
Certain sequelae of myocardial infarction, not elsewhere classified, acquired cardiac septal defect.42979
Certain sequelae of myocardial infarction, not elsewhere classified, other.42981
Other disorders of papillary muscle.42982
Hyperkinetic heart disease.42983
Takotsubo syndrome.4329
Unspecified intracranial hemorrhage.4350
Basilar artery syndrome.4351
Vertebral artery syndrome.4352
Subclavian steal syndrome.4353
Vertebrobasilar artery syndrome.4358
Other specified transient cerebral ischemias.4359
Unspecified transient cerebral ischemia.436
Acute, but ill-defined, cerebrovascular disease.4371
Other generalized ischemic cerebrovascular disease.4372
Hypertensive encephalopathy.4374
Cerebral arteritis.4375
Moyamoya disease.4376
Nonpyogenic thrombosis of intracranial venous sinus.43820
Hemiplegia affecting unspecified side.43821
Hemiplegia affecting dominant side.43822
Hemiplegia affecting nondominant side.44024
Atherosclerosis of native arteries of the extremities with gangrene.4440
Embolism and thrombosis of abdominal aorta.4441
Embolism and thrombosis of thoracic aorta.44421
Arterial embolism and thrombosis of upper extremity.44422
Arterial embolism and thrombosis of lower extremity.44481
Embolism and thrombosis of iliac artery.44489
Embolism and thrombosis of other artery.4449
Embolism and thrombosis of unspecified artery.44501
Atheroembolism, upper extremity.44502
Atheroembolism, lower extremity.44581
Atheroembolism, kidney.44589
Atheroembolism, other site.4460
Polyarteritis nodosa.4461
Acute febrile mucocutaneous lymph node syndrome (mcls).44620
Hypersensitivity angiitis, unspecified.44621
Goodpasture's syndrome.44629
Other specified hypersensitivity angiitis.4463
Lethal midline granuloma.4464
Wegener's granulomatosis.4467
Takayasu's disease.4472
Rupture of artery.4474
Celiac artery compression syndrome.( print page 25039)4475
Necrosis of artery.449
Septic arterial embolism.45119
Phlebitis and thrombophlebitis of other.45181
Phlebitis and thrombophlebitis of iliac vein.45183
Phlebitis and thrombophlebitis of deep veins of upper extremities.45189
Phlebitis and thrombophlebitis of other sites.4531
Thrombophlebitis migrans.4533
Embolism and thrombosis of renal vein.45340
Venous embolism and thrombosis of unspecified deep vessels of lower extremity.45341
Venous embolism and thrombosis of deep vessels of proximal lower extremity.45342
Venous embolism and thrombosis of deep vessels of distal lower extremity.4538
Embolism and thrombosis of other specified veins.4539
Embolism and thrombosis of unspecified site.4542
Varicose veins of lower extremities with ulcer and inflammation.4561
Esophageal varices without mention of bleeding.45621
Esophageal varices in diseases classified elsewhere, without mention of bleeding.45911
Postphlebetic syndrome with ulcer.45913
Postphlebetic syndrome with ulcer and inflammation.4592
Compression of vein.45931
Chronic venous hypertension with ulcer.45933
Chronic venous hypertension with ulcer and inflammation.46430
Acute epiglottitis without mention of obstruction.46611
Acute bronchiolitis due to respiratory syncytial virus (RSV).46619
Acute bronciolitis due to other infectious organisms.475
Peritonsillar abscess.47821
Cellulitis of pharynx or nasopharynx.47822
Parapharyngeal abscess.47824
Retropharyngeal abscess.47834
Complete bilateral paralysis of vocal cords.47871
Cellulitis and perichondritis of larynx.49121
Obstructive chronic bronchitis, with (acute) exacerbation.49122
Obstructive chronic bronchitis with acute bronchitis.49301
Extrinsic asthma with status asthmaticus.49302
Extrinsic asthma, with (acute) exacerbation.49311
Intrinsic asthma with status asthmaticus.49312
Intrinsic asthma, with (acute) exacerbation.49321
Chronic obstructive asthma with status asthmaticus.49322
Chronic obstructive asthma, with (acute) exacerbation.49391
Asthma, unspecified type, with status asthmaticus.49392
Asthma, unspecified type, with (acute) exacerbation.4941
Bronchiectasis with acute exacerbation.4957
'Ventilation' pneumonitis.4958
Other specified allergic alveolitis and pneumonitis.4959
Unspecified allergic alveolitis and pneumonitis.5060
Bronchitis and pneumonitis due to fumes and vapors.5080
Acute pulmonary manifestations due to radiation.5081
Chronic and other pulmonary manifestations due to radiation.5119
Unspecified pleural effusion.5121
Iatrogenic pneumothorax.5128
Other spontaneous pneumothorax.514
Pulmonary congestion and hypostasis.5160
Pulmonary alveolar proteinosis.5161
Idiopathic pulmonary hemosiderosis.5162
Pulmonary alveolar microlithiasis.5163
Idiopathic fibrosing alveolitis.5168
Other specified alveolar and parietoalveolar pneumonopathies.5169
Unspecified alveolar and parietoalveolar pneumonopathy.5171
Rheumatic pneumonia.5172
Lung involvement in systemic sclerosis.5173
Acute chest syndrome.5180
Pulmonary collapse.5183
Pulmonary eosinophilia.5186
Allergic bronchopulmonary aspergilliosis.5187
Transfusion related acute lung injury (TRALI).51882
Other pulmonary insufficiency, not elsewhere classified.51883
Chronic respiratory failure.51900
Tracheostomy complication, unspecified.51901
Infection of tracheostomy.51902
Mechanical complication of tracheostomy.51909
Other tracheostomy complications.5220
Pulpitis.5224
Acute apical periodontitis of pulpal origin.( print page 25040)5273
Abscess of salivary gland.5274
Fistula of salivary gland.5283
Cellulitis and abscess of oral soft tissues.53012
Acute esophagitis.53020
Ulcer of esophagus without bleeding.53086
Infection of esophagostomy.53087
Mechanical complication of esophagostomy.53130
Acute gastric ulcer without mention of hemorrhage or perforation, without mention of obstruction.53230
Acute duodenal ulcer without mention of hemorrhage or perforation, without mention of obstruction.53330
Acute peptic ulcer of unspecified site without mention of hemorrhage and perforation, without mention of obstruction.53430
Acute gastrojejunal ulcer without mention of hemorrhage or perforation, without mention of obstruction.5361
Acute dilatation of stomach.53641
Infection of gastrostomy.53642
Mechanical complication of gastrostomy.5370
Acquired hypertrophic pyloric stenosis.5373
Other obstruction of duodenum.5374
Fistula of stomach or duodenum.538
Gastrointestinal mucositis (ulcerative).5409
Acute appendicitis without mention of peritonitis.55010
Unilateral or unspecified inguinal hernia, with obstruction, without mention of gangrene.55011
Recurrent unilateral or unspecified inguinal hernia with obstruction, without mention of gangrene.55012
Bilateral inguinal hernia, with obstruction, without mention of gangrene.55013
Recurrent bilateral inguinal hernia, with obstruction, without mention of gangrene.55200
Unilateral or unspecified femoral hernia with obstruction.55201
Recurrent unilateral or unspecified femoral hernia with obstruction.55202
Bilateral femoral hernia with obstruction.55203
Recurrent bilateral femoral hernia with obstruction.5521
Umbilical hernia with obstruction.55220
Unspecified ventral hernia with obstruction.55221
Incisional hernia with obstruction.55229
Other ventral hernia with obstruction.5523
Diaphragmatic hernia with obstruction.5528
Hernia of other specified sites, with obstruction.5529
Hernia of unspecified site, with obstruction.5550
Regional enteritis of small intestine.5551
Regional enteritis of large intestine.5552
Regional enteritis of small intestine with large intestine.5559
Regional enteritis of unspecified site.5560
Ulcerative (chronic) enterocolitis.5561
Ulcerative (chronic) ileocolitis.5562
Ulcerative (chronic) proctitis.5563
Ulcerative (chronic) proctosigmoiditis.5564
Pseudopolyposis of colon.5565
Left-sided ulcerative (chronic) colitis.5566
Universal ulcerative (chronic) colitis.5568
Other ulcerative colitis.5569
Ulcerative colitis, unspecified.5571
Chronic vascular insufficiency of intestine.5579
Unspecified vascular insufficiency of intestine.5581
Gastroenteritis and colitis due to radiation.5582
Toxic gastroenteritis and colitis.5600
Intussusception.5601
Paralytic ileus.56030
Impaction of intestine, unspecified.56031
Gallstone ileus.56039
Other impaction of intestine.56081
Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection).56089
Other specified intestinal obstruction.5609
Unspecified intestinal obstruction.56201
Diverticulitis of small intestine (without mention of hemorrhage).56211
Diverticulitis of colon (without mention of hemorrhage).5647
Megacolon, other than hirschsprung's.56481
Neurogenic bowel.566
Abscess of anal and rectal regions.56782
Sclerosing mesenteritis.56882
Peritoneal effusion (chronic).5693
Hemorrhage of rectum and anus.56941
Ulcer of anus and rectum.5695
Abscess of intestine.56961
Infection of colostomy or enterostomy.56962
Mechanical complication of colostomy and enterostomy.( print page 25041)56969
Other colostomy and enterostomy complication.56981
Fistula of intestine, excluding rectum and anus.56982
Ulceration of intestine.5723
Portal hypertension.5731
Hepatitis in viral diseases classified elsewhere.5732
Hepatitis in other infectious diseases classified elsewhere.57400
Calculus of gallbladder with acute cholecystitis, without mention of obstruction.57401
Calculus of gallbladder with acute cholecystitis, with obstruction.57410
Calculus of gallbladder with other cholecystitis, without mention of obstruction.57411
Calculus of gallbladder with other cholecystitis, with obstruction.57421
Calculus of gallbladder without mention of cholecystitis, with obstruction.57430
Calculus of bile duct with acute cholecystitis without mention of obstruction.57431
Calculus of bile duct with acute cholecystitis, with obstruction.57440
Calculus of bile duct with other cholecystitis, without mention of obstruction.57441
Calculus of bile duct with other cholecystitis, with obstruction.57451
Calculus of bile duct without mention of cholecystitis, with obstruction.57460
Calculus of gallbladder and bile duct with acute cholecystitis, without mention of obstruction.57461
Calculus of gallbladder and bile duct with acute cholecystitis, with obstruction.57470
Calculus of gallbladder and bile duct with other cholecystitis, without mention of obstruction.57471
Calculus of gallbladder and bile duct with other cholecystitis, with obstruction.57480
Calculus of gallbladder and bile duct with acute and chronic cholecystitis, without mention of obstruction.57491
Calculus of gallbladder and bile duct without cholecystitis, with obstruction.5750
Acute cholecystitis.57512
Acute and chronic cholecystitis.5752
Obstruction of gallbladder.5753
Hydrops of gallbladder.5755
Fistula of gallbladder.5761
Cholangitis.5764
Fistula of bile duct.5771
Chronic pancreatitis.5772
Cyst and pseudocyst of pancreas.5780
Hematemesis.5781
Blood in stool.5789
Hemorrhage of gastrointestinal tract, unspecified.5791
Tropical sprue.5792
Blind loop syndrome.5793
Other and unspecified postsurgical nonabsorption.5794
Pancreatic steatorrhea.5798
Other specified intestinal malabsorption.5799
Unspecified intestinal malabsorption.5810
Nephrotic syndrome with lesion of proliferative glomerulonephritis.5811
Nephrotic syndrome with lesion of membranous glomerulonephritis.5812
Nephrotic syndrome with lesion of membranoproliferative glomerulonephritis.5813
Nephrotic syndrome with lesion of minimal change glomerulonephritis.58181
Nephrotic syndrome in diseases classified elsewhere.58189
Other nephrotic syndrome with specified pathological lesion in kidney.5819
Nephrotic syndrome with unspecified pathological lesion in kidney.5820
Chronic glomerulonephritis with lesion of proliferative glomerulonephritis.5821
Chronic glomerulonephritis with lesion of membranous glomerulonephritis.5822
Chronic glomerulonephritis with lesion of membranoproliferative glomerulonephritis.5824
Chronic glomerulonephritis with lesion of rapidly progressive glomerulonephritis.58281
Chronic glomerulonephritis in diseases classified elsewhere.58289
Other chronic glomerulonephritis with specified pathological lesion in kidney.5829
Chronic glomerulonephritis with unspecified pathological lesion in kidney.5830
Nephritis and nephropathy, not specified as acute or chronic, with lesion of proliferative glomerulonephritis.5831
Nephritis and nephropathy, not specified as acute or chronic, with lesion of membranous glomerulonephritis.5832
Nephritis and nephropathy, not specified as acute or chronic, with lesion of membranoproliferative glomerulonephritis.5837
Nephritis and nephropathy, not specified as acute or chronic, with lesion of renal medullary necrosis.5854
Chronic kidney disease, Stage IV (severe).5855
Chronic kidney disease, Stage V.5881
Nephrogenic diabetes insipidus.58881
Secondary hyperparathyroidism (of renal origin).59001
Chronic pyelonephritis with lesion of renal medullary necrosis.59010
Acute pyelonephritis without lesion of renal medullary necrosis.5903
Pyeloureteritis cystica.59080
Pyelonephritis, unspecified.59081
Pyelitis or pyelonephritis in diseases classified elsewhere.591
Hydronephrosis.5921
Calculus of ureter.5934
Other ureteric obstruction.5935
Hydroureter.( print page 25042)59381
Vascular disorders of kidney.59382
Ureteral fistula.5950
Acute cystitis.59582
Irradiation cystitis.5961
Intestinovesical fistula.5962
Vesical fistula, not elsewhere classified.5967
Hemorrhage into bladder wall.5970
Urethral abscess.5990
Urinary tract infection, site not specified.5991
Urethral fistula.6010
Acute prostatitis.6012
Abscess of prostate.6031
Infected hydrocele.6040
Orchitis, epididymitis, and epididymo-orchitis, with abscess.6073
Priapism.60782
Vascular disorders of penis.60820
Torsion of testis, unspecified.60821
Extravaginal torsion of spermatic cord.60822
Intravaginal torsion of spermatic cord.60823
Torsion of appendix testis.60824
Torsion of appendix epididymis.6140
Acute salpingitis and oophoritis.6143
Acute parametritis and pelvic cellulitis.6147
Other chronic pelvic peritonitis, female.6150
Acute inflammatory diseases of uterus, except cervix.6163
Abscess of bartholin's gland.6164
Other abscess of vulva.61681
Mucositis (ulcerative) of cervix, vagina, and vulva.6190
Urinary-genital tract fistula, female.6191
Digestive-genital tract fistula, female.6192
Genital tract-skin fistula, female.6198
Other specified fistulas involving female genital tract.6199
Unspecified fistula involving female genital tract.6205
Torsion of ovary, ovarian pedicle, or fallopian tube.63300
Abdominal pregnancy without intrauterine pregnancy.63301
Abdominal pregnancy with intrauterine pregnancy.63310
Tubal pregnancy without intrauterine pregnancy.63311
Tubal pregnancy with intrauterine pregnancy.63320
Ovarian pregnancy without intrauterine pregnancy.63321
Ovarian pregnancy with intrauterine pregnancy.63380
Other ectopic pregnancy without intrauterine pregnancy.63381
Other ectopic pregnancy with intrauterine pregnancy.63390
Unspecified ectopic pregnancy without intrauterine pregnancy.63391
Unspecified ectopic pregnancy with intrauterine pregnancy.63400
Spontaneous abortion, unspecified, complicated by genital tract and pelvic infection.63401
Spontaneous abortion, incomplete, complicated by genital tract and pelvic infection.63402
Spontaneous abortion, complete, complicated by genital tract and pelvic infection.63420
Spontaneous abortion, unspecified, complicated by damage to pelvic organs or tissues.63421
Spontaneous abortion, incomplete, complicated by damage to pelvic organs or tissues.63422
Spontaneous abortion, complete, complicated by damage to pelvic organs or tissues.63440
Spontaneous abortion, unspecified, complicated by metabolic disorder.63441
Spontaneous abortion, incomplete, complicated by metabolic disorder.63442
Spontaneous abortion, complete, complicated by metabolic disorder.63460
Spontaneous abortion, unspecified, complicated by embolism.63470
Spontaneous abortion, unspecified, with other specified complications.63471
Spontaneous abortion, incomplete, with other specified complications.63472
Spontaneous abortion, complete, with other specified complications.63480
Spontaneous abortion, unspecified, with unspecified complication.63481
Spontaneous abortion, incomplete, with unspecified complication.63482
Spontaneous abortion, complete, with unspecified complication.63500
Legally induced abortion, unspecified, complicated by genital tract and pelvic infection.63501
Legally induced abortion, incomplete, complicated by genital tract and pelvic infection.63502
Legally induced abortion, complete, complicated by genital tract and pelvic infection.63520
Legally induced abortion, unspecified, complicated by damage to pelvic organs or tissues.63521
Legally induced abortion, incomplete, complicated by damage to pelvic organs or tissues.63522
Legally induced abortion, complete, complicated by damage to pelvic organs or tissues.63540
Legally induced abortion, unspecified, complicated by metabolic disorder.63541
Legally induced abortion, incomplete, complicated by metabolic disorder.63542
Legally induced abortion, complete, complicated by metabolic disorder.63570
Legally induced abortion, unspecified, with other specified complications.63571
Legally induced abortion, incomplete, with other specified complications.63572
Legally induced abortion, complete, with other specified complications.( print page 25043)63580
Legally induced abortion, unspecified, with unspecified complication.63581
Legally induced abortion, incomplete, with unspecified complication.63582
Legally induced abortion, complete, with unspecified complication.63600
Illegal abortion, unspecified, complicated by genital tract and pelvic infection.63601
Illegal abortion, incomplete, complicated by genital tract and pelvic infection.63602
Illegal abortion, complete, complicated by genital tract and pelvic infection.63620
Illegal abortion, unspecified, complicated by damage to pelvic organs or tissues.63621
Illegal abortion, incomplete, complicated by damage to pelvic organs or tissues.63622
Illegal abortion, complete, complicated by damage to pelvic organs or tissues.63640
Illegal abortion, unspecified, complicated by metabolic disorder.63641
Illegal abortion, incomplete, complicated by metabolic disorder.63642
Illegal abortion, complete, complicated by metabolic disorder.63670
Illegal abortion, unspecified, with other specified complications.63671
Illegal abortion, incomplete, with other specified complications.63672
Illegal abortion, complete, with other specified complications.63680
Illegal abortion, unspecified, with unspecified complication.63681
Illegal abortion, incomplete, with unspecified complication.63682
Illegal abortion, complete, with unspecified complication.63700
Unspecified type of abortion, unspecified, complicated by genital tract and pelvic infection.63701
Unspecified abortion, incomplete, complicated by genital tract and pelvic infection.63702
Unspecified abortion, complete, complicated by genital tract and pelvic infection.63720
Legally unspecified type of abortion, unspecified, complicated by damage to pelvic organs or tissues.63721
Legally unspecified abortion, incomplete, complicated by damage to pelvic organs or tissues.63722
Legally unspecified abortion, complete, complicated by damage to pelvic organs or tissues.63740
Legally unspecified type of abortion, unspecified, complicated by metabolic disorder.63741
Legally unspecified abortion, incomplete, complicated by metabolic disorder.63742
Legally unspecified abortion, complete, complicated by metabolic disorder.63770
Legally unspecified type of abortion, unspecified, with other specified complications.63771
Legally unspecified abortion, incomplete, with other specified complications.63772
Legally unspecified abortion, complete, with other specified complications.63780
Legally unspecified type of abortion, unspecified, with unspecified complication.63781
Legally unspecified abortion, incomplete, with unspecified complication.63782
Legally unspecified abortion, complete, with unspecified complication.6380
Failed attempted abortion complicated by genital tract and pelvic infection.6381
Failed attempted abortion complicated by delayed or excessive hemorrhage.6382
Failed attempted abortion complicated by damage to pelvic organs or tissues.6384
Failed attempted abortion complicated by metabolic disorder.6387
Failed attempted abortion with other specified complications.6388
Failed attempted abortion with unspecified complication.6390
Genital tract and pelvic infection following abortion or ectopic and molar pregnancies.6391
Delayed or excessive hemorrhage following abortion or ectopic and molar pregnancies.6392
Damage to pelvic organs and tissues following abortion or ectopic and molar pregnancies.6394
Metabolic disorders following abortion or ectopic and molar pregnancies.6398
Other specified complications following abortion or ectopic and molar pregnancies.6399
Unspecified complication following abortion or ectopic and molar pregnancies.64001
Threatened abortion, delivered.64003
Threatened abortion, antepartum.64093
Unspecified hemorrhage in early pregnancy, antepartum.64101
Placenta previa without hemorrhage, with delivery.64103
Placenta previa without hemorrhage, antepartum.64123
Premature separation of placenta, antepartum.64201
Benign essential hypertension with delivery.64202
Benign essential hypertension, with delivery, with mention of postpartum complication.64203
Antepartum benign essential hypertension.64213
Hypertension secondary to renal disease, antepartum.64214
Hypertension secondary to renal disease, postpartum.64231
Transient hypertension of pregnancy, with delivery.64232
Transient hypertension of pregnancy, with delivery, with mention of postpartum complication.64241
Mild or unspecified pre-eclampsia, with delivery.64243
Mild or unspecified pre-eclampsia, antepartum.64244
Mild or unspecified pre-eclampsia, postpartum.64291
Unspecified hypertension, with delivery.64292
Unspecified hypertension, with delivery, with mention of postpartum complication.64293
Unspecified antepartum hypertension.64294
Unspecified postpartum hypertension.64413
Other threatened labor, antepartum.64420
Early onset of delivery, unspecified as to episode of care.64621
Unspecified renal disease in pregnancy, with delivery.64622
Unspecified renal disease in pregnancy, with delivery, with mention of postpartum complication.64623
Unspecified antepartum renal disease.64624
Unspecified postpartum renal disease.64631
Habitual aborter, delivered, with or without mention of antepartum condition.( print page 25044)64661
Infections of genitourinary tract in pregnancy, with delivery.64662
Infections of genitourinary tract in pregnancy, with delivery, with mention of postpartum complication.64663
Antepartum infections of genitourinary tract.64664
Postpartum infections of genitourinary tract.64671
Liver disorders in pregnancy, with delivery.64673
Antepartum liver disorders.64701
Syphilis of mother, complicating pregnancy, with delivery.64702
Syphilis of mother, complicating pregnancy, with delivery, with mention of postpartum complication.64703
Antepartum syphilis.64704
Postpartum syphilis.64711
Gonorrhea of mother, with delivery.64712
Gonorrhea of mother, with delivery, with mention of postpartum complication.64713
Antepartum gonorrhea.64714
Postpartum gonorrhea.64721
Other venereal diseases of mother, with delivery.64722
Other venereal diseases of mother, with delivery, with mention of postpartum complication.64723
Other antepartum venereal diseases.64724
Other postpartum venereal diseases.64731
Tuberculosis of mother, with delivery.64732
Tuberculosis of mother, with delivery, with mention of postpartum complication.64733
Antepartum tuberculosis.64734
Postpartum tuberculosis.64741
Malaria of mother, with delivery.64742
Malaria of mother, with delivery, with mention of postpartum complication.64743
Antepartum malaria.64744
Postpartum malaria.64751
Rubella of mother, with delivery.64752
Rubella of mother, with delivery, with mention of postpartum complication.64753
Antepartum rubella.64754
Postpartum rubella.64761
Other viral diseases of mother, with delivery.64762
Other viral diseases of mother, with delivery, with mention of postpartum complication.64763
Other antepartum viral diseases.64764
Other postpartum viral diseases.64781
Other specified infectious and parasitic diseases of mother, with delivery.64782
Other specified infectious and parasitic diseases of mother, with delivery, with mention of postpartum complication.64783
Other specified infectious and parasitic diseases of mother, antepartum.64784
Other specified infectious and parasitic diseases of mother, postpartum.64791
Unspecified infection or infestation of mother, with delivery.64792
Unspecified infection or infestation of mother, with delivery, with mention of postpartum complication.64793
Unspecified infection or infestation of mother, antepartum.64794
Unspecified infection or infestation of mother, postpartum.64800
Diabetes mellitus of mother, complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care.64803
Antepartum diabetes mellitus.64804
Postpartum diabetes mellitus.64831
Drug dependence of mother, with delivery.64832
Drug dependence of mother, with delivery, with mention of postpartum complication.64833
Antepartum drug dependence.64834
Postpartum drug dependence.64851
Congenital cardiovascular disorders of mother, with delivery.64852
Congenital cardiovascular disorders of mother, with delivery, with mention of postpartum complication.64853
Congenital cardiovascular disorders of mother, antepartum.64854
Congenital cardiovascular disorders of mother, postpartum.64861
Other cardiovascular diseases of mother, with delivery.64862
Other cardiovascular diseases of mother, with delivery, with mention of postpartum complication.64863
Other cardiovascular diseases of mother, antepartum.64864
Other cardiovascular diseases of mother, postpartum.64871
Bone and joint disorders of back, pelvis, and lower limbs of mother, with delivery.64872
Bone and joint disorders of back, pelvis, and lower limbs of mother, with delivery, with mention of postpartum complication.64873
Bone and joint disorders of back, pelvis, and lower limbs of mother, antepartum.64874
Bone and joint disorders of back, pelvis, and lower limbs of mother, postpartum.64930
Coagulation defects complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not applicable.64931
Coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepartum condition.64932
Coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complication.64933
Coagulation defects complicating pregnancy, childbirth, or the puerperium, antepartum condition or complication.( print page 25045)64934
Coagulation defects complicating pregnancy, childbirth, or the puerperium, postpartum condition or complication.64941
Epilepsy complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepartum condition.64942
Epilepsy complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complication.64943
Epilepsy complicating pregnancy, childbirth, or the puerperium, antepartum condition or complication.64944
Epilepsy complicating pregnancy, childbirth, or the puerperium, postpartum condition or complication.65101
Twin pregnancy, delivered.65111
Triplet pregnancy, delivered.65113
Triplet pregnancy, antepartum condition or complication.65121
Quadruplet pregnancy, delivered.65123
Quadruplet pregnancy, antepartum condition or complication.65141
Triplet pregnancy with fetal loss and retention of one or more fetus(es), delivered, with or without mention of antepartum condition.65143
Triplet pregnancy with fetal loss and retention of one or more fetus(es), antepartum condition or complication.65151
Quadruplet pregnancy with fetal loss and retention of one or more fetus(es), delivered, with or without mention of antepartum condition.65153
Quadruplet pregnancy with fetal loss and retention of one or more fetus(es), antepartum condition or complication.65181
Other specified multiple gestation, delivered.65183
Other specified multiple gestation, antepartum condition or complication.65613
Rhesus isoimmunization, affecting management of mother, antepartum condition.65631
Fetal distress, affecting management of mother, delivered.65641
Intrauterine death, affecting management of mother, delivered.65643
Intrauterine death, affecting management of mother, antepartum.65651
Poor fetal growth, affecting management of mother, delivered.65701
Polyhydramnios, with delivery.65801
Oligohydramnios, delivered.65803
Oligohydramnios, antepartum.65881
Other problems associated with amniotic cavity and membranes, delivered.65921
Unspecified type maternal pyrexia during labor, delivered.66003
Obstruction caused by malposition of fetus at onset of labor, antepartum.66211
Unspecified type prolonged labor, delivered.66421
Third-degree perineal laceration, with delivery.66431
Fourth-degree perineal laceration, with delivery.66461
Anal sphincter tear complicating delivery, not associated with third-degree perineal laceration,delivered, with or without mention of antepartum condition.66464
Anal sphincter tear complicating delivery, not associated with third-degree perineal laceration,postpartum condition or complication.66522
Inversion of uterus, delivered with postpartum complication.66531
Laceration of cervix, with delivery.66541
High vaginal laceration, with delivery.66551
Other injury to pelvic organs, with delivery.66561
Damage to pelvic joints and ligaments, with delivery.66571
Pelvic hematoma, with delivery.66572
Pelvic hematoma, delivered with postpartum complication.66602
Third-stage postpartum hemorrhage, with delivery.66604
Third-stage postpartum hemorrhage.66612
Other immediate postpartum hemorrhage, with delivery.66614
Other immediate postpartum hemorrhage.66622
Delayed and secondary postpartum hemorrhage, with delivery.66624
Delayed and secondary postpartum hemorrhage.66632
Postpartum coagulation defects, with delivery.66924
Maternal hypotension syndrome, postpartum.67120
Superficial thrombophlebitis complicating pregnancy and the puerperium, unspecified as to episode of care.67121
Superficial thrombophlebitis with delivery, with or without mention of antepartum condition.67122
Superficial thrombophlebitis with delivery, with mention of postpartum complication.67123
Antepartum superficial thrombophlebitis.67124
Postpartum superficial thrombophlebitis.67130
Deep phlebothrombosis, antepartum, unspecified as to episode of care.67140
Deep phlebothrombosis, postpartum, unspecified as to episode of care.67150
Other phlebitis and thrombosis complicating pregnancy and the puerperium, unspecified as to episode of care.67151
Other phlebitis and thrombosis with delivery, with or without mention of antepartum condition.67152
Other phlebitis and thrombosis with delivery, with mention of postpartum complication.67153
Other antepartum phlebitis and thrombosis.67154
Other postpartum phlebitis and thrombosis.67180
Other venous complications of pregnancy and the puerperium, unspecified as to episode of care.67181
Other venous complications, with delivery, with or without mention of antepartum condition.67182
Other venous complications, with delivery, with mention of postpartum complication.67183
Other antepartum venous complications.67184
Other postpartum venous complications.( print page 25046)67190
Unspecified venous complication of pregnancy and the puerperium, unspecified as to episode of care.67191
Unspecified venous complication, with delivery, with or without mention of antepartum condition.67192
Unspecified venous complication, with delivery, with mention of postpartum complication.67202
Puerperal pyrexia of unknown origin, delivered, with mention of postpartum complication.67204
Puerperal pyrexia of unknown origin, postpartum.67330
Obstetrical pyemic and septic embolism, unspecified as to episode of care.67402
Cerebrovascular disorders, with delivery, with mention of postpartum complication.67403
Antepartum cerebrovascular disorders.67404
Postpartum cerebrovascular disorders.67511
Abscess of breast associated with childbirth, delivered, with or without mention of antepartum condition.67512
Abscess of breast associated with childbirth, delivered, with mention of postpartum complication.6820
Cellulitis and abscess of face.6821
Cellulitis and abscess of neck.6822
Cellulitis and abscess of trunk.6823
Cellulitis and abscess of upper arm and forearm.6824
Cellulitis and abscess of hand, except fingers and thumb.6825
Cellulitis and abscess of buttock.6826
Cellulitis and abscess of leg, except foot.6827
Cellulitis and abscess of foot, except toes.6828
Cellulitis and abscess of other specified sites.6829
Cellulitis and abscess of unspecified sites.6850
Pilonidal cyst with abscess.68601
Pyoderma gangrenosum.6944
Pemphigus.6945
Pemphigoid.6950
Toxic erythema.6951
Erythema multiforme.70700
Decubitus ulcer, unspecified site.70701
Decubitus ulcer, elbow.70709
Decubitus ulcer, other site.70710
Unspecified ulcer of lower limb.70711
Ulcer of thigh.70712
Ulcer of calf.70713
Ulcer of ankle.70714
Ulcer of heel and midfoot.70719
Ulcer of other part of lower limb.7103
Dermatomyositis.7104
Polymyositis.7105
Eosinophilia myalgia syndrome.7108
Other specified diffuse diseases of connective tissue.71100
Pyogenic arthritis, site unspecified.71101
Pyogenic arthritis involving shoulder region.71102
Pyogenic arthritis involving upper arm.71103
Pyogenic arthritis involving forearm.71104
Pyogenic arthritis involving hand.71105
Pyogenic arthritis involving pelvic region and thigh.71106
Pyogenic arthritis involving lower leg.71107
Pyogenic arthritis involving ankle and foot.71108
Pyogenic arthritis involving other specified sites.71109
Pyogenic arthritis involving multiple sites.71110
Arthropathy, site unspecified, associated with reiter's disease and nonspecific urethritis.71111
Arthropathy involving shoulder region associated with reiter's disease and nonspecific urethritis.71112
Arthropathy involving upper arm associated with reiter's disease and nonspecific urethritis.71113
Arthropathy involving forearm associated with reiter's disease and nonspecific urethritis.71114
Arthropathy involving hand associated with reiter's disease and nonspecific urethritis.71115
Arthropathy involving pelvic region and thigh associated with reiter's disease and nonspecific urethritis.71116
Arthropathy involving lower leg associated with reiter's disease and nonspecific urethritis.71117
Arthropathy involving ankle and foot associated with reiter's disease and nonspecific urethritis.71118
Arthropathy involving other specified sites associated with reiter's disease and nonspecific urethritis.71119
Arthropathy involving multiple sites associated with reiter's disease and nonspecific urethritis.71120
Arthropathy in behcet's syndrome, site unspecified.71121
Arthropathy in behcet's syndrome involving shoulder region.71122
Arthropathy in behcet's syndrome involving upper arm.71123
Arthropathy in behcet's syndrome involving forearm.71124
Arthropathy in behcet's syndrome involving hand.71125
Arthropathy in behcet's syndrome involving pelvic region and thigh.71126
Arthropathy in behcet's syndrome involving lower leg.71127
Arthropathy in behcet's syndrome involving ankle and foot.71128
Arthropathy in behcet's syndrome involving other specified sites.71129
Arthropathy in behcet's syndrome involving multiple sites.71130
Postdysenteric arthropathy, site unspecified.71131
Postdysenteric arthropathy involving shoulder region.( print page 25047)71132
Postdysenteric arthropathy involving upper arm.71133
Postdysenteric arthropathy involving forearm.71134
Postdysenteric arthropathy involving hand.71135
Postdysenteric arthropathy involving pelvic region and thigh.71136
Postdysenteric arthropathy involving lower leg.71137
Postdysenteric arthropathy involving ankle and foot.71138
Postdysenteric arthropathy involving other specified sites.71139
Postdysenteric arthropathy involving multiple sites.71140
Arthropathy, site unspecified, associated with other bacterial diseases.71141
Arthropathy involving shoulder region associated with other bacterial diseases.71142
Arthropathy involving upper arm associated with other bacterial diseases.71143
Arthropathy involving forearm associated with other bacterial diseases.71144
Arthropathy involving hand associated with other bacterial diseases.71145
Arthropathy involving pelvic region and thigh associated with other bacterial diseases.71146
Arthropathy involving lower leg associated with other bacterial diseases.71147
Arthropathy involving ankle and foot associated with other bacterial disease.71148
Arthropathy involving other specified sites associated with other bacterial diseases.71149
Arthropathy involving multiple sites associated with other bacterial diseases.71150
Arthropathy, site unspecified, associated with other viral diseases.71151
Arthropathy involving shoulder region associated with other viral diseases.71152
Arthropathy involving upper arm associated with other viral diseases.71153
Arthropathy involving forearm associated with other viral diseases.71154
Arthropathy involving hand associated with other viral diseases.71155
Arthropathy involving pelvic region and thigh associated with other viral diseases.71156
Arthropathy involving lower leg associated with other viral diseases.71157
Arthropathy involving ankle and foot associated with other viral diseases.71158
Arthropathy involving other specified sites associated with other viral diseases.71159
Arthropathy involving multiple sites associated with other viral diseases.71160
Arthropathy, site unspecified, associated with mycoses.71161
Arthropathy involving shoulder region associated with mycoses.71162
Arthropathy involving upper arm associated with mycoses.71163
Arthropathy involving forearm associated with mycoses.71164
Arthropathy involving hand associated with mycoses.71165
Arthropathy involving pelvic region and thigh associated with mycoses.71166
Arthropathy involving lower leg associated with mycoses.71167
Arthropathy involving ankle and foot associated with mycoses.71168
Arthropathy involving other specified sites associated with mycoses.71169
Arthropathy involving multiple sites associated with mycoses.71170
Arthropathy, site unspecified, associated with helminthiasis.71171
Arthropathy involving shoulder region associated with helminthiasis.71172
Arthropathy involving upper arm associated with helminthiasis.71173
Arthropathy involving forearm associated with helminthiasis.71174
Arthropathy involving hand associated with helminthiasis.71175
Arthropathy involving pelvic region and thigh associated with helminthiasis.71176
Arthropathy involving lower leg associated with helminthiasis.71177
Arthropathy involving ankle and foot associated with helminthiasis.71178
Arthropathy involving other specified sites associated with helminthiasis.71179
Arthropathy involving multiple sites associated with helminthiasis.71180
Arthropathy, site unspecified, associated with other infectious and parasitic diseases.71181
Arthropathy involving shoulder region associated with other infectious and parasitic diseases.71182
Arthropathy involving upper arm associated with other infectious and parasitic diseases.71183
Arthropathy involving forearm associated with other infectious and parasitic diseases.71184
Arthropathy involving hand associated with other infectious and parasitic diseases.71185
Arthropathy involving pelvic region and thigh associated with other infectious and parasitic diseases.71186
Arthropathy involving lower leg associated with other infectious and parasitic diseases.71187
Arthropathy involving ankle and foot associated with other infectious and parasitic diseases.71188
Arthropathy involving other specified sites associated with other infectious and parasitic diseases.71189
Arthropathy involving multiple sites associated with other infectious and parasitic diseases.71190
Unspecified infective arthritis, site unspecified.71191
Unspecified infective arthritis involving shoulder region.71192
Unspecified infective arthritis involving upper arm.71193
Unspecified infective arthritis involving forearm.71194
Unspecified infective arthritis involving hand.71195
Unspecified infective arthritis involving pelvic region and thigh.71196
Unspecified infective arthritis involving lower leg.71197
Unspecified infective arthritis involving ankle and foot.71198
Unspecified infective arthritis involving other specified sites.71199
Unspecified infective arthritis involving multiple sites.71431
Acute polyarticular juvenile rheumatoid arthritis.71910
Hemarthrosis, site unspecified.71911
Herarthrosis involving shoulder region.71912
Hemarthorsis involving upper arm.( print page 25048)71913
Hemarthrosis involving forearm.71914
Hemarthrosis involving hand.71915
Hemarthrosis involving pelvic region and thigh.71916
Hemarthrosis involving lower leg.71917
Hemarthrosis involving ankle and foot.71918
Hemarthrosis involving other specified sites.71919
Hemarthrosis involving multiple sites.7211
Cervical spondylosis with myelopathy.72141
Spondylosis with myelopathy, thoracic region.72142
Spondylosis with myelopathy, lumbar region.7217
Traumatic spondylopathy.72191
Spondylosis of unspecified site with myelopathy.72271
Intervertebral disc disorder with myelopathy, cervical region.72272
Intervertebral disc disorder with myelopathy, thoracic region.72273
Intervertebral disc disorder with myelopathy, lumbar region.7280
Infective myositis.72888
Rhabdomyolysis.72971
Nontraumatic compartment syndrome of upper extremity.72972
Nontraumatic compartment syndrome of lower extremity.72973
Nontraumatic compartment syndrome of abdomen.72979
Nontraumatic compartment syndrome of other sites.73000
Acute osteomyelitis, site unspecified.73001
Acute osteomyelitis involving shoulder region.73002
Acute osteomyelitis involving upper arm.73003
Acute osteomyelitis involving forearm.73004
Acute osteomyelitis involving hand.73005
Acute osteomyelitis involving pelvic region and thigh.73006
Acute osteomyelitis involving lower leg.73007
Acute osteomyelitis involving ankle and foot.73008
Acute osteomyelitis involving other specified sites.73009
Acute osteomyelitis involving multiple sites.73010
Chronic osteomyelitis, site unspecified.73011
Chronic osteomyelitis involving shoulder region.73012
Chronic osteomyelitis involving upper arm.73013
Chronic osteomyelitis involving forearm.73014
Chronic osteomyelitis involving hand.73015
Chronic osteomyelitis involving pelvic region and thigh.73016
Chronic osteomyelitis involving lower leg.73017
Chronic osteomyelitis involving ankle and foot.73018
Chronic osteomyelitis involving other specified sites.73019
Chronic osteomyelitis involving multiple sites.73020
Unspecified osteomyelitis, site unspecified.73021
Unspecified osteomyelitis involving shoulder region.73022
Unspecified osteomyelitis involving upper arm.73023
Unspecified osteomyelitis involving forearm.73024
Unspecified osteomyelitis involving hand.73025
Unspecified osteomyelitis involving pelvic region and thigh.73026
Unspecified osteomyelitis involving lower leg.73027
Unspecified osteomyelitis involving ankle and foot.73028
Unspecified osteomyelitis involving other specified sites.73029
Unspecified osteomyelitis involving multiple sites.73080
Other infections involving bone in diseases classified elsewhere, site unspecified.73081
Other infections involving bone of shoulder region in diseases classified elsewhere.73082
Other infections involving upper arm bone in diseases classified elsewhere.73083
Other infections involving forearm bone in diseases classified elsewhere.73084
Other infections involving hand bone in diseases classified elsewhere.73085
Other infections involving bone of pelvic region and thigh in diseases classified elsewhere.73086
Other infections involving lower leg bone in diseases classified elsewhere.73087
Other infections involving ankle and foot bone in diseases classified elsewhere.73088
Other infections involving bone, of other specified sites, in diseases classified elsewhere.73089
Other infections involving bone, of multiple sites, in diseases classified elsewhere.73090
Unspecified infection of bone, site unspecified.73091
Unspecified infection of bone of shoulder region.73092
Unspecified infection of upper arm bone.73093
Unspecified infection of forearm bone.73094
Unspecified infection of hand bone.73095
Unspecified infection of bone of pelvic region and thigh.73096
Unspecified infection of lower leg bone.73097
Unspecified infection of ankle and foot bone.73098
Unspecified infection of bone of other specified sites.73099
Unspecified infection of bone in multiple sites.73310
Pathologic fracture, unspecified site.( print page 25049)73311
Pathologic fracture of humerus.73312
Pathologic fracture of distal radius and ulna.73313
Pathologic fracture of vertebrae.73314
Pathologic fracture of neck of femur.73315
Pathologic fracture of other specified part of femur.73316
Pathologic fracture of tibia or fibula.73319
Pathologic fracture of other specified site.73340
Aseptic necrosis of bone, site unspecified.73341
Aseptic necrosis of head of humerus.73342
Aseptic necrosis of head and neck of femur.73343
Aseptic necrosis of medial femoral condyle.73344
Aseptic necrosis of talus.73345
Aseptic necrosis of bone, jaw.73349
Aseptic necrosis of other bone sites.73381
Malunion of fracture.73382
Nonunion of fracture.74100
Spina bifida, unspecified region, with hydrocephalus.74101
Spina bifida, cervical region, with hydrocephalus.74102
Spina bifida, dorsal (thoracic) region, with hydrocephalus.74103
Spina bifida, lumbar region, with hydrocephalus.7420
Encephalocele.7424
Other specified congenital anomalies of brain.74512
Corrected transposition of great vessels.7454
Ventricular septal defect.7455
Ostium secundum type atrial septal defect.74560
Endocardial cushion defect, unspecified type.74561
Ostium primum defect.74569
Other endocardial cushion defects.74600
Congenital pulmonary valve anomaly, unspecified.74602
Stenosis of pulmonary valve, congenital.74609
Other congenital anomalies of pulmonary valve.7463
Congenital stenosis of aortic valve.7464
Congenital insufficiency of aortic valve.7465
Congenital mitral stenosis.7466
Congenital mitral insufficiency.74683
Infundibular pulmonic stenosis, congenital.74685
Coronary artery anomaly, congenital.74687
Malposition of heart and cardiac apex.7470
Patent ductus arteriosus.74710
Coarctation of aorta (preductal) (postductal).74720
Congenital anomaly of aorta, unspecified.74721
Congenital anomalies of aortic arch.74722
Congenital atresia and stenosis of aorta.74729
Other congenital anomalies of aorta.74740
Congenital anomaly of great veins, unspecified.74741
Total anomalous pulmonary venous connection.74742
Partial anomalous pulmonary venous connection.74749
Other anomalies of great veins.74782
Spinal vessel anolmaly.74789
Other specified congenital anomalies of circulatory system.7479
Unspecified congenital anomaly of circulatory system.7483
Other congenital anomalies of larynx, trachea, and bronchus.7484
Congenital cystic lung.74861
Congenital bronchiectasis.7504
Other specified congenital anomalies of esophagus.7511
Congenital atresia and stenosis of small intestine.7512
Congenital atresia and stenosis of large intestine, rectum, and anal canal.7513
Hirschsprung's disease and other congenital functional disorders of colon.7514
Congenital anomalies of intestinal fixation.7515
Other congenital anomalies of intestine.75160
Unspecified congenital anomaly of gallbladder, bile ducts, and liver.75162
Congenital cystic disease of liver.75169
Other congenital anomalies of gallbladder, bile ducts, and liver.7517
Congenital anomalies of pancreas.7530
Renal agenesis and dysgenesis.75310
Cystic kidney disease, unspecified.75311
Congenital single renal cyst.75312
Polycystic kidney, unspecified type.75313
Polycystic kidney, autosomal dominant.75314
Polycystic kidney, autosomal recessive.75315
Renal dysplasia.75316
Medullary cystic kidney.( print page 25050)75317
Medullary sponge kidney.75319
Other specified cystic kidney disease.75320
Unspecified obstructive defect of renal pelvis and ureter.75321
Congenital obstruction of ureteropelvic junction.75322
Congenital obstruction of ureterovesical junction.75323
Congenital ureterocele.75329
Other obstructive defect of renal pelvis and ureter.7535
Exstrophy of urinary bladder.7536
Congenital atresia and stenosis of urethra and bladder neck.7542
Congenital musculoskeletal deformities of spine.75489
Other specified nonteratogenic anomalies.75613
Absence of vertebra, congenital.7563
Other congenital anomalies of ribs and sternum.75651
Osteogenesis imperfecta.75652
Osteopetrosis.75683
Ehlers-danlos syndrome.7581
Patau's syndrome.7582
Edwards' syndrome.75831
Cri-du-chat syndrome.75833
Other microdeletions.75839
Other autosomal deletions.7590
Anomalies of spleen, congenital.7593
Situs inversus.7595
Tuberous sclerosis.7596
Other congenital hamartoses, not elsewhere classified.7597
Multiple congenital anomalies, so described.75981
Prader-willi syndrome.75982
Marfan syndrome.75989
Other specified congenital anomalies.76711
Epicranial subaponeurotic hemorrhage (massive).7704
Primary atelectasis of newborn.7705
Other and unspecified atelectasis of newborn.77081
Primary apnea of newborn.77082
Other apnea of newborn.77083
Cyanotic attacks of newborn.7710
Congenital rubella.7714
Omphalitis of the newborn.7715
Neonatal infective mastitis.77182
Urinary tract infection of newborn.77183
Bacteremia of newborn.77189
Other infections specific to the perinatal period.77210
Intraventricular hemorrhage unspecified grade.77211
Intraventricular hemorrhage grade i.77212
Intraventricular hemorrhage grade ii.7725
Adrenal hemorrhage of fetus or newborn.7751
Neonatal diabetes mellitus.7752
Neonatal myasthenia gravis.7753
Neonatal thyrotoxicosis.7754
Hypocalcemia and hypomagnesemia of newborn.77581
Other acidosis of newborn.77589
Other neonatal endocrine and metabolic disturbances.7760
Hemorrhagic disease of newborn.7763
Other transient neonatal disorders of coagulation.7765
Congenital anemia.7766
Anemia of prematurity.7774
Transitory ileus of newborn.7781
Sclerema neonatorum.7785
Other and unspecified edema of newborn.7794
Drug reactions and intoxications specific to newborn.7795
Drug withdrawal syndrome in newborn.78001
Coma.78003
Persistent vegetative state.7801
Hallucinations.78031
Febrile convulsions (simple), unspecified.78032
Complex febrile convulsions.7814
Transient paralysis of limb.7816
Meningismus.7817
Tetany.7818
Neurological neglect syndrome.7824
Jaundice, unspecified, not of newborn.7843
Aphasia.7854
Gangrene.( print page 25051)78550
Shock, unspecified.78604
Cheyne-stokes respiration.7863
Hemoptysis.7888
Extravasation of urine.78951
Malignant ascites.78959
Other ascites.79001
Precipitous drop in hematocrit.7907
Bacteremia.7911
Chyluria.7913
Myoglobinuria.79901
Asphyxia.7994
Cachexia.80000
Closed fracture of vault of skull without mention of intracranial injury, with state of consciousness unspecified.80001
Closed fracture of vault of skull without mention of intracranial injury, with no loss of consciousness.80002
Closed fracture of vault of skull without mention of intracranial injury, with brief (less than one hour) loss of consciousness.80006
Closed fracture of vault of skull without mention of intra cranial injury, with loss of consciousness of unspecified duration.80009
Closed fracture of vault of skull without mention of intracranial injury, with concussion, unspecified.80040
Closed fracture of vault of skull with intracranial injury of other and unspecified nature, with state of consciousness unspecified.80041
Closed fracture of vault of skull with intracranial injury of other and unspecified nature, with no loss of consciousness.80042
Closed fracture of vault of skull with intracranial injury of other and unspecified nature, with brief (less than one hour) loss of consciousness.80046
Closed fracture of vault of skull with intracranial injury of other and unspecified nature, with loss of consciousness of unspecified duration.80049
Closed fracture of vault of skull with intracranial injury of other and unspecified nature, with concussion, unspecified.80100
Closed fracture of base of skull without mention of intra cranial injury, with state of consciousness unspecified.80101
Closed fracture of base of skull without mention of intra cranial injury, with no loss of consciousness.80102
Closed fracture of base of skull without mention of intra cranial injury, with brief (less than one hour) loss of consciousness.80106
Closed fracture of base of skull without mention of intra cranial injury, with loss of consciousness of unspecified duration.80109
Closed fracture of base of skull without mention of intra cranial injury, with concussion, unspecified.80140
Closed fracture of base of skull with intracranial injury of other and unspecified nature, with state of consciousness unspecified.80141
Closed fracture of base of skull with intracranial injury of other and unspecified nature, with no loss of consciousness.80142
Closed fracture of base of skull with intracranial injury of other and unspecified nature, with brief (less than one hour) loss of consciousness.80146
Closed fracture of base of skull with intracranial injury of other and unspecified nature, with loss of consciousness of unspecified duration.80149
Closed fracture of base of skull with intracranial injury of other and unspecified nature, with concussion, unspecified.8021
Open fracture of nasal bones.80220
Closed fracture of unspecified site of mandible.80221
Closed fracture of condylar process of mandible.80222
Closed fracture of subcondylar process of mandible.80223
Closed fracture of coronoid process of mandible.80224
Closed fracture of unspecified part of ramus of mandible.80225
Closed fracture of angle of jaw.80226
Closed fracture of symphysis of body of mandible.80227
Closed fracture of alveolar border of body of mandible.80228
Closed fracture of other and unspecified part of body of mandible.80229
Closed fracture of multiple sites of mandible.80230
Open fracture of unspecified site of mandible.80231
Open fracture of condylar process of mandible.80232
Open fracture of subcondylar process of mandible.80233
Open fracture of coronoid process of mandible.80234
Open fracture of unspecified part of ramus of mandible.80235
Open fracture of angle of jaw.80236
Open fracture of symphysis of body of mandible.80237
Open fracture of alveolar border of body of mandible.80238
Open fracture of body of mandible, other and unspecified.80239
Open fracture of multiple sites of mandible.8024
Closed fracture of malar and maxillary bones.8025
Open fracture of malar and maxillary bones.8026
Closed fracture of orbital floor (blow-out).8027
Open fracture of orbital floor (blow-out).8028
Closed fracture of other facial bones.( print page 25052)8029
Open fracture of other facial bones.80300
Other closed skull fracture without mention of intracranial injury, with state of consciousness unspecified.80301
Other closed skull fracture without mention of intracranial injury, with no loss of consciousness.80302
Other closed skull fracture without mention of intracranial injury, with brief (less than one hour) loss of consciousness.80306
Other closed skull fracture without mention of intracranial injury, with loss of consciousness of unspecified duration.80309
Other closed skull fracture without mention of intracranial injury, with concussion, unspecified.80340
Other closed skull fracture with intracranial injury of other and unspecified nature, with state of consciousness unspecified.80341
Other closed skull fracture with intracranial injury of other and unspecified nature, with no loss of consciousness.80342
Other closed skull fracture with intracranial injury of other and unspecified nature, with brief (less than one hour) loss of consciousness.80346
Other site of closed skull fracture with intracranial injury of other and unspecified nature, with loss of consciousness of unspecified duration.80349
Other site of closed skull fracture with intracranial injury of other and unspecified nature, with concussion, unspecified.80400
Closed fractures involving skull or face with other bones, without mention of intracranial injury, with state of consciousness unspecified.80401
Closed fractures involving skull or face with other bones, without mention of intracranial injury, with no loss of consciousness.80402
Closed fractures involving skull or face with other bones, without mention of intracranial injury, with brief (less than one hour) loss of consciousness.80406
Closed fractures involving skull of face with other bones, without mention of intracranial injury, with loss of consciousness of unspecified duration.80409
Closed fractures involving skull of face with other bones, without mention of intracranial injury, with concussion, unspecified.80440
Closed fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with state of consciousness unspecified.80441
Closed fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with no loss of consciousness.80442
Closed fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with brief (less than one hour) loss of consciousness.80446
Closed fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with loss of consciousness of unspecified duration.80449
Closed fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with concussion, unspecified.80450
Open fractures involving skull or face with other bones, without mention of intracranial injury, with state of consciousness unspecified.80451
Open fractures involving skull or face with other bones, without mention of intracranial injury, with no loss of consciousness.80452
Open fractures involving skull or face with other bones, without mention of intracranial injury, with brief (less than one hour) loss of consciousness.80456
Open fractures involving skull or face with other bones, without mention of intracranial injury, with loss of consciousness of unspecified duration.80459
Open fractures involving skull or face with other bones, without mention of intracranial injury, with concussion, unspecified.80490
Open fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with state of consciousness unspecified.80491
Open fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with no loss of consciousness.80492
Open fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with brief (less than one hour) loss of consciousness.80496
Open fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with loss of consciousness of unspecified duration.80499
Open fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with concussion, unspecified.80500
Closed fracture of cervical vertebra, unspecified level.80501
Closed fracture of first cervical vertebra.80502
Closed fracture of second cervical vertebra.80503
Closed fracture of third cervical vertebra.80504
Closed fracture of fourth cervical vertebra.80505
Closed fracture of fifth cervical vertebra.80506
Closed fracture of sixth cervical vertebra.80507
Closed fracture of seventh cervical vertebra.80508
Closed fracture of multiple cervical vertebrae.8052
Closed fracture of dorsal (thoracic) vertebra without mention of spinal cord injury.8054
Closed fracture of lumbar vertebra without mention of spinal cord injury.8056
Closed fracture of sacrum and coccyx without mention of spinal cord injury.8058
Closed fracture of unspecified part of vertebral column without mention of spinal cord injury.80700
Closed fracture of rib(s), unspecified.( print page 25053)80701
Closed fracture of one rib.80702
Closed fracture of two ribs.80703
Closed fracture of three ribs.80704
Closed fracture of four ribs.80705
Closed fracture of five ribs.80706
Closed fracture of six ribs.80707
Closed fracture of seven ribs.80708
Closed fracture of eight or more ribs.80709
Closed fracture of multiple ribs, unspecified.8072
Closed fracture of sternum.8082
Closed fracture of pubis.80841
Closed fracture of ilium.80842
Closed fracture of ischium.80843
Multiple closed pelvic fractures with disruption of pelvic circle.80849
Closed fracture of other specified part of pelvis.8088
Unspecified closed fracture of pelvis.8090
Fracture of bones of trunk, closed.81010
Open fracture of clavicle, unspecified part.81011
Open fracture of sternal end of clavicle.81012
Open fracture of shaft of clavicle.81013
Open fracture of acromial end of clavicle.81110
Open fracture of scapula, unspecified part.81111
Open fracture of acromial process of scapula.81112
Open fracture of coracoid process.81113
Open fracture of glenoid cavity and neck of scapula.81119
Open fracture of other part of scapula.81200
Fracture of unspecified part of upper end of humerus, closed.81201
Fracture of surgical neck of humerus, closed.81202
Fracture of anatomical neck of humerus, closed.81203
Fracture of greater tuberosity of humerus, closed.81209
Other closed fractures of upper end of humerus.81220
Fracture of unspecified part of humerus, closed.81221
Fracture of shaft of humerus, closed.81240
Fracture of unspecified part of lower end of humerus, closed.81241
Supracondylar fracture of humerus, closed.81242
Fracture of lateral condyle of humerus, closed.81243
Fracture of medial condyle of humerus, closed.81244
Fracture of unspecified condyle(s) of humerus, closed.81249
Other closed fractures of lower end of humerus.81320
Fracture of shaft of radius or ulna, unspecified, closed.81321
Fracture of shaft of radius (alone), closed.81322
Fracture of shaft of ulna (alone), closed.81323
Fracture of shaft of radius with ulna, closed.81340
Closed fracture of lower end of forearm, unspecified.81341
Colles' fracture, closed.81342
Other closed fractures of distal end of radius (alone).81343
Fracture of distal end of ulna (alone), closed.81344
Fracture of lower end of radius with ulna, closed.81345
Torus fracture of radius.81380
Closed fracture of unspecified part of forearm.81382
Fracture of unspecified part of ulna (alone), closed.81383
Fracture of unspecified part of radius with ulna, closed.81410
Open fracture of carpal bone, unspecified.81411
Open fracture of navicular (scaphoid) bone of wrist.81412
Open fracture of lunate (semilunar) bone of wrist.81413
Open fracture of triquetral (cuneiform) bone of wrist.81414
Open fracture of pisiform bone of wrist.81415
Open fracture of trapezium bone (larger multangular) of wrist.81416
Open fracture of trapezoid bone (smaller multangular) of wrist.81417
Open fracture of capitate bone (os magnum) of wrist.81418
Open fracture of hamate (unciform) bone of wrist.81419
Open fracture of other bone of wrist.81510
Open fracture of metacarpal bone(s), site unspecified.81511
Open fracture of base of thumb (first) metacarpal.81512
Open fracture of base of other metacarpal bone(s).81513
Open fracture of shaft of metacarpal bone(s).81514
Open fracture of neck of metacarpal bone(s).81519
Open fracture of multiple sites of metacarpus.81610
Open fracture of phalanx or phalanges of hand, unspecified.81611
Open fracture of middle or proximal phalanx or phalanges of hand.81612
Open fracture of distal phalanx or phalanges of hand.81613
Open fracture of multiple sites of phalanx or phalanges of hand.( print page 25054)8171
Multiple open fractures of hand bones.8181
Ill-defined open fractures of upper limb.8190
Multiple closed fractures involving both upper limbs, and upper limb with rib(s) and sternum.8191
Multiple open fractures involving both upper limbs, and upper limb with rib(s) and sternum.82120
Fracture of lower end of femur, unspecified part, closed.82121
Fracture of femoral condyle, closed.82122
Fracture of lower epiphysis of femur, closed.82123
Supracondylar fracture of femur, closed.82129
Other fracture of lower end of femur, closed.8220
Closed fracture of patella.8221
Open fracture of patella.82300
Closed fracture of upper end of tibia.82302
Closed fracture of upper end of fibula with tibia.82320
Closed fracture of shaft of tibia.82322
Closed fracture of shaft of fibula with tibia.82340
Torus fracture, tibia alone.82342
Torus fracture, fibula with tibia.82380
Closed fracture of unspecified part of tibia.82382
Closed fracture of unspecified part of fibula with tibia.8241
Fracture of medial malleolus, open.8243
Fracture of lateral malleolus, open.8245
Bimalleolar fracture, open.8247
Trimalleolar fracture, open.8249
Unspecified fracture of ankle, open.8251
Fracture of calcaneus, open.82530
Fracture of unspecified bone(s) of foot (except toes), open.82531
Fracture of astragalus, open.82532
Fracture of navicular (scaphoid) bone of foot, open.82533
Fracture of cuboid bone, open.82534
Fracture of cuneiform bone of foot, open.82535
Fracture of metatarsal bone(s), open.82539
Other fractures of tarsal and metatarsal bones, open.8271
Other, multiple and ill-defined fractures of lower limb, open.8301
Open dislocation of jaw.83110
Open dislocation of shoulder, unspecified.83111
Open anterior dislocation of humerus.83112
Open posterior dislocation of humerus.83113
Open inferior dislocation of humerus.83114
Open dislocation of acromioclavicular (joint).83119
Open dislocation of other site of shoulder.83210
Open dislocation of elbow, unspecified site.83211
Open anterior dislocation of elbow.83212
Open posterior dislocation of elbow.83213
Open medial dislocation of elbow.83214
Open lateral dislocation of elbow.83219
Open dislocation of other site of elbow.83310
Open dislocation of wrist, unspecified part.83311
Open dislocation of radioulnar (joint), distal.83312
Open dislocation of radiocarpal (joint).83313
Open dislocation of midcarpal (joint).83314
Open dislocation of carpometacarpal (joint).83315
Open dislocation of metacarpal (bone), proximal end.83319
Open dislocation of other part of wrist.83500
Closed dislocation of hip, unspecified site.83501
Closed posterior dislocation of hip.83502
Closed obturator dislocation of hip.83503
Other closed anterior dislocation of hip.8364
Dislocation of patella, open.83660
Dislocation of knee, unspecified part, open.83661
Anterior dislocation of tibia, proximal end, open.83662
Posterior dislocation of tibia, proximal end, open.83663
Medial dislocation of tibia, proximal end, open.83664
Lateral dislocation of tibia, proximal end, open.83669
Other dislocation of knee, open.8371
Open dislocation of ankle.83900
Closed dislocation, cervical vertebra, unspecified.83901
Closed dislocation, first cervical vertebra.83902
Closed dislocation, second cervical vertebra.83903
Closed dislocation, third cervical vertebra.83904
Closed dislocation, fourth cervical vertebra.83905
Closed dislocation, fifth cervical vertebra.83906
Closed dislocation, sixth cervical vertebra.( print page 25055)83907
Closed dislocation, seventh cervical vertebra.83908
Closed dislocation, multiple cervical vertebrae.83951
Open dislocation, coccyx.83952
Open dislocation, sacrum.83961
Closed dislocation, sternum.83979
Open dislocation, other location.8399
Open dislocation, multiple and ill-defined sites.85011
Concussion, with loss of consciousness of 30 minutes or less.85012
Concussion, with loss of consciousness from 31 to 59 minutes.8502
Concussion with moderate loss of consciousness.8503
Concussion with prolonged loss of consciousness and return to pre-existing conscious level.8505
Concussion with loss of consciousness of unspecified duration.85102
Cortex (cerebral) contusion without mention of open intracranial wound, with brief (less than one hour) loss of consciousness.85103
Cortex (cerebral) contusion without mention of open intracranial wound, with moderate (1-24 hours) loss of consciousness.85104
Cortex (cerebral) contusion without mention of open intracranial wound, with prolonged (more than 24 hours) loss of consciousness and return to pre-exisiting conscious level.85106
Cortex (cerebral) contusion without mention of open intracranial wound, with loss of consciousness of unspecified duration.85142
Cerebellar or brain stem contusion without mention of open intracranial wound, with brief (less than one hour) loss of consciousness.85143
Cerebellar or brain stem contusion without mention of open intracranial wound, with moderate (1-24 hours) loss of consciousness.85144
Cerebellar or brain stem contusion without mention of open intracranial wound, with prolonged (more than 24 hours) loss consciousness and return to pre-existing conscious level.85146
Cerebellar or brain stem contusion without mention of open intracranial wound, with loss of consciousness of unspecified duration.85402
Intracranial injury of other and unspecified nature, without mention of open intracranial wound, with brief (less than one hour) loss of consciousness.85403
Intracranial injury of other and unspecified nature, without mention of open intracranial wound, with moderate (1-24 hours) loss of consciousness.85404
Intracranial injury of other and unspecified nature, without mention of open intracranial wound, with prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level.85406
Intracranial injury of other and unspecified nature, without mention of open intracranial wound, with loss of consciousness of unspecified duration.8600
Traumatic pneumothorax without mention of open wound into thorax.86100
Unspecified injury of heart without mention of open wound into thorax.86101
Contusion of heart without mention of open wound into thorax.86120
Unspecified injury of lung without open wound into thorax.86121
Contusion of lung without open wound into thorax.8620
Injury to diaphragm without mention of open wound into cavity.86229
Injury to other specified intrathoracic organs without mention of open wound into cavity.8628
Injury to multiple and unspecified intrathoracic organs without mention of open wound into cavity.8630
Injury to stomach without mention of open wound into cavity.86320
Injury to small intestine, unspecified site, without open wound into cavity.86321
Injury to duodenum without open wound into cavity.86329
Other injury to small intestine without open wound into cavity.86340
Injury to colon, unspecified site, without mention of open wound into cavity.86341
Injury to ascending (right) colon without open wound into cavity.86342
Injury to transverse colon without open wound into cavity.86343
Injury to descending (left) colon without open wound into cavity.86344
Injury to sigmoid colon without open wound into cavity.86345
Injury to rectum without open wound into cavity.86346
Injury to multiple sites in colon and rectum without open wound into cavity.86349
Other injury to colon and rectum, without open wound into cavity.86380
Injury to gastrointestinal tract, unspecified site, without open wound into cavity.86381
Injury to pancreas head without mention of open wound into cavity.86382
Injury to pancreas body without mention of open wound into cavity.86383
Injury to pancreas tail without mention of open wound into cavity.86384
Injury to pancreas, multiple and unspecified sites, without open wound into cavity.86385
Injury to appendix without open wound into cavity.86389
Injury to other and unspecified gastrointestinal sites without open wound into cavity.86400
Unspecified injury to liver without mention of open wound into cavity.86401
Hematoma and contusion of liver without mention of open wound into cavity.86402
Laceration of liver, minor, without mention of open wound into cavity.86405
Laceration of liver, unspecified, without mention of open wound into cavity.86409
Other injury to liver without mention of open wound into cavity.86500
Unspecified injury to spleen without mention of open wound into cavity.86501
Hematoma of spleen, without rupture of capsule, without mention of open wound into cavity.86502
Capsular tears to spleen, without major disruption of parenchyma, without mention of open wound into cavity.86509
Other injury into spleen without mention of open wound into cavity.( print page 25056)86600
Unspecified injury to kidney without mention of open wound into cavity.86601
Hematoma of kidney, without rupture of capsule, without mention of open wound into cavity.86602
Laceration of kidney without mention of open wound into cavity.8670
Injury to bladder and urethra without mention of open wound into cavity.8672
Injury to ureter without mention of open wound into cavity.8674
Injury to uterus without mention of open wound into cavity.8676
Injury to other specified pelvic organs without mention of open wound into cavity.8678
Injury to unspecified pelvic organ without mention of open wound into cavity.86800
Injury to unspecified intra-abdominal organ without mention of open wound into cavity.86801
Injury to adrenal gland without mention of open wound into cavity.86802
Injury to bile duct and gallbladder without mention of open wound into cavity.86803
Injury to peritoneum without mention of open wound into cavity.86804
Injury to retroperitoneum without mention of open wound into cavity.86809
Injury to other and multiple intra-abdominal organs without mention of open wound into cavity.8690
Internal injury to unspecified or ill-defined organs without mention of open wound into cavity.8702
Laceration of eyelid involving lacrimal passages.8703
Penetrating wound of orbit, without mention of foreign body.8704
Penetrating wound of orbit with foreign body.8708
Other specified open wounds of ocular adnexa.8709
Unspecified open wound of ocular adnexa.8710
Ocular laceration without prolapse of intraocular tissue.8711
Ocular laceration with prolapse or exposure of intraocular tissue.8712
Rupture of eye with partial loss of intraocular tissue.8713
Avulsion of eye.8715
Penetration of eyeball with magnetic foreign body.8716
Penetration of eyeball with (nonmagnetic) foreign body.8719
Unspecified open wound of eyeball.87212
Open wound of auditory canal, complicated.87261
Open wound of ear drum, uncomplicated.87262
Open wound of ossicles, uncomplicated.87263
Open wound of eustachian tube, uncomplicated.87264
Open wound of cochlea, uncomplicated.87269
Open wound of other and multiple sites, uncomplicated.87271
Open wound of ear drum, complicated.87272
Open wound of ossicles, complicated.87273
Open wound of eustachian tube, complicated.87274
Open wound of cochlea, complicated.87279
Open wound of other and multiple sites, complicated.87323
Open wound of nasal sinus, uncomplicated.87333
Open wound of nasal sinus, complicated.8742
Open wound of thyroid gland, without mention of complication.8743
Open wound of thyroid gland, complicated.8744
Open wound of pharynx, without mention of complication.8745
Open wound of pharynx, complicated.8750
Open wound of chest (wall), without mention of complication.8751
Open wound of chest (wall), complicated.88020
Open wound of shoulder region, with tendon involvement.88021
Open wound of scapular region, with tendon involvement.88022
Open wound of axillary region, with tendon involvement.88023
Open wound of upper arm, with tendon involvement.88029
Open wound of multiple sites of shoulder and upper arm, with tendon involvement.88120
Open wound of forearm, with tendon involvement.88121
Open wound of elbow, with tendon involvement.88122
Open wound of wrist, with tendon involvement.8822
Open wound of hand except fingers alone, with tendon involvement.8832
Open wound of fingers, with tendon involvement.8842
Multiple and unspecified open wound of upper limb, with tendon involvement.8870
Traumatic amputation of arm and hand (complete) (partial), unilateral, below elbow, without mention of complication.8871
Traumatic amputation of arm and hand (complete) (partial), unilateral, below elbow, complicated.8872
Traumatic amputation of arm and hand (complete) (partial), unilateral, at or above elbow, without mention of complication.8873
Traumatic amputation of arm and hand (complete) (partial), unilateral, at or above elbow, complicated.8874
Traumatic amputation of arm and hand (complete) (partial), unilateral, level not specified, without mention of complication.8875
Traumatic amputation of arm and hand (complete) (partial), unilateral, level not specified, complicated.8902
Open wound of hip and thigh, with tendon involvement.8912
Open wound of knee, leg (except thigh), and ankle, with tendon involvement.8922
Open wound of foot except toe(s) alone, with tendon involvement.8932
Open wound of toe(s), with tendon involvement.8942
Multiple and unspecified open wound of lower limb, with tendon involvement.8960
Traumatic amputation of foot (complete) (partial), unilateral, without mention of complication.( print page 25057)8961
Traumatic amputation of foot (complete) (partial), unilateral, complicated.8970
Traumatic amputation of leg(s) (complete) (partial), unilateral, below knee, without mention of complication.8971
Traumatic amputation of leg(s) (complete) (partial), unilateral, below knee, complicated.8972
Traumatic amputation of leg(s) (complete) (partial), unilateral, at or above knee, without mention of complication.8973
Traumatic amputation of leg(s) (complete) (partial), unilateral, at or above knee, complicated.8974
Traumatic amputation of leg(s) (complete) (partial), unilateral, level not specified, without mention of complication.8975
Traumatic amputation of leg(s) (complete) (partial), unilateral, level not specified, complicated.90000
Injury to carotid artery, unspecified.90001
Injury to common carotid artery.90002
Injury to external carotid artery.90003
Injury to internal carotid artery.9001
Injury to internal jugular vein.90081
Injury to external jugular vein.90082
Injury to multiple blood vessels of head and neck.90089
Injury to other specified blood vessels of head and neck.9009
Injury to unspecified blood vessel of head and neck.90181
Injury to intercostal artery or vein.90182
Injury to internal mammary artery or vein.90189
Injury to other specified blood vessels of thorax.9019
Injury to unspecified blood vessel of thorax.90255
Injury to uterine artery.90256
Injury to uterine vein.90281
Injury to ovarian artery.90282
Injury to ovarian vein.90289
Injury to other specified blood vessels of abdomen and pelvis.9029
Injury to unspecified blood vessel of abdomen and pelvis.9031
Injury to brachial blood vessels.9032
Injury to radial blood vessels.9033
Injury to ulnar blood vessels.9034
Injury to palmar artery.9035
Injury to digital blood vessels.9038
Injury to other specified blood vessels of upper extremity.9039
Injury to unspecified blood vessel of upper extremity.9043
Injury to saphenous veins.90450
Injury to tibial vessel(s), unspecified.90451
Injury to anterior tibial artery.90452
Injury to anterior tibial vein.90453
Injury to posterior tibial artery.90454
Injury to posterior tibial vein.9046
Injury to deep plantar blood vessels.9047
Injury to other specified blood vessels of lower extremity.9048
Injury to unspecified blood vessel of lower extremity.9049
Injury to blood vessels of unspecified site.9251
Crushing injury of face and scalp.9252
Crushing injury of neck.92800
Crushing injury of thigh.92801
Crushing injury of hip.9340
Foreign body in trachea.9341
Foreign body in main bronchus.9348
Foreign body in other specified parts bronchus and lung.9405
Burn with resulting rupture and destruction of eyeball.94130
Full-thickness skin loss due to burn (third degree nos) of unspecified site of face and head.94131
Full-thickness skin loss due to burn (third degree nos) of ear (any part).94132
Full-thickness skin loss due to burn (third degree nos) of of eye (with other parts of face, head, and neck).94133
Full-thickness skin loss due to burn (third degree nos) of lip(s).94134
Full-thickness skin loss due to burn (third degree nos) of chin.94135
Full-thickness skin loss due to burn (third degree nos) of nose (septum).94136
Full-thickness skin loss due to burn (third degree nos) of scalp (any part).94137
Full-thickness skin loss due to burn (third degree nos) of forehead and cheek.94138
Full-thickness skin loss due to burn (third degree nos) of neck.94139
Full-thickness skin loss due to burn (third degree nos) of multiple sites (except with eye) of face, head, and neck.94140
Deep necrosis of underlying tissues due to burn (deep third degree) of unspecified site of face and head, without mention of loss of body part.94141
Deep necrosis of underlying tissues due to burn (deep third degree) of ear (any part), without mention of loss of ear.94142
Deep necrosis of underlying tissues due to burn (deep third degree) of eye (with other parts of face, head, and neck), without mention of loss of body part.94143
Deep necrosis of underlying tissues due to burn (deep third degree) of lip(s), without mention of loss of lip(s).94144
Deep necrosis of underlying tissues due to burn (deep third degree) of chin, without mention of loss of chin.( print page 25058)94145
Deep necrosis of underlying tissues due to burn (deep third degree) of nose (septum), without mention of loss of nose.94146
Deep necrosis of underlying tissues due to burn (deep third degree) of scalp (any part), without mention of loss of scalp.94147
Deep necrosis of underlying tissues due to burn (deep third degree) of forehead and cheek, without mention of loss of forehead and cheek.94148
Deep necrosis of underlying tissues due to burn (deep third degree) of neck, without mention of loss of neck.94149
Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites (except with eye) of face, head, and neck, without mention of loss of a body part.94150
Deep necrosis of underlying tissues due to burn (deep third degree) of face and head, unspecified site, with loss of body part.94151
Deep necrosis of underlying tissues due to burn (deep third degree) of ear (any part), with loss of ear.94152
Deep necrosis of underlying tissues due to burn (deep third degree) of eye (with other parts of face, head, and neck), with loss of a body part.94153
Deep necrosis of underlying tissues due to burn (deep third degree) of lip(s), with loss of lip(s).94154
Deep necrosis of underlying tissues due to burn (deep third degree) of chin, with loss of chin.94155
Deep necrosis of underlying tissues due to burn (deep third degree) of nose (septum), with loss of nose.94156
Deep necrosis of underlying tissues due to burn (deep third degree) of scalp (any part), with loss of scalp.94157
Deep necrosis of underlying tissues due to burn (deep third degree) of forehead and cheek, with loss of forehead and cheek.94158
Deep necrosis of underlying tissues due to burn (deep third degree) of neck, with loss of neck.94159
Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites (except eye) of face, head, and neck, with loss of a body part.94230
Full-thickness skin loss due to burn (third degree nos) of unspecified site of trunk.94231
Full-thickness skin loss due to burn (third degree nos) of breast.94232
Full-thickness skin loss due to burn (third degree nos) of chest wall, excluding breast and nipple.94233
Full-thickness skin loss due to burn (third degree nos) of abdominal wall.94234
Full-thickness skin loss due to burn (third degree nos) of back (any part).94235
Full-thickness skin loss due to burn (third degree nos) of genitalia.94239
Full-thickness skin loss due to burn (third degree nos) of other and multiple sites of trunk.94240
Deep necrosis of underlying tissues due to burn (deep third degree) of trunk, unspecified site, without mention of loss of body part.94241
Deep necrosis of underlying tissues due to burn (deep third degree) of breast, without mention of loss of breast.94242
Deep necrosis of underlying tissues due to burn (deep third degree) of chest wall, excluding breast and nipple, without mention of loss of chest wall.94243
Deep necrosis of underlying tissues due to burn (deep third degree) of abdominal wall, without mention of loss of abdominal wall.94244
Deep necrosis of underlying tissues due to burn (deep third degree) of back (any part), without mention of loss of back.94245
Deep necrosis of underlying tissues due to burn (deep third degree) of genitalia, without mention of loss of genitalia.94249
Deep necrosis of underlying tissues due to burn (deep third degree) of other and multiple sites of trunk, without mention of loss of body part.94250
Deep necrosis of underlying tissues due to burn (deep third degree) of unspecified site of trunk, with loss of body part.94251
Deep necrosis of underlying tissues due to burn (deep third degree) of breast, with loss of breast.94252
Deep necrosis of underlying tissues due to burn (deep third degree) of chest wall, excluding breast and nipple, with loss of chest wall.94253
Deep necrosis of underlying tissues due to burn (deep third degree) of abdominal wall with loss of abdominal wall.94254
Deep necrosis of underlying tissues due to burn (deep third degree) of back (any part), with loss of back.94255
Deep necrosis of underlying tissues due to burn (deep third degree) of genitalia, with loss of genitalia.94259
Deep necrosis of underlying tissues due to burn (deep third degree) of other and multiple sites of trunk, with loss of a body part.94330
Full-thickness skin loss due to burn (third degree nos) of unspecified site of upper limb.94331
Full-thickness skin loss due to burn (third degree nos) of forearm.94332
Full-thickness skin loss due to burn (third degree nos) of elbow.94333
Full-thickness skin loss due to burn (third degree nos) of upper arm.94334
Full-thickness skin loss due to burn (third degree nos) of axilla.94335
Full-thickness skin loss due to burn (third degree nos) of shoulder.94336
Full-thickness skin loss due to burn (third degree nos) of scapular region.94339
Full-thickness skin loss due to burn (third degree nos) of multiple sites of upper limb, except wrist and hand.94340
Deep necrosis of underlying tissues due to burn (deep third degree) of unspecified site of upper limb, without mention of loss of a body part.94341
Deep necrosis of underlying tissues due to burn (deep third degree) of forearm, without mention of loss of forearm.94342
Deep necrosis of underlying tissues due to burn (deep third degree) of elbow, without mention of loss of elbow.94343
Deep necrosis of underlying tissues due to burn (deep third degree) of upper arm, without mention of loss of upper arm.94344
Deep necrosis of underlying tissues due to burn of axilla, without mention of loss of axilla.( print page 25059)94345
Deep necrosis of underlying tissues due to burn (deep third degree) of shoulder, without mention of loss of shoulder.94346
Deep necrosis of underlying tissues due to burn (deep third degree) of scapular region, without mention of loss of scapula.94349
Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites of upper limb, except wrist and hand, without mention of loss of upper limb.94350
Deep necrosis of underlying tissues due to burn (deep third degree) of unspecified site of upper limb, with loss of a body part.94351
Deep necrosis of underlying tissues due to burn (deep third degree) of forearm, with loss of forearm.94352
Deep necrosis of underlying tissues due to burn (deep third degree) of elbow, with loss of elbow.94353
Deep necrosis of underlying tissues due to burn (deep third degree) of upper arm, with loss of upper arm.94354
Deep necrosis of underlying tissues due to burn (deep third degree) of axilla, with loss of axilla.94355
Deep necrosis of underlying tissues due to burn (deep third degree) of shoulder, with loss of shoulder.94356
Deep necrosis of underlying tissues due to burn (deep third degree) of scapular region, with loss of scapula.94359
Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites of upper limb, except wrist and hand, with loss of upper limb.94430
Full-thickness skin loss due to burn (third degree nos) of unspecified site of hand.94431
Full-thickness skin loss due to burn (third degree nos) of single digit (finger (nail)) other than thumb.94432
Full-thickness skin loss due to burn (third degree nos) of thumb (nail).94433
Full-thickness skin loss due to burn (third degree nos) of two or more digits of hand, not including thumb.94434
Full-thickness skin loss due to burn (third degree nos) of two or more digits of hand including thumb.94435
Full-thickness skin loss due to burn (third degree nos) of palm of hand.94436
Full-thickness skin loss due to burn (third degree nos) of back of hand.94437
Full-thickness skin loss due to burn (third degree nos) of wrist.94438
Full-thickness skin loss due to burn (third degree nos) of multiple sites of wrist(s) and hand(s).94440
Deep necrosis of underlying tissues due to burn (deep third degree) of unspecified site of hand, without mention of loss of hand.94441
Deep necrosis of underlying tissues due to burn (deep third degree) of single digit (finger (nail)) other than thumb, without mention of loss of finger.94442
Deep necrosis of underlying tissues due to burn (deep third degree) of thumb (nail), without mention of loss of thumb.94443
Deep necrosis of underlying tissues due to burn (deep third degree) of two or more digits of hand, not including thumb, without mention of fingers.94444
Deep necrosis of underlying tissues due to burn (deep third degree) of two or more digits of hand including thumb, without mention of loss of fingers.94445
Deep necrosis of underlying tissues due to burn (deep third degree) of palm of hand, without mention of loss of palm.94446
Deep necrosis of underlying tissues due to burn (deep third degree) of back of hand, without mention of loss of back of hand.94447
Deep necrosis of underlying tissues due to burn (deep third degree) of wrist, without mention of loss of wrist.94448
Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites of wrist(s) and hand(s), without mention of loss of a body part.94450
Deep necrosis of underlying tissues due to burn (deep third degree) of unspecified site of hand, with loss of hand.94451
Deep necrosis of underlying tissues due to burn (deep third degree) of single digit (finger (nail)) other than thumb, with loss of finger.94452
Deep necrosis of underlying tissues due to burn (deep third degree) of thumb (nail), with loss of thumb.94453
Deep necrosis of underlying tissues due to burn (deep third degree) of two or more digits of hand, not including thumb, with loss of fingers.94454
Deep necrosis of underlying tissues due to burn (deep third degree) of two or more digits of hand including thumb, with loss of fingers.94455
Deep necrosis of underlying tissues due to burn (deep third degree) of palm of hand, with loss of palm of hand.94456
Deep necrosis of underlying tissues due to burn (deep third degree) of back of hand, with loss of back of hand.94457
Deep necrosis of underlying tissues due to burn (deep third degree) of wrist, with loss of wrist.94458
Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites of wrist(s) and hand(s), with loss of a body part.94530
Full-thickness skin loss due to burn (third degree nos) of unspecified site of lower limb.94531
Full-thickness skin loss due to burn (third degree nos) of toe(s) (nail).94532
Full-thickness skin loss due to burn (third degree nos) of foot.94533
Full-thickness skin loss due to burn (third degree nos) of ankle.94534
Full-thickness skin loss due to burn (third degree nos) of lower leg.94535
Full-thickness skin loss due to burn (third degree nos) of knee.94536
Full-thickness skin loss due to burn (third degree nos) of thigh (any part).94539
Full-thickness skin loss due to burn (third degree nos) of multiple sites of lower limb(s).94540
Deep necrosis of underlying tissues due to burn (deep third degree) of unspecified site of lower limb (leg), without mention of loss of a body part.94541
Deep necrosis of underlying tissues due to burn (deep third degree) of toe(s) (nail), without mention of loss of toe(s).94542
Deep necrosis of underlying tissues due to burn (deep third degree) of foot, without mention of loss of foot.94543
Deep necrosis of underlying tissues due to burn (deep third degree) of ankle, without mention of loss of ankle.( print page 25060)94544
Deep necrosis of underlying tissues due to burn (deep third degree) of lower leg, without mention of loss of lower leg.94545
Deep necrosis of underlying tissues due to burn (deep third degree) of knee, without mention of loss of knee.94546
Deep necrosis of underlying tissues due to burn (deep third degree) of thigh (any part), without mention of loss of thigh.94549
Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites of lower limb(s), without mention of loss of a body part.94550
Deep necrosis of underlying tissues due to burn (deep third degree) of unspecified site lower limb (leg), with loss of a body part.94551
Deep necrosis of underlying tissues due to burn (deep third degree) of toe(s) (nail), with loss of toe(s).94552
Deep necrosis of underlying tissues due to burn (deep third degree) of foot, with loss of foot.94553
Deep necrosis of underlying tissues due to burn (deep third degree) of ankle, with loss of ankle.94554
Deep necrosis of underlying tissues due to burn (deep third degree) of lower leg, with loss of lower leg.94555
Deep necrosis of underlying tissues due to burn (deep third degree) of knee, with loss of knee.94556
Deep necrosis of underlying tissues due to burn (deep third degree) of thigh (any part), with loss of thigh.94559
Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites of lower limb(s), with loss of a body part.9463
Full-thickness skin loss due to burn (third degree nos) of multiple specified sites.9464
Deep necrosis of underlying tissues due to burn (deep third degree) of multiple specified sites, without mention of loss of a body part.9465
Deep necrosis of underlying tissues due to burn (deep third degree) of multiple specified sites, with loss of a body part.9471
Burn of larynx, trachea, and lung.9472
Burn of esophagus.9473
Burn of gastrointestinal tract.9474
Burn of vagina and uterus.94810
Burn (any degree) involving 10-19 percent of body surface with third degree burn of less than 10 percent or unspecified amount.94811
Burn (any degree) involving 10-19 percent of body surface with third degree burn of 10-19%.94820
Burn (any degree) involving 20-29 percent of body surface with third degree burn of less than 10 percent or unspecified amount.94830
Burn (any degree) involving 30-39 percent of body surface with third degree burn of less than 10 percent or unspecified amount.94840
Burn (any degree) involving 40-49 percent of body surface with third degree burn of less than 10 percent or unspecified amount.94850
Burn (any degree) involving 50-59 percent of body surface with third degree burn of less than 10 percent or unspecified amount.94860
Burn (any degree) involving 60-69 percent of body surface with third degree burn of less than 10 percent or unspecified amount.94870
Burn (any degree) involving 70-79 percent of body surface with third degree burn of less than 10 percent or unspecified amount.94880
Burn (any degree) involving 80-89 percent of body surface with third degree burn of less than 10 percent or unspecified amount.94890
Burn (any degree) involving 90 percent or more of body surface with third degree burn of less than 10 percent or unspecified amount.9493
Full-thickness skin loss due to burn (third degree nos), unspecified site.9494
Deep necrosis of underlying tissue due to burn (deep third degree), unspecified site without mention of loss of a body part.9495
Deep necrosis of underlying tissues due to burn (deep third degree, unspecified site with loss of a body part.9500
Optic nerve injury.9501
Injury to optic chiasm.9502
Injury to optic pathways.9503
Injury to visual cortex.9509
Injury to unspecified optic nerve and pathways.9510
Injury to oculomotor nerve.9511
Injury to trochlear nerve.9512
Injury to trigeminal nerve.9513
Injury to abducens nerve.9514
Injury to facial nerve.9515
Injury to acoustic nerve.9516
Injury to accessory nerve.9517
Injury to hypoglossal nerve.9518
Injury to other specified cranial nerves.9519
Injury to unspecified cranial nerve.9582
Secondary and recurrent hemorrhage as an early complication of trauma.9583
Posttraumatic wound infection not elsewhere classified.9587
Traumatic subcutaneous emphysema.95890
Compartment syndrome, unspecified.95891
Traumatic compartment syndrome of upper extremity.95892
Traumatic compartment syndrome of lower extremity.95893
Traumatic compartment syndrome of abdomen.95899
Traumatic compartment syndrome of other sites.( print page 25061)9910
Frostbite of face.9911
Frostbite of hand.9912
Frostbite of foot.9913
Frostbite of other and unspecified sites.9914
Immersion foot.9920
Heat stroke and sunstroke.9933
Caisson disease.9941
Drowning and nonfatal submersion.9947
Asphyxiation and strangulation.9950
Other anaphylactic shock, not elsewhere classified.9954
Shock due to anesthesia, not elsewhere classified.99550
Unspecified child abuse.99551
Child emotional/psychological abuse.99552
Child neglect (nutritional).99553
Child sexual abuse.99554
Child physical abuse.99555
Shaken baby syndrome.99559
Other child abuse and neglect.99560
Anaphylactic shock due to unspecified food.99561
Anaphylactic shock due to peanuts.99562
Anaphylactic shock due to crustaceans.99563
Anaphylactic shock due to fruits and vegetables.99564
Anaphylactic shock due to tree nuts and seeds.99565
Anaphylactic shock due to fish.99566
Anaphylactic shock due to food additives.99567
Anaphylactic shock due to milk products.99568
Anaphylactic shock due to eggs.99569
Anaphylactic shock due to other specified food.99580
Unspecified adult maltreatment.99581
Adult physical abuse.99583
Adult sexual abuse.99584
Adult neglect (nutritional).99585
Other adult abuse and neglect.99586
Malignant hyperthermia.99590
Systemic inflammatory response syndrome, unspecified.99593
Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction.99600
Mechanical complications of unspecified cardiac device, implant, and graft.99601
Mechanical complication due to cardiac pacemaker (electrode).99602
Mechanical complication due to heart valve prosthesis.99603
Mechanical complication due to coronary bypass graft.99604
Mechanical complication of automatic implantable cardiac defibrillator.99609
Other mechanical complication of cardiac device, implant, and graft.9961
Mechanical complication of other vascular device, implant, and graft.9962
Mechanical complication of nervous system device, implant, and graft.99630
Mechanical complication of unspecified genitourinary device, implant, and graft.99639
Other mechanical complication of genitourinary device, implant, and graft.99640
Unspecified mechanical complication of internal orthopedic device, implant, and graft.99641
Mechanical loosening of prosthetic joint.99642
Dislocation of prosthetic joint.99643
Prosthetic joint implant failure.99644
Peri-prosthetic fracture around prosthetic joint.99645
Peri-prosthetic osteolysis.99646
Articular bearing surface wear of prosthetic joint.99647
Other mechanical complication of prosthetic joint implant.99649
Other mechanical complication of other internal orthopedic device, implant, and graft.99651
Mechanical complication of prosthetic corneal graft.99652
Mechanical complication of prosthetic graft of other tissue, not elsewhere classified.99653
Mechanical complication of prosthetic ocular lens prosthesis.99654
Mechanical complication of breast prosthesis.99655
Mechanical complication due to artificial skin graft and decellularized allodermis.99656
Mechanical complication due to peritoneal dialysis catheter.99657
COMPLICATION, DUE TO INSULIN PUMP.99659
Mechanical complication of other implant and internal device, not elsewhere classfied.99660
Infection and inflammatory reaction due to unspecified device, implant, and graft.99661
Infection and inflammatory reaction due to cardiac device, implant, and graft.99662
Infection and inflammatory reaction due to other vascular device, implant, and graft.99663
Infection and inflammatory reaction due to nervous system device, implant, and graft.99664
Infection and inflammatory reaction due to indwelling urinary catheter.99665
Infection and inflammatory reaction due to other genitourinary device, implant, and graft.99666
Infection and inflammatory reaction due to internal joint prosthesis.99667
Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft.99668
Infection and inflammatory reaction due to peritoneal dialysis catheter.( print page 25062)99669
Infection and inflammatory reaction due to other internal prosthetic device, implant, and graft.99671
Other complications due to heart valve prosthesis.99672
Other complications due to other cardiac device, implant, and graft.99673
Other complications due to renal dialysis device, implant, and graft.99674
Other complications due to other vascular device, implant, and graft.99675
Other complications due to nervous system device, implant, and graft.99676
Other complications due to genitourinary device, implant, and graft.99677
Other complications due to internal joint prosthesis.99678
Other complications due to other internal orthopedic device, implant, and graft.99679
Other complications due to other internal prosthetic device, implant, and graft.99680
Complications of unspecified transplanted organ.99681
Complications of transplanted kidney.99682
Complications of transplanted liver.99683
Complications of transplanted heart.99684
Complications of transplanted lung.99685
Complications of transplanted bone marrow.99686
Complications of transplanted pancreas.99687
Complications of transplanted organ, intestine.99689
Complications of other specified transplanted organ.99690
Complications of unspecified reattached extremity.99691
Complications of reattached forearm.99692
Complications of reattached hand.99693
Complications of reattached finger(s).99694
Complications of reattached upper extremity, other and unspecified.99695
Complication of reattached foot and toe(s).99696
Complication of reattached lower extremity, other and unspecified.99699
Complication of other specified reattached body part.99701
Central nervous system complication.99702
Iatrogenic cerebrovascular infarction or hemorrhage.99709
Other nervous system complications.9971
Cardiac complications, not elsewhere classified.9972
Peripheral vascular complications, not elsewhere classified.9973
Respiratory complications, not elsewhere classified.9974
Digestive system complications, not elsewhere classified.99762
Infection (chronic) of amputation stump.99771
Vascular complications of mesenteric artery.99772
Vascular complications of renal artery.99779
Vascular complications of other vessels.99799
Complications affecting other specified body systems, not elsewhere classified.9980
Postoperative shock, not elsewhere classified.99811
Hemorrhage complicating a procedure.99812
Hematoma complicating a procedure.99813
Seroma complicating a procedure.9982
Accidental puncture or laceration during a procedure, not elsewhere classified.99831
Disruption of internal operation wound.99832
Disruption of external operation wound.9984
Foreign body accidentally left during a procedure, not elsewhere classified.99851
Infected postoperative seroma.99859
Other postoperative infection.9986
Persistent postoperative fistula, not elsewhere classified.9987
Acute reaction to foreign substance accidentally left during a procedure, not elsewhere classified.99883
Non-healing surgical wound.9990
Generalized vaccinia as a complication of medical care, not elsewhere classified.9992
Other vascular complications of medical care, not elsewhere classified.9993
Other infection due to medical care, not elsewhere classified.9994
Anaphylactic shock due to serum, not elsewhere classified.9995
Other serum reaction, not elsewhere classified.9996
Abo incompatibility reaction, not elsewhere classified.9997
Rh incompatibility reaction, not elsewhere classified.9998
Other transfusion reaction, not elsewhere classified.V420
Kidney replaced by transplant.V421
Heart replaced by transplant.V426
Lung replaced by transplant.V427
Liver replaced by transplant.V4281
Bone marrow replaced by transplant.V4282
Peripheral stem cells replaced by transplant.V4283
Pancreas replaced by transplant.V4284
Organ or tissue replaced by transplant, intestines.V4321
Organ or tissue replaced by other means, heart assist device.V4322
Organ or tissue replaced by other means, fully implantable artificial heart.V4611
Dependence on respirator, status.V4612
Encounter for respirator dependence during power failure.( print page 25063)V4613
Encounter for weaning from respirator [ventilator].V4614
Mechanical complication of respirator [ventilator].V551
Attention to gastrostomy.V6284
Suicidal ideation.V850
Body Mass Index less than 19, adult.V854
Body Mass Index 40 and over, adult.
 Table 7A.—Medicare Prospective Payment System Selected Percentile Lengths of Stay FY 2006 MedPAR Update—December 2006 Grouper V24.0 CMS DRGs
DRG
Number of discharges
Arithmetic mean LOS
10th percentile
25th percentile
50th percentile
75th percentile
90th percentile1
24,941
9.4334
2
4
7
12
192
9,519
4.2485
1
2
3
6
83
3
31.6667
2
2
42
51
516
254
2.9409
1
1
2
4
67
14,373
9.0353
2
4
7
11
188
3,072
2.7119
1
1
2
3
69
1,749
5.7616
1
2
4
7
1110
18,799
5.7674
2
3
4
7
1111
2,768
3.6120
1
2
3
5
712
56,172
5.3189
2
3
4
6
1013
7,636
4.8707
2
3
4
6
814
262,424
5.2666
2
3
4
6
1015
13,780
3.8482
1
2
3
5
716
20,050
6.2493
2
3
5
8
1217
3,109
3.2078
1
1
2
4
618
33,745
5.1228
2
3
4
6
1019
7,451
3.3182
1
2
3
4
621
2,071
6.1772
2
3
5
8
1222
3,366
5.1242
2
2
4
6
1023
10,269
3.7083
1
2
3
5
726
32
2.8750
1
1
2
4
727
6,179
4.6716
1
1
3
6
1028
21,197
5.4894
1
2
4
7
1129
6,674
3.0853
1
1
3
4
631
4,986
3.7706
1
2
3
5
732
1,691
2.2389
1
1
2
3
434
29,326
4.6962
1
2
4
6
935
7,738
2.9340
1
1
2
4
536
270
1.9370
1
1
1
2
437
1,171
4.1076
1
1
3
5
938
52
2.3846
1
1
2
3
439
274
2.2336
1
1
1
2
540
1,098
4.4791
1
2
4
5
942
1,470
2.5966
1
1
1
3
643
127
3.0236
1
1
2
4
544
1,261
4.8882
2
3
4
6
945
2,846
2.9301
1
2
2
4
546
4,002
3.9725
1
2
3
5
847
1,258
2.9754
1
1
2
4
649
2,449
4.2450
1
2
3
5
850
1,973
1.7988
1
1
1
2
351
177
2.7910
1
1
1
3
652
181
1.5304
1
1
1
2
253
1,896
3.8745
1
1
2
5
955
1,234
2.7626
1
1
1
3
656
369
2.5799
1
1
2
3
557
732
3.4549
1
1
2
4
758
1
1.0000
1
1
1
1
159
111
2.4414
1
1
1
3
460
5
3.4000
1
1
1
6
861
212
5.8821
1
1
4
7
1362
1
4.0000
4
4
4
4
463
2,551
4.5468
1
2
3
6
1064
3,044
6.0798
1
2
4
8
1365
39,254
2.7302
1
1
2
3
566
7,743
3.2033
1
1
2
4
667
348
3.6063
1
2
3
4
768
14,437
3.7100
1
2
3
5
7( print page 25064)69
3,512
2.7958
1
2
2
4
570
22
2.4545
1
1
2
3
471
64
3.8125
1
2
3
5
772
1,377
3.3834
1
2
3
4
673
9,817
4.3653
1
2
3
6
875
46,052
9.3570
3
4
7
12
1976
45,066
10.1322
3
5
8
13
1977
1,766
4.4077
1
2
4
6
978
52,142
5.9448
2
4
5
7
1079
149,996
7.8785
3
4
6
10
1580
5,865
5.2055
2
3
4
6
1081
8
3.1250
1
2
3
3
482
60,815
6.5333
2
3
5
8
1383
7,094
5.0369
2
3
4
6
984
1,294
3.0077
1
2
3
4
585
22,232
6.1018
2
3
5
8
1286
1,423
3.3710
1
2
3
4
787
104,584
6.2374
2
3
5
8
1288
375,666
4.7615
2
3
4
6
989
468,634
5.3910
2
3
4
7
1090
33,813
3.5880
1
2
3
4
691
42
5.1667
1
2
3
6
892
15,894
5.8223
2
3
5
7
1193
1,094
3.5932
1
2
3
5
794
13,571
5.8596
2
3
5
8
1195
1,396
3.4362
1
2
3
4
796
52,187
4.1808
1
2
3
5
897
20,991
3.2644
1
2
3
4
698
11
4.6364
1
2
4
6
799
20,681
3.0888
1
1
2
4
6100
5,367
2.0781
1
1
2
3
4101
24,043
4.1874
1
2
3
5
8102
4,155
2.4363
1
1
2
3
5103
957
36.6813
8
13
25
46
80104
19,277
14.5529
6
8
12
18
26105
31,935
9.9262
4
6
8
11
18106
3,273
10.9050
5
7
9
13
19108
9,206
10.4328
4
6
8
13
19110
56,354
7.8017
1
3
6
10
16111
10,370
2.7754
1
1
2
4
6113
30,526
12.4437
4
6
10
15
24114
7,216
8.1332
2
4
7
10
16117
7,054
4.0186
1
1
2
5
9118
7,940
3.0072
1
1
2
4
7119
788
5.5063
1
1
4
8
12120
30,139
9.0112
1
3
6
12
19121
131,942
5.9604
2
3
5
8
11122
47,504
3.2315
1
1
3
4
6123
24,024
4.6391
1
1
3
6
11124
110,702
4.4070
1
2
3
6
9125
85,159
2.6783
1
1
2
3
5126
5,156
10.7455
3
6
8
13
20127
627,657
5.0473
2
3
4
6
9128
3,363
4.9854
2
3
4
6
8129
3,233
2.6087
1
1
1
3
6130
83,923
5.2374
1
3
4
7
10131
20,275
3.6403
1
2
3
5
6132
84,452
2.7444
1
1
2
3
5133
4,929
2.0801
1
1
2
3
4134
37,743
3.0024
1
1
2
4
6135
6,937
4.2093
1
2
3
5
8136
893
2.4894
1
1
2
3
5138
206,453
3.8403
1
2
3
5
7139
67,628
2.3918
1
1
2
3
4140
24,872
2.3395
1
1
2
3
4141
125,207
3.3954
1
2
3
4
6142
44,070
2.4524
1
1
2
3
4143
220,824
2.1144
1
1
2
3
4144
105,937
5.8550
1
2
4
7
12145
4,992
2.5032
1
1
2
3
5( print page 25065)146
9,704
9.6600
4
6
8
11
17147
2,408
5.3218
2
4
5
7
8149
18,456
5.4416
3
4
5
7
8150
23,405
10.4474
3
6
9
13
19151
5,118
4.9334
1
2
4
7
9152
4,885
7.8047
3
4
6
9
14153
1,840
4.7315
2
3
4
6
7155
5,761
3.7808
1
2
3
5
8156
3
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4
5
7
11
17502
688
5.4230
2
3
5
7
9503
5,421
3.8493
1
2
3
5
7504
182
28.9670
9
15
25
40
54505
155
5.9097
1
1
2
6
14506
980
14.7245
3
7
12
19
29507
274
7.3869
1
3
6
11
15508
557
7.3878
2
3
5
9
14509
137
4.5766
1
2
3
5
10510
1,681
6.0684
1
2
4
7
13511
498
3.8313
1
1
3
5
8512
560
11.8982
6
7
9
13
20513
177
10.2486
6
7
9
12
16515
57,719
3.5718
1
1
1
4
9518
24,896
2.4103
1
1
1
3
5519
13,824
4.5428
1
1
2
6
11520
17,200
1.8812
1
1
1
2
4521
30,284
5.3526
2
3
4
6
10522
3,408
10.4745
3
5
8
14
21523
13,997
3.7162
1
2
3
4
6524
103,803
3.0689
1
2
3
4
6525
150
11.9600
1
2
6
15
34528
1,710
16.5509
5
9
15
22
29529
5,094
6.8828
1
2
4
9
16530
3,221
2.8712
1
1
2
3
5531
5,251
9.2400
2
3
7
12
19532
2,973
3.6266
1
1
3
5
7533
40,452
3.5306
1
1
2
4
8534
34,384
1.6709
1
1
1
2
3535
8,642
8.7836
2
4
7
11
17536
7,797
7.1789
2
3
6
9
14537
9,423
6.5040
1
3
5
8
13538
5,014
2.8957
1
1
2
4
6539
4,747
10.5886
2
3
7
14
23540
1,406
3.3940
1
1
2
4
7( print page 25070)541
24,001
40.4864
16
23
34
49
72542
21,753
29.2444
11
17
24
36
51543
5,669
11.3277
2
4
9
16
23544
440,451
4.3239
3
3
4
5
7545
43,688
5.0764
3
3
4
6
8546
3,558
7.8111
3
4
6
9
15547
29,673
12.1403
6
8
10
14
20548
26,417
8.6920
5
6
8
10
13549
12,901
10.1190
5
6
8
12
18550
29,627
6.6683
4
5
6
8
10551
51,141
6.0806
1
2
5
8
12552
78,452
3.3411
1
1
2
4
7553
44,355
8.8636
1
3
7
12
19554
77,753
5.1191
1
2
3
7
11555
37,647
4.6506
1
2
3
6
10556
17,813
1.9014
1
1
1
2
4557
128,804
3.9579
1
2
3
5
8558
184,255
1.7491
1
1
1
2
3559
4,814
6.8467
2
4
5
8
13560
3,365
9.9964
3
5
8
13
19561
2,944
9.4440
3
5
8
12
18562
52,768
4.7011
1
2
4
6
9563
19,974
3.1487
1
2
3
4
6564
16,370
3.3764
1
2
3
4
6565
46,197
14.9311
6
9
13
18
26566
79,447
7.2748
1
3
6
10
14567
9,976
15.6049
6
8
12
19
29568
16,065
11.0504
2
5
9
14
22569
58,700
14.1940
5
8
12
18
26570
68,714
9.8921
4
6
8
12
18571
10,974
4.8136
2
2
4
6
9572
54,656
6.9428
2
4
5
8
13573
6,467
10.8919
4
6
8
12
20574
27,588
5.7540
2
3
4
7
11575
13,709
15.2387
6
8
13
19
27576
295,836
7.0992
2
3
6
9
14577
11,072
2.3475
1
1
1
2
5578
38,795
15.6194
5
8
12
19
29579
19,756
10.6732
3
5
8
13
2211,663,472
 Table 7B.—Medicare Prospective Payment System Selected Percentile Lengths of Stay FY 2006 MedPAR Update—December 2006 Grouper V25.0 MS-DRGs
DRG
Number of discharges
Arithmetic mean LOS
10th percentile
25th percentile
50th percentile
75th percentile
90th percentile1
628
43.9968
10
17
32
56
922
329
22.7173
8
10
15
27
463
24,007
40.4921
16
23
34
49
724
21,748
29.2363
11
17
24
36
515
842
22.5713
7
10
16
28
506
495
9.9717
5
7
9
11
167
413
17.3123
8
10
14
20
298
560
11.8982
6
7
9
13
209
1,359
21.7454
10
15
20
24
3310
177
10.2486
6
7
9
12
1611
1,290
16.1558
6
8
13
19
2812
1,923
10.9111
4
6
9
13
1913
1,484
7.2352
3
4
7
9
1220
901
19.1088
6
11
18
25
3421
558
15.5430
7
10
14
20
2622
251
9.6096
3
5
9
13
1723
3,113
13.5888
3
6
11
19
2724
2,576
8.5901
1
3
7
12
1825
8,419
13.3480
4
7
11
17
2526
11,628
8.2665
3
4
7
11
1527
14,459
4.6581
1
2
4
6
928
1,611
14.6629
4
7
11
18
28( print page 25071)29
2,862
7.6530
2
4
6
10
1530
3,751
3.6726
1
1
3
5
731
1,058
13.1361
3
5
10
18
2632
2,989
5.7969
1
2
4
7
1333
4,270
3.0745
1
1
2
4
634
814
7.2715
1
2
5
10
1535
2,510
3.0351
1
1
2
4
736
7,748
1.6075
1
1
1
2
337
4,777
8.6847
2
3
7
11
1838
14,603
3.8074
1
1
2
5
939
55,391
1.8575
1
1
1
2
340
4,549
13.5997
4
6
10
17
2641
7,720
7.4211
2
4
6
9
1442
5,430
3.6440
1
1
2
5
852
1,156
6.6678
2
3
5
8
1353
593
3.9949
1
2
3
5
854
4,665
7.2223
2
3
5
9
1455
16,902
5.0128
1
2
4
6
1056
7,719
7.8009
2
4
6
9
1557
48,453
4.9236
2
3
4
6
958
789
8.0279
2
4
6
9
1659
2,640
5.2098
2
3
4
6
960
4,205
4.0587
2
2
4
5
761
1,340
9.7060
3
5
8
12
1962
2,289
6.3451
3
4
5
8
1163
1,185
4.5823
2
3
4
6
864
55,567
7.6787
2
4
6
10
1565
112,235
5.3134
2
3
4
7
1066
94,622
3.7946
1
2
3
5
767
1,383
6.2133
2
3
5
8
1268
12,397
3.5843
1
2
3
5
769
103,803
3.0689
1
2
3
4
670
7,093
7.9026
2
4
6
10
1571
10,005
5.6338
2
3
5
7
1072
6,061
3.7703
1
2
3
5
773
8,660
6.4130
2
3
5
8
1374
32,536
4.3661
1
2
4
5
875
1,197
7.6115
3
4
6
10
1476
874
4.2128
2
2
3
5
877
1,101
7.1599
2
3
6
9
1478
1,307
4.5792
2
2
4
6
879
958
3.5282
1
2
3
4
680
2,077
4.8681
1
2
4
6
981
8,192
3.4143
1
2
3
4
682
1,646
6.3991
1
1
4
9
1583
1,941
5.2849
1
2
4
7
1084
2,592
3.1154
1
1
2
4
685
5,330
7.9328
2
3
6
10
1686
10,385
5.1475
1
3
4
7
1087
12,156
3.3901
1
2
3
4
688
717
6.1046
1
3
4
7
1289
2,641
3.7830
1
2
3
5
790
3,319
2.4760
1
1
2
3
591
6,678
6.5861
2
3
5
8
1392
14,897
4.4665
1
2
4
6
893
15,489
3.2219
1
2
3
4
694
1,521
12.4938
4
7
11
16
2395
1,089
9.1726
3
5
8
12
1696
755
6.1536
2
3
5
8
1197
1,253
11.8164
4
6
10
16
2298
1,048
8.5334
3
5
7
11
1599
643
6.3048
2
3
6
8
11100
15,840
6.2835
2
3
5
8
13101
56,927
3.7154
1
2
3
5
7102
1,352
5.0473
1
2
4
6
10103
15,025
3.2255
1
2
3
4
6113
568
5.6039
1
2
4
7
12114
603
2.6982
1
1
2
3
6115
1,098
4.4791
1
2
4
5
9116
665
3.4602
1
1
2
4
8( print page 25072)117
1,401
1.9807
1
1
1
2
4121
587
5.8245
2
3
5
7
11122
674
4.0727
1
2
3
5
8123
2,846
2.9301
1
2
2
4
5124
679
5.2901
1
2
4
7
11125
4,708
3.4904
1
2
3
4
7129
1,374
5.0786
1
2
4
6
10130
1,075
3.1795
1
1
2
4
6131
655
5.6260
1
2
4
7
11132
728
2.5742
1
1
2
3
5133
1,352
6.3750
1
2
4
8
14134
2,662
2.3020
1
1
1
3
5135
781
6.0948
1
2
4
8
13136
1,115
2.3193
1
1
1
3
5137
1,109
5.4238
1
2
4
7
11138
1,372
2.4249
1
1
2
3
5139
2,150
1.8805
1
1
1
2
3146
687
10.2227
2
4
7
13
20147
1,422
5.7771
1
2
4
7
12148
935
3.4963
1
1
2
5
7149
39,254
2.7302
1
1
2
3
5150
939
5.4494
1
2
4
7
11151
6,804
2.8933
1
1
2
4
5152
2,352
4.6947
1
2
4
6
9153
16,031
3.3617
1
2
3
4
6154
1,843
6.4704
2
3
5
8
12155
4,208
4.5696
1
2
4
6
9156
5,143
3.1808
1
2
3
4
6157
1,145
6.9092
2
3
5
9
14158
3,039
4.4659
1
2
3
6
9159
2,418
3.0790
1
1
2
4
6163
13,433
14.9768
5
8
13
19
27164
18,051
8.3639
3
5
7
10
15165
14,557
5.3898
2
3
5
7
9166
20,293
13.0059
4
7
10
16
24167
20,775
8.1439
3
4
7
10
15168
5,758
5.4139
1
2
5
7
10175
11,958
7.4075
3
4
6
9
13176
40,184
5.5095
2
4
5
7
9177
57,194
9.1881
3
5
8
12
17178
71,205
7.4692
3
4
6
9
14179
27,468
5.6397
2
3
5
7
10180
22,478
7.9687
2
4
7
10
15181
32,170
5.9642
2
3
5
8
12182
6,167
4.2701
1
2
3
6
8183
1,654
7.1826
2
4
6
9
14184
4,141
4.6450
2
3
4
6
8185
2,593
3.2815
1
2
3
4
6186
8,534
7.5378
2
4
6
10
14187
9,970
5.4881
2
3
4
7
11188
5,151
4.1561
1
2
3
5
8189
104,581
6.2368
2
3
5
8
12190
57,046
6.4788
2
3
5
8
12191
121,674
5.1201
2
3
4
6
9192
196,930
4.0420
2
2
3
5
7193
88,072
6.8766
2
4
6
9
13194
266,642
5.3586
2
3
5
7
9195
147,775
4.1514
2
2
4
5
7196
5,143
7.3502
2
4
6
9
14197
6,895
5.4181
2
3
5
7
10198
4,944
4.2945
1
2
4
5
8199
3,258
8.4936
3
4
7
11
16200
8,186
5.1467
1
2
4
7
10201
3,523
4.1198
1
2
3
5
8202
31,594
4.5021
2
2
4
6
8203
41,595
3.4745
1
2
3
4
6204
26,048
2.8805
1
1
2
4
6205
5,777
5.6382
1
3
4
7
11206
22,421
3.4891
1
2
3
4
7207
46,195
14.9298
6
9
13
18
26( print page 25073)208
79,446
7.2748
1
3
6
10
14215
150
11.9600
1
2
6
15
34216
8,411
18.6918
8
11
16
23
32217
7,610
12.3029
6
8
11
15
20218
3,256
9.1198
5
6
8
11
14219
10,063
14.4558
6
8
11
18
27220
13,483
8.6970
5
6
7
10
14221
8,389
6.4682
4
5
6
7
10222
2,869
13.2426
5
7
11
17
24223
5,773
6.5676
1
3
6
9
13224
1,920
11.5104
4
6
9
14
22225
5,877
5.7638
2
3
5
7
11226
7,049
9.3723
1
3
8
13
19227
50,670
2.7649
1
1
1
3
7228
3,087
14.6317
6
8
12
18
26229
4,130
9.1191
4
6
8
11
15230
1,989
6.6435
3
4
6
8
11231
1,478
13.2104
5
7
11
16
24232
1,795
9.0067
5
6
8
11
14233
16,914
14.2938
7
9
12
17
24234
39,176
8.8853
5
6
8
11
13235
9,630
11.4974
5
7
9
14
21236
32,898
6.6079
4
5
6
8
10237
21,792
11.4604
2
5
9
15
23238
44,932
4.8672
1
2
4
7
10239
13,821
15.5449
5
8
12
19
29240
13,355
10.5939
4
6
8
13
20241
3,350
7.0236
3
4
6
9
13242
17,182
8.9305
3
4
7
11
17243
37,874
5.1880
1
2
4
7
10244
68,296
2.9635
1
1
2
4
6245
6,241
3.3249
1
1
2
4
8246
32,667
6.3103
1
2
5
8
13247
280,392
2.2324
1
1
1
3
5248
5,013
6.5163
1
3
5
9
13249
29,674
2.5339
1
1
2
3
5250
5,740
7.5240
1
3
6
10
15251
39,929
2.9531
1
1
2
4
6252
44,611
8.7554
1
3
6
12
19253
46,868
6.2739
1
2
5
8
13254
59,053
2.9056
1
1
2
4
6255
2,609
9.9279
2
4
8
13
19256
3,833
7.5458
2
4
6
10
14257
774
4.9922
1
2
4
7
10258
598
7.5769
2
3
6
10
15259
7,342
2.6350
1
1
2
3
6260
867
10.1753
2
4
8
13
20261
2,804
3.9675
1
1
3
5
8262
3,383
2.4830
1
1
2
3
5263
788
5.5063
1
1
4
8
12264
30,138
9.0102
1
3
6
12
19280
60,743
7.4498
2
4
6
9
14281
57,742
4.9623
2
3
4
6
9282
60,961
3.2953
1
2
3
4
6283
15,856
5.4845
1
1
3
7
13284
4,912
3.4770
1
1
2
4
8285
3,256
2.2752
1
1
1
3
5286
23,286
7.0619
2
3
6
9
14287
172,575
3.1957
1
1
2
4
6288
3,248
12.2155
4
7
10
15
23289
1,423
8.7850
3
5
7
11
15290
485
6.6536
2
4
6
8
12291
183,811
6.6240
2
3
5
8
13292
217,099
5.0937
2
3
4
6
9293
226,747
3.7248
1
2
3
5
7294
1,705
5.5666
2
3
5
7
9295
1,658
4.3878
2
3
4
6
7296
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4
6689
55,402
6.3745
2
3
5
8
12690
200,093
4.3011
2
2
4
5
8691
898
4.1648
1
2
3
5
9692
655
2.2580
1
1
2
3
4693
2,235
5.2098
1
2
4
7
10694
19,221
2.5735
1
1
2
3
5695
975
5.7323
2
3
4
7
12696
10,566
3.2277
1
2
3
4
6697
575
3.2835
1
1
2
4
6698
21,065
6.7737
2
3
5
8
13699
22,826
5.0096
1
2
4
6
10700
15,094
3.6045
1
2
3
5
7707
4,875
4.8568
2
2
4
6
9708
17,032
2.4324
1
1
2
3
4709
755
6.6715
1
2
4
8
15710
2,037
1.8949
1
1
1
2
3711
922
7.9469
1
3
6
10
16712
819
3.0024
1
1
2
4
7713
11,760
4.1367
1
2
3
5
9714
32,760
2.0154
1
1
2
2
3715
638
6.1661
1
2
4
8
14716
1,389
1.5227
1
1
1
1
2717
635
7.6567
1
3
5
10
16718
633
2.7994
1
1
2
4
5722
871
7.4409
2
3
6
9
14723
2,038
5.4328
2
3
4
7
10724
666
3.3498
1
1
3
4
7725
802
5.6160
2
3
4
7
11726
3,941
3.5202
1
2
3
4
7727
1,098
6.5556
2
3
5
8
12728
6,177
4.0570
1
2
3
5
7729
578
5.1488
1
2
4
7
10730
552
3.2591
1
1
2
4
6734
1,470
7.7129
3
4
5
9
15735
1,329
3.5056
1
2
3
4
6736
840
13.8619
5
8
12
18
25737
3,429
7.4278
3
4
6
9
13738
955
3.9874
2
3
4
5
6739
975
10.2318
4
5
7
13
20740
4,370
5.2190
2
3
4
6
9741
6,562
3.1617
2
2
3
4
5742
10,709
4.7158
2
2
3
5
9743
35,368
2.3568
1
2
2
3
4744
1,498
5.9012
1
2
4
7
12745
2,194
2.6135
1
1
2
3
5746
2,487
4.2059
1
2
3
5
8747
11,231
1.9232
1
1
2
2
3748
21,201
1.8026
1
1
1
2
3749
1,038
9.9075
2
4
7
13
21750
484
3.3306
1
2
3
4
6( print page 25079)754
1,083
8.8144
2
4
7
11
19755
3,152
5.6551
1
3
4
7
11756
832
3.3221
1
1
3
4
7757
1,323
8.9131
3
4
7
11
17758
1,597
6.1327
2
3
5
8
11759
1,186
4.6256
2
2
4
6
8760
1,703
3.8227
1
2
3
5
7761
1,918
2.4937
1
1
2
3
5765
2,501
5.3215
2
3
4
5
8766
2,637
3.2461
2
2
3
4
4767
119
2.8824
1
2
2
3
5768
10
5.8000
2
3
4
8
9769
86
5.7326
1
2
3
7
12770
181
2.7017
1
1
1
2
6774
1,443
3.2467
2
2
3
3
4775
5,236
2.3067
1
2
2
3
3776
492
3.5691
1
2
2
4
7777
178
2.0674
1
1
2
3
3778
489
2.7607
1
1
2
3
5779
107
2.6449
1
1
1
2
4780
47
2.7021
1
1
1
1
2781
3,004
3.8129
1
1
3
4
7782
125
2.7920
1
1
1
2
5790
1
65.0000
65
65
65
65
65793
1
7.0000
7
7
7
7
7794
7
1.2857
1
1
1
1
2799
623
14.2472
4
7
11
19
28800
700
8.3700
3
4
6
11
17801
602
4.8688
2
2
4
6
9802
692
12.9538
3
6
10
16
26803
1,004
6.5787
1
3
5
8
13804
996
3.3203
1
1
2
4
7808
8,316
7.9752
2
4
6
10
15809
15,532
5.0147
2
2
4
6
9810
3,819
3.9296
1
2
3
5
7811
18,353
5.5474
1
2
4
7
11812
83,122
3.7292
1
2
3
5
7813
15,074
5.1932
1
2
4
7
11814
1,631
7.1594
2
3
5
9
15815
3,340
4.9177
2
2
4
6
9816
2,359
3.4349
1
2
3
4
7820
1,481
18.3849
5
8
14
24
37821
2,530
7.8375
1
3
6
10
16822
2,142
3.7250
1
1
3
5
8823
2,437
15.3943
5
8
13
20
28824
3,039
8.8427
2
4
7
12
17825
2,010
4.7866
1
2
3
7
10826
562
17.3488
5
8
13
21
34827
1,318
7.6115
2
4
6
9
15828
872
3.7500
1
2
3
5
7829
1,375
10.4611
2
4
7
14
23830
531
3.6591
1
1
2
4
8834
5,260
14.6249
2
4
9
23
35835
1,469
8.2178
1
3
5
9
20836
1,526
5.0125
1
2
3
6
10837
1,624
22.6558
5
9
23
30
39838
900
9.2122
3
4
5
7
25839
1,385
6.0368
3
4
5
6
8840
15,155
9.5956
2
4
7
12
20841
11,017
6.6239
2
3
5
8
13842
7,682
4.2890
1
2
3
6
8843
1,477
8.7204
2
4
7
11
17844
2,856
6.0007
2
3
5
8
12845
1,008
4.3065
1
2
3
6
9846
2,481
8.4869
2
3
5
10
19847
23,676
3.2722
1
2
3
4
6848
1,701
2.9259
1
1
2
4
5849
1,500
5.9887
1
3
4
6
13853
31,446
16.7084
5
8
13
21
31854
6,882
11.1935
4
6
9
14
20( print page 25080)855
467
7.5096
2
4
6
10
14856
6,188
16.1577
5
7
12
20
32857
10,066
8.8965
3
4
7
11
17858
3,502
6.0888
2
3
5
7
11862
7,426
8.2665
2
4
6
10
16863
21,813
5.2222
2
3
4
7
9864
19,829
4.0996
1
2
3
5
8865
2,019
6.8366
2
3
5
8
15866
9,410
3.5129
1
2
3
4
6867
5,307
9.9354
3
4
7
13
20868
2,371
6.0017
2
3
5
7
11869
1,101
4.3697
2
2
4
5
8870
13,711
15.2393
6
8
13
19
27871
203,725
7.6898
2
4
6
10
15872
92,141
5.7923
2
3
5
7
10876
968
11.1746
1
4
8
14
24880
10,497
3.2223
1
1
2
4
6881
4,577
4.1534
1
2
3
5
8882
1,656
4.4771
1
2
3
5
8883
786
7.4288
1
2
4
8
16884
21,621
5.3979
2
3
4
6
10885
77,784
7.5960
2
3
6
9
15886
376
5.8963
1
2
4
6
11887
424
4.5825
1
2
3
5
8894
4,480
2.9406
1
1
2
3
6895
6,477
10.4868
3
5
8
14
21896
5,372
6.6035
2
3
5
8
13897
35,839
4.0848
1
2
3
5
7901
917
14.4275
3
5
9
17
30902
2,136
8.0108
2
3
6
10
16903
1,740
4.8977
1
2
4
6
10904
941
12.3528
2
4
7
14
22905
798
4.8070
1
2
4
6
9906
745
3.2725
1
1
2
4
7907
8,101
11.6595
3
5
8
14
24908
7,885
7.0411
2
3
5
9
14909
5,974
3.6696
1
2
3
5
7913
813
6.0873
2
3
5
8
12914
6,959
3.3993
1
2
3
4
6915
915
4.6120
1
2
3
6
10916
5,370
2.1391
1
1
2
3
4917
14,156
5.2280
1
2
4
6
11918
34,873
2.7266
1
1
2
3
5919
10,570
6.2364
1
3
4
8
13920
12,143
4.4851
1
2
3
6
9921
11,663
2.9882
1
1
2
4
6922
1,005
6.0836
1
2
4
8
14923
4,212
3.2946
1
1
2
4
6927
182
28.9670
9
15
25
40
54928
795
16.1975
4
8
14
20
31929
459
7.7930
2
3
6
11
16933
155
5.9097
1
1
2
6
14934
694
6.8329
1
3
5
8
14935
2,179
5.5571
1
2
4
7
12939
423
10.9622
2
4
8
14
22940
690
6.4580
1
3
5
8
14941
1,077
3.1309
1
1
2
4
6945
5,058
10.5042
4
6
9
13
19946
3,199
7.8634
4
5
7
9
12947
6,546
4.9904
1
2
4
6
10948
34,333
3.4084
1
2
3
4
6949
742
4.1631
1
1
2
5
8950
476
3.4286
1
1
2
4
6951
990
3.7434
1
1
2
3
6955
446
12.2825
2
6
10
16
23956
3,720
9.4664
4
5
7
11
18957
1,157
16.7398
3
8
14
21
31958
737
11.5875
3
6
10
14
21959
816
7.7132
1
4
6
10
15963
1,395
9.4803
1
4
8
13
19( print page 25081)964
1,578
6.8054
2
4
6
9
12965
2,016
4.6984
1
3
4
6
9969
598
19.0033
5
8
14
24
38970
231
11.7965
2
5
8
15
25974
7,276
9.3487
2
4
7
12
20975
3,463
8.0323
2
3
6
10
16976
2,729
5.5790
2
3
4
7
11977
4,874
5.2154
1
2
4
6
10981
26,287
15.2524
5
8
12
19
28982
18,597
10.0533
3
5
8
13
19983
6,767
5.5626
1
2
5
7
11984
669
14.6114
5
8
13
18
27985
1,048
9.8559
2
5
9
13
18986
890
5.2213
1
2
4
8
11987
8,037
13.1528
4
6
11
17
25988
11,880
7.9806
2
4
7
10
15989
6,538
4.2389
1
1
3
6
911,663,472
 Table 8A.—Proposed Statewide Average Operating Cost-to-Charge Ratios—March 2007
State
Urban
RuralAlabama
0.26
0.34Alaska
0.42
0.714Arizona
0.28
0.43Arkansas
0.332
0.353California
0.23
0.33Colorado
0.302
0.446Connecticut
0.417
0.502Delaware
0.496
0.462District of Columbia
0.351Florida
0.246
0.288Georgia
0.341
0.392Hawaii
0.37
0.444Idaho
0.47
0.565Illinois
0.319
0.403Indiana
0.411
0.447Iowa
0.374
0.455Kansas
0.296
0.441Kentucky
0.379
0.375Louisiana
0.307
0.355Maine
0.495
0.466Maryland
0.732
0.799Massachusetts
0.48Michigan
0.371
0.467Minnesota
0.385
0.526Mississippi
0.317
0.369Missouri
0.329
0.372Montana
0.431
0.49Nebraska
0.363
0.457Nevada
0.224
0.483New Hampshire
0.456
0.443New Jersey
0.183New Mexico
0.379
0.386New York
0.358
0.523North Carolina
0.434
0.414North Dakota
0.443
0.467Ohio
0.361
0.534Oklahoma
0.308
0.394Oregon
0.467
0.42Pennsylvania
0.275
0.436Puerto Rico
0.452Rhode Island
0.394South Carolina
0.284
0.317South Dakota
0.352
0.442Tennessee
0.316
0.379Texas
0.271
0.348Utah
0.418
0.571Vermont
0.54
0.637Virginia
0.363
0.37Washington
0.401
0.447West Virginia
0.484
0.474Wisconsin
0.425
0.476Wyoming
0.431
0.53
 Table 8B.—Proposed Statewide Average Capital Cost-to-Charge Ratios—March 2007
State
RatioAlabama
0.025Alaska
0.039Arizona
0.024Arkansas
0.025California
0.016Colorado
0.029Connecticut
0.028Delaware
0.036District of Columbia
0.025Florida
0.023Georgia
0.029Hawaii
0.032Idaho
0.04Illinois
0.026Indiana
0.037Iowa
0.028Kansas
0.03Kentucky
0.029Louisiana
0.03Maine
0.033Maryland
0.055Massachusetts
0.032Michigan
0.03Minnesota
0.028Mississippi
0.028Missouri
0.027Montana
0.036Nebraska
0.038Nevada
0.023New Hampshire
0.034New Jersey
0.013New Mexico
0.032New York
0.029North Carolina
0.036North Dakota
0.04Ohio
0.029Oklahoma
0.029Oregon
0.032Pennsylvania
0.023Puerto Rico
0.035Rhode Island
0.021South Carolina
0.025South Dakota
0.033Tennessee
0.031Texas
0.027Utah
0.037Vermont
0.042Virginia
0.037Washington
0.031West Virginia
0.033Wisconsin
0.039Wyoming
0.044
 Table 8C.—Proposed Statewide Average Total Cost-to-Charge Ratios for LTCHS—March 2007
State
Urban
RuralAlabama
0.283
0.372Alaska
0.453
0.776Arizona
0.305
0.465Arkansas
0.355
0.383California
0.244
0.351Colorado
0.329
0.491Connecticut
0.445
0.543Delaware
0.532
0.504( print page 25082)District of Columbia *
0.376Florida
0.269
0.32Georgia
0.369
0.427Hawaii
0.4
0.482Idaho
0.509
0.609Illinois
0.344
0.436Indiana
0.448
0.493Iowa
0.398
0.496Kansas
0.323
0.482Kentucky
0.408
0.405Louisiana
0.337
0.385Maine
0.53
0.495Maryland **
0.445
0.351Massachusetts *
0.512Michigan
0.4
0.503Minnesota
0.412
0.564Mississippi
0.344
0.398Missouri
0.354
0.406Montana
0.463
0.533Nebraska
0.398
0.504Nevada
0.246
0.549New Hampshire
0.491
0.475New Jersey *
0.196New Mexico
0.412
0.417New York
0.387
0.56North Carolina
0.47
0.449North Dakota
0.48
0.515Ohio
0.388
0.575Oklahoma
0.336
0.425Oregon
0.5
0.451Pennsylvania
0.295
0.469Puerto Rico *
0.487Rhode Island *
0.415South Carolina
0.309
0.344South Dakota
0.381
0.481Tennessee
0.346
0.413Texas
0.297
0.379Utah
0.454
0.627Vermont
0.584
0.676Virginia
0.4
0.408Washington
0.432
0.48West Virginia
0.517
0.507Wisconsin
0.464
0.516Wyoming
0.466
0.583* All counties in the State or Territory are classified as urban, with the exception of Massachusetts, which has areas designated as rural. However, no short-term acute care IPPS hospitals or LTCHs are located in those areas as of March 2007.**National average IPPS total cost-to-charge ratios, as discussed in section VI.E. of this proposed rule.
 Table 9A.—Hospital Reclassifications and Redesignations—FY 2008
Provider No.
Geographic CBSA
Reclassified CBSA
LUGAR010005
01
26620010009
19460
26620010010
01
13820010012
01
40660010022
01
12060
LUGAR010025
01
17980010029
12220
17980010035
01
13820010044
01
13820010045
01
13820010054
19460
26620010059
19460
26620010065
01
13820010072
01
11500
LUGAR010083
01
33660010085
19460
26620010090
33660
37700010100
01
37860010101
01
13820
LUGAR010118
01
46220010126
01
33860010143
01
13820010150
01
33860010158
01
19460010164
01
11500
LUGAR020008
02
11260030007
39140
22380
LUGAR030033
03
22380030055
29420
39140030101
29420
29820040014
04
30780040017
04
22220040019
04
32820040020
27860
32820040027
04
44180040039
04
26040041
04
30780040069
04
32820040071
38220
30780040076
04
30780
LUGAR040078
26300
30780040080
04
27860040085
04
32820040088
04
33740040091
04
45500( print page 25083)040100
04
30780040119
04
30780050006
05
39820050009
34900
46700050013
34900
46700050014
05
40900050022
40140
42044050042
05
39820050046
37100
31084050054
40140
42044050065
42044
31084050069
42044
31084050071
41940
36084050073
46700
36084050076
41884
36084050082
37100
31084050089
40140
31084050090
42220
41884050099
40140
31084050101
46700
36084050102
40140
42044050118
44700
33700050129
40140
31084050133
49700
40900050136
42220
41884050140
40140
31084050150
05
0900050159
37100
31084050168
42044
31084050173
42044
31084050174
42220
41884050193
42044
31084050194
42100
41940050197
41884
36084050224
42044
31084050226
42044
31084050230
42044
31084050236
37100
31084050242
42100
41940050243
40140
42044050245
40140
31084050272
40140
31084050279
40140
31084050291
42220
41884050292
40140
42044050298
40140
31084050300
40140
31084050301
05
42220050327
40140
31084050329
40140
42044050348
42044
31084050367
46700
36084050385
42220
41884050390
40140
42044050394
37100
31084050423
40140
42044050426
42044
31084050476
05
42220050494
05
40900050510
41884
36084050517
40140
31084050526
42044
31084050534
40140
42044050535
42044
31084050541
41884
36084050543
42044
31084050547
42220
41884050548
42044
31084050549
37100
31084050550
42044
31084050551
42044
31084( print page 25084)050567
42044
31084050570
42044
31084050573
40140
42044050580
42044
31084050584
40140
31084050585
42044
31084050586
40140
31084050589
42044
31084050592
42044
31084050594
42044
31084050603
42044
31084050609
42044
31084050616
37100
31084050667
34900
46700050678
42044
31084050680
46700
36084050684
40140
42044050686
40140
42044050690
42220
41884050693
42044
31084050694
40140
42044050701
40140
42044050709
40140
31084050714
42100
41940050718
40140
42044050720
42044
31084050749
37100
31084060001
24540
19740060003
14500
19740060023
24300
19740060027
14500
19740060049
06
22660060075
06
24300060096
06
19740060103
14500
19740060116
14500
19740070001
35300
35004070003
07
25540
LUGAR070005
35300
35004070006
14860
35644070010
14860
35644070015
25540
35644070016
35300
35004070017
35300
35004070018
14860
35644070019
35300
35004070022
35300
35004070028
14860
35644070031
35300
35004070033
14860
35644070034
14860
35644070036
25540
35300070038
35300
35004070039
35300
35004080001
48864
37964080003
48864
37964080004
20100
48864080006
08
20100080007
08
36140090011
47894
13644100002
48424
22744100014
19660
36740100017
19660
36740100022
33124
22744100023
10
36740100024
10
33124100045
19660
36740100047
39460
42260100049
10
29460100068
19660
36740100072
19660
36740( print page 25085)100077
39460
42260100080
48424
22744100081
10
23020
LUGAR100105
42680
38940100109
10
36740100118
37380
27260100130
48424
22744100139
10
23540
LUGAR100150
10
33124100156
10
23540100157
29460
45300100168
48424
22744100176
48424
22744100217
42680
38940100232
10
23540100234
48424
22744100236
39460
42260100239
45300
42260100249
10
45300100252
10
42680100253
48424
22744100258
48424
22744100268
48424
22744100269
48424
22744100275
48424
22744100287
48424
22744100288
48424
22744100292
10
23020
LUGAR110002
11
12060110016
11
17980110023
11
12060110029
23580
12060110038
11
45220110040
11
12060
LUGAR110041
11
12060110052
11
16860
LUGAR110054
40660
12060110069
47580
31420110075
11
42340110088
11
12060
LUGAR110095
11
10500110117
11
12060
LUGAR110121
11
45220110122
46660
45220110125
11
31420110128
11
42340110146
11
27260110150
11
12060110153
47580
31420110168
40660
12060110187
11
12060
LUGAR110189
11
12060120028
12
26180130002
13
29130003
30300
28420130018
26820
38540130049
17660
44060130067
13
26820
LUGAR140010
16974
16974140012
14
16974140015
14
41180140032
14
41180140033
29404
16974140034
14
41180140040
14
37900140043
14
19340140046
14
41180140058
14
41180140064
14
37900140084
29404
16974140100
29404
16974( print page 25086)140110
14
16974140130
29404
16974140143
14
16974140155
28100
16974140160
14
40420140161
14
16974140164
14
41180140186
28100
16974140202
29404
16974140233
40420
16974140236
14
28100
LUGAR140291
29404
16974150002
23844
16974150004
23844
16974150006
33140
43780150008
23844
16974150011
15
26900150018
21140
43780150026
21140
43780150030
15
26900
LUGAR150034
23844
16974150042
15
14020150045
15
23060150048
15
17140150051
14020
26900150065
15
26900150069
15
17140150076
15
43780150088
11300
26900150090
23844
16974150091
15
23060150102
15
23844
LUGAR150112
18020
26900150113
11300
26900150115
15
21780150122
15
26900150125
23844
16974150126
23844
16974150133
15
23060150146
15
23060150147
23844
16974160001
16
11180160016
16
11180160057
16
26980160064
16
47940160080
16
19340160089
16
26980160147
16
11180170006
17
27900170012
17
48620170013
17
48620170020
17
48620170023
17
48620170033
17
48620170058
17
28140170068
17
11100170120
17
27900170142
17
45820170175
17
48620170190
17
45820170193
17
48620180002
18
49180005
18
26580180011
18
30460180012
21060
31140180013
14540
34980180017
18
21060180019
18
17140180024
18
31140180027
18
17300180029
18
30460( print page 25087)180044
18
26580180048
18
31140180049
18
30460180050
18
28700180066
18
34980180069
18
26580180075
18
14540
LUGAR180078
18
26580180080
18
28940180093
18
21780180102
18
17300180104
18
17300180116
18
17300180124
14540
34980180127
18
31140180132
18
30460190003
19
29180190015
19
35380190086
19
33740190088
19
43340190099
19
12940190106
19
10780190144
19
43340190155
19
12940
LUGAR190164
19
45190167
19
29180190184
19
33740190191
19
29180190208
19
04190218
19
43340190223
19
12940
LUGAR200020
38860
40484200024
30340
38860200034
30340
38860200039
20
38860200050
20
12620200063
20
38860220001
49340
14484220002
15764
14484220008
39300
14484220010
37764
14484220011
15764
14484220019
49340
14484220020
39300
14484220025
49340
14484220028
49340
14484220029
37764
14484220033
37764
14484220035
37764
14484220049
15764
14484220058
49340
14484220062
49340
14484220063
15764
14484220070
15764
14484220073
39300
14484220077
44140
25540220080
37764
14484220082
15764
14484220084
15764
14484220090
49340
14484220095
49340
14484220098
15764
14484220101
15764
14484220105
15764
14484220133
15764
14484220163
49340
14484220171
15764
14484220174
37764
14484230002
19804
11460230003
26100
34740230013
47644
22420( print page 25088)230019
47644
22420230020
19804
11460230021
35660
28020230022
23
29620230024
19804
11460230029
47644
22420230030
23
40980230035
23
24340
LUGAR230036
23
13020230037
23
11460230038
24340
34740230047
47644
19804230053
19804
11460230054
23
24580230059
24340
34740230065
19804
11460230069
47644
11460230071
47644
22420230072
26100
34740230077
40980
22420230080
23
13020230089
19804
11460230092
27100
11460230096
23
28020230097
23
24340230099
33780
11460230104
19804
11460230105
23
13020230106
24340
34740230119
19804
11460230121
23
29620
LUGAR230130
47644
22420230134
23
26100
LUGAR230135
19804
11460230142
19804
11460230146
19804
11460230151
47644
22420230165
19804
11460230174
26100
34740230176
19804
11460230195
47644
19804230204
47644
19804230207
47644
22420230208
23
24340
LUGAR230217
12980
29620230222
23
13020230223
47644
22420230227
47644
19804230236
24340
34740230244
19804
11460230254
47644
22420230257
47644
19804230264
47644
19804230269
47644
22420230270
19804
11460230273
19804
11460230277
47644
22420230279
47644
11460230293
19804
11460230295
23
26100
LUGAR240030
24
41060240036
41060
33460240064
24
20260240069
24
40340240071
24
40340240075
24
41060240088
24
41060240093
24
33460240105
24
40340
LUGAR240150
24
40340
LUGAR240187
24
33460( print page 25089)250002
25
22520250004
25
32820250006
25
32820250009
25
27180250023
25
25060
LUGAR250031
25
27140250034
25
32820250040
37700
25060250042
25
32820250044
25
22520250069
25
46220250078
25620
25060250079
25
27140250081
25
46220250082
25
38220250094
25620
25060250097
25
12940250099
25
27140250100
25
46220250104
25
46220250117
25
25060
LUGAR260009
26
28140260015
26
27860260017
26
27620260022
26
16260025
26
41180260049
26
44180
LUGAR260050
26
41140260064
26
17860260074
26
17860260094
26
44180260110
26
41180260113
26
14260119
26
27860260175
26
28140260183
26
41180260186
26
27620270003
27
24500270017
27
33540280009
28
30700280023
28
30700280032
28
30700280061
28
53280065
28
24540280125
28
43580290002
29
16180
LUGAR290006
29
39900290008
29
41620290019
16180
39900300011
31700
15764300012
31700
15764300014
40484
31700300018
40484
31700300019
30
15764300020
31700
15764300034
31700
15764310002
35084
35644310009
35084
35644310013
35084
35644310014
15804
37964310015
35084
35644310017
35084
35644310018
35084
35644310021
45940
35084310031
15804
20764310032
47220
48864310038
20764
35644310039
20764
35644310048
20764
35084310050
35084
35644310054
35084
35644( print page 25090)310070
20764
35644310076
35084
35644310081
15804
37964310083
35084
35644310093
35084
35644310096
35084
35644310108
20764
35644310119
35084
35644320003
32
42140320005
22140
10740320006
32
10740320013
32
42140320014
32
29740320033
32
42140
LUGAR320063
32
36220320065
32
36220330004
28740
39100330008
33
15380
LUGAR330023
39100
14860330027
35004
35644330038
33
40380
LUGAR330049
39100
14860330067
39100
14860330073
33
40380
LUGAR330079
33
47330085
33
45060330094
33
28740330103
33
39330106
35004
35644330126
39100
35644330136
33
45060330157
33
45060330167
35004
35644330181
35004
35644330182
35004
35644330191
24020
10580330198
35004
35644330224
28740
39100330225
35004
35644330229
33
21500330235
33
45060
LUGAR330239
33
21500330250
33
15540330259
35004
35644330277
33
27060330331
35004
35644330332
35004
35644330372
35004
35644330386
33
35084340004
24660
49180340008
34
16740340010
24140
39580340013
34
16740340015
34
16740340021
34
16740340023
11700
24860340027
34
24780340039
34
16740340050
34
22180340051
34
25860340068
34
48900340069
39580
20500340070
15500
24660340071
34
39580
LUGAR340073
39580
20500340091
24660
49180340109
34
47260340114
39580
20500340115
34
20500340124
34
39580
LUGAR340126
34
39580( print page 25091)340127
34
20500
LUGAR340129
34
16740340131
34
24780340136
34
20500
LUGAR340138
39580
20500340144
34
16740340145
34
16740
LUGAR340147
40580
39580340173
39580
20500350003
35
13900350006
35
13900350009
35
22020360008
36
26580360010
36
15940360011
36
18140360013
36
30620360014
36
18140360019
10420
17460360020
10420
17460360025
41780
45780360027
10420
17460360036
36
17460360039
36
18140360054
36
26580360065
36
45780360078
10420
17460360079
19380
17140360084
15940
10420360086
44220
19380360095
36
45780360096
36
49660
LUGAR360107
36
45780360121
36
45780360150
10420
17460360159
36
18140360175
36
18140360185
36
49660
LUGAR360187
44220
19380360197
36
18140360211
48260
38300360238
36
49660
LUGAR360241
10420
17460360245
36
17460
LUGAR360253
19380
17140370004
37
27900370006
37
46140370014
37
43300370015
37
46140370016
37
36420370018
37
46140370022
37
30020370025
37
46140370026
37
36420370047
37
36420370049
37
36420370113
37
22220370149
37
36420380001
38
38900380022
38
18700
LUGAR380027
38
21660380050
38
32780380090
38
21660390006
39
25420390013
39
25420390016
39
36390030
39
10900390031
39
39740
LUGAR390044
39740
37964390046
49620
29540390048
39
25420390065
39
12580( print page 25092)390066
30140
25420390071
39
48700
LUGAR390079
39
13780390081
37964
48864390086
39
27780390091
39
49660390093
39
38300390096
39740
37964390110
27780
38300390113
39
49660390133
10900
37964390138
39
25420390150
39
38300
LUGAR390151
39
13644390156
37964
48864390162
10900
35084390180
37964
48864390222
37964
48864390246
39
48700390313
39
39740
LUGAR400048
25020
41980410001
39300
14484410004
39300
14484410005
39300
14484410007
39300
14484410010
39300
14484410011
39300
14484410012
39300
14484410013
39300
35980420007
43900
24860420009
42
24860
LUGAR420020
42
16770420027
11340
24860420028
42
44940
LUGAR420030
42
16700420036
42
16740420039
42
43900
LUGAR420062
42
16740420067
42
42340420068
42
16700420069
42
44940
LUGAR420071
42
24860420080
42
42340420083
43900
24860420085
34820
48900420098
42
34820430012
43
43620430013
43
43620430014
43
22020440002
27180
32820440008
44
27180440020
44
26620440024
17420
16860440025
44
34440035
17300
34980440056
34100
28940440060
44
27180440067
34100
28700440068
44
16860440072
44
32820440073
44
34980440148
44
34980440151
44
34980440175
44
34980440185
17420
16860440192
44
34980450007
45
41700450032
45
43340450039
23104
19124450059
41700
12420450064
23104
19124( print page 25093)450080
45
30980450087
23104
19124450099
45
11100450121
23104
19124450135
23104
19124450137
23104
19124450148
23104
19124450178
45
36220450187
45
26420450196
45
19124450211
45
30980450214
45
26420450224
45
46340450283
45
19124
LUGAR450286
45
17780
LUGAR450324
43300
19124450347
45
26420450351
45
23104450389
45
19124
LUGAR450393
43300
19124450395
45
26420450419
23104
19124450438
45
26420450447
45
19124450465
45
26420450469
43300
19124450484
45
30980450508
45
30980450563
23104
19124450596
45
23104450639
23104
19124450656
45
30980450672
23104
19124450675
23104
19124450677
23104
19124450747
45
46340450770
45
12420
LUGAR450779
23104
19124450813
45
41700450830
45
36220450839
45
43340450858
23104
19124450872
23104
19124450880
23104
19124460004
36260
41620460005
36260
41620460007
46
41100460011
46
39340460021
41100
29820460026
46
39340460039
46
30860460041
36260
41620460042
36260
41620470001
47
30470012
47
38340490004
25500
16820490005
49020
47894490013
49
31340490018
49
16820490019
49
47894490042
13980
40220490048
40220
31340490079
49
49180490092
49
40060490097
49
40060490105
49
28700490106
49
16820490109
47260
40060500002
50
28420500003
34580
42644500007
34580
42644( print page 25094)500016
48300
42644500021
45104
42644500024
36500
45104500031
50
36500500039
14740
42644500041
31020
38900500072
50
14740500079
45104
42644500108
45104
42644500129
45104
42644500139
36500
45104500143
36500
45104510001
34060
38300510002
51
40220510006
51
34060510018
51
16620
LUGAR510024
34060
38300510030
51
34060510046
51
13980510047
51
38300510062
51
16620510070
51
16620510071
51
13980510077
51
26580520002
52
48140520021
29404
16974520028
52
31540
LUGAR520037
52
48140520059
39540
29404520071
52
33340
LUGAR520076
52
31540520095
52
31540520102
52
33340
LUGAR520107
52
22540520113
52
24580520116
52
33340
LUGAR520189
29404
16974530015
53
26820
 Table 9C.—Hospitals Redesignated as Rural Under Section 1886(
                            d
                            )(8)(E) of the Act—FY 2008
Provider No.
Geographic CBSA
Redesignated rural area050192
23420
05050528
32900
05050618
40140
05070004
25540
07100048
37860
10100134
27260
10140167
14
14170137
29940
17220051
38340
22230078
35660
23250126
32820
25260006
41140
26260047
27620
26260195
44180
26330044
46540
33330245
46540
33330268
10580
33360125
36
36370054
36420
37380040
13460
38390181
39
39390183
39
39390201
39
39440135
34980
44440144
44
44450052
45
45( print page 25095)450078
10180
45450243
10180
45450348
45
45500148
48300
50520060
52
52
 Table 10.—Geometric Mean Plus the Lesser of .75 of the National Adjusted Operating Standardized Payment Amount (Increased to Reflect the Difference Between Costs and Charges) or .75 of One Standard Deviation of Mean Charges by Proposed Medicare Severity Diagnosisrelated Group (MS-DRG) April 2007 1
Proposed MS-DRG
Number of cases
Threshold1
629
$368,0152
328
$193,4973
23,999
$290,2544
21,742
$177,9645
842
$174,3806
495
$99,2147
413
$141,6238
560
$101,1609
1,358
$104,43610
177
$78,62911
1,289
$77,49512
1,923
$55,13613
1,484
$39,38520
901
$151,50321
558
$117,02622
251
$80,99323
3,112
$88,34524
2,576
$65,14625
8,417
$85,62326
11,626
$56,51927
14,454
$43,78128
1,609
$79,47429
2,862
$48,07530
3,751
$32,13131
1,057
$64,22632
2,987
$37,36733
4,263
$30,93534
813
$61,46735
2,506
$44,31436
7,710
$38,14037
4,777
$54,61538
14,602
$34,54239
55,357
$25,68740
4,549
$62,71541
7,720
$41,78242
5,430
$36,03652
1,156
$31,04253
593
$23,80854
4,664
$32,13355
16,896
$25,98756
7,716
$30,53657
48,432
$19,65758
789
$29,81059
2,639
$23,21960
4,201
$17,67961
1,340
$56,59862
2,288
$44,31963
1,185
$38,04764
55,552
$36,31565
112,189
$28,25366
94,547
$21,58667
1,383
$32,33168
12,393
$23,59369
103,747
$18,93670
7,092
$35,87671
10,001
$27,57072
6,056
$20,62873
8,655
$28,28074
32,523
$21,42775
1,197
$35,84676
874
$24,62377
1,101
$34,91278
1,307
$25,66379
957
$20,52380
2,077
$25,44481
8,190
$17,50282
1,646
$36,20483
1,940
$30,06284
2,591
$23,35685
5,328
$37,79286
10,382
$27,62587
12,152
$20,14488
717
$31,77589
2,641
$24,25790
3,319
$17,87491
6,676
$31,19492
14,890
$22,31393
15,484
$17,17294
1,521
$60,74395
1,088
$45,38996
755
$38,57697
1,252
$54,57398
1,048
$37,84599
642
$31,587100
15,837
$30,385101
56,905
$19,341102
1,352
$25,466103
15,023
$17,133113
568
$33,509114
601
$21,640115
1,098
$26,668116
665
$24,976117
1,400
$16,827121
587
$23,703122
674
$13,518123
2,843
$19,108124
679
$25,406125
4,705
$16,568129
1,374
$39,926130
1,072
$30,097131
655
$38,488132
728
$28,470133
1,352
$32,869134
2,661
$20,306135
781
$37,347136
1,113
$24,451137
1,108
$29,974138
1,370
$20,587139
2,145
$22,300146
687
$37,368147
1,422
$26,407148
935
$18,944149
39,248
$15,883150
939
$26,227151
6,801
$13,607152
2,352
$23,720153
16,028
$15,145154
1,843
$29,263155
4,207
$22,020156
5,140
$16,103157
1,145
$29,722158
3,039
$21,662159
2,418
$15,345163
13,431
$84,838164
18,047
$50,487165
14,553
$39,842166
20,290
$62,666167
20,772
$42,250168
5,758
$31,795175
11,954
$35,088176
40,173
$26,922177
57,179
$38,623178
71,192
$31,821179
27,454
$25,264180
22,474
$34,645181
32,156
$27,982182
6,163
$23,372183
1,654
$31,015184
4,141
$22,561185
2,593
$15,740186
8,533
$33,538( print page 25096)187
9,968
$26,845188
5,148
$20,974189
104,531
$30,042190
57,041
$29,138191
121,659
$24,641192
196,903
$18,419193
88,053
$31,201194
266,599
$25,213195
147,744
$18,274196
5,143
$32,537197
6,894
$26,836198
4,943
$21,129199
3,257
$34,933200
8,185
$24,946201
3,523
$17,676202
31,587
$20,635203
41,587
$15,003204
26,039
$17,394205
5,775
$27,595206
22,415
$18,854207
46,165
$89,753208
79,432
$43,969215
150
$161,680216
8,411
$176,029217
7,609
$124,842218
3,256
$104,178219
10,062
$140,684220
13,481
$99,812221
8,383
$85,690222
2,865
$159,922223
5,770
$123,934224
1,919
$147,237225
5,871
$115,628226
7,048
$120,197227
50,536
$93,738228
3,084
$135,095229
4,128
$94,076230
1,989
$77,297231
1,478
$147,555232
1,795
$114,348233
16,911
$128,139234
39,167
$91,908235
9,628
$103,136236
32,871
$71,913237
21,789
$90,628238
44,929
$56,647239
13,814
$69,191240
13,349
$45,896241
3,350
$33,094242
17,179
$68,158243
37,856
$52,815244
68,201
$44,155245
6,241
$57,244246
32,661
$68,691247
279,972
$49,206248
5,013
$61,557249
29,657
$43,877250
5,739
$56,715251
39,905
$40,116252
44,602
$51,463253
46,864
$45,888254
59,029
$36,249255
2,609
$42,857256
3,833
$32,015257
774
$23,818258
598
$53,008259
7,328
$36,819260
867
$50,387261
2,804
$29,564262
3,378
$23,301263
788
$30,589264
30,137
$42,489280
60,735
$38,714281
57,734
$29,876282
60,951
$23,031283
15,852
$32,521284
4,911
$24,328285
3,254
$17,351286
23,282
$42,720287
172,488
$29,775288
3,245
$53,565289
1,423
$38,265290
484
$29,384291
183,774
$30,658292
217,052
$24,625293
226,688
$17,810294
1,704
$21,989295
1,658
$13,805296
1,730
$28,035297
943
$20,306298
554
$12,889299
17,443
$29,542300
46,820
$21,997301
39,910
$15,712302
7,873
$24,885303
81,458
$15,192304
2,084
$25,286305
35,646
$15,139306
1,379
$29,019307
6,447
$18,857308
33,528
$28,534309
79,751
$20,827310
160,738
$14,816311
24,867
$13,364312
169,247
$18,273313
220,769
$14,894314
60,053
$32,586315
30,730
$24,616316
20,101
$16,823326
11,567
$94,842327
10,901
$52,780328
9,333
$33,659329
48,135
$85,323330
66,303
$49,556331
31,391
$36,640332
1,890
$78,691333
6,196
$48,432334
4,023
$35,774335
7,161
$72,588336
12,516
$45,452337
8,835
$34,087338
1,499
$61,541339
3,192
$41,786340
3,607
$31,931341
874
$45,417342
2,536
$33,389343
6,875
$24,258344
898
$54,574345
2,915
$35,196346
2,909
$27,779347
1,568
$38,823348
3,985
$29,136349
5,787
$19,265350
1,669
$43,250351
3,997
$29,564352
8,419
$19,894353
3,182
$46,944354
9,118
$32,066355
17,451
$23,281356
8,366
$62,960357
8,046
$42,318358
2,714
$32,613368
3,052
$33,308369
4,005
$26,885370
3,914
$20,084371
16,843
$34,017372
22,903
$27,955373
14,897
$20,598374
9,414
$36,691375
19,730
$27,763376
4,816
$22,720377
50,503
$32,599378
84,806
$25,682379
128,748
$19,140380
2,917
$34,352381
4,894
$28,117382
5,445
$20,581383
1,303
$29,683384
8,664
$21,556385
2,107
$35,137386
7,221
$26,066387
5,230
$20,543388
18,267
$31,162389
46,328
$23,425390
48,052
$16,336391
47,511
$25,915392
306,515
$17,829393
23,917
$30,478394
45,952
$24,292395
26,460
$17,594405
3,903
$90,226406
5,241
$52,384407
2,310
$38,743408
1,644
$71,983409
1,713
$49,309410
722
$37,665411
978
$69,625( print page 25097)412
1,063
$50,630413
881
$39,302414
5,596
$63,496415
6,847
$42,806416
6,222
$31,773417
16,671
$49,010418
27,563
$38,299419
38,264
$29,285420
714
$65,599421
1,091
$38,623422
364
$30,085423
1,500
$68,219424
912
$46,919425
157
$38,094432
16,259
$32,310433
9,022
$23,457434
945
$17,210435
11,908
$34,335436
13,987
$27,538437
4,357
$24,539438
14,426
$33,536439
24,816
$26,419440
27,346
$18,913441
13,912
$30,900442
12,756
$24,488443
6,698
$18,374444
12,447
$32,912445
16,757
$26,999446
16,849
$20,274453
846
$174,685454
1,496
$117,216455
1,875
$90,966456
764
$142,125457
1,763
$100,035458
1,534
$82,734459
3,180
$98,971460
50,317
$64,868461
1,062
$82,101462
14,234
$61,454463
5,283
$68,787464
6,322
$44,864465
2,942
$32,894466
4,152
$74,863467
10,818
$55,556468
28,701
$46,551469
29,730
$60,216470
410,173
$43,290471
2,227
$76,468472
6,218
$50,893473
22,546
$41,804474
2,829
$54,927475
3,530
$37,782476
1,698
$26,665477
2,257
$60,431478
7,144
$43,558479
10,267
$34,775480
25,866
$53,540481
59,136
$40,012482
64,739
$34,370483
5,729
$46,686484
17,949
$39,280485
967
$59,138486
1,535
$43,053487
1,214
$34,867488
1,551
$34,851489
3,866
$26,609490
19,803
$35,660491
58,396
$24,028492
4,700
$51,225493
15,248
$38,100494
30,563
$29,460495
1,867
$54,818496
5,049
$36,082497
7,519
$28,326498
1,177
$38,828499
1,245
$22,858500
1,349
$50,966501
3,679
$32,218502
6,825
$23,032503
736
$40,314504
2,155
$32,350505
3,214
$24,352506
909
$25,086507
779
$34,570508
2,722
$26,249509
465
$25,608510
957
$40,566511
4,008
$31,428512
11,961
$23,087513
1,287
$31,071514
1,339
$20,718515
3,577
$54,297516
10,963
$39,039517
18,263
$31,703533
828
$28,832534
3,634
$15,819535
6,844
$28,150536
34,321
$15,408537
654
$20,405538
1,164
$12,954539
3,379
$36,833540
4,187
$28,818541
1,858
$22,002542
6,158
$34,845543
18,413
$26,086544
12,644
$18,008545
4,016
$36,462546
5,881
$25,135547
4,880
$18,469548
591
$34,989549
1,077
$26,366550
904
$18,381551
9,502
$31,033552
87,859
$18,492553
2,790
$25,374554
20,253
$14,944555
1,995
$23,282556
19,168
$14,428557
3,184
$30,733558
14,178
$19,372559
1,635
$30,332560
3,979
$20,901561
7,617
$13,636562
4,996
$28,213563
36,056
$15,451564
1,606
$28,809565
3,237
$21,478566
2,779
$15,695573
5,687
$50,477574
12,100
$35,412575
6,468
$26,698576
558
$47,915577
2,179
$32,787578
3,299
$23,686579
3,088
$48,029580
6,766
$33,258581
5,288
$23,944582
8,972
$24,930583
15,549
$19,001584
1,431
$29,247585
2,818
$20,786592
3,982
$32,110593
12,832
$24,303594
2,955
$16,562595
1,082
$31,299596
5,755
$19,571597
548
$31,103598
1,483
$24,558599
350
$15,943600
572
$22,870601
865
$15,125602
21,307
$28,307603
130,923
$18,145604
2,627
$26,277605
22,672
$16,152606
1,363
$24,074607
7,169
$14,791614
1,376
$47,229615
1,626
$34,519616
1,132
$65,696617
6,822
$39,614618
343
$29,975619
663
$64,216620
1,877
$43,862621
6,556
$37,409622
1,234
$49,435623
3,268
$35,278624
487
$26,158625
1,098
$42,919626
2,522
$28,885627
14,305
$19,134628
3,267
$55,480629
3,958
$43,435630
684
$33,106637
16,283
$28,425638
40,811
$20,070639
41,135
$14,010( print page 25098)640
55,690
$25,143641
188,104
$16,575642
1,542
$24,193643
5,014
$32,744644
11,845
$25,227645
8,402
$18,520652
10,437
$62,402653
1,585
$91,794654
3,231
$57,305655
1,650
$42,998656
3,721
$59,955657
7,359
$40,718658
8,479
$33,723659
4,442
$54,626660
7,444
$38,339661
4,745
$31,241662
988
$44,122663
2,131
$30,611664
4,676
$23,754665
690
$49,701666
2,213
$31,959667
3,948
$19,910668
3,757
$41,676669
12,491
$29,038670
13,411
$19,410671
884
$30,142672
965
$19,128673
12,577
$46,104674
10,503
$42,636675
11,704
$32,785682
75,827
$31,972683
112,129
$26,767684
43,451
$19,020685
2,493
$20,233686
1,581
$32,841687
3,322
$25,246688
1,198
$18,441689
55,398
$27,175690
200,059
$18,352691
898
$33,393692
654
$25,534693
2,235
$29,001694
19,213
$17,667695
974
$25,020696
10,565
$14,808697
575
$17,475698
21,061
$29,461699
22,820
$24,300700
15,089
$17,723707
4,874
$37,314708
17,015
$29,414709
755
$36,305710
2,037
$29,222711
921
$36,269712
819
$20,449713
11,755
$26,239714
32,745
$15,644715
638
$36,067716
1,382
$28,098717
634
$33,174718
633
$19,455722
871
$30,591723
2,037
$24,888724
666
$15,999725
802
$24,549726
3,940
$16,420727
1,098
$27,652728
6,176
$16,848729
578
$23,477730
552
$14,387734
1,470
$42,020735
1,328
$26,263736
840
$73,881737
3,429
$41,554738
954
$29,484739
975
$51,269740
4,366
$33,218741
6,554
$24,119742
10,705
$31,515743
35,310
$21,122744
1,498
$30,509745
2,189
$20,066746
2,486
$29,036747
11,218
$20,664748
21,171
$19,841749
1,037
$45,581750
484
$24,671754
1,083
$33,538755
3,152
$25,336756
831
$16,790757
1,322
$32,841758
1,597
$25,832759
1,186
$19,161760
1,703
$19,848761
1,918
$13,557765
2,497
$22,146766
2,634
$14,889767
119
$15,750768
10
$29,739769
86
$31,941770
181
$18,191774
1,442
$12,637775
5,224
$9,066776
491
$15,413777
177
$19,480778
489
$8,798779
107
$14,082780
47
$5,638781
3,004
$13,343782
125
$8,369794
7
$2,880799
623
$80,879800
699
$48,145801
602
$37,100802
691
$55,325803
1,003
$35,487804
996
$25,527808
8,315
$35,924809
15,527
$25,920810
3,818
$21,504811
18,344
$25,759812
83,082
$18,156813
15,031
$26,262814
1,631
$31,374815
3,337
$24,871816
2,355
$18,234820
1,481
$89,134821
2,529
$42,943822
2,139
$30,127823
2,436
$68,790824
3,039
$42,669825
2,009
$31,129826
562
$82,779827
1,318
$42,427828
872
$30,710829
1,374
$47,009830
531
$26,963834
5,257
$54,533835
1,469
$32,379836
1,526
$24,423837
1,623
$91,611838
900
$44,011839
1,385
$28,304840
15,152
$40,430841
11,012
$30,388842
7,678
$23,796843
1,477
$34,387844
2,854
$26,126845
1,008
$21,865846
2,480
$39,831847
23,667
$26,464848
1,699
$20,748849
1,498
$28,295853
31,444
$83,950854
6,881
$53,045855
467
$37,927856
6,187
$74,156857
10,059
$39,007858
3,500
$30,128862
7,425
$34,703863
21,807
$21,882864
19,826
$20,564865
2,019
$29,189866
9,406
$16,786867
5,306
$40,813868
2,369
$25,734869
1,100
$20,520870
13,710
$99,453871
203,702
$35,587872
92,118
$26,548876
968
$43,100880
10,494
$15,328881
4,576
$11,727882
1,656
$12,481883
786
$17,701884
21,619
$19,048885
77,763
$16,598( print page 25099)886
376
$14,393887
423
$18,850894
4,480
$8,389895
6,474
$16,201896
5,369
$26,659897
35,835
$13,689901
917
$51,824902
2,135
$33,272903
1,739
$24,889904
941
$42,415905
798
$26,522906
745
$24,393907
8,098
$57,686908
7,884
$37,304909
5,971
$27,385913
813
$27,433914
6,958
$16,346915
915
$25,250916
5,369
$10,725917
14,155
$30,038918
34,847
$14,539919
10,569
$29,326920
12,135
$22,791921
11,659
$15,316922
1,005
$28,199923
4,211
$16,053927
182
$206,517928
794
$66,194929
459
$35,403933
155
$33,800934
694
$25,296935
2,179
$22,619939
423
$45,897940
690
$34,557941
1,077
$27,512945
5,053
$21,694946
3,199
$17,198947
6,544
$24,507948
34,325
$15,485949
742
$18,955950
476
$12,079951
990
$14,489955
446
$89,598956
3,718
$58,558957
1,157
$112,575958
737
$76,928959
816
$58,670963
1,395
$49,648964
1,578
$34,426965
2,016
$29,169969
598
$83,524970
231
$52,404974
7,276
$37,920975
3,463
$32,068976
2,728
$25,665977
4,871
$24,657981
26,280
$82,945982
18,594
$56,659983
6,766
$40,536984
669
$59,799985
1,048
$41,065986
890
$29,062987
8,036
$58,165988
11,880
$38,036989
6,537
$27,418999
18
$16,0061
                             Cases taken from the FY 2006 MedPAR file; proposed MSDRGs are from GROUPER Version 25.0.
 Table 11.—Proposed FY 2008 MS-LTC-DRGs, Relative Weights, Geometric Average Length of Stay, and    5/6ths of the Geometric Average Length of Stay
Proposed MS-LTC-DRG
Proposed MS-LTC-DRG description
Base MS-LTC-DRG
FY 2006 LTCH cases
Proposed relative weight
Proposed geometric average length of stay
Proposed 
                                 5/6ths of the Geometric average length of stay1
Heart transplant or implant of heart assist system w MCC 7
1
0
0.0000
0.0
0.02
Heart transplant or implant of heart assist system w/o MCC 7
1
0
0.0000
0.0
0.03
ECMO or trach w MV 96+ hrs or PDX exc face, mouth & neck w maj O.R
3
270
4.2008
64.5
53.84
Trach w MV 96+ hrs or PDX exc face, mouth & neck w/o maj O.R
4
1,069
2.9804
46.7
38.95
Liver transplant w MCC or intestinal transplant 7
5
0
0.0000
0.0
0.06
Liver transplant w/o MCC 7
5
0
0.0000
0.0
0.07
Lung transplant 7
7
0
0.0000
0.0
0.08
Simultaneous pancreas/kidney transplant 7
8
0
0.0000
0.0
0.09
Bone marrow transplant 8
9
0
1.0950
30.3
25.310
Pancreas transplant 7
10
0
0.0000
0.0
0.011
Tracheostomy for face, mouth & neck diagnoses w MCC 9
11
0
1.6489
36.5
30.412
Tracheostomy for face, mouth & neck diagnoses w CC 5
11
1
1.6489
36.5
30.413
Tracheostomy for face, mouth & neck diagnoses w/o CC/MCC 9
11
0
1.6489
36.5
30.420
Intracranial vascular procedures w PDX hemorrhage w  MCC 8
20
0
1.6489
36.5
30.421
Intracranial vascular procedures w PDX hemorrhage w CC 8
20
0
0.4800
19.9
16.6( print page 25100)22
Intracranial vascular procedures w PDX hemorrhage w/o CC/MCC 8
20
0
0.4800
19.9
16.623
Craniotomy w major device implant or acute complex CNS PDX w MCC 8
23
0
1.6489
36.5
30.424
Craniotomy w major device implant or acute complex CNS PDX w/o MCC 8
23
0
0.4800
19.9
16.625
Craniotomy & endovascular intracranial procedures w MCC 9
25
0
1.6489
36.5
30.426
Craniotomy & endovascular intracranial procedures w CC 5
25
2
1.6489
36.5
30.427
Craniotomy & endovascular intracranial procedures w/o CC/MCC 9
25
0
1.6489
36.5
30.428
Spinal procedures w MCC 4
28
6
1.0950
30.3
25.329
Spinal procedures w CC 4
28
4
1.0950
30.3
25.330
Spinal procedures w/o CC/MCC 1
28
2
0.4800
19.9
16.631
Ventricular shunt procedures w MCC 5
31
2
1.6489
36.5
30.432
Ventricular shunt procedures w CC 1
31
1
0.4800
19.9
16.633
Ventricular shunt procedures w/o CC/MCC 1
31
1
0.4800
19.9
16.634
Carotid artery stent procedure w MCC 8
34
0
1.6489
36.5
30.435
Carotid artery stent procedure w CC 8
34
0
1.0950
30.3
25.336
Carotid artery stent procedure w/o CC/MCC 8
34
0
1.0950
30.3
25.337
Extracranial procedures w MCC 5
37
12
1.6489
36.5
30.438
Extracranial procedures w CC 4
37
7
1.0950
30.3
25.339
Extracranial procedures w/o CC/MCC 4
37
1
1.0950
30.3
25.340
Periph & cranial nerve & other nerv syst proc w MCC
40
156
1.3371
36.3
30.341
Periph & cranial nerve & other nerv syst proc w CC
40
99
0.9653
34.3
28.642
Periph & cranial nerve & other nerv syst proc w/o CC/MCC 3
40
10
0.8072
24.6
20.552
Spinal disorders & injuries w CC/MCC
52
78
1.0786
32.8
27.353
Spinal disorders & injuries w/o CC/MCC 3
52
19
0.8072
24.6
20.554
Nervous system neoplasms w MCC
54
50
0.7245
23.6
19.755
Nervous system neoplasms w/o MCC
54
67
0.6543
22.0
18.356
Degenerative nervous system disorders w MCC
56
1,320
0.7993
26.4
22.057
Degenerative nervous system disorders w/o MCC
56
2,623
0.5844
24.4
20.358
Multiple sclerosis & cerebellar ataxia w MCC 6
58
23
0.5405
22.2
18.559
Multiple sclerosis & cerebellar ataxia w CC
58
44
0.5405
22.2
18.560
Multiple sclerosis & cerebellar ataxia w/o CC/MCC 6
58
22
0.5405
22.2
18.561
Acute ischemic stroke w use of thrombolytic agent w MCC 8
61
0
0.8131
24.0
20.062
Acute ischemic stroke w use of thrombolytic agent w CC 8
61
0
0.4800
19.9
16.663
Acute ischemic stroke w use of thrombolytic agent w/o CC/MCC 8
61
0
0.4800
19.9
16.664
Intracranial hemorrhage or cerebral infarction w MCC
64
126
0.8199
25.1
20.965
Intracranial hemorrhage or cerebral infarction w CC
64
116
0.6159
23.5
19.666
Intracranial hemorrhage or cerebral infarction w/o CC/MCC 1
64
24
0.4800
19.9
16.667
Nonspecific cva & precerebral occlusion w/o infarct w MCC 1
67
5
0.4800
19.9
16.668
Nonspecific cva & precerebral occlusion w/o infarct w/o MCC 1
67
8
0.4800
19.9
16.669
Transient ischemia 1
69
17
0.4800
19.9
16.670
Nonspecific cerebrovascular  disorders w MCC
70
103
0.8131
24.0
20.071
Nonspecific cerebrovascular  disorders w CC
70
86
0.5751
22.7
18.972
Nonspecific cerebrovascular disorders w/o CC/MCC 1
70
9
0.4800
19.9
16.673
Cranial & peripheral nerve disorders w MCC
73
83
0.8630
24.9
20.874
Cranial & peripheral nerve  disorders w/o MCC
73
173
0.5645
23.3
19.475
Viral meningitis w CC/MCC 2
75
20
0.6513
22.7
18.976
Viral meningitis w/o CC/MCC 1
75
1
0.4800
19.9
16.677
Hypertensive encephalopathy w MCC 2
77
4
0.6513
22.7
18.978
Hypertensive encephalopathy w CC 2, 6
77
9
0.6513
22.7
18.979
Hypertensive encephalopathy w/o CC/MCC 1
77
1
0.4800
19.9
16.680
Nontraumatic stupor & coma w MCC
80
40
0.6767
24.6
20.581
Nontraumatic stupor & coma w/o MCC
80
71
0.5395
23.1
19.382
Traumatic stupor & coma, coma >1 hr w MCC
82
27
0.8821
29.5
24.683
Traumatic stupor & coma, coma >1 hr w CC2
82
12
0.6513
22.7
18.9( print page 25101)84
Traumatic stupor & coma, coma >1 hr w/o CC/MCC 2
82
4
0.6513
22.7
18.985
Traumatic stupor & coma, coma  <1 hr w MCC
85
102
0.9666
28.3
23.686
Traumatic stupor & coma, coma <1 hr w CC
85
86
0.6711
25.2
21.087
Traumatic stupor & coma, coma <1 hr w/o CC/MCC
85
30
0.5363
20.1
16.888
Concussion w MCC 4, 6
88
1
1.0950
30.3
25.389
Concussion w CC 4
88
2
1.0950
30.3
25.390
Concussion w/o CC/MCC 9
88
0
1.0950
30.3
25.391
Other disorders of nervous system w MCC
91
243
0.8500
25.7
21.492
Other disorders of nervous system w CC
91
189
0.5981
21.9
18.393
Other disorders of nervous system w/o CC/MCC
91
54
0.4835
20.0
16.794
Bacterial & tuberculous infections of nervous system w MCC
94
211
1.0574
28.0
23.395
Bacterial & tuberculous infections of nervous system w CC
94
105
0.8454
26.8
22.396
Bacterial & tuberculous infections of nervous system w/o CC/MCC
94
26
0.8454
26.8
22.397
Non-bacterial infect of nervous sys exc viral meningitis w MCC
97
57
0.9189
26.2
21.898
Non-bacterial infect of nervous sys exc viral meningitis w CC
97
33
0.8242
22.7
18.999
Non-bacterial infect of nervoussys exc viral meningitis w/o CC/MCC 2
97
10
0.6513
22.7
18.9100
Seizures w MCC
100
40
0.8295
26.5
22.1101
Seizures w/o MCC
100
37
0.5564
21.4
17.8102
Headaches w MCC 3, 6
102
6
0.8072
24.6
20.5103
Headaches w/o MCC 3
102
11
0.8072
24.6
20.5113
Orbital procedures w CC/MCC 2
113
1
0.6513
22.7
18.9114
Orbital procedures w/o CC/MCC 9
113
0
0.6513
22.7
18.9115
Extraocular procedures exceptorbit 8
115
0
0.6513
22.7
18.9116
Intraocular procedures w CC/MCC 8
116
0
0.6513
22.7
18.9117
Intraocular procedures w/o CC/MCC 8
116
0
0.6513
22.7
18.9121
Acute major eye infections w CC/MCC 2
121
8
0.6513
22.7
18.9122
Acute major eye infections w/o CC/MCC 1
121
2
0.4800
19.9
16.6123
Neurological eye disorders 1
123
3
0.4800
19.9
16.6124
Other disorders of the eye w MCC 4
124
2
1.0950
30.3
25.3125
Other disorders of the eye w/o MCC 2
124
10
0.6513
22.7
18.9129
Major head & neck procedures w CC/MCC or major device 8
129
0
1.0950
30.3
25.3130
Major head & neck procedures w/o CC/MCC 8
129
0
0.6513
22.7
18.9131
Cranial/facial procedures w CC/MCC 5
131
2
1.6489
36.5
30.4132
Cranial/facial procedures w/o CC/MCC 9
131
0
1.6489
36.5
30.4133
Other ear, nose, mouth & throat O.R. procedures w CC/MCC 3, 6
133
3
0.8072
24.6
20.5134
Other ear, nose, mouth & throat O.R. procedures w/o CC/MCC 3, 6
133
1
0.8072
24.6
20.5135
Sinus & mastoid procedures w CC/MCC 8
135
0
0.8072
24.6
20.5136
Sinus & mastoid procedures w/o CC/MCC 8
135
0
0.8072
24.6
20.5137
Mouth procedures w CC/MCC 5
137
1
1.6489
36.5
30.4138
Mouth procedures w/o CC/MCC 9
137
0
1.6489
36.5
30.4139
Salivary gland procedures 5
139
1
1.6489
36.5
30.4146
Ear, nose, mouth & throat malignancy w MCC
146
44
1.2620
26.4
22.0147
Ear, nose, mouth & throat malignancy w CC
146
37
0.9530
24.9
20.8148
Ear, nose, mouth & throat malignancy w/o CC/MCC 2
146
4
0.6513
22.7
18.9149
Dysequilibrium 1
149
9
0.4800
19.9
16.6150
Epistaxis w MCC 8
150
0
0.6513
22.7
18.9151
Epistaxis w/o MCC 8
150
0
0.4800
19.9
16.6152
Otitis media & URI w MCC 2
152
10
0.6513
22.7
18.9153
Otitis media & URI w/o MCC 1
152
23
0.4800
19.9
16.6154
Nasal trauma & deformity w MCC
154
55
0.7560
21.2
17.7155
Nasal trauma & deformity w CC
154
44
0.7320
20.4
17.0156
Nasal trauma & deformity w/o CC/MCC 2
154
11
0.6513
22.7
18.9157
Dental & Oral Diseases w MCC 3, 6
157
9
0.8072
24.6
20.5158
Dental & Oral Diseases w CC 3, 6
157
18
0.8072
24.6
20.5159
Dental & Oral Diseases w/o  CC/MCC 3, 6
157
2
0.8072
24.6
20.5163
Major chest procedures w MCC
163
27
2.2983
39.7
33.1164
Major chest procedures w CC 5
163
10
1.6489
36.5
30.4( print page 25102)165
Major chest procedures w/o  CC/MCC 9
163
0
1.6489
36.5
30.4166
Other resp system O.R. procedures w MCC
166
1,568
2.4517
42.4
35.3167
Other resp system O.R. procedures w CC
166
233
1.8802
37.6
31.3168
Other resp system O.R. procedures w/o CC/MCC 4
166
10
1.0950
30.3
25.3175
Pulmonary embolism w MCC
175
103
0.7766
22.9
19.1176
Pulmonary embolism w/o MCC
175
139
0.5350
20.2
16.8177
Respiratory infections & inflammations w MCC
177
2,943
0.8638
23.6
19.7178
Respiratory infections & inflammations w CC
177
2,247
0.7254
22.2
18.5179
Respiratory infections & inflammations w/o CC/MCC
177
390
0.5896
19.2
16.0180
Respiratory neoplasms w MCC
180
162
0.8433
20.1
16.8181
Respiratory neoplasms w CC
180
110
0.6481
19.3
16.1182
Respiratory neoplasms w/o CC/MCC 1
180
19
0.4800
19.9
16.6183
Major chest trauma w MCC 1
183
1
0.4800
19.9
16.6184
Major chest trauma w CC 1, 6
183
1
0.4800
19.9
16.6185
Major chest trauma w/o CC/MCC 9
183
0
0.4800
19.9
16.6186
Pleural effusion w MCC
186
136
0.8571
23.6
19.7187
Pleural effusion w CC
186
64
0.6165
21.1
17.6188
Pleural effusion w/o CC/MCC 6
186
14
0.6165
21.1
17.6189
Pulmonary edema & respiratory failure
189
5,686
0.9560
23.9
19.9190
Chronic obstructive pulmonary disease w MCC
190
1,657
0.7195
20.9
17.4191
Chronic obstructive pulmonary disease w CC
190
1,542
0.6024
19.6
16.3192
Chronic obstructive pulmonary disease w/o CC/MCC
190
894
0.5192
17.2
14.3193
Simple pneumonia & pleurisy w  MCC
193
1,689
0.7400
21.6
18.0194
Simple pneumonia & pleurisy w CC
193
2,090
0.6108
19.8
16.5195
Simple pneumonia & pleurisy w/o CC/MCC
193
475
0.5321
18.1
15.1196
Interstitial lung disease w MCC
196
114
0.6613
20.0
16.7197
Interstitial lung disease w CC
196
94
0.5863
19.6
16.3198
Interstitial lung disease w/o CC/MCC
196
45
0.5717
19.7
16.4199
Pneumothorax w MCC
199
25
0.7596
22.4
18.7200
Pneumothorax w CC2
199
16
0.6513
22.7
18.9201
Pneumothorax w/o CC/MCC 1
199
11
0.4800
19.9
16.6202
Bronchitis & asthma w CC/MCC
202
92
0.6915
21.4
17.8203
Bronchitis & asthma w/o CC/MCC
202
38
0.4994
16.6
13.8204
Respiratory signs & symptoms
204
313
0.8025
22.0
18.3205
Other respiratory system diagnoses w MCC
205
260
0.8221
22.5
18.8206
Other respiratory system diagnoses w/o MCC
205
169
0.7446
21.7
18.1207
Respiratory system diagnosis w ventilator support 96+ hours
207
12,390
1.9944
34.2
28.5208
Respiratory system diagnosis w ventilator support 96 hours
208
1,879
1.5234
27.8
23.2215
Other heart assist system implant 8
215
0
0.8072
24.6
20.5216
Cardiac valve & oth maj  cardiothoracic proc w card cath w MCC 8
216
0
1.6489
36.5
30.4217
Cardiac valve & oth maj  cardiothoracic proc w card cath w CC 8
216
0
0.8072
24.6
20.5218
Cardiac valve & oth maj cardiothoracic proc w card cath w/o CC/MCC 8
216
0
0.8072
24.6
20.5219
Cardiac valve & oth maj  cardiothoracic proc w/o card cath w MCC 8
219
0
1.6489
36.5
30.4220
Cardiac valve & oth maj cardiothoracic proc w/o card cath w CC 8
219
0
0.8072
24.6
20.5221
Cardiac valve & oth maj cardiothoracic proc w/o card cath w/o CC/MCC 8
219
0
0.8072
24.6
20.5222
Cardiac defib implant w cardiaccath w AMI/HF/shock w MCC 8
222
0
1.6489
36.5
30.4223
Cardiac defib implant w cardiac cath w AMI/HF/shock w/o MCC 8
222
0
1.6489
36.5
30.4224
Cardiac defib implant w cardiac cath w/o AMI/HF/shock w MCC 8
224
0
1.6489
36.5
30.4225
Cardiac defib implant w cardiac cath w/o AMI/HF/shock w/o MCC 8
224
0
1.6489
36.5
30.4226
Cardiac defibrillator implant w/o cardiac cath w MCC 5
226
11
1.6489
36.5
30.4227
Cardiac defibrillator implant w/o cardiac cath w/o MCC 5
226
4
1.6489
36.5
30.4228
Other cardiothoracic procedures w MCC 8
228
0
1.6489
36.5
30.4229
Other cardiothoracic procedures w CC 8
228
0
1.0950
30.3
25.3230
Other cardiothoracic procedures w/o CC/MCC 8
228
0
1.0950
30.3
25.3( print page 25103)231
Coronary bypass w PTCA w MCC 8
231
0
1.6489
36.5
30.4232
Coronary bypass w PTCA w/o MCC 8
231
0
0.8072
24.6
20.5233
Coronary bypass w cardiac cath w MCC 8
233
0
1.6489
36.5
30.4234
Coronary bypass w cardiac cath w/o MCC 8
233
0
0.8072
24.6
20.5235
Coronary bypass w/o cardiac cath w MCC 8
235
0
1.6489
36.5
30.4236
Coronary bypass w/o cardiac cath w/o MCC 8
235
0
0.8072
24.6
20.5237
Major cardiovascular procedures w MCC 5
237
3
1.6489
36.5
30.4238
Major cardiovascular procedures w/o MCC 3
237
3
0.8072
24.6
20.5239
Amputation for circ sys disorders exc upper limb & toe w MCC
239
171
1.3954
37.4
31.2240
Amputation for circ sys disorders exc upper limb & toe w CC
239
92
1.2100
36.1
30.1241
Amputation for circ sys  disorders exc upper limb & toe w/o CC/MCC 4
239
6
1.0950
30.3
25.3242
Permanent cardiac pacemaker implant w MCC 5, 6
242
14
1.6489
36.5
30.4243
Permanent cardiac pacemaker implant w CC 5
242
9
1.6489
36.5
30.4244
Permanent cardiac pacemaker implant w/o CC/MCC 4
242
3
1.0950
30.3
25.3245
AICD lead & generator procedures 2
245
2
0.6513
22.7
18.9246
Percutaneous cardiovascular proc w drug-eluting stent w MCC 3
246
1
0.8072
24.6
20.5247
Percutaneous cardiovascular proc w drug-eluting stent w/o MCC 9
246
0
0.8072
24.6
20.5248
Percutaneous cardiovasc proc w non-drug-eluting stent w MCC 5
248
1
1.6489
36.5
30.4249
Percutaneous cardiovasc proc w non-drug-eluting stent w/o MCC 9
248
0
1.6489
36.5
30.4250
Perc cardiovasc proc w/o coronary artery stent or AMI w MCC 3
250
1
0.8072
24.6
20.5251
Perc cardiovasc proc w/o coronary artery stent or AMI w/o MCC 9
250
0
0.8072
24.6
20.5252
Other vascular procedures w MCC
252
107
1.5938
34.9
29.1253
Other vascular procedures w CC
252
54
1.0987
30.8
25.7254
Other vascular procedures w/o CC/MCC 4
252
6
1.0950
30.3
25.3255
Upper limb & toe amputation for circ system disorders w MCC
255
45
1.2596
33.7
28.1256
Upper limb & toe amputation for circ system disorders w CC
255
37
0.8278
29.4
24.5257
Upper limb & toe amputation for circ system disorders w/o CC/MCC 6
255
1
0.8278
29.4
24.5258
Cardiac pacemaker device replacement w MCC 5
258
1
1.6489
36.5
30.4259
Cardiac pacemaker device replacement w/o MCC 9
258
0
1.6489
36.5
30.4260
Cardiac pacemaker revision except device replacement w MCC 5
260
1
1.6489
36.5
30.4261
Cardiac pacemaker revision except device replacement w CC 1
260
1
0.4800
19.9
16.6262
Cardiac pacemaker revision except device replacement w/o CC/MCC 1
260
1
0.4800
19.9
16.6263
Vein ligation & stripping 3
263
1
0.8072
24.6
20.5264
Other circulatory system O.R. procedures
264
596
1.0516
31.6
26.3280
Circulatory disorders w AMI, discharged alive w MCC
280
107
0.7177
21.4
17.8281
Circulatory disorders w AMI, discharged alive w CC
280
60
0.6709
23.3
19.4282
Circulatory disorders w AMI, discharged alive w/o CC/MCC 2
280
9
0.6513
22.7
18.9283
Circulatory disorders w AMI, expired w MCC
283
26
0.6486
17.0
14.2284
Circulatory disorders w AMI, expired w CC 6
283
5
0.6486
17.0
14.2285
Circulatory disorders w AMI, expired w/o CC/MCC 6
283
1
0.6486
17.0
14.2286
Circulatory disorders except AMI, w card cath w MCC 4
286
15
1.0950
30.3
25.3287
Circulatory disorders except AMI, w card cath w/o MCC 3
286
7
0.8072
24.6
20.5288
Acute & subacute endocarditis w MCC
288
450
0.9199
26.4
22.0289
Acute & subacute endocarditis w CC
288
216
0.8385
26.7
22.3290
Acute & subacute endocarditis w/o CC/MCC
288
61
0.6409
25.1
20.9291
Heart failure & shock w MCC
291
1,603
0.7271
21.4
17.8292
Heart failure & shock w CC
291
1,115
0.5887
20.5
17.1293
Heart failure & shock w/o CC/MCC
291
461
0.5015
18.6
15.5294
Deep vein thrombophlebitis w CC/MCC 3
294
7
0.8072
24.6
20.5295
Deep vein thrombophlebitis w/o CC/MCC 9
294
0
0.8072
24.6
20.5( print page 25104)296
Cardiac arrest, unexplained w MCC 8
296
0
0.6513
22.7
18.9297
Cardiac arrest, unexplained w CC 8
296
0
0.6513
22.7
18.9298
Cardiac arrest, unexplained w/o CC/MCC 8
296
0
0.6513
22.7
18.9299
Peripheral vascular disorders w MCC
299
551
0.7657
24.7
20.6300
Peripheral vascular disorders w CC
299
790
0.5711
22.2
18.5301
Peripheral vascular disorders w/o CC/MCC
299
103
0.4906
19.4
16.2302
Atherosclerosis w MCC
302
68
0.6324
22.3
18.6303
Atherosclerosis w/o MCC
302
94
0.5383
20.3
16.9304
Hypertension w MCC 2
304
12
0.6513
22.7
18.9305
Hypertension w/o MCC
304
42
0.5464
22.2
18.5306
Cardiac congenital & valvular disorders w MCC
306
54
0.9077
24.2
20.2307
Cardiac congenital & valvular disorders w/o MCC
306
39
0.7090
23.1
19.3308
Cardiac arrhythmia & conduction disorders w MCC
308
87
0.8126
24.7
20.6309
Cardiac arrhythmia & conduction disorders w CC
308
79
0.5311
20.6
17.2310
Cardiac arrhythmia & conduction disorders w/o CC/MCC
308
39
0.4341
16.5
13.8311
Angina pectoris 2
311
4
0.6513
22.7
18.9312
Syncope & collapse
312
44
0.5159
19.7
16.4313
Chest pain 1
313
5
0.4800
19.9
16.6314
Other circulatory system diagnoses w MCC
314
1,393
0.8267
23.0
19.2315
Other circulatory system diagnoses w CC
314
426
0.6380
21.6
18.0316
Other circulatory system diagnoses w/o CC/MCC
314
122
0.5126
19.4
16.2326
Stomach, esophageal & duodenal proc w MCC
326
33
2.0279
36.0
30.0327
Stomach, esophageal & duodenal proc w CC 5
326
9
1.6489
36.5
30.4328
Stomach, esophageal & duodenal proc w/o CC/MCC 1
326
1
0.4800
19.9
16.6329
Major small & large bowel procedures w MCC 5
329
24
1.6489
36.5
30.4330
Major small & large bowel procedures w CC 5
329
20
1.6489
36.5
30.4331
Major small & large bowel procedures w/o CC/MCC 1
329
1
0.4800
19.9
16.6332
Rectal resection w MCC 8
332
0
1.6489
36.5
30.4333
Rectal resection w CC 8
332
0
1.0950
30.3
25.3334
Rectal resection w/o CC/MCC 8
332
0
0.8072
24.6
20.5335
Peritoneal adhesiolysis w MCC 5
335
4
1.6489
36.5
30.4336
Peritoneal adhesiolysis w CC2
335
2
0.6513
22.7
18.9337
Peritoneal adhesiolysis w/o CC/MCC 9
335
0
0.6513
22.7
18.9338
Appendectomy w complicated principal diag w MCC 8
338
0
0.8072
24.6
20.5339
Appendectomy w complicated principal diag w CC 8
338
0
0.6513
22.7
18.9340
Appendectomy w complicated principal diag w/o CC/MCC 8
338
0
0.4800
19.9
16.6341
Appendectomy w/o complicated  principal diag w MCC 8
341
0
0.8072
24.6
20.5342
Appendectomy w/o complicated principal diag w CC 8
341
0
0.6513
22.7
18.9343
Appendectomy w/o complicated principal diag w/o CC/MCC 8
341
0
0.4800
19.9
16.6344
Minor small & large bowel procedures w MCC 8
344
0
0.8072
24.6
20.5345
Minor small & large bowel procedures w CC 8
344
0
0.6513
22.7
18.9346
Minor small & large bowel procedures w/o CC/MCC 8
344
0
0.4800
19.9
16.6347
Anal & stomal procedures w MCC 3
347
5
0.8072
24.6
20.5348
Anal & stomal procedures w CC 3
347
3
0.8072
24.6
20.5349
Anal & stomal procedures w/o CC/MCC 1
347
1
0.4800
19.9
16.6350
Inguinal & femoral hernia procedures w MCC 5
350
1
1.6489
36.5
30.4351
Inguinal & femoral hernia  procedures w CC 4
350
1
1.0950
30.3
25.3352
Inguinal & femoral hernia procedures w/o CC/MCC 3
350
1
0.8072
24.6
20.5353
Hernia procedures except inguinal & femoral w MCC 9
353
0
0.8072
24.6
20.5354
Hernia procedures except  inguinal & femoral w CC 3
353
1
0.8072
24.6
20.5355
Hernia procedures except inguinal & femoral w/o CC/MCC 9
353
0
0.8072
24.6
20.5356
Other digestive system O.R. procedures w MCC
356
107
1.4828
36.0
30.0357
Other digestive system O.R. procedures w CC
356
45
1.1816
30.8
25.7358
Other digestive system O.R. procedures w/o CC/MCC 3
356
3
0.8072
24.6
20.5368
Major esophageal disorders w MCC 4
368
22
1.0950
30.3
25.3369
Major esophageal disorders w  CC 4
368
8
1.0950
30.3
25.3370
Major esophageal disorders w/o CC/MCC 4, 6
368
1
1.0950
30.3
25.3371
Major gastrointestinal disorders & peritoneal infections w MCC
371
667
0.9214
24.0
20.0372
Major gastrointestinal disorders & peritoneal infections w CC
371
422
0.6969
22.2
18.5373
Major gastrointestinal disorders & peritoneal infections w/o CC/MCC
371
55
0.5312
19.8
16.5( print page 25105)374
Digestive malignancy w MCC
374
122
0.8609
22.9
19.1375
Digestive malignancy w CC
374
83
0.7077
19.7
16.4376
Digestive malignancy w/o CC/MCC 1
374
9
0.4800
19.9
16.6377
G.I. hemorrhage w MCC
377
94
0.7327
22.5
18.8378
G.I. hemorrhage w CC
377
54
0.6107
21.7
18.1379
G.I. hemorrhage w/o CC/MCC
377
26
0.4401
19.0
15.8380
Complicated peptic ulcer w MCC 3
380
14
0.8072
24.6
20.5381
Complicated peptic ulcer w CC 3
380
17
0.8072
24.6
20.5382
Complicated peptic ulcer w/o CC/MCC 2
380
6
0.6513
22.7
18.9383
Uncomplicated peptic ulcer w  MCC 3
383
6
0.8072
24.6
20.5384
Uncomplicated peptic ulcer w/o MCC 2
383
6
0.6513
22.7
18.9385
Inflammatory bowel disease w MCC
385
32
0.9337
24.6
20.5386
Inflammatory bowel disease w CC
385
26
0.6932
22.9
19.1387
Inflammatory bowel disease w/o CC/MCC 6
385
5
0.6932
22.9
19.1388
G.I. obstruction w MCC
388
189
0.9293
22.7
18.9389
G.I. obstruction w CC
388
89
0.7306
22.2
18.5390
G.I. obstruction w/o CC/MCC 2
388
14
0.6513
22.7
18.9391
Esophagitis, gastroent & misc digest disorders w MCC
391
246
0.9179
24.3
20.3392
Esophagitis, gastroent & misc digest disorders w/o MCC
391
270
0.6195
20.4
17.0393
Other digestive system diagnoses w MCC
393
680
1.0363
25.6
21.3394
Other digestive system diagnoses w CC
393
385
0.7624
22.1
18.4395
Other digestive system diagnoses w/o CC/MCC
393
33
0.5956
19.8
16.5405
Pancreas, liver & shunt procedures w MCC 5
405
9
1.6489
36.5
30.4406
Pancreas, liver & shunt procedures w CC 5
405
2
1.6489
36.5
30.4407
Pancreas, liver & shunt  procedures w/o CC/MCC 4
405
1
1.0950
30.3
25.3408
Biliary tract proc except only cholecyst w or w/o c.d.e. w MCC 5, 6
408
1
1.6489
36.5
30.4409
Biliary tract proc except only cholecyst w or w/o c.d.e. w CC 5
408
1
1.6489
36.5
30.4410
Biliary tract proc except only cholecyst w or w/o c.d.e. w/o CC/MCC 9
408
0
1.6489
36.5
30.4411
Cholecystectomy w c.d.e. w MCC 9
411
0
1.0950
30.3
25.3412
Cholecystectomy w c.d.e. w CC 4
411
1
1.0950
30.3
25.3413
Cholecystectomy w c.d.e. w/o CC/MCC 9
411
0
1.0950
30.3
25.3414
Cholecystectomy except by laparoscope w/o c.d.e. w MCC 4
414
2
1.0950
30.3
25.3415
Cholecystectomy except by laparoscope w/o c.d.e. w CC 4
414
3
1.0950
30.3
25.3416
Cholecystectomy except by laparoscope w/o c.d.e. w/o CC/MCC 9
414
0
1.0950
30.3
25.3417
Laparoscopic cholecystectomy w/o c.d.e. w MCC 5
417
7
1.6489
36.5
30.4418
Laparoscopic cholecystectomy  w/o c.d.e. w CC 4
417
5
1.0950
30.3
25.3419
Laparoscopic cholecystectomy  w/o c.d.e. w/o CC/MCC 9
417
0
1.0950
30.3
25.3420
Hepatobiliary diagnostic procedures w MCC 3
420
2
0.8072
24.6
20.5421
Hepatobiliary diagnostic procedures w CC 3
420
1
0.8072
24.6
20.5422
Hepatobiliary diagnostic procedures w/o CC/MCC 9
420
0
0.8072
24.6
20.5423
Other hepatobiliary or pancreas O.R. procedures w MCC 4
423
23
1.0950
30.3
25.3424
Other hepatobiliary or pancreas O.R. procedures w CC 3
423
4
0.8072
24.6
20.5425
Other hepatobiliary or pancreas O.R. procedures w/o CC/MCC 3
423
1
0.8072
24.6
20.5432
Cirrhosis & alcoholic hepatitis w MCC
432
98
0.6000
18.7
15.6433
Cirrhosis & alcoholic hepatitis w CC 6
432
21
0.6000
18.7
15.6434
Cirrhosis & alcoholic hepatitis w/o CC/MCC 6
432
1
0.6000
18.7
15.6435
Malignancy of hepatobiliary system or pancreas w MCC
435
48
0.7447
20.2
16.8436
Malignancy of hepatobiliary system or pancreas w CC
435
35
0.7039
20.5
17.1437
Malignancy of hepatobiliary system or pancreas w/o CC/MCC 2
435
4
0.6513
22.7
18.9438
Disorders of pancreas except malignancy w MCC
438
251
1.0728
24.3
20.3439
Disorders of pancreas except malignancy w CC
438
167
0.7538
21.9
18.3440
Disorders of pancreas except malignancy w/o CC/MCC
438
29
0.5185
19.0
15.8441
Disorders of liver except malig, cirr, alc hepa w MCC
441
117
0.7825
21.8
18.2442
Disorders of liver except malig, cirr, alc hepa w CC
441
66
0.6893
22.1
18.4443
Disorders of liver except malig, cirr, alc hepa w/o CC/MCC 2
441
13
0.6513
22.7
18.9444
Disorders of the biliary tract w MCC
444
71
0.8602
24.0
20.0( print page 25106)445
Disorders of the biliary tract w CC
444
39
0.6390
22.2
18.5446
Disorders of the biliary tract w/o CC/MCC 1
444
9
0.4800
19.9
16.6453
Combined anterior/posterior  spinal fusion w MCC 9
453
0
1.6489
36.5
30.4454
Combined anterior/posterior spinal fusion w CC 5
453
1
1.6489
36.5
30.4455
Combined anterior/posterior spinal fusion w/o CC/MCC 9
453
0
1.6489
36.5
30.4456
Spinal fusion exc cerv w spinal curv, malig or 9+ fusions w MCC 5
456
1
1.6489
36.5
30.4457
Spinal fusion exc cerv w spinal curv, malig or 9+ fusions w CC 8
456
0
1.6489
36.5
30.4458
Spinal fusion exc cerv w spinal curv, malig or 9+ fusions w/o CC/MCC 9
456
0
1.6489
36.5
30.4459
Spinal fusion except cervical w MCC 5
459
2
1.6489
36.5
30.4460
Spinal fusion except cervical  w/o MCC 5
459
3
1.6489
36.5
30.4461
Bilateral or multiple major joint procs of lower extremity w MCC 8
461
0
1.6489
36.5
30.4462
Bilateral or multiple major joint procs of lower extremity w/o MCC 8
461
0
1.0950
30.3
25.3463
Wnd debrid & skn grft exc hand, for musculo-conn tiss dis w MCC
463
506
1.4061
38.7
32.3464
Wnd debrid & skn grft exc hand, for musculo-conn tiss dis w CC
463
310
1.0963
36.5
30.4465
Wnd debrid & skn grft exc hand, for musculo-conn tiss dis w/o CC/MCC
463
60
0.8588
28.5
23.8466
Revision of hip or knee replacement w MCC 5
466
3
1.6489
36.5
30.4467
Revision of hip or knee replacement w CC 5
466
4
1.6489
36.5
30.4468
Revision of hip or knee replacement w/o CC/MCC 9
466
0
1.6489
36.5
30.4469
Major joint replacement or reattachment of lower extremity w MCC 5
469
2
1.6489
36.5
30.4470
Major joint replacement or  reattachment of lower extremity w/o MCC 5
469
2
1.6489
36.5
30.4471
Cervical spinal fusion w MCC 5
471
5
1.6489
36.5
30.4472
Cervical spinal fusion w CC 4
471
2
1.0950
30.3
25.3473
Cervical spinal fusion w/o CC/MCC 9
471
0
1.0950
30.3
25.3474
Amputation for musculoskeletal sys & conn tissue dis w MCC
474
91
1.3850
36.6
30.5475
Amputation for musculoskeletal sys & conn tissue dis w CC
474
52
0.9993
32.7
27.3476
Amputation for musculoskeletal sys & conn tissue dis w/o CC/MCC 6
474
10
0.9993
32.7
27.3477
Biopsies of musculoskeletal system & connective tissue w MCC 5
477
13
1.6489
36.5
30.4478
Biopsies of musculoskeletal system & connective tissue w CC 4
477
14
1.0950
30.3
25.3479
Biopsies of musculoskeletal  system & connective tissue w/o CC/MCC 4
477
5
1.0950
30.3
25.3480
Hip & femur procedures except major joint w MCC 5
480
10
1.6489
36.5
30.4481
Hip & femur procedures except major joint w CC 5
480
19
1.6489
36.5
30.4482
Hip & femur procedures except major joint w/o CC/MCC 4
480
1
1.0950
30.3
25.3483
Major joint & limb reattachment proc of upper extremity w CC/MCC 8
483
0
1.6489
36.5
30.4484
Major joint & limb reattachment proc of upper extremity w/o CC/MCC 8
483
0
1.0950
30.3
25.3485
Knee procedures w pdx of infection w MCC 5
485
10
1.6489
36.5
30.4486
Knee procedures w pdx of infection w CC 4
485
9
1.0950
30.3
25.3487
Knee procedures w pdx of infection w/o CC/MCC 4
485
1
1.0950
30.3
25.3488
Knee procedures w/o pdx of infection w CC/MCC 5
488
2
1.6489
36.5
30.4489
Knee procedures w/o pdx of infection w/o CC/MCC 9
488
0
1.6489
36.5
30.4490
Back & neck procedures except spinal fusion w CC/MCC or disc devices 4
490
7
1.0950
30.3
25.3491
Back & neck procedures except spinal fusion w/o CC/MCC 9
490
0
1.0950
30.3
25.3492
Lower extrem & humer proc except hip, foot, femur w MCC 5
492
5
1.6489
36.5
30.4493
Lower extrem & humer proc except hip, foot, femur w CC 4
492
18
1.0950
30.3
25.3( print page 25107)494
Lower extrem & humer proc except hip, foot, femur w/o CC/MCC 3
492
2
0.8072
24.6
20.5495
Local excision & removal int  fix devices exc hip & femur w MCC
495
32
1.4142
38.1
31.8496
Local excision & removal int fix devices exc hip & femur w CC
495
26
1.1010
38.3
31.9497
Local excision & removal int fix devices exc hip & femur w/o CC/MCC 4
495
3
1.0950
30.3
25.3498
Local excision & removal int  fix devices of hip & femur w  CC/MCC 5
498
8
1.6489
36.5
30.4499
Local excision & removal int fix devices of hip & femur w/o CC/MCC 2
498
2
0.6513
22.7
18.9500
Soft tissue procedures w MCC
500
46
1.3054
35.2
29.3501
Soft tissue procedures w CC
500
27
1.2940
30.9
25.8502
Soft tissue procedures w/o CC/MCC 3
500
4
0.8072
24.6
20.5503
Foot procedures w MCC 4
503
18
1.0950
30.3
25.3504
Foot procedures w CC 3
503
13
0.8072
24.6
20.5505
Foot procedures w/o CC/MCC 1
503
1
0.4800
19.9
16.6506
Major thumb or joint procedures 8
506
0
0.6513
22.7
18.9507
Major shoulder or elbow joint procedures w CC/MCC 3
507
3
0.8072
24.6
20.5508
Major shoulder or elbow joint procedures w/o CC/MCC 9
507
0
0.8072
24.6
20.5509
Arthroscopy 8
509
0
0.4800
19.9
16.6510
Shoulder,elbow or forearm proc, exc major joint proc w MCC 9
510
0
1.0950
30.3
25.3511
Shoulder,elbow or forearm proc, exc major joint proc w CC 4
510
4
1.0950
30.3
25.3512
Shoulder,elbow or forearm proc, exc major joint proc w/o CC/MCC 1
510
1
0.4800
19.9
16.6513
Hand or wrist proc, except major thumb or joint proc w CC/MCC 5
513
4
1.6489
36.5
30.4514
Hand or wrist proc, except major thumb or joint proc w/o CC/MCC 2
513
4
0.6513
22.7
18.9515
Other musculoskelet sys & conn tiss O.R. proc w MCC
515
48
1.3557
34.7
28.9516
Other musculoskelet sys & conn tiss O.R. proc w CC 4
515
21
1.0950
30.3
25.3517
Other musculoskelet sys & conn tiss O.R. proc w/o CC/MCC 3
515
6
0.8072
24.6
20.5533
Fractures of femur w MCC 3
533
3
0.8072
24.6
20.5534
Fractures of femur w/o MCC 2
533
7
0.6513
22.7
18.9535
Fractures of hip & pelvis w MCC 2
535
18
0.6513
22.7
18.9536
Fractures of hip & pelvis w/o MCC
535
34
0.5447
23.7
19.8537
Sprains, strains, &  dislocations of hip, pelvis & thigh w CC/MCC 8
537
0
0.4800
19.9
16.6538
Sprains, strains, & dislocations of hip, pelvis & thigh w/o CC/MCC 8
537
0
0.4800
19.9
16.6539
Osteomyelitis w MCC
539
932
0.9369
29.7
24.8540
Osteomyelitis w CC
539
745
0.7697
28.9
24.1541
Osteomyelitis w/o CC/MCC
539
273
0.6853
26.4
22.0542
Pathological fractures & musculoskelet & conn tiss malig w MCC
542
56
0.7914
21.7
18.1543
Pathological fractures & musculoskelet & conn tiss malig w CC
542
61
0.5904
21.3
17.8544
Pathological fractures & musculoskelet & conn tiss malig w/o CC/MCC 1
542
18
0.4800
19.9
16.6545
Connective tissue disorders w  MCC
545
58
0.9349
24.0
20.0546
Connective tissue disorders w  CC
545
39
0.5510
20.7
17.3547
Connective tissue disorders w/o  CC/MCC 1
545
13
0.4800
19.9
16.6548
Septic arthritis w MCC
548
166
0.9257
28.1
23.4549
Septic arthritis w CC
548
187
0.6862
26.4
22.0550
Septic arthritis w/o CC/MCC
548
72
0.5780
23.6
19.7551
Medical back problems w MCC
551
109
0.8081
26.6
22.2552
Medical back problems w/o MCC
551
248
0.5575
22.8
19.0553
Bone diseases & arthropathies w MCC 2
553
24
0.6513
22.7
18.9554
Bone diseases & arthropathies w/o MCC
553
66
0.4534
20.5
17.1555
Signs & symptoms of musculoskeletal system & conn tissue w MCC 2
555
13
0.6513
22.7
18.9( print page 25108)556
Signs & symptoms of musculoskeletal system & conn tissue w/o MCC 2
555
15
0.6513
22.7
18.9557
Tendonitis, myositis & bursitis w MCC
557
86
0.8676
25.9
21.6558
Tendonitis, myositis & bursitis w/o MCC
557
113
0.6167
21.4
17.8559
Aftercare, musculoskeletal system & connective tissue w MCC
559
1,366
0.7654
26.2
21.8560
Aftercare, musculoskeletal system & connective tissue w CC
559
1,995
0.6174
24.7
20.6561
Aftercare, musculoskeletal system & connective tissue w/o CC/MCC
559
1,074
0.5146
21.6
18.0562
Fx, sprn, strn & disl except femur, hip, pelvis & thigh w MCC 4
562
6
1.0950
30.3
25.3563
Fx, sprn, strn & disl except  femur, hip, pelvis & thigh w/o MCC 1
562
23
0.4800
19.9
16.6564
Other musculoskeletal sys & connective tissue diagnoses w MCC
564
240
0.8462
24.9
20.8565
Other musculoskeletal sys & connective tissue diagnoses w CC
564
225
0.6991
25.1
20.9566
Other musculoskeletal sys & connective tissue diagnoses w/o CC/MCC
564
75
0.6073
21.6
18.0573
Skin graft &/or debrid for skn ulcer or cellulitis w MCC
573
1,862
1.3619
38.0
31.7574
Skin graft &/or debrid for skn ulcer or cellulitis w CC
573
1,898
1.0731
37.1
30.9575
Skin graft &/or debrid for skn ulcer or cellulitis w/o CC/MCC
573
215
0.8813
31.6
26.3576
Skin graft &/or debrid exc for skin ulcer or cellulitis w MCC 4
576
22
1.0950
30.3
25.3577
Skin graft &/or debrid exc for skin ulcer or cellulitis w CC 4
576
24
1.0950
30.3
25.3578
Skin graft &/or debrid exc for skin ulcer or cellulitis w/o CC/MCC 2
576
5
0.6513
22.7
18.9579
Other skin, subcut tiss & breast proc w MCC
579
489
1.3275
36.7
30.6580
Other skin, subcut tiss & breast proc w CC
579
414
1.0027
34.9
29.1581
Other skin, subcut tiss & breast proc w/o CC/MCC
579
35
0.7370
29.7
24.8582
Mastectomy for malignancy w CC/MCC 5
582
3
1.6489
36.5
30.4583
Mastectomy for malignancy w/o CC/MCC 9
582
0
1.6489
36.5
30.4584
Breast biopsy, local excision & other breast procedures w CC/MCC 4
584
2
1.0950
30.3
25.3585
Breast biopsy, local excision & other breast procedures w/o CC/MCC 9
584
0
1.0950
30.3
25.3592
Skin ulcers w MCC
592
2,984
0.9267
27.0
22.5593
Skin ulcers w CC
592
3,110
0.7339
26.8
22.3594
Skin ulcers w/o CC/MCC
592
437
0.6369
24.2
20.2595
Major skin disorders w MCC
595
30
0.8062
24.5
20.4596
Major skin disorders w/o MCC
595
54
0.5954
23.9
19.9597
Malignant breast disorders w MCC 3
597
13
0.8072
24.6
20.5598
Malignant breast disorders w  CC 2, 6
597
17
0.6513
22.7
18.9599
Malignant breast disorders w/o CC/MCC 2, 6
597
4
0.6513
22.7
18.9600
Non-malignant breast disorders w CC/MCC 2
600
12
0.6513
22.7
18.9601
Non-malignant breast disorders w/o CC/MCC 2
600
9
0.6513
22.7
18.9602
Cellulitis w MCC
602
757
0.7127
22.4
18.7603
Cellulitis w/o MCC
602
1,492
0.5136
19.4
16.2604
Trauma to the skin, subcut tiss & breast w MCC 3
604
23
0.8072
24.6
20.5605
Trauma to the skin, subcut tiss & breast w/o MCC
604
60
0.5413
21.5
17.9606
Minor skin disorders w MCC
606
60
0.8986
23.2
19.3607
Minor skin disorders w/o MCC
606
84
0.6120
22.6
18.8614
Adrenal & pituitary proceduresw CC/MCC 8
614
0
1.0950
30.3
25.3615
Adrenal & pituitary procedures w/o CC/MCC 8
614
0
0.4800
19.9
16.6616
Amputat of lower limb for endocrine,nutrit,& metabol dis w MCC
616
62
1.5681
41.0
34.2617
Amputat of lower limb for endocrine,nutrit,& metabol dis w CC
616
116
1.1395
32.9
27.4618
Amputat of lower limb for endocrine,nutrit,& metabol dis w/o CC/MCC 3
616
2
0.8072
24.6
20.5619
O.R. procedures for obesity w MCC 3
619
2
0.8072
24.6
20.5620
O.R. procedures for obesity w CC 3, 6
619
3
0.8072
24.6
20.5621
O.R. procedures for obesity w/o CC/MCC 9
619
0
0.8072
24.6
20.5( print page 25109)622
Skin grafts & wound debrid for endoc, nutrit & metab dis w MCC
622
165
1.2199
35.6
29.7623
Skin grafts & wound debrid for endoc, nutrit & metab dis w CC
622
338
0.9703
32.2
26.8624
Skin grafts & wound debrid for endoc, nutrit & metab dis w/o CC/MCC 3
622
15
0.8072
24.6
20.5625
Thyroid, parathyroid & thyroglossal procedures w MCC 8
625
0
1.6489
36.5
30.4626
Thyroid, parathyroid & thyroglossal procedures w CC 8
625
0
1.0950
30.3
25.3627
Thyroid, parathyroid & thyroglossal procedures w/o CC/MCC 8
625
0
0.4800
19.9
16.6628
Other endocrine, nutrit & metab O.R. proc w MCC
628
52
1.4033
35.9
29.9629
Other endocrine, nutrit & metab O.R. proc w CC
628
88
1.1143
33.3
27.8630
Other endocrine, nutrit & metab O.R. proc w/o CC/MCC 1
628
5
0.4800
19.9
16.6637
Diabetes w MCC
637
363
0.8347
25.8
21.5638
Diabetes w CC
637
1,041
0.6491
24.1
20.1639
Diabetes w/o CC/MCC
637
114
0.5241
20.1
16.8640
Nutritional & misc metabolic disorders w MCC
640
606
0.8190
23.2
19.3641
Nutritional & misc metabolic disorders w/o MCC
640
620
0.6364
22.0
18.3642
Inborn errors of metabolism 2
642
4
0.6513
22.7
18.9643
Endocrine disorders w MCC
643
27
0.8880
27.3
22.8644
Endocrine disorders w CC 3
643
18
0.8072
24.6
20.5645
Endocrine disorders w/o CC/MCC 1
643
6
0.4800
19.9
16.6652
Kidney transplant 7
652
0
0.0000
0.0
0.0653
Major bladder procedures w MCC 8
653
0
1.0950
30.3
25.3654
Major bladder procedures w CC 8
653
0
0.6513
22.7
18.9655
Major bladder procedures w/o CC/MCC 8
653
0
0.4800
19.9
16.6656
Kidney & ureter procedures for neoplasm w MCC 9
656
0
0.8072
24.6
20.5657
Kidney & ureter procedures forneoplasm w CC 3
656
1
0.8072
24.6
20.5658
Kidney & ureter procedures for neoplasm w/o CC/MCC 9
656
0
0.8072
24.6
20.5659
Kidney & ureter procedures for non-neoplasm w MCC 4
659
9
1.0950
30.3
25.3660
Kidney & ureter procedures for non-neoplasm w CC2
659
4
0.6513
22.7
18.9661
Kidney & ureter procedures for non-neoplasm w/o CC/MCC 1
659
1
0.4800
19.9
16.6662
Minor bladder procedures w MCC 3
662
2
0.8072
24.6
20.5663
Minor bladder procedures w CC9
662
0
0.8072
24.6
20.5664
Minor bladder procedures w/o  CC/MCC 5
662
1
1.6489
36.5
30.4665
Prostatectomy w MCC 3
665
2
0.8072
24.6
20.5666
Prostatectomy w CC 8
665
0
0.8072
24.6
20.5667
Prostatectomy w/o CC/MCC 3
665
1
0.8072
24.6
20.5668
Transurethral procedures w MCC 5
668
8
1.6489
36.5
30.4669
Transurethral procedures w CC 5
668
5
1.6489
36.5
30.4670
Transurethral procedures w/o CC/MCC 5
668
1
1.6489
36.5
30.4671
Urethral procedures w CC/MCC 8
671
0
0.6513
22.7
18.9672
Urethral procedures w/o CC/MCC 8
671
0
0.4800
19.9
16.6673
Other kidney & urinary tract procedures w MCC
673
226
1.3376
33.5
27.9674
Other kidney & urinary tract procedures w CC
673
87
1.1684
30.6
25.5675
Other kidney & urinary tract procedures w/o CC/MCC 4
673
13
1.0950
30.3
25.3682
Renal failure w MCC
682
1,334
0.8784
23.6
19.7683
Renal failure w CC
682
726
0.7271
21.9
18.3684
Renal failure w/o CC/MCC
682
184
0.5951
20.1
16.8685
Admit for renal dialysis
685
50
0.7543
25.9
21.6686
Kidney & urinary tract neoplasms w MCC
686
31
0.9234
23.6
19.7687
Kidney & urinary tract neoplasms w CC2
686
17
0.6513
22.7
18.9688
Kidney & urinary tract neoplasms w/o CC/MCC 1
686
3
0.4800
19.9
16.6689
Kidney & urinary tract infections w MCC
689
760
0.6796
22.8
19.0690
Kidney & urinary tract infections w/o MCC
689
727
0.5158
20.2
16.8691
Urinary stones w esw lithotripsy w CC/MCC 5
691
4
1.6489
36.5
30.4692
Urinary stones w esw lithotripsy w/o CC/MCC 9
691
0
1.6489
36.5
30.4693
Urinary stones w/o esw lithotripsy w MCC 2
693
16
0.6513
22.7
18.9694
Urinary stones w/ot esw lithotripsy w/o MCC 2, 6
693
12
0.6513
22.7
18.9695
Kidney & urinary tract signs & symptoms w MCC 3
695
4
0.8072
24.6
20.5696
Kidney & urinary tract signs & symptoms w/o MCC 1
695
1
0.4800
19.9
16.6697
Urethral stricture 8
697
0
0.4800
19.9
16.6698
Other kidney & urinary tract   diagnoses w MCC
698
270
0.8112
22.7
18.9699
Other kidney & urinary tract diagnoses w CC
698
155
0.7032
22.2
18.5700
Other kidney & urinary tract diagnoses w CC
698
52
0.5387
20.2
16.8( print page 25110)707
Major male pelvic procedures w CC/MCC 8
707
0
0.6513
22.7
18.9708
Major male pelvic procedures w/o CC/MCC 8
707
0
0.4800
19.9
16.6709
Penis procedures w CC/MCC 4
709
6
1.0950
30.3
25.3710
Penis procedures w/o CC/MCC 9
709
0
1.0950
30.3
25.3711
Testes procedures w CC/MCC 4, 6
711
7
1.0950
30.3
25.3712
Testes procedures w/o CC/MCC 4, 6
711
1
1.0950
30.3
25.3713
Transurethral prostatectomy w CC/MCC 5
713
1
1.6489
36.5
30.4714
Transurethral prostatectomy w/o CC/MCC 1
713
1
0.4800
19.9
16.6715
Other male reproductive system O.R. proc for malignancy w CC/MCC 5
715
1
1.6489
36.5
30.4716
Other male reproductive system O.R. proc for malignancy w/o CC/MCC 9
715
0
1.6489
36.5
30.4717
Other male reproductive system O.R. proc exc malignancy w CC/MCC 4
717
17
1.0950
30.3
25.3718
Other male reproductive system O.R. proc exc malignancy w/o CC/MCC 1
717
2
0.4800
19.9
16.6722
Malignancy, male reproductive system w MCC 3
722
12
0.8072
24.6
20.5723
Malignancy, male reproductive system w CC2
722
7
0.6513
22.7
18.9724
Malignancy, male reproductive system w/o CC/MCC 1
722
2
0.4800
19.9
16.6725
Benign prostatic hypertrophy w MCC 4
725
2
1.0950
30.3
25.3726
Benign prostatic hypertrophy w/o MCC 1
725
3
0.4800
19.9
16.6727
Inflammation of the male reproductive system w MCC
727
37
0.8768
25.9
21.6728
Inflammation of the male reproductive system w/o MCC
727
57
0.5605
20.9
17.4729
Other male reproductive system diagnoses w CC/MCC
729
34
1.0242
26.6
22.2730
Other male reproductive system diagnoses w/o CC/MCC 2
729
2
0.6513
22.7
18.9734
Pelvic evisceration, rad hysterectomy & rad vulvectomy w CC/MCC 8
734
0
1.0950
30.3
25.3735
Pelvic evisceration, rad hysterectomy & rad vulvectomy w/o CC/MCC 8
734
0
0.4800
19.9
16.6736
Uterine & adnexa proc for ovarian or adnexal malignancy w MCC 8
736
0
1.0950
30.3
25.3737
Uterine & adnexa proc for ovarian or adnexal malignancy w CC 8
736
0
0.8072
24.6
20.5738
Uterine & adnexa proc for ovarian or adnexal malignancy w/o CC/MCC 8
736
0
0.4800
19.9
16.6739
Uterine, adnexa proc for non-ovarian/adnexal malig w MCC 8
739
0
1.0950
30.3
25.3740
Uterine, adnexa proc for non-ovarian/adnexal malig w CC 8
739
0
0.8072
24.6
20.5741
Uterine, adnexa proc for non-ovarian/adnexal malig w/o CC/MCC 8
739
0
0.4800
19.9
16.6742
Uterine & adnexa proc for non-malignancy w CC/MCC 8
742
0
0.8072
24.6
20.5743
Uterine & adnexa proc for non-malignancy w/o CC/MCC 8
742
0
0.4800
19.9
16.6744
D&C, conization, laparascopy & tubal interruption w CC/MCC 2
744
1
0.6513
22.7
18.9745
D&C, conization, laparascopy & tubal interruption w/o CC/MCC 9
744
0
0.6513
22.7
18.9746
Vagina, cervix & vulva procedures w CC/MCC 3
746
3
0.8072
24.6
20.5747
Vagina, cervix & vulva procedures w/o CC/MCC 9
746
0
0.8072
24.6
20.5748
Female reproductive system reconstructive procedures 8
748
0
0.8072
24.6
20.5749
Other female reproductive system O.R. procedures w CC/MCC 3
749
3
0.8072
24.6
20.5750
Other female reproductive system O.R. procedures w/o CC/MCC 9
749
0
0.8072
24.6
20.5754
Malignancy, female reproductive system w MCC 4
754
14
1.0950
30.3
25.3755
Malignancy, female reproductive system w CC 3
754
15
0.8072
24.6
20.5756
Malignancy, female reproductive system w/o CC/MCC 1
754
1
0.4800
19.9
16.6757
Infections, female reproductive system w MCC
757
29
0.8441
22.6
18.8758
Infections, female reproductive system w CC
757
25
0.8274
27.2
22.7759
Infections, female reproductive system w/o CC/MCC 1
757
5
0.4800
19.9
16.6760
Menstrual & other female reproductive system disorders w CC/MCC 4
760
3
1.0950
30.3
25.3761
Menstrual & other female reproductive system disorders w/o CC/MCC 1
760
1
0.4800
19.9
16.6765
Cesarean section w CC/MCC 8
765
0
0.6513
22.7
18.9( print page 25111)766
Cesarean section w/o CC/MCC 8
765
0
0.6513
22.7
18.9767
Vaginal delivery w sterilization &/or D&C8
767
0
0.6513
22.7
18.9768
Vaginal delivery w O.R. proc except steril &/or D&C8
768
0
0.6513
22.7
18.9769
Postpartum & post abortion diagnoses w O.R. procedure 2
769
1
0.6513
22.7
18.9770
Abortion w D&C, aspiration curettage or hysterotomy 8
770
0
0.6513
22.7
18.9774
Vaginal delivery w complicating  diagnoses 8
774
0
0.6513
22.7
18.9775
Vaginal delivery w/o complicating diagnoses 8
775
0
0.6513
22.7
18.9776
Postpartum & post abortion diagnoses w/o O.R. procedure 4
776
3
1.0950
30.3
25.3777
Ectopic pregnancy 8
777
0
0.6513
22.7
18.9778
Threatened abortion 8
778
0
0.4800
19.9
16.6779
Abortion w/o D&C 8
779
0
0.4800
19.9
16.6780
False labor 8
780
0
0.4800
19.9
16.6781
Other antepartum diagnoses w medical complications 4
781
1
1.0950
30.3
25.3782
Other antepartum diagnoses w/o medical complications 8
782
0
0.4800
19.9
16.6789
Neonates, died or transferred to another acute care facility 8
789
0
0.4800
19.9
16.6790
Extreme immaturity or respiratory distress syndrome, neonate 8
790
0
0.4800
19.9
16.6791
Prematurity w major problems 8
791
0
1.0950
30.3
25.3792
Prematurity w/o major problems 8
792
0
0.4800
19.9
16.6793
Full term neonate w major problems 8
793
0
1.0950
30.3
25.3794
Neonate w other significant problems 8
794
0
1.0950
30.3
25.3795
Normal newborn 8
795
0
0.4800
19.9
16.6799
Splenectomy w MCC 8
799
0
1.0950
30.3
25.3800
Splenectomy w CC 8
799
0
0.8072
24.6
20.5801
Splenectomy w/o CC/MCC 8
799
0
0.8072
24.6
20.5802
Other O.R. proc of the blood & blood forming organs w MCC 5
802
7
1.6489
36.5
30.4803
Other O.R. proc of the blood & blood forming organs w CC2
802
3
0.6513
22.7
18.9804
Other O.R. proc of the blood & blood forming organs w/o CC/MCC 9
802
0
0.6513
22.7
18.9808
Major hematol/immun diag exc  sickle cell crisis & coagul w MCC
808
26
0.8185
22.7
18.9809
Major hematol/immun diag exc  sickle cell crisis & coagul w CC 3
808
24
0.8072
24.6
20.5810
Major hematol/immun diag exc  sickle cell crisis & coagul w/o CC/MCC 3
808
3
0.8072
24.6
20.5811
Red blood cell disorders w MCC
811
35
0.6773
22.8
19.0812
Red blood cell disorders w/o  MCC
811
48
0.5210
19.5
16.3813
Coagulation disorders
813
49
0.7876
21.5
17.9814
Reticuloendothelial & immunity disorders w MCC
814
40
0.7805
22.6
18.8815
Reticuloendothelial & immunity disorders w CC2
814
17
0.6513
22.7
18.9816
Reticuloendothelial & immunity disorders w/o CC/MCC 2, 6
814
6
0.6513
22.7
18.9820
Lymphoma & leukemia w major O.R. procedure w MCC 9
820
0
0.8072
24.6
20.5821
Lymphoma & leukemia w major O.R. procedure w CC 3
820
2
0.8072
24.6
20.5822
Lymphoma & leukemia w major O.R. procedure w/o CC/MCC 9
820
0
0.8072
24.6
20.5823
Lymphoma & non-acute leukemia w other O.R. proc w MCC 4
823
12
1.0950
30.3
25.3824
Lymphoma & non-acute leukemia w other O.R. proc w CC 4
823
3
1.0950
30.3
25.3825
Lymphoma & non-acute leukemia w other O.R. proc w/o CC/MCC 1
823
1
0.4800
19.9
16.6826
Myeloprolif disord or poorly  diff neopl w maj O.R. proc w MCC 3
826
1
0.8072
24.6
20.5827
Myeloprolif disord or poorly diff neopl w maj O.R. proc w CC 8
826
0
0.8072
24.6
20.5828
Myeloprolif disord or poorly diff neopl w maj O.R. proc w/o CC/MCC ?
826
0
0.8072
24.6
20.5829
Myeloprolif disord or poorly diff neopl w other O.R. proc w CC/MCC 5
829
9
1.6489
36.5
30.4830
Myeloprolif disord or poorly diff neopl w other O.R. proc w/o CC/MCC 9
829
0
1.6489
36.5
30.4( print page 25112)834
Acute leukemia w/o major O.R. procedure w MCC 3
834
20
0.8072
24.6
20.5835
Acute leukemia w/o major O.R. procedure w CC 3
834
3
0.8072
24.6
20.5836
Acute leukemia w/o major O.R. procedure w/o CC/MCC 1
834
1
0.4800
19.9
16.6837
Chemo w acute leukemia as sdxor w  high dose chemo agent w MCC 5
837
1
1.6489
36.5
30.4838
Chemo w acute leukemia as sdx  or w high dose chemo agent w CC 3
837
2
0.8072
24.6
20.5839
Chemo w acute leukemia as sdx or w high dose chemo agent w/o CC/MCC 9
837
0
0.8072
24.6
20.5840
Lymphoma & non-acute leukemia w MCC ENT>840
174
0.8758
20.8
17.3841
Lymphoma & non-acute leukemia w CC
840
65
0.7405
20.1
16.8842
Lymphoma & non-acute leukemia w/o CC/MCC 2
840
11
0.6513
22.7
18.9843
Other myeloprolif dis or poorly diff neopl diag w MCC 4, 6
843
19
1.0950
30.3
25.3844
Other myeloprolif dis or poorly diff neopl diag w CC 4, 6
843
13
1.0950
30.3
25.3845
Other myeloprolif dis or poorly diff neopl diag w/o CC/MCC 4, 6
843
3
1.0950
30.3
25.3846
Chemotherapy w/o acute leukemia as secondary diagnosis w MCC
846
31
1.8155
37.9
31.6847
Chemotherapy w/o acute leukemia as secondary diagnosis w CC
846
61
1.3078
27.6
23.0848
Chemotherapy w/o acute leukemia as secondary diagnosis w/o CC/MCC 2
846
1
0.6513
22.7
18.9849
Radiotherapy
849
141
0.8756
23.5
19.6853
Infectious & parasitic diseases w O.R. procedure w MCC
853
698
1.7901
38.1
31.8854
Infectious & parasitic diseases w O.R. procedure w CC
853
94
1.1472
31.0
25.8855
Infectious & parasitic diseases w O.R. procedure w/o CC/MCC 3
853
3
0.8072
24.6
20.5856
Postoperative or post-traumatic infections w O.R. proc w MCC
856
338
1.5473
36.2
30.2857
Postoperative or post-traumatic infections w O.R. proc w CC
856
230
1.0438
31.6
26.3858
Postoperative or post-traumatic infections w O.R. proc w/o CC/MCC
856
30
0.8873
27.9
23.3862
Postoperative & post-traumatic infections w MCC
862
1,172
0.9120
25.1
20.9863
Postoperative & post-traumatic infections w/o MCC
862
1,298
0.6802
23.4
19.5864
Fever of unknown origin 2
864
16
0.6513
22.7
18.9865
Viral illness w MCC
865
56
0.8213
21.8
18.2866
Viral illness w/o MCC
865
33
0.5498
21.2
17.7867
Other infectious & parasitic diseases diagnoses w MCC
867
293
1.1329
23.6
19.7868
Other infectious & parasitic diseases diagnoses w CC
867
80
0.7220
22.0
18.3869
Other infectious & parasitic diseases diagnoses w/o CC/MCC 1
867
11
0.4800
19.9
16.6870
Septicemia w MV 96+ hours
870
585
1.9084
30.4
25.3871
Septicemia w/o MV 96+ hours w MCC
871
3,871
0.8437
23.5
19.6872
Septicemia w/o MV 96+ hours w/o MCC
871
1,532
0.6551
21.8
18.2876
O.R. procedure w principal diagnoses of mental illness 1
876
5
0.4800
19.9
16.6880
Acute adjustment reaction & psychosocial dysfunction 4
880
21
1.0950
30.3
25.3881
Depressive neuroses 1
881
15
0.4800
19.9
16.6882
Neuroses except depressive 1
882
16
0.4800
19.9
16.6883
Disorders of personality & impulse control 1
883
15
0.4800
19.9
16.6884
Organic disturbances & mental retardation
884
201
0.4785
23.2
19.3885
Psychoses
885
1,386
0.4066
23.7
19.8886
Behavioral & developmental disorders 1
886
18
0.4800
19.9
16.6887
Other mental disorder diagnoses 8
887
0
0.4800
19.9
16.6894
Alcohol/drug abuse or dependence, left ama 1
894
1
0.4800
19.9
16.6895
Alcohol/drug abuse or dependence w rehabilitation therapy 1
895
1
0.4800
19.9
16.6896
Alcohol/drug abuse or dependence w/o rehabilitation therapy w MCC 3
896
10
0.8072
24.6
20.5897
Alcohol/drug abuse or dependence w/o rehabilitation therapy w/o MCC 2
896
24
0.6513
22.7
18.9901
Wound debridements for injuries w MCC
901
222
1.4003
35.2
29.3902
Wound debridements for injuries w CC
901
159
1.0434
33.4
27.8903
Wound debridements for injuries w/o CC/MCC 2
901
23
0.6513
22.7
18.9904
Skin grafts for injuries w CC/MCC
904
87
1.3377
40.7
33.9905
Skin grafts for injuries w/o CC/MCC 2
904
8
0.6513
22.7
18.9( print page 25113)906
Hand procedures for injuries 1
906
1
0.4800
19.9
16.6907
Other O.R. procedures for injuries w MCC
907
85
1.7294
36.8
30.7908
Other O.R. procedures for injuries w CC
907
44
1.1963
34.2
28.5909
Other O.R. procedures for injuries w/o CC/MCC 4
907
7
1.0950
30.3
25.3913
Traumatic injury w MCC
913
50
0.9333
26.8
22.3914
Traumatic injury w/o MCC
913
70
0.5330
21.3
17.8915
Allergic reactions w MCC 9
915
0
0.4800
19.9
16.6916
Allergic reactions w/o MCC 1
915
1
0.4800
19.9
16.6917
Poisoning & toxic effects of  drugs w MCC 2
917
7
0.6513
22.7
18.9918
Poisoning & toxic effects of  drugs w/o MCC 2
917
6
0.6513
22.7
18.9919
Complications of treatment w MCC
919
1,066
1.0291
26.2
21.8920
Complications of treatment w CC
919
811
0.7703
24.6
20.5921
Complications of treatment w/o CC/MCC
919
113
0.6374
22.6
18.8922
Other injury, poisoning & toxic effect diag w MCC 1
922
5
0.4800
19.9
16.6923
Other injury, poisoning & toxic effect diag w/o MCC 1
922
9
0.4800
19.9
16.6927
Extensive burns or full thickness burns w MV 96+ hrs w skin graft 8
927
0
1.0950
30.3
25.3928
Full thickness burn w skin graft or inhal inj w CC/MCC 4
928
10
1.0950
30.3
25.3929
Full thickness burn w skin graft or inhal inj w/o CC/MCC 2
928
1
0.6513
22.7
18.9933
Extensive burns or full thickness burns w MV 96+ hrs w/o skin graft 4
933
7
1.0950
30.3
25.3934
Full thickness burn w/o skin grft or inhal inj
934
48
0.6866
24.2
20.2935
Non-extensive burns
935
40
0.7294
24.9
20.8939
O.R. proc w diagnoses of other contact w health services w MCC
939
378
1.2925
33.8
28.2940
O.R. proc w diagnoses of other contact w health services w CC
939
210
1.0280
33.9
28.3941
O.R. proc w diagnoses of other contact w health services w/o CC/MCC
939
38
0.7470
28.9
24.1945
Rehabilitation w CC/MCC
945
2,173
0.5928
22.3
18.6946
Rehabilitation w/o CC/MCC
945
527
0.4271
18.9
15.8947
Signs & symptoms w MCC
947
88
0.6459
22.8
19.0948
Signs & symptoms w/o MCC
947
168
0.5300
23.5
19.6949
Aftercare w CC/MCC
949
4,486
0.6728
22.1
18.4950
Aftercare w/o CC/MCC
949
839
0.4847
18.5
15.4951
Other factors influencing health status
951
38
1.2107
24.0
20.0955
Craniotomy for multiple significant trauma 8
955
0
1.6489
36.5
30.4956
Limb reattachment, hip & femur proc for multiple significant trauma 2
956
1
0.6513
22.7
18.9957
Other O.R. procedures for multiple significant trauma w MCC 5
957
3
1.6489
36.5
30.4958
Other O.R. procedures for multiple significant trauma w CC 4
957
1
1.0950
30.3
25.3959
Other O.R. procedures for multiple significant trauma w/o CC/MCC 9
957
0
1.0950
30.3
25.3963
Other multiple significant trauma w MCC 3
963
12
0.8072
24.6
20.5964
Other multiple significant trauma w CC 2
963
9
0.6513
22.7
18.9965
Other multiple significant trauma w/o CC/MCC 2
963
3
0.6513
22.7
18.9969
HIV w extensive O.R. procedure w MCC 5
969
7
1.6489
36.5
30.4970
HIV w extensive O.R. procedure w/o MCC 5
969
3
1.6489
36.5
30.4974
HIV w major related condition w MCC
974
160
0.9279
21.8
18.2975
HIV w major related condition w CC
974
70
0.6707
20.7
17.3976
HIV w major related condition  w/o CC/MCC
974
43
0.6703
19.2
16.0977
HIV w or w/o other related condition 2
977
21
0.6513
22.7
18.9981
Extensive O.R. procedure unrelated to principal diagnosis w MCC
981
1,065
2.2695
41.8
34.8982
Extensive O.R. procedure unrelated to principal diagnosis w CC
981
279
1.4994
37.8
31.5983
Extensive O.R. procedure unrelated to principal diagnosis w/o CC/MCC 4
981
24
1.0950
30.3
25.3984
Prostatic O.R. procedure unrelated to principal diagnosis w MCC 5
984
14
1.6489
36.5
30.4985
Prostatic O.R. procedure unrelated to principal diagnosis w CC 4
984
13
1.0950
30.3
25.3986
Prostatic O.R. procedure unrelated to principal diagnosis w/o CC/MCC 4
984
1
1.0950
30.3
25.3( print page 25114)987
Non-extensive O.R. proc unrelated to principal diagnosis w MCC
987
391
1.8112
37.9
31.6988
Non-extensive O.R. proc unrelated to principal diagnosis w CC
987
182
1.0902
33.0
27.5989
Non-extensive O.R. proc  unrelated to principal diagnosis w/o CC/MCC 3
987
21
0.8072
24.6
20.5998
Ungroupable 7
998
0
0.0000
0.0
0.0999
Principal diagnosis invalid as discharge diagnosis 7
999
0
0.0000
0.0
0.01
                             Proposed relative weights for these proposed MS-LTC-DRGs were determined by assigning these cases to proposed low-volume quintile 1.2
                             Proposed relative weights for these proposed MS-LTC-DRGs were determined by assigning these cases to proposed low-volume quintile 2.3
                             Proposed relative weights for these proposed MS-LTC-DRGs were determined by assigning these cases to proposed low-volume quintile 3.4
                             Proposed relative weights for these proposed MS-LTC-DRGs were determined by assigning these cases to proposed low-volume quintile 4.5
                             Proposed relative weights for these proposed MS-LTC-DRGs were determined by assigning these cases to proposed low-volume quintile 5.6
                             Proposed relative weights for these proposed MS-LTC-DRGs were determined after adjusting to account for nonmonotonicity (see step 4 in section II.I.4. of the Addendum of this proposed rule).7
                             Proposed relative weights for these proposed MS-LTC-DRGs were assigned a proposed relative weight of 0.0000.8
                             Proposed relative weights for these proposed MS-LTC-DRGs were determined by cross-walking these cases to the appropriate proposed MS-LTC-DRG and then assigning them to the appropriate proposed low volume quintile because they had no LTCH cases in the FY 2006 MedPAR file (see step 5 in section II.I.4 of the Addendum of this proposed rule).9
                             Proposed relative weights for these proposed MS-LTC-DRGs were determined by combining with its base MS-LTC-DRG because they had no LTCH cases in the FY 2006 MedPAR file (see step 5 in section II.I.4 of the Addendum of this proposed rule).
 Appendix A—Regulatory Impact Analysis I. Overall Impact We have examined the impacts of this proposed rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review) and the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132. Executive Order 12866 (as amended by Executive Order 13258, which merely reassigns responsibility of duties) directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any 1 year). We have determined that this rule is a major rule as defined in 5 U.S.C. 804(2). We estimate that the proposed changes for FY 2008 operating and capital payments will redistribute in excess of $100 million among different types of inpatient cases. The market basket update to the IPPS rates required by the statute, in conjunction with other proposed payment changes in this proposed rule, would result in an approximate $3.3 billion increase in FY 2008 operating and capital payments. This amount does not reflect changes in hospital admissions or case-mix intensity in operating PPS payments, which would also affect overall payment changes. The RFA requires agencies to analyze options for regulatory relief of small businesses. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and government agencies. Most hospitals and most other providers and suppliers are considered to be small entities, either by nonprofit status or by having revenues of $31 million in any 1 year. (For details on the latest standards for health care providers, we refer readers to the Small Business Administration Web site at: 
                            *http://sba.gov/​idc/​groups/​pubic/​documents/​sba_​homepage/​serv_​sstd_​tablepdf.pdf.*) For purposes of the RFA, all hospitals and other providers and suppliers are considered to be small entities. Individuals and States are not included in the definition of a small entity. We believe that this proposed rule will have a significant impact on small entities as explained in this Appendix. Because we acknowledge that many of the affected entities are small entities, the analysis discussed throughout the preamble of this proposed rule constitutes our initial regulatory flexibility analysis. Therefore, we are soliciting comments on our estimates and analysis of the impact of the proposed rule on those small entities. In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis for any proposed rule that may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 603 of the RFA. With the exception of hospitals located in certain New England counties, for purposes of section 1102(b) of the Act, we previously defined a small rural hospital as a hospital with fewer than 100 beds that is located outside of a Metropolitan Statistical Area (MSA) or New England County Metropolitan Area (NECMA). However, under the current labor market definitions, we no longer employ NECMAs to define urban areas in New England. Therefore, we now define a small rural hospital as a hospital that is located outside of an MSA and has fewer than 100 beds. Section 601(g) of the Social Security Amendments of 1983 (Pub. L. 98-21) designated hospitals in certain New England counties as belonging to the adjacent NECMA. Thus, for purposes of the IPPS, we continue to classify these hospitals as urban hospitals. Section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4) also requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any 1 year of $100 million in 1995 dollars, updated annually for inflation. That threshold level is currently approximately $120 million. This proposed rule will not mandate any requirements for State, local, or tribal governments, nor will it affect private sector costs. Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications. As stated above, this proposed rule would not have a substantial effect on State and local governments. The following analysis, in conjunction with the remainder of this document, demonstrates that this rule is consistent with the regulatory philosophy and principles identified in Executive Order 12866, the RFA, and section 1102(b) of the Act. The rule will affect payments to a substantial number of small rural hospitals, as well as other classes of hospitals, and the effects on some hospitals may be significant. 
                            ( print page 25115) II. Objectives The primary objective of the IPPS is to create incentives for hospitals to operate efficiently and minimize unnecessary costs while at the same time ensuring that payments are sufficient to adequately compensate hospitals for their legitimate costs. In addition, we share national goals of preserving the Medicare Hospital Insurance Trust Fund. We believe the proposed changes in this proposed rule would further each of these goals while maintaining the financial viability of the hospital industry and ensuring access to high quality health care for Medicare beneficiaries. We expect that these proposed changes would ensure that the outcomes of this payment system are reasonable and equitable while avoiding or minimizing unintended adverse consequences. III. Limitations of Our Analysis The following quantitative analysis presents the projected effects of our proposed policy changes, as well as statutory changes effective for FY 2008, on various hospital groups. We estimate the effects of individual proposed policy changes by estimating payments per case while holding all other payment policies constant. We use the best data available, but, generally, we do not attempt to predict behavioral responses to our proposed policy changes, and we do not make adjustments for future changes in such variables as admissions, lengths of stay, or case-mix. However, we believe that adoption of the MS-DRGs proposed in this proposed rule would create a risk of increased aggregate levels of payment as a result of more comprehensive documentation and coding. As explained earlier in this proposed rule, the Secretary has broad discretion under section 1886(d)(3)(A)(vi) of the Act to adjust the standardized amount so as to eliminate the effect of changes in coding or classification of discharges that do not reflect real changes in case-mix. Using this authority, the Medicare Actuary estimates that an adjustment of 4.8 percent over 2 years will be necessary to maintain budget neutrality for the transition to the MS-DRGs. We are proposing to reduce the IPPS standardized amounts by −2.4 percent each year for FY 2008 and FY 2009. The payment impacts shown below illustrate the impact of changes in hospital payment, including the proposed −2.4 percent adjustment to the IPPS standardized amounts both prior to and following the assumed growth in case-mix. As we have done in the previous rules, we are soliciting comments and information about the anticipated effects of these proposed changes on hospitals and our methodology for estimating them. IV. Hospitals Included In and Excluded From the IPPS The prospective payment systems for hospital inpatient operating and capital-related costs encompass nearly all general short-term, acute care hospitals that participate in the Medicare program. There were 35 Indian Health Service hospitals in our database, which we excluded from the analysis due to the special characteristics of the prospective payment methodology for these hospitals. Among other short-term, acute care hospitals, only the 45 such hospitals in Maryland remain excluded from the IPPS under the waiver at section 1814(b)(3) of the Act. As of March 2007, there are 3,535 IPPS hospitals to be included in our analysis. This represents about 59 percent of all Medicare-participating hospitals. The majority of this impact analysis focuses on this set of hospitals. There are also approximately 1,283 CAHs. These small, limited service hospitals are paid on the basis of reasonable costs rather than under the IPPS. There are also 1,186 specialty hospitals and 2,315 specialty units that are excluded from the IPPS. These specialty hospitals include IPFs, IRFs, LTCHs, RNHCIs, children's hospitals, and cancer hospitals. Proposed changes in payments for IPFs and IRFs are made through other separate rulemaking. Payment impacts for these specialty hospitals and units, other than the reasonable cost updates for IPFs paid under a blend, are not included in this proposed rule. There is also a separate rule to update and propose changes to the LTCHs for its July 1 to June 30 rate year. However, we have traditionally used the IPPS rule to update the LTCH relative weights because the LTCH PPS uses the same DRGs as the IPPS, resulting in the LTCH relative weights being recalibrated according to the same schedule as the IPPS (that is, for each Federal fiscal year). The impacts of our proposed policy changes on LTCHs, where applicable, are discussed below. V. Effects on Excluded Hospitals and Hospital Units As of March 2007, there were 1,197 hospitals excluded from the IPPS. Of these 1,187 hospitals, 483 IPFs, 6 LTCHs, 81 children's hospitals, 11 cancer hospitals, and 16 RNHCIs are either being paid, on a reasonable cost basis or have a portion of the PPS payment based on a reasonable cost subject to the rate-of-increase ceiling under § 413.40. The remaining providers, 216 IRFs and 371 LTCHs, are paid 100 percent of the Federal prospective rate under the IRF PPS and the LTCH PPS, respectively. As stated above, IRFs and IPFS are not affected by this proposed rule. The impacts of the changes to LTCHs are discussed separately below. In addition, there are 1,283 IPFs co-located in hospitals otherwise subject to IPPS, paid on a blend of the IPF PPS per diem payment and the reasonable cost-based payment and 996 IRFs (paid under the IRF PPS) co-located in hospitals otherwise subject to the IPPS. Under § 413.40(a)(2)(i)(A), the rate-of-increase ceiling is not applicable to the 93 IPPS excluded hospitals and units in Maryland that are paid in accordance with the waiver at section 1814(b)(3) of the Act. In the past, hospitals and units excluded from the IPPS have been paid based on their reasonable costs subject to limits as established by the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA). Hospitals that continue to be paid fully on a reasonable cost basis are subject to TEFRA limits for FY 2008. For these hospitals (cancer and children's hospitals), consistent with section 1886(b)(3)(B)(ii) of the Act, the proposed update will be the percentage increase in the FY 2008 IPPS operating market basket, currently estimated to be 3.3 percent. In addition, in accordance with § 403.752(a) of the regulations, RNHCIs are paid under § 413.40, which also uses section 1886(b)(3)(B)(ii) of the Act to update the percentage increase in the rate-of-increase limits. For RNHCIs, the update will be the percentage increase in the FY 2008 IPPS operating market basket increase, currently estimated to be 3.3 percent. Effective for cost reporting periods beginning on or after October 1, 2002, LTCHs that elected to be paid based on 100 percent of the LTCH PPS rule are paid, based on a Federal prospective payment amount that is updated annually. Existing LTCHs would receive a PPS blended payment that consisted of the Federal prospective payment rate and a reasonable cost-based payment rate over a 5-year transition period, unless the LTCH elected to be paid at 100 percent of the Federal prospective rate at the beginning of any of its cost reporting periods during the 5-year transition period. In accordance with § 412.533, for cost reporting periods beginning on or after October 1, 2006, the LTCH PPS transition blend percentages are 100 percent of the Federal prospective payment amount and zero percent of the PPS amount calculated under reasonable cost principles. FY 2007 was the fifth year of the 5-year transition period established under § 412.533. Because the reasonable cost principles amount is zero percent for cost reporting periods beginning during FY 2008, LTCHs no longer receive a portion of their payment that is based in part on a reasonable cost subject to the rate-of-increase ceiling. Thus, there is no longer a need for an update factor for LTCHs' TEFRA target amount for FY 2008. The final rule implementing the IPF PPS (69 FR 66922) established a 3-year transition to the IPF PPS during which some providers will receive a blend of the IPF PPS per diem payment and the TEFRA reasonable cost-based payment. For purposes of determining what the TEFRA payment to the IPF will be, we updated the IPF's TEFRA target amount by the excluded hospital market basket percentage increase of 3.4 percent. The impact on excluded hospitals and hospital units of the proposed update in the rate-of-increase limit depends on the cumulative cost increases experienced by each excluded hospital or unit since its applicable base period. For excluded hospitals and units that have maintained their cost increases at a level below the rate-of-increase limits since their base period, the major effect is on the level of incentive payments these hospitals and hospital units receive. Conversely, for excluded hospitals and hospital units with per-case cost increases above the cumulative update in their rate-of-increase limits, the major effect is the amount of excess costs that will not be reimbursed. We note that, under § 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, 
                            ( print page 25116)
                            not to exceed 110 percent of its limit. In addition, under the various provisions set forth in § 413.40, certain excluded hospitals and hospital units can obtain payment adjustments for justifiable increases in operating costs that exceed the limit. VI. Quantitative Effects of the Proposed Policy Changes Under the IPPS for Operating Costs A. Basis and Methodology of Estimates In this proposed rule, we are announcing proposed policy changes and proposed payment rate updates for the IPPS for operating costs. Proposed changes to the capital payments are discussed in section VIII. of this Appendix. Based on the overall percentage change in payments per case estimated using our payment simulation model, we estimate that proposed total FY 2008 operating payments would increase 3.3 percent compared to FY 2007 largely due to the statutorily mandated update to the IPPS rates. This amount reflects an adjustment of −2.4 percent to the IPPS standardized amounts to offset an anticipated increase in payments resulting from improved documentation and coding that does not represent real increases in underlying resource demands and patient acuity due to the proposed adoption of MS-DRGs. The impacts do not illustrate changes in hospital admissions or real case-mix intensity, which would also affect overall payment changes. We have prepared separate impact analyses of the proposed changes to each system. This section deals with proposed changes to the operating prospective payment system. Our payment simulation model relies on the most recent available data to enable us to estimate the impacts on payments per case of certain changes in this proposed rule. However, there are other proposed changes for which we do not have data available that would allow us to estimate the payment impacts using this model. For those proposed changes, we have attempted to predict the payment impacts based upon our experience and other more limited data. The data used in developing the quantitative analyses of proposed changes in payments per case presented below are taken from the FY 2006 MedPAR file and the most current Provider-Specific File that is used for payment purposes. Although the analyses of the changes to the operating PPS do not incorporate cost data, data from the most recently available hospital cost report were used to categorize hospitals. Our analysis has several qualifications. First, in this analysis, we do not make adjustments for future changes in such variables as admissions, lengths of stay, or underlying growth in real case-mix. Second, due to the interdependent nature of the IPPS payment components, it is very difficult to precisely quantify the impact associated with each proposed change. Third, we use various sources for the data used to categorize hospitals in the tables. In some cases, particularly the number of beds, there is a fair degree of variation in the data from different sources. We have attempted to construct these variables with the best available source overall. However, for individual hospitals, some miscategorizations are possible. Using cases from the FY 2006 MedPAR file, we simulated payments under the operating IPPS given various combinations of payment parameters. Any short-term, acute care hospitals not paid under the IPPS (Indian Health Service hospitals and hospitals in Maryland) were excluded from the simulations. The impact of payments under the capital IPPS, or the impact of payments for costs other than inpatient operating costs, are not analyzed in this section. Estimated payment impacts of proposed FY 2008 changes to the capital IPPS are discussed in section VIII of this Appendix. The proposed changes discussed separately below are the following: The effects of the proposed annual reclassification of diagnoses and procedures and the proposed recalibration of the DRG relative weights required by section 1886(d)(4)(C) of the Act.
                        The effects of the proposed changes in hospitals' wage index values reflecting wage data from hospitals' cost reporting periods beginning during FY 2004, compared to the FY 2003 wage data.
                        The effects of the proposed wage and recalibration budget neutrality factors.
                        The effects of the expiration of the labor market area transition for those hospitals that were urban under the old labor market area designations and are now considered rural hospitals.
                        The effects of the expiration of the 3-year provision for applying an imputed rural floor to States that have no rural areas and to States that have rural areas but no IPPS hospitals are located in those areas (69 FR 49109).
                        The effects of geographic reclassifications by the MGCRB that will be effective in FY 2008.
                        The effects of the proposed adjustment to the application of the rural floor budget neutrality provision on the wage index instead of on the standardized amount.
                        The effects of the September 30, 2007 expiration of section 508 ofPub. L. 108-173, which allowed qualifying hospitals to appeal the wage index classification otherwise and apply for reclassification to another area of the State in which the hospital is located (or, at the discretion of the Secretary, to an area within a contiguous State).
                        The effects of section 505 ofPub. L. 108-173, which provides for an increase in a hospital's wage index if the hospital qualifies by meeting a threshold percentage of residents of the county where the hospital is located who commute to work at hospitals in counties with higher wage indexes.
                        The effect of the budget neutrality adjustment being made for the adoption of the proposed MS-DRGs under section 1886(d)(3)(A)(iv) of the Act for the change in aggregate payments that is a result of changes in the coding or classification of discharges that do not reflect real changes in case-mix.
                        The total estimated change in payments based on proposed FY 2008 policies relative to payments based on FY 2007 policies. To illustrate the impacts of the proposed FY 2008 changes, our analysis begins with a FY 2007 baseline simulation model using: the proposed FY 2008 update of 3.3 percent; the FY 2007 DRG GROUPER (Version 24.0); the most current CBSA designations for hospitals based on OMB's MSA definitions; the FY 2007 wage index; and no MGCRB reclassifications. Outlier payments are set at 5.1 percent of total operating DRG and outlier payments. Section 1886(b)(3)(B)(viii) of the Act, as added by section 5001(a) of Pub. L. 109-171, provides that for FY 2007 and subsequent years, the update factor will be reduced by 2.0 percentage points for any hospital that does not submit quality data in a form and manner and at a time specified by the Secretary. At the time this impact was prepared, 147 providers did not receive the full market basket rate-of-increase for FY 2007 because they failed the quality data submission process. For purposes of the simulations shown below, we modeled the proposed payment changes for FY 2008 using a reduced update for these 147 hospitals. However, we do not have enough information to determine which hospitals will not receive the full market basket rate-of-increase for FY 2008 at this time. Each proposed and statutory policy change is then added incrementally to this baseline, finally arriving at an FY 2008 model incorporating all of the proposed changes. This simulation allows us to isolate the effects of each proposed change. Our final comparison illustrates the proposed percent change in payments per case from FY 2007 to FY 2008. Three factors not discussed separately have significant impacts here. The first is the update to the standardized amount. In accordance with section 1886(b)(3)(B)(i) of the Act, we are updating the standardized amounts for FY 2008 using the most recently forecasted hospital market basket increase for FY 2008 of 3.3 percent. (Hospitals that fail to comply with the quality data submission requirement to receive the full update will receive an update reduced by 2.0 percentage points to 1.3 percent.) Under section 1886(b)(3)(B)(iv) of the Act, the updates to the hospital-specific amounts for SCHs and for MDHs are also equal to the market basket increase, or 3.3 percent. A second significant factor that affects the proposed changes in hospitals' payments per case from FY 2007 to FY 2008 is the change in a hospital's geographic reclassification status from one year to the next. That is, payments may be reduced for hospitals reclassified in FY 2007 that are no longer reclassified in FY 2008. Conversely, payments may increase for hospitals not reclassified in FY 2007 that are reclassified in FY 2008. Particularly with the expiration of section 508 of Pub. L. 108-173, the reclassification provision, these impacts can be quite substantial, so if a relatively small number of hospitals in a particular category lose their reclassification status, the percentage change in payments for the category may be below the national mean. A third significant factor is that we currently estimate that actual outlier payments during FY 2007 will be 4.9 percent of total DRG payments. When the FY 2007 final rule was published, we projected FY 2007 outlier payments would be 5.1 percent 
                            ( print page 25117)
                            of total DRG plus outlier payments; the average standardized amounts were offset correspondingly. The effects of the lower than expected outlier payments during FY 2008 (as discussed in the Addendum to this proposed rule) are reflected in the analyses below comparing our current estimates of FY 2007 payments per case to estimated FY 2008 payments per case (with outlier payments projected to equal 5.1 percent of total DRG payments). B. Analysis of Table I Table I displays the results of our analysis of the proposed changes for FY 2008. The table categorizes hospitals by various geographic and special payment consideration groups to illustrate the varying impacts on different types of hospitals. The top row of the table shows the overall impact on the 3,535 hospitals included in the analysis. The next four rows of Table I contain hospitals categorized according to their geographic location: All urban, which is further divided into large urban and other urban; and rural. There are 2,540 hospitals located in urban areas included in our analysis. Among these, there are 1,409 hospitals located in large urban areas (populations over 1 million), and 1,131 hospitals in other urban areas (populations of 1 million or fewer). In addition, there are 995 hospitals in rural areas. The next two groupings are by bed-size categories, shown separately for urban and rural hospitals. The final groupings by geographic location are by census divisions, also shown separately for urban and rural hospitals. The second part of Table I shows hospital groups based on hospitals' FY 2008 payment classifications, including any reclassifications under section 1886(d)(10) of the Act. For example, the rows labeled urban, large urban, other urban, and rural show that the number of hospitals paid based on these categorizations after consideration of geographic reclassifications (including reclassifications under section 1886(d)(8)(B) and section 1886(d)(8)(E) of the Act that have implications for capital payments) are 2,619, 1,436, 1,183 and 916, respectively. The next three groupings examine the impacts of the proposed changes on hospitals grouped by whether or not they have GME residency programs (teaching hospitals that receive an IME adjustment) or receive DSH payments, or some combination of these two adjustments. There are 2,479 nonteaching hospitals in our analysis, 816 teaching hospitals with fewer than 100 residents, and 240 teaching hospitals with 100 or more residents. In the DSH categories, hospitals are grouped according to their DSH payment status, and whether they are considered urban or rural for DSH purposes. The next category groups together hospitals considered urban after geographic reclassification, in terms of whether they receive the IME adjustment, the DSH adjustment, both, or neither. The next five rows examine the impacts of the proposed changes on rural hospitals by special payment groups (SCHs, RRCs, and MDHs), as well as rural hospitals not receiving a special payment designation. There were 59 RRCs, 45 SCHs, 21 MDHs, 17 hospitals that are both SCHs and RRCs, and 1 hospital that is both MDH and RRC. The next series of groupings concern the geographic reclassification status of hospitals. The first grouping displays all urban hospitals that were reclassified by the MGCRB for FY 2008. The second grouping shows the MGCRB rural reclassifications. The final two groupings are based on the type of ownership and the hospital's Medicare utilization expressed as a percent of total patient days. These data were taken from the FY 2004 Medicare cost reports. 
 
  
 
  
 
  
 
  
 
  
 
  C. Effects of the Proposed Changes to the DRG Reclassifications and Relative Cost-Based Weights (Column 2) In Column 2 of Table I, we present the combined effects of the proposed DRG reclassifications and recalibration, as discussed in section II. of the preamble to this proposed rule. Section 1886(d)(4)(C)(i) of the Act requires us annually to make appropriate classification changes in order to reflect changes in treatment patterns, technology, and any other factors that may change the relative use of hospital resources. As discussed in the preamble of this proposed rule, we are proposing to continue the 3-year transition from charge-based to cost-based relative weights. The proposed relative weights for FY 2008 will be 
                            2/3
                             cost-based and 
                            1/3
                             charge-based. Further, we are proposing to adopt MS-DRGs that would increase the number of DRGs from 538 to 745. In column 2, we compare aggregate payments using the proposed FY 2008 MS-DRGS (GROUPER Version 25.0) and blended relative weights to the FY 2007 CMS DRG blended relative weights (GROUPER Version 24.0). The proposed methods of calculating the relative weights and the reclassification changes to the GROUPER are described in more detail in section II.H. of the preamble to this proposed rule. We note that, consistent with section 1886(d)(4)(C)(iii) of the Act, we are proposing to apply a budget neutrality factor to ensure that the overall payment impact of the proposed DRG changes (combined with the proposed wage index changes) is budget neutral. This proposed budget neutrality factor of 0.999317 is applied to payments in Column 4 and not Column 2 because it is a combined DRG reclassification and recalibration and wage index budget neutrality factor. We estimate that proposed changes to the relative weights and DRGs will increase payments to hospitals located in large urban areas (populations over 1 million) by approximately 0.9 percent. These changes generally increase payments to hospitals in all urban areas (0.4 percent) and large teaching hospitals (0.7 percent). Rural hospitals will generally experience a decrease in payments from these changes (−1.8 percent). However, it is important to evaluate these changes together with the cost weights that we adopted in the FY 2007 IPPS final rule. We are adopting cost weights over a transition period from FY 2007 to FY 2009. The cost weights generally increased payments to rural hospitals. Column 2 shows the changes for the proposed rule only and therefore reflects the full payment impact of the MS-DRGs while showing only the FY 2008 portion of the transition to cost weights finalized in last year's rule. In FY 2007, we are paying hospitals using a blend of 
                            1/3
                             cost and 
                            2/3
                             charge relative weights. In FY 2008, we will pay hospitals using a blend of 
                            2/3
                             cost and 
                            1/3
                             charge relative weights. In FY 2009, we will pay hospitals using 100 percent cost relative weights. Therefore, there will likely be some additional increases in payments to rural hospitals from the final year of the transition to fully implemented cost weights that are not illustrated in the above table. Cardiac specialty hospitals would experience the greatest decline in payments (4.0 percent) from the proposed changes to adopt MS-DRGs and the blended relative cost weights. D. Effects of Proposed Wage Index Changes (Column 3) Section 1886(d)(3)(E) of the Act requires that, beginning October 1, 1993, we annually update the wage data used to calculate the wage index. In accordance with this requirement, the proposed wage index for FY 2008 is based on data submitted for hospital cost reporting periods beginning on or after October 1, 2003 and before October 1, 2004. The estimated impact of the proposed wage data on hospital payments is isolated in Column 3 by holding the other payment parameters constant in this simulation. That is, Column 3 shows the percentage changes in payments when going from a model using the FY 2007 wage index, based on FY 2003 wage data and having a 100-percent occupational mix adjustment applied, to a model using the FY 2008 pre-reclassification wage index, adjusted for occupational mix, based on FY 2004 wage data. The wage data collected on the FY 2004 cost report include overhead costs for contract labor that were not collected on FY 2003 and earlier cost reports. The impacts below incorporate the effects of the FY 2004 wage data collected on hospital cost reports, including additional overhead costs for contract labor compared to the wage data from FY 2003 cost reports that were used to calculate the FY 2007 wage index. Column 3 shows the impacts of updating the wage data using FY 2004 cost reports. Overall, the new wage data will lead to a −0.1 percent change for all hospitals. This decrease could be attributed to fluctuations in the wage data. Among the regions, the largest increase is in the rural Pacific region, which experiences a 0.5 percent increase. The largest decline from updating the wage data is seen in the Puerto Rico region (a 0.5 percent decrease). In looking at the wage data itself, the national average hourly wage increased 4.3 percent compared to FY 2007. Therefore, the only manner in which to maintain or exceed the previous year's wage index was to match or exceed the national 4.3 percent increase in average hourly wage. Of the 3,486 hospitals with wage data for both FYs 2007 and 2008, 1,709, or 49.0 percent, experienced an average hourly wage increase of 4.3 percent or more. The following chart compares the shifts in wage index values for hospitals for FY 2008 relative to FY 2007. Among urban hospitals, 52 will experience an increase of more than 5 percent and less than 10 percent and 6 will experience an increase of more than 10 percent. Among rural hospitals, 21 will experience an increase of more than 5 percent and less than 10 percent, and 4 will experience an increase of more than 10 percent. However, 965 rural hospitals will experience increases or decreases of less than 5 percent, while 2,384 urban hospitals will experience increases or decreases of less than 5 percent. Thirty-three urban hospitals will experience decreases in their wage index values of more than 5 percent and less than 10 percent. Twenty-one urban hospitals will experience decreases in their wage index values of greater than 10 percent. No rural hospitals will experience decreases of more than 5 percent. The following chart shows the projected impact for urban and rural hospitals. Percentage change in area wage    index values
Number of hospitalsUrban
RuralIncrease more than 10 percent
6
4Increase more than 5 percent and less than 10 percent
52
21Increase or decrease less than 5 percent
2,384
965Decrease more than 5 percent and less than 10 percent
33
0Decrease more than 10 percent
21
0
 E. Combined Effects of Proposed DRG and Wage Index Changes (Column 4) Section 1886(d)(4)(C)(iii) of the Act requires that changes to DRG reclassifications and the relative weights cannot increase or decrease aggregate payments. In addition, section 1886(d)(3)(E) of the Act specifies that any updates or adjustments to the wage index are to be budget neutral. As noted in the Addendum to this proposed rule, in determining the budget neutrality factor, we equated simulated aggregate payments for FY 2007 and FY 2008 using the FY 2006 Medicare utilization data after applying the proposed changes to the DRG relative weights and the wage index. We computed a wage and DRG recalibration budget neutrality factor of 0.999317. The 0.0 percent impact for all hospitals demonstrates that these proposed changes, in combination with the proposed budget neutrality factor, are budget neutral. In Table I, the combined overall impacts of the effects of both the proposed DRG reclassifications and the updated wage index are shown in Column 4. The estimated changes shown in this column reflect the combined effects of the proposed changes in Columns 2 and 3 and the budget neutrality factor for the revised FY 2008 wage index. 
                            ( print page 25125)
                            Due to the proposed changes to the application of the rural floor budget neutrality, this column does not include the wage index floor for urban areas as required by section 4410 of Pub. L. 105-33. The effects of that provision are included in Column 7. There also may be some variation of plus or minus 0.1 percentage point due to rounding. F. Effects of the Expiration of the 3-Year Provision Allowing Urban Hospitals That Were Converted to Rural as a Result of the FY 2005 Labor Market Area Changes To Maintain the Wage Index of the Urban Labor Market Area in Which They Were Formerly Located (Column 5) The policy adopted in FY 2005 for urban hospitals that became rural under the new labor market area definitions is to expire in FY 2008. In FY 2005, we adopted a policy that allowed urban hospitals that became rural under the new labor market area regions to maintain the wage index assignment of the MSA where they were located for the 3-year period FY 2005, FY 2006, and FY 2007. Beginning in FY 2008, these hospitals will receive their statewide rural wage index or their FY 2008 MGCRB reclassified wage index. Column 5 shows the impact of the expiration of the labor market area transition for those hospitals that were urban under the old labor market area designations and are now considered rural hospitals. Currently, the rural hospital row shows a 0.2 percent decrease from the end of the provision as these hold harmless hospitals are now considered geographically rural and are now receiving the wage index of the MSA where they are currently located. G. Effects of MGCRB Reclassifications (Column 6) Our impact analysis to this point has assumed hospitals are paid on the basis of their actual geographic location (with the exception of ongoing policies that provide that certain hospitals receive payments on other bases than where they are geographically located). The proposed changes in Column 6 reflect the per case payment impact of moving from this baseline to a simulation incorporating the MGCRB decisions for FY 2008 which affect hospitals' wage index area assignments. By February 28 of each year, the MGCRB makes reclassification determinations that will be effective for the next fiscal year, which begins on October 1. The MGCRB may approve a hospital's reclassification request for the purpose of using another area's wage index value. The proposed FY 2008 wage index values incorporate all of the MGCRB's reclassification decisions for FY 2008. The wage index values also reflect any decisions made by the CMS Administrator through the appeals and review process through February 28, 2007. The overall effect of geographic reclassification is required by section 1886(d)(8)(D) of the Act to be budget neutral. Therefore, we are proposing to apply an adjustment of 0.991938 to ensure that the effects of the section 1886(d)(10) reclassifications are budget neutral. (See section II.A. of the Addendum to this proposed rule.) Geographic reclassification generally benefits hospitals in rural areas. We estimate that geographic reclassification will increase payments to rural hospitals by an average of 1.7 percent. H. Effects of the Adjustment to the Application of the Rural Floor (Column 7) As discussed in section III.G. of the preamble of this proposed rule, section 4410 of Pub. L. 105-33 established the rural floor by requiring that the wage index for a hospital in any urban area cannot be less than the area wage index determined for the state's rural area. Since FY 1998, we have implemented this provision by adjusting the standardized amounts. In this proposed rule, we are proposing to change how we apply budget neutrality to the rural floor beginning in FY 2008. Rather than applying a budget neutrality adjustment to the standardized amount, a uniform budget neutrality adjustment would be applied to the wage index. Therefore, we are proposing to apply an adjustment to the wage index of 0.997084 (−0.29 percent) to ensure that the rural floor adjustments are budget neutral as indicated by the zero effect on payments to hospitals overall. Column 7 shows the projected impact of change in the application of the rural floor. The column compares the post-reclassification FY 2008 wage index of providers before the rural floor adjustment and the post-reclassification FY 2008 wage index of providers with the rural floor adjustment. Only urban hospitals can benefit from the rural floor provision. Because the provision is budget neutral, all other hospitals (that is, all rural hospitals and those urban hospitals to which the adjustment is not made) will experience a decrease in payments due to the budget neutrality adjustment. We project rural hospitals will experience a 0.1 percent decrease in payments. We project hospitals located in other urban areas (populations of 1 million or fewer) will experience a 0.1 percent increase in payments. The rural floor will benefit 77 percent of the hospitals in New Hampshire (10) and 45 percent of the hospitals in Connecticut (15), explaining the average increase of 1 percent shown in the table for hospitals located in New England. The average increase among hospitals in the Pacific region is estimated at 0.4 percent and is explained by application of the rural floor to 34 percent of the hospitals in California (114) and 18 percent of the hospitals in Washington (9). I. Effects of the Expiration of the Imputed Rural Floor (Column 8) The FY 2005 IPPS final rule (69 FR 49109) established a temporary imputed rural floor for all urban States from FY 2005 to FY 2007. The rural floor requires that an urban wage index cannot be lower than the wage index for any rural hospital in that State. Therefore, an imputed rural floor was established for States that do not have rural areas or rural IPPS hospitals. The provision will expire at the end of FY 2007 unless we were to adopt a change to the regulation to continue it for FY 2008. Column 8 shows the effects of the expiration of the imputed rural floor. Only hospitals located in Massachusetts and New Jersey were affected by the provision. However, as explained in section III.G. of the preamble of this proposed rule, the imputed rural floor will no longer apply in Massachusetts even if it were to be continued because one hospital acquired rural status under § 412.103 of the regulations. Urban providers in New England (MA) and the Mid-Atlantic region (NJ) will experience a decrease by 0.1 percent and by 0.2 percent respectively from the imputed rural floor no longer being applied in those States. J. Effects of the Expiration of Section 508 of Pub. L. 108-173 (Column 9) Section 508 of Pub. L. 108-173 will expire on September 30, 2007. As stated in the FY 2007 IPPS final rule (71 FR 48333), we established procedural rules under section 1886(d)(10)(D)(v) of the Act to address specific circumstances where individual and group reclassifications involve a section 508 hospital. In the final rule, the rules were designed to recognize the special circumstances of section 508 hospital reclassifications ending mid-year during FY 2007 and were intended to allow previously approved reclassifications to continue through March 31, 2007, and new section 1886(d)(10) reclassifications to begin April 1, 2007, upon the conclusion of the section 508 reclassifications. Under these procedural rules, some section 1886(d)(10) hospital reclassifications are only in effect for the second half of the fiscal year. However, Division B, Title I, section 106(a) of the MIEA-TRHCA (Pub. L. 109-432) extended any geographic reclassifications of hospitals that would expire on March 31, 2007, by 6 months until September 30, 2007. For FY 2008, the providers that had been reclassified under section 508 in FY 2007 will receive payment using the wage index for the area where they are currently located. The impact of the expiration of the policy is modeled in Column 9 of Table I. Section 508 of Pub. L. 108-173 was not a budget neutral provision of statute. Its enactment increased total payments for Medicare inpatient hospital services. Therefore, relative to FY 2007, the expiration of section 508 of Pub. L. 108-173 will reduce Medicare inpatient hospital payments by an estimated 0.1 percent. K. Effects of the Proposed Wage Index Adjustment for Out-Migration (Column 10) Section 1886(d)(13) of the Act, as added by section 505 of Pub. L. 108-173, provides for an increase in the wage index for hospitals located in certain counties that have a relatively high percentage of hospital employees who reside in the county, but work in a different area with a higher wage index. Hospitals located in counties that qualify for the payment adjustment are to receive an increase in the wage index that is equal to a weighted average of the difference between the wage index of the resident county, post-reclassification and the higher wage index work area(s), weighted by the overall percentage of workers who are employed in an area with a higher wage index. With the out-migration adjustment, rural providers will experience a 0.1 percent increase in payments in FY 2008 relative to 
                            ( print page 25126)
                            no adjustment at all. We included these additional payments to providers in the impact table shown above, and we estimate the impact of these providers receiving the out-migration increase to be approximately $15 million. L. Effects of All Proposed Changes With CMI Adjustment Prior to Assumed Growth (Column 11) Column 11 compares our estimate of payments per case between FY 2007 and FY 2008 with all proposed changes reflected in this proposed rule for FY 2008 including a 0.976 adjustment to the payment rates to account for anticipated improvements in documentation and coding that is expected to increase case-mix. We generally apply an adjustment to the DRGs to ensure budget neutrality assuming constant utilization. However, with the proposed adoption of the MS-DRGs, the number of DRGs will expand from 538 to 745. Therefore, we expect an increase in the CMI due to improved coding and have applied an additional adjustment to achieve budget neutrality. However, because we modeled the impact, including the adjustment for anticipated case-mix increase but not the actual case-mix increase itself in column 11, this column illustrates a total payment changes that is less than what is anticipated to occur. M. Effects of All Proposed Changes With CMI Adjustment and Assumed Growth (Column 12) Column 12 compares our estimate of payments per case between FY 2007 and FY 2008, incorporating all proposed changes reflected in this proposed rule for FY 2008 (including statutory changes). This column includes all of the proposed policy changes and assumes the 2.4 percent increase in case-mix from improved documentation and coding will occur equally across all hospitals. Column 12 reflects the impact of all proposed FY 2008 changes relative to FY 2007, including those shown in Columns 2 through 10. The average increase for all hospitals is approximately 3.3 percent. This increase includes the effects of the proposed 3.3 percent market basket update. It also reflects the 0.2 percentage point difference between the projected outlier payments in FY 2008 (5.1 percent of total DRG payments) and the current estimate of the percentage of actual outlier payments in FY 2007 (4.9 percent), as described in the introduction to this Appendix and the Addendum to this proposed rule. As a result, payments are projected to be 0.2 percentage points lower in FY 2007 than originally estimated, resulting in a 0.2 percentage point greater increase for FY 2008 than would otherwise occur. In addition, the impact of expiration of section 508 of Pub. L. 108-173 reclassification accounts for a 0.1 percent decrease in estimated payments. As stated earlier, section 1886(d)(13) of the Act provides for an increase in the wage index for hospitals located in certain counties that have a relatively high percentage of hospital employees who reside in the county, but work in a different area with a higher wage index. This provision of the statute is not budget neutral. Although the out-migration adjustment will increase payments to some hospitals in FY 2008 relative to not having an adjustment at all, the total number of hospitals receiving the adjustment will be less in FY 2008 than FY 2007, resulting in a 0.1 percent reduction in total IPPS payments. There might also be interactive effects among the various factors comprising the payment system that we are not able to isolate. For these reasons, the values in Column 10 may not equal the product of the percentage changes described above. The proposed overall change in payments per case for hospitals in FY 2008 is estimated to increase by 3.3 percent. Hospitals in urban areas would experience an estimated 3.6 percent increase in payments per case compared to FY 2007. Hospitals in large urban areas would experience an estimated 4.2 percent increase and hospitals in other urban areas would experience an estimated 2.8 percent increase in payments per case in FY 2008. Hospitals' payments per case in rural areas are estimated to increase 0.9 percent. Among urban census divisions, the largest estimated payment increases would be 4.7 percent in the Pacific region and 4.2 percent in the South Atlantic region. The smallest urban increase is estimated at 2.6 percent in the New England region. Among rural regions in Column 12, the providers in the West South Central region experience an estimated decrease in payments by 0.7 percent. The Pacific and South Atlantic regions would benefit the most, with 2.0 and 1.8 percent estimated increases, respectively. Among special categories of rural hospitals in Column 12, the one MDH/RRC provider would experience an estimated decrease in payments of 0.8 percent and MDH providers would receive an estimated increase of 0.3 percent. RRCs would experience an estimated increase in payments by 2.5 percent. Urban hospitals reclassified for FY 2008 are anticipated to receive an increase of 3.3 percent, while urban hospitals that not reclassified for FY 2008 are expected to receive an increase of 3.6 percent. Rural hospitals reclassifying for FY 2008 are anticipated to receive a 1.5 percent payment increase. N. Effects of Proposed Policy on Payment Adjustments for Low-Volume Hospitals For FY 2008, we are proposing to continue to apply the volume adjustment criteria we specified in the FY 2005 IPPS final rule (69 FR 49099). We expect that three providers would receive the low-volume adjustment for FY 2008. We included these additional payments to providers in the impact table shown above and we estimate the impact of these providers receiving the additional 25-percent payment increase to be approximately $50,000. O. Impact Analysis of Table II Table II presents the projected impact of the proposed changes for FY 2008 for urban and rural hospitals and for the different categories of hospitals shown in Table I. It compares the estimated payments per case for FY 2007 with the proposed average estimated per case payments for FY 2008, as calculated under our models. Thus, this table presents, in terms of the average dollar amounts paid per discharge, the combined effects of the proposed changes presented in Table I. The proposed percentage changes shown in the last column of Table II equal the percentage changes in average payments from Column 12 of Table I. Table II.—Impact Analysis of Proposed Changes for FY 2008 Operating Prospective Payment System
[Payments per case]
Number of hospitals 
                                     (1)
Average FY 2007 payment per case 1
                                      
                                     (2)
Average proposed FY 2008 payment per case 1
                                      
                                     (3)
All proposed FY 2008 changes 
                                     (4)All hospitals
3535
9004
9299
3.3By Geographic Location:Urban hospitals
2540
9343
9678
3.6Large urban areas (populations over 1 million)
1409
9750
10156
4.2Other urban areas (populations of 1 million or fewer)
1131
8854
9103
2.8Rural hospitals
995
7060
7123
0.9Bed Size (Urban):0-99 beds
632
7236
7263
0.4100-199 beds
849
7904
8170
3.4200-299 beds
480
8815
9120
3.5300-499 beds
412
9749
10136
4.0500 or more beds
167
11762
12234
4.0( print page 25127)Bed Size (Rural):0-49 beds
342
6161
6065
−1.650-99 beds
369
6558
6588
0.5100-149 beds
172
6867
6960
1.3150-199 beds
67
7626
7735
1.4200 or more beds
45
8759
8938
2.0Urban by Region:New England
126
9748
10001
2.6Middle Atlantic
350
10243
10529
2.8South Atlantic
388
8801
9175
4.2East North Central
395
8890
9197
3.4East South Central
166
8512
8784
3.2West North Central
156
9064
9321
2.8West South Central
358
8819
9174
4.0Mountain
153
9507
9826
3.3Pacific
395
11136
11657
4.7Puerto Rico
53
4368
4525
3.6Rural by Region:New England
19
9675
9714
0.4Middle Atlantic
72
7466
7525
0.8South Atlantic
173
6579
6700
1.8East North Central
124
7521
7574
0.7East South Central
177
6400
6479
1.2West North Central
115
7743
7792
0.6West South Central
194
6381
6339
−0.7Mountain
80
7766
7834
0.9Pacific
41
8725
8896
2.0By Payment Classification:Urban hospitals
2619
9298
9629
3.6Large urban areas (populations over 1 million)
1436
9725
10127
4.1Other urban areas (populations of 1 million or fewer)
1183
8789
9034
2.8Rural areas
916
7175
7242
0.9Teaching Status:Non-teaching
2479
7648
7851
2.7Fewer than 100 Residents
816
9067
9384
3.5100 or more Residents
240
13006
13533
4.1Urban DSH:Non-DSH
879
8146
8307
2.0100 or more beds
1527
9792
10182
4.0Less than 100 beds
359
6574
6697
1.9Rural DSH:SCH
391
6992
7013
0.3RRC
189
7686
7818
1.7100 or more beds
36
5902
6028
2.1Less than 100 beds
154
5333
5353
0.4Urban teaching and DSH:Both teaching and DSH
805
10750
11185
4.0Teaching and no DSH
192
8861
9078
2.5No teaching and DSH
1081
7990
8283
3.7No teaching and no DSH
541
7664
7812
1.9Rural Hospital Types:RRC
59
8155
8358
2.5SCH
45
9225
9301
0.8MDH
21
6321
6339
0.3SCH and RRC
17
9968
10239
2.7MDH and RRC
1
9755
9674
−0.8Type of Ownership:Voluntary
2069
9136
9424
3.2Proprietary
823
8173
8478
3.7Government
598
9270
9593
3.5Medicare Utilization as a Percent of Inpatient Days:0-25
230
12731
13443
5.625-50
1292
10160
10570
4.050-65
1453
7913
8116
2.6Over 65
441
7240
7331
1.2( print page 25128)Hospitals Reclassified by the Medicare Geographic Classification Review Board:FY 2008 Reclassifications:All Reclassified Hospitals FY 2008
801
8695
8938
2.8All Non-Reclassified Hospitals FY 2008
2734
9106
9417
3.4Urban Reclassified Hospitals FY 2008
434
9273
9581
3.3Urban Non-reclassified Hospitals FY 2008
2105
9359
9701
3.6Rural Reclassified Hospitals FY 2008
367
7555
7669
1.5Rural Nonreclassified Hospitals FY 2008
568
6411
6392
−0.3All Section 401 Reclassified Hospitals
31
8647
8799
1.8Other Reclassified Hospitals (Section 1886(d)(8)(B))
61
6635
6729
1.4Former Section 508 Hospitals
107
9766
9814
0.5Specialty Hospitals:Cardiac Specialty Hospitals
22
10736
10676
−0.61
                                 These payment amounts per case do not reflect any estimates of annual case-mix increase.
 VII. Effects of Other Proposed Policy Changes In addition to those proposed policy changes discussed above that we are able to model using our IPPS payment simulation model, we are proposing to make various other changes in this proposed rule. Generally, we have limited or no specific data available with which to estimate the impacts of these proposed changes. Our estimates of the likely impacts associated with these other proposed changes are discussed below. A. Effects of Proposed Policy on Hospital-Acquired Conditions, Including Infections In section II.F. of the preamble of this proposed rule, we discuss our proposal to implement section 5001(c) of Pub. L. 109-171, which requires the Secretary to identify, by October 1, 2007, at least two conditions that are (a) high cost or high volume or both, (2) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through application of evidence-based guidelines. For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case will be paid as though the secondary diagnosis was not present. However, the statute also requires the Secretary to continue counting the condition as a secondary diagnosis that results in a higher IPPS payment when doing the budget neutrality calculations for DRG reclassifications and recalibration. Therefore, we do our budget neutrality calculations as though the payment provision did not apply but Medicare will make a lower payment to the hospital for the specific case that includes the secondary diagnosis. Thus, the provision will result in cost savings to the Medicare program. Although we believe there will be modest savings to the Medicare program from implementation of this provision, we cannot estimate them at this time. To estimate savings associated with this provision, we would need to know the frequency that the selected conditions are not present on admission in the Medicare population. Medicare will not begin collecting this information from hospitals until October 1, 2007. Therefore, there is currently no data upon which to estimate the savings of this provision. The provision does not go into effect until October 1, 2008. For this reason, there will be no savings for FY 2008. Any savings associated with this provision will not be realized until FY 2009. Based on the data available to us for next year's IPPS rule, we will estimate the savings associated with the conditions we selected under this provision for FY 2009 and subsequent years. We further note that the provision will only apply when the selected conditions are the only secondary diagnosis present on the claim that will lead to higher payment. Therefore, if a nonselected secondary diagnosis that leads to the same higher payment is on the claim, the case will continue to be assigned to the higher paying DRG and there will be no savings to Medicare from the case. Our analysis of the Medicare claims suggests that patients will generally have multiple secondary diagnoses during a hospital stay. Patients having one MCC or CC will frequently have additional conditions that also lead to higher payment. In only a small percentage of the cases did we find that a patient had only one secondary diagnosis that would lead to higher payment, and in these cases, we have no information to suggest whether the condition was acquired after admission. Therefore, we believe the savings associated with this provision are likely to be very modest. Again, once we have data on the frequency of occurrence of the selected conditions after admission, we will refine our analysis. B. Effects of Proposed MS-LTC-DRG Reclassifications and Relative Weights for LTCHs In section II.I. of the preamble to this final rule, we discuss the proposed changes to adopt MS-LTC-DRG relative weights for FY 2008, which are based on the Version 25.0 of the CMS GROUPER (including the changes in the classifications, relative weights, and geometric mean length of stay for each proposed MS-LTC-DRG). We noted in the same section that, in the FY 2008 LTCH PPS proposed rule (72 FR 4784 through 4786), we proposed that, beginning with the MS-LTC-DRG update for FY 2008, the annual update to the proposed MS-LTC-DRG classifications and relative weights would be done in a budget neutral manner, such that estimated aggregate LTCH PPS payments would be unaffected; that is, they would be neither greater than nor less than the estimated aggregate LTCH PPS payments that would have been made without the proposed MS-LTC-DRG classification and relative weight changes. However, if the budget neutrality policy had not been proposed, we are estimating that, under the current payment policies (RY 2007), using the most recent available claims data (FY 2006 MedPAR files) for the 376 LTCHs in our database, the proposed changes to the MS-LTC-DRG classifications and relative weights for FY 2008 would have resulted in an aggregate decrease in LTCH PPS payments of approximately 1.6 percent. In applying the budget neutrality adjustment described above, we assumed constant utilization. However, with the proposed adoption of the MS-LTC-DRGs, we expect an increase in coding or classification of discharges that do not reflect real change in case-mix due to the adoption of the new patient classification system. Therefore, we have applied an additional adjustment of 0.976 to the proposed MS-LTC-DRG relative weights for the anticipated increase in case-mix due to improved documentation and coding. 
                            ( print page 25129) C. Effects of Proposed New Technology Add-On Payments In section II.I. of the preamble to this proposed rule, we discuss proposed add-on payments for new medical services and technologies. As explained in that section, we are not required to ensure that any add-on payments for new technology under section 1886(d)(5)(K) of the Act are budget neutral. As discussed earlier in this proposed rule, we have yet to determine whether Wingspan® meets the criteria for new technology add-on payments for FY 2008. Therefore, it is premature to estimate the potential payment impact in FY 2008 of any potential decision to make new technology add-on payments for Wingspan®. In addition, for FY 2008, we have proposed to discontinue new technology add-on payments for GORE TAG, Restore®, and X STOP. In the FY 2007 IPPS final rule (71 FR 48344), we estimated that FY 2007 IPPS new technology add-on payments would be $16.61 million, $6.01 million, and $9.35 million, respectively, for these technologies. We have no additional information to further refine these estimates. Therefore, we estimate that Medicare's new technology add-on payments will decline by approximately $32 million (the sum of our estimates for FY 2007) in FY 2008 compared to FY 2007. D. Effects of Requirements for Hospital Reporting of Quality Data for Annual Hospital Payment Update In section IV.A. of the preamble of this proposed rule, we discuss the requirements for hospitals to report quality data in order for hospitals to receive the full annual hospital payment update for FY 2008 and FY 2009. We also note that, for the FY 2008 payment update, hospitals must pass our validation requirement of a minimum of 80 percent reliability, based upon our chart-audit validation process, for the first three quarters of data from CY 2006. These data were due to the QIO Clinical Warehouse by August 15, 2006 (first quarter CY 2006 discharges), November 15, 2006 (second quarter CY 2006 discharges), and February 15, 2007 (third quarter CY 2006 discharges). We have continued our efforts to ensure that QIOs provide assistance to all hospitals that wish to submit data. In the preamble of this proposed rule, we are providing additional validation criteria to ensure that the quality data being sent to CMS are accurate. The requirement of 5 charts per hospital will result in approximately 21,500 charts per quarter total submitted to the agency. We reimburse hospitals for the cost of sending charts to the Clinical Data Abstraction Center (CDAC) at the rate of 12 cents per page for copying and approximately $4.00 per chart for postage. Our experience shows that the average chart received at the CDAC is approximately 150 pages. Thus, the agency will have expenditures of approximately $473,200 per quarter to collect the charts. Given that we reimburse for the data collection effort, we believe that a requirement for five charts per hospital per quarter represents a minimal burden to the participating hospital. E. Effects of Proposed Policy on Cancellation of Classification of Acquired Rural Status and Rural Referral Centers In section IV.C.2. of the preamble of this proposed rule, we are proposing to revise our regulations to change the effective date of cancellation of acquired rural status for rural referral centers from “the hospital's next full cost reporting period following the date of its request for cancellation” to the next cost reporting period for hospitals paid on the basis of reasonable costs (such as CAHs) and for hospitals under the IPPS, after at least one 12-month cost reporting period as rural and not until the beginning of the Federal fiscal year following the date of its request for cancellation. Currently, there are about 100 IPPS hospitals that have acquired rural status. During this fiscal year (FY 2007), we have only received requests for cancellations from five hospitals. However, this number may increase if the current policy is not changed. We anticipate that the proposed policy change would, at a minimum, affect these five hospitals. However, we estimate that the proposed policy change would not have a significant impact on IPPS hospitals. F. Effects of Proposed Policy on Payment for IME and Direct GME In section IV.D.3. of the preamble of this proposed rule, we discuss our proposed changes related to whether vacation and sick leave as well as orientation should be included in the FTE count for IME and direct GME payment purposes. We are proposing, for cost reporting periods beginning on or after October, 1, 2007, for direct GME and IME, that time spent by residents on vacation or sick leave be removed from the total time considered to constitute an FTE resident. In addition, we are proposing to continue our existing policy to count time spent by residents in orientation activities for both IME and direct GME payment purposes. Because we are proposing to remove vacation and sick leave from the total time considered to constitute an FTE resident, we believe the impact of this change would be negligible. In addition, there is no impact from the clarification of the policy for orientation time since it is not a change in policy. G. Effects of Proposed Policy Changes Relating to Emergency Services Under EMTALA During an Emergency Period In section IV.F. of the preamble of this proposed rule, we are proposing to amend the EMTALA regulations regarding EMTALA implementation in emergency areas during an emergency period. Section 1135 of the Act authorizes the Secretary to temporarily waive or modify the application of several requirements and their implementing regulations as they relate to actions taken in an emergency area during an emergency period. The EMTALA regulations (§ 489.24(a)(2)) now specify that sanctions for inappropriate transfer during a national emergency do not apply to a hospital with a dedicated emergency department located in an emergency area. To make our regulations better reflect the scope of the authority under section 1135 of the Act, we are proposing to revise them to clarify that such waivers also may apply to sanctions for the redirection or relocation of an individual to an alternate location to receive a medical screening examination where that direction or relocation occurs pursuant to a State emergency preparedness plan. We also are proposing to revise the regulations to incorporate changes made by the Pandemic and All-Hazards Preparedness Act. That legislation amended section 1135 of the Act to state that, in the case of a public health emergency that involves a pandemic infectious disease, sanctions for the direction or relocation of an individual to an alternative location for screening may be waived based on either a State emergency preparedness plan or a State pandemic preparedness plan, whichever applies in the State. In addition, section 1135 of the Act was amended to create an exception to the otherwise applicable 72-hour limitation on the duration of waivers or modifications of sanctions for EMTALA violations in cases where a public health emergency involves a pandemic infectious disease (such as pandemic influenza). As described more fully earlier in this preamble, these changes are not discretionary and do not impose any substantive new requirements. On the contrary, they merely update our regulations to make them consistent with current statutory requirements. Because of this, we are estimating no impact on Medicare expenditures and no significant impact on hospitals with emergency departments. H. Effects of Proposed Policy on Disclosure of Physician Ownership in Hospitals and Patient Safety Measures In section IV.G. of the preamble of this proposed rule, we discuss our proposals to adopt a requirement relating to disclosure of physician ownership in hospitals and to increase patient safety measures. In the strategic and implementing plan included in our “Final Report to the Congress and Strategic and Implementing Plan” required under section 5006 of the Deficit Reduction Act of 2005, we stated that we would adopt a disclosure requirement that would require hospitals to disclose to patients whether they are physician-owned and, if so, the names of the physician-owners. In addition, we recognize that patients should be made aware of whether or not a physician is present in the hospital at all times, and the hospital's plans to address patients' emergency medical conditions when a physician is not present. We believe this proposed rule would impose minimal additional costs on hospitals. We believe the cost of implementing these provisions borne by hospitals would be limited to a one-time cost associated with completing minor revisions to portions of the medical staff bylaws and policies and procedures related to patient admission and registration, as well as providing written notification to patients and affected staff. In addition, the proposed changes concerning disclosure of physician ownership in hospitals are consistent with current practices of members of the physician-owned specialty hospital associations. Therefore, we do not believe that these proposed changes will have any significant economic impact on hospitals. 
                            ( print page 25130) I. Effects of Implementation of Rural Community Hospital Demonstration Program In section IV.H. of the preamble to this proposed rule, we discuss our implementation of section 410A of Pub. L. 108-173 that required the Secretary to establish a demonstration that will modify reimbursement for inpatient services for up to 15 small rural hospitals. Section 410A(c)(2) requires that “in conducting the demonstration program under this section, the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration program under this section was not implemented.” As discussed in section IV.H. of the preamble to this proposed rule, we are satisfying this requirement by adjusting national IPPS rates by a factor that is sufficient to account for the added costs of this demonstration. We estimate that the average additional annual payment for FY 2008 that would be made to each participating hospital under the demonstration would be approximately $1,075,765. We based this estimate on the recent historical experience of the difference between inpatient cost and payment for hospitals that are participating in the demonstration. For the 9 participating hospitals, the total annual impact of the demonstration program is estimated to be $9,681,893. The proposed adjustment factor to the Federal rate used in calculating Medicare inpatient prospective payments as a result of the demonstration is 0.999899. J. Effects of Proposed Policy on Services Furnished to Beneficiaries in Custody of Penal Authorities In section VII. of the preamble of this proposed rule, we discuss our proposal to revise our regulations relating to the special conditions under which Medicare payment may be made for services furnished to individuals in custody of penal authorities. We are proposing to indicate that, for purposes of Medicare payment, individuals who are in custody include, but are not limited to, individuals who are under arrest, incarcerated, imprisoned, escaped from confinement, under supervised release, required to reside in mental health facilities, required to reside in halfway houses, required to live under home detention, or confined completely or partially in any way under a penal statute or rule. This proposed definition is in accordance with how custody has been defined by Federal courts for purposes of the habeas corpus protections of the Constitution and is consistent with current CMS policy. We anticipate that this proposed change would have no measurable impact on Medicare expenditures. VIII. Impact of Proposed Changes in the Capital IPPS A. General Considerations Fiscal year (FY) 2001 was the last year of the 10-year transition period established to phase in the PPS for hospital capital-related costs. During the transition period, hospitals were paid under one of two payment methodologies: fully prospective or hold harmless. Under the fully prospective methodology, hospitals were paid a blend of the capital Federal rate and their hospital-specific rate (see § 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 § 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 § 412.312, the basic methodology for determining a capital PPS payment includes a large urban add-on adjustment. However, as discussed above and in section V. of the preamble of this proposed rule, we are proposing to eliminate the large urban add-on adjustment to capital IPPS payments in FY 2008. The proposed basic methodology for calculating capital IPPS payments in FY 2008 would be:  (Standard Federal Rate) × (DRG weight) × (GAF) × (COLA for hospitals located in Alaska and Hawaii) × (1 + Disproportionate Share Adjustment Factor + IME Adjustment Factor, if applicable). In addition, hospitals may also receive outlier payments for those cases that qualify under the threshold established for each fiscal year. The data used in developing the impact analysis presented below are taken from the December 2006 update of the FY 2006 MedPAR file and the December 2006 update of the Provider-Specific File that is used for payment purposes. Although the analyses of the proposed changes to the capital prospective payment system do not incorporate cost data, we used the December 2006 update of the most recently available hospital cost report data (FYs 2004 and 2005) to categorize hospitals. Our analysis has several qualifications. In general, we do not make adjustments for behavioral changes that hospitals may adopt in response to proposed policy changes. However, as discussed in section III. of the Addendum to this proposed rule, we proposed that the capital rates would be adjusted to account for upcoding under the proposed MS-DRGs. Furthermore, due to the interdependent nature of the IPPS, it is very difficult to precisely quantify the impact associated with each proposed change. In addition, we draw upon various sources for the data used to categorize hospitals in the tables. In some cases (for instance, the number of beds), there is a fair degree of variation in the data from different sources. We have attempted to construct these variables with the best available sources overall. However, for individual hospitals, some miscategorizations are possible. Using cases from the December 2006 update of the FY 2006 MedPAR file, we simulated payments under the capital PPS for FY 2007 and FY 2008 for a comparison of total payments per case. Any short-term, acute care hospitals not paid under the general IPPS (Indian Health Service hospitals and hospitals in Maryland) are excluded from the simulations. As we explain in section III.A. of the Addendum to this proposed rule, payments are no longer made under the regular exceptions provision under §§ 412.348(b) through (e). Therefore, we no longer use the actuarial capital cost model (described in Appendix B of the August 1, 2001 proposed rule (66 FR 40099)). We modeled payments for each hospital by multiplying the capital Federal rate by the GAF and the hospital's case-mix. We then added estimated payments for indirect medical education, disproportionate share, large urban add-on, and outliers, if applicable. (We note that, consistent with our proposal to eliminate the large urban add-on beginning in FY 2008, such estimated payments under this policy are only reflected in the payments we modeled for FY 2007 and were not included in the payments we modeled for FY 2008.) For purposes of this impact analysis, the model includes the following assumptions: We estimate that the Medicare case-mix index will increase by 1.0 percent in both FYs 2007 and 2008. (We note that this does not reflect the proposed adjustment to the capital rates to account for assumed growth in case mix due to improvement in documentation and coding (upcoding) under the proposed MS-DRGs, as discussed in section III. of the Addendum of this proposed rule.)
                        We estimate that the Medicare discharges will be 12.925 million in FY 2007 and 12.995 million in FY 2008 for an estimated 0.54 percent increase from FY 2007 to FY 2008.
                        The capital Federal rate was updated beginning in FY 1996 by an analytical framework that considers changes in the prices associated with capital-related costs and adjustments to account for forecast error, changes in the case-mix index, allowable changes in intensity, and other factors. As discussed in section V. of the preamble and section III.A. of the Addendum to this proposed rule, the proposed FY 2008 update for rural hospitals is 0.8 percent. We are proposing a 0.0 percent update for urban hospitals in FY 2008.
                        In addition to the proposed FY 2008 update factors, the proposed FY 2008 capital Federal rate for both urban and rural hospitals was calculated based on a proposed GAF/DRG budget neutrality factor of 1.0018, a proposed outlier adjustment factor of 0.9484, and a proposed exceptions adjustment factor of 0.9997.
                        For FY 2008, as discussed in section V. of the preamble and section III.A. of the Addendum to this proposed rule, the proposed FY 2008 capital rates for all hospitals was further adjusted by a factor of 0.976 (or −2.4 percent) to maintain budget neutrality if the proposed MS-DRGs are implemented by eliminating the effect of changes in coding or classification of discharges that do not reflect real case mix changes.( print page 25131) B. Results We used the actuarial model described above to estimate the potential impact of our proposed changes for FY 2008 on total capital payments per case, using a universe of 3,535 hospitals. As described above, the individual hospital payment parameters are taken from the best available data, including the December 2006 update of the FY 2006 MedPAR file, the December 2006 update to the Provider-Specific File, and the most recent cost report data from the December 2006 update of HCRIS. In Table III, we present a comparison of total payments per case for FY 2007 compared to proposed FY 2008 based on the proposed FY 2008 payment policies. Column 2 shows estimates of payments per case under our model for FY 2007. Column 3 shows estimates of payments per case under our model for FY 2008. Column 4 shows the total percentage change in payments from FY 2007 to FY 2008. The change represented in Column 4 includes the proposed 0.8 percent update to the capital Federal rate for rural hospitals and a 0.0 percent update for urban hospitals, a 1.0 percent increase in case-mix, changes in the adjustments to the capital Federal rate (for example, the effect of the hospital wage index on the GAF), reclassifications by the MGCRB, and the proposed additional 2.4 percent reduction to all of the rates to account for upcoding or changes in coding that do not reflect real changes in case-mix if the proposed MS-DRGs are implemented. The comparisons are provided by: (1) geographic location; (2) region; and (3) payment classification. The simulation results show that, on average, capital payments per case can be expected to decrease 0.7 percent in FY 2008. In addition to the proposed 0.0 percent update for urban hospitals, this projected decrease in capital payments per case can be attributed to the proposed −2.4 percent adjustment to all hospitals to account for assumed growth in case mix due to improvements in documentation and coding prior to the assumed growth occurring if the proposed MS-DRGs are implemented. Although the proposed GAF/DRG factor is expected to increase payments slightly (0.18 percent) in FY 2008 as compared to FY 2007, the proposed outlier factor is expected to contribute to the estimated decrease in capital payments from FY 2007 to FY 2008 by 0.88 percent. The results of our comparisons by geographic location and by region are consistent with the results we expected after proposing to eliminate the large urban add-on adjustment, and the proposed 0.0 percent update for urban hospitals. The geographic comparison shows that urban hospitals are expected to experience a 0.6 percent decrease in IPPS capital payments per case, while rural hospitals are expected to experience a 0.9 percent decrease in capital payments per case. This difference is mostly due to the proposed MS-DRGs. Specifically, based on existing hospital claims data, under the proposed MS-DRGs, the better recognition of severity of illness is expected to increase payments to urban hospitals that treat a more acutely ill mix of patients and improvement in the DRG system will increase their payments. Similarly, however, the improved recognition of severity of illness will decrease payments to rural hospitals because they are treating less severely ill patients. Therefore we project a lower increase in estimated payments for rural hospitals due to the proposed DRG changes as compared to urban hospitals. In addition to the effect of the proposed DRG changes, the capital impact is also somewhat affected by the proposed wage-index changes because the GAF values are derived from the proposed wage index. Another factor contributing to the decrease in payments for rural hospitals is the expiration of the 3-year hold harmless provision for urban hospitals that were converted to rural under the new CBSAs in FY 2005. The policy allowed urban hospitals under the old labor market area designations that became rural under the CBSAs to receive payment using the wage index of the MSA where they were previously classified as urban for 3 years: FY 2005 through FY 2007. Beginning in FY 2008, these rural hospitals will receive the wage index for the area that they are currently located in. As a result, rural hospitals will experience a decrease in payments because of the addition of these formerly urban hospitals. More than half of all regions are estimated to experience a decrease in total capital payments per case from FY 2007 to FY 2008. These decreases vary by region and range from a −2.3 percent in the Middle Atlantic urban region to a −0.7 in the East South Central urban region. For most of the regions projected to experience a larger than average decrease in capital payments, the difference is mostly due to changes in the proposed GAF and the elimination of the large urban add-on adjustment. In the regions experiencing an increase in total capital payments per case, the range is from 0.7 in the Pacific rural region to a 0.1 percent increase in the South Atlantic rural region. For most of the regions projected to experience an increase in capital payments, it is mostly due to changes to adopt the proposed MS-DRGs. The change in payments per case for all hospitals is −0.7 percent. By type of ownership, voluntary hospitals are estimated to experience a decrease of −1.0 percent in capital payments per case, while proprietary and government hospitals are estimated to experience 0.1 percent and 0.2 percent increases in payments, respectively. Government hospitals and proprietary hospitals are projected to have slight increases in capital payments mostly due to a smaller than average estimated decrease in payments due to proposed changes in the GAF and a slightly larger than average estimated increase in payments due to proposed changes to adopt MS-DRGs. Section 1886(d)(10) of the Act established the MGCRB. Before FY 2005, hospitals could apply to the MGCRB for reclassification for purposes of the standardized amount, wage index, or both. Section 401(c) of Pub. L. 108-173 equalized the standardized amounts under the operating IPPS. Therefore, beginning in FY 2005, there is no longer reclassification for the purposes of the standardized amounts; however, hospitals still may apply for reclassification for purposes of the wage index for FY 2008. Reclassification for wage index purposes also affects the GAF because that factor is constructed from the hospital wage index. To present the effects of the hospitals being reclassified for FY 2008, we show the average payments per case for reclassified hospitals for FY 2007. Rural nonreclassified hospitals are expected to have the largest decrease in payments (−2.0 percent), as compared to the −0.3 percent for rural reclassified hospitals for FY 2008. This difference is mostly due to proposed changes in the GAF and proposed changes to adopt MS-DRGs. Urban hospitals are expected to experience a decrease in payments of 0.9 percent and 0.6 percent, respectively, for reclassified and nonreclassified hospitals. This difference is mostly due to the proposed elimination of the large urban add-on. Table III.—Comparison of Total Payments Per Case
[FY 2007 payments compared to FY 2008 payments]
Number of hospitals
Average FY 2007 payments/case
Average FY 2008 payments/case
ChangeBy Geographic Location:All hospitals
3,535
758
753
−0.7Large urban areas (populations over 1 million)
1,409
842
833
−1.1Other urban areas (populations of 1 million or fewer)
1,131
747
747
0.0Rural areas
995
524
519
−0.9Urban hospitals
2,540
799
794
−0.60-99 beds
632
628
618
−1.7100-199 beds
849
683
677
−0.8200-299 beds
480
754
748
−0.8300-499 beds
412
828
824
−0.5( print page 25132)500 or more beds
167
1,002
999
−0.3Rural hospitals
995
524
519
−0.90-49 beds
342
430
418
−2.850-99 beds
369
480
473
−1.5100-149 beds
172
523
521
−0.3150-199 beds
67
576
573
−0.5200 or more beds
45
657
656
−0.1By Region:Urban by Region
2,540
799
794
−0.6New England
126
847
830
−2.1Middle Atlantic
350
875
855
−2.3South Atlantic
388
756
759
0.3East North Central
395
783
777
−0.8East South Central
166
723
718
−0.7West North Central
156
780
772
−1.0West South Central
358
749
750
0.2Mountain
153
797
799
0.2Pacific
395
914
918
0.5Puerto Rico
53
348
344
−1.2Rural by Region
995
524
519
−0.9New England
19
694
683
−1.5Middle Atlantic
72
536
531
−0.8South Atlantic
173
508
508
0.1East North Central
124
557
548
−1.6East South Central
177
487
481
−1.2West North Central
115
556
550
−1.1West South Central
194
478
469
−2.0Mountain
80
522
524
0.4Pacific
41
634
639
0.7By Payment Classification:All hospitals
3,535
758
753
−0.7Large urban areas (populations over 1 million)
1,436
840
831
−1.1Other urban areas (populations of 1 million or fewer)
1,183
742
742
0.1Rural areas
916
527
522
−1.0Teaching Status:Non-teaching
2,479
640
636
−0.6Fewer than 100 Residents
816
770
764
−0.8100 or more Residents
240
1,096
1,090
−0.5Urban DSH:100 or more beds
1,527
823
820
−0.2Less than 100 beds
359
551
542
−1.7Rural DSH:Sole Community (SCH/EACH)
391
469
463
−1.3Referral Center (RRC/EACH)
189
584
583
−0.2Other Rural:100 or more beds
36
479
478
−0.2Less than 100 beds
154
433
425
−1.8Urban teaching and DSH:Both teaching and DSH
805
902
899
−0.4Teaching and no DSH
192
807
788
−2.3No teaching and DSH
1,081
672
672
−0.1No teaching and no DSH
541
704
694
−1.4Rural Hospital Types:Non special status hospitals
2,477
801
796
−0.6RRC/EACH
59
693
692
−0.2SCH/EACH
45
633
623
−1.5Medicare-dependent hospitals (MDH)
21
450
433
−3.7SCH, RRC and EACH
17
741
740
0.0Hospitals Reclassified by the Medicare Geographic Classification Review Board:FY2008 Reclassifications:All Urban Reclassified
434
793
786
−0.9All Urban Non-Reclassified
2,105
800
796
−0.6All Rural Reclassified
367
570
568
−0.3All Rural Non-Reclassified
568
459
450
−2.0Other Reclassified Hospitals (Section 1886(d)(8)(B))
61
511
501
−2.1Type of Ownership:Voluntary
2,069
776
768
−1.0Proprietary
823
689
690
0.1( print page 25133)Government
598
745
746
0.2Medicare Utilization as a Percent of Inpatient Days:0-25
230
1,001
1,006
0.525-50
1,292
857
854
−0.450-65
1,453
672
666
−1.0Over 65
441
605
594
−1.8
 IX. Alternatives Considered This proposed rule contains a range of proposed policies. The preamble of this proposed rule provides descriptions of the statutory provisions that are addressed, identifies those proposed policies when discretion has been exercised, presents rationale for our decisions and, where relevant, alternatives that were considered. X. Overall Conclusion The changes we are proposing in this proposed rule would affect all classes of hospitals. Some hospitals are expected to experience significant gains and others less significant gains, but overall hospitals are projected to experience positive updates in IPPS payments in FY 2008. Table I of section VI of this Appendix demonstrates the estimated distributional impact of the IPPS budget neutrality requirements for proposed DRG and wage index changes, and for the wage index reclassifications under the MGCRB. Table I also shows an overall increase of 3.3 percent in operating payments, an estimated increase of $3.28 billion, which includes hospital reporting of quality data program costs ($1.89 million) and all operating payment policies as described in section VI. of this Appendix. Capital payments are estimated to decrease by 0.7 percent per case, as shown in Table III of section VIII. of this Appendix.  Therefore, we project that capital payments will decline by $13 million in FY 2008 compared to FY 2007. The operating and capital payments should result in a net increase of $3.269 billion to IPPS providers. The discussions presented in the previous pages, in combination with the rest of this proposed rule, constitute a regulatory impact analysis. XI. Accounting Statement As required by OMB Circular A-4 (available at 
                            *http://www.whitehousegov/​omb/​circulars/​a004/​a-4.pdf*), in Table IV below, we have prepared an accounting statement showing the classification of the expenditures associated with the provisions of this proposed rule. This table provides our best estimate of the increase in Medicare payments on providers as a result of the proposed changes to the IPPS presented in this rule. All expenditures are classified as transfers to Medicare providers. Table IV.—Accounting Statement: Classification of Estimated Expenditures From FY 2007 to FY 2008
Category
TransfersAnnualized Monetized  Transfers
$3.269 Billion.From Whom to Whom
Federal Government to IPPS Medicare Providers.Total
$3.269 Billion.
 XII. Executive Order 12866 In accordance with the provisions of Executive Order 12866, the Office of Management and Budget reviewed this proposed rule. (If you choose to comment on issues in this section, please include the caption “Update Factors” at the beginning of your comment.) I. Background Section 1886(e)(4)(A) of the Act requires that the Secretary, taking into consideration the recommendations of the MedPAC, recommend update factors for inpatient hospital services for each fiscal year that take into account the amounts necessary for the efficient and effective delivery of medically appropriate and necessary care of high quality. Under section 1886(e)(5)(B) of the Act, we are required to publish the proposed and final update factors recommended by the Secretary in the proposed and final IPPS rules, respectively. Accordingly, this Appendix provides the recommendations of appropriate update factors for the IPPS standardized amount, the hospital-specific rates for SCHs and MDHs, and the rate-of-increase limits for hospitals and hospital units excluded from the IPPS, as well as IPFs and IRFs. We also discuss our response to MedPAC's recommended update factors for inpatient hospital services. II. Inpatient Hospital Update for FY 2008 Section 1886(b)(3)(B)(i)(XX) of the Act, as amended by section 5001(a) of Pub. L. 109-171, sets the FY 2008 percentage increase in the operating cost standardized amount equal to the rate-of-increase in the hospital market basket for IPPS hospitals in all areas, subject to the hospital submitting quality information under rules established by the Secretary in accordance with 1886(b)(3)(B)(viii) of the Act. For hospitals that do not provide these data, the update is equal to the market basket percentage increase less 2.0 percentage points. Consistent with current law, based on the Office of the Actuary's first quarter 2007 forecast of the FY 2008 market basket increase, we are estimating that the FY 2008 update to the standardized amount will be 3.3 percent (that is, the current estimate of the market basket rate-of-increase) for hospitals in all areas, provided the hospital submits quality data in accordance with our rules. For hospitals that do not submit quality data, we are estimating that the update to the standardized amount will be 1.3 percent (that is, the current estimate of the market basket rate-of-increase minus 2.0 percentage points). Section 1886(b)(3)(B)(iv) of the Act sets the FY 2008 percentage increase in the hospital-specific rates applicable to SCHs and MDHs equal to the rate set forth in section 1886(b)(3)(B)(i) of the Act (that is, the same update factor as for all other hospitals subject to the IPPS, or the rate-of-increase in the market basket). Therefore, the update to the hospital-specific rates applicable to SCHs and MDHs is also estimated to be 3.3 percent. Section 1886(b)(3)(B)(ii) of the Act is used for purposes of determining the percentage increase in the rate-of-increase limits for children's and cancer hospitals. Section 1886(b)(3)(B)(ii) of the Act sets the percentage increase in the rate-of-increase limits equal to the market basket percentage increase. In accordance with § 403.752(a) of the regulations, RNHCIs are paid under § 413.40, which also uses section 1886(b)(3)(B)(ii) of the Act to update the percentage increase in the rate-of-increase limits. Section 1886(j)(3)(C) of the Act addresses the increase factor for the Federal prospective payment rate of IRFs. Section 123 of Pub. L. 106-113, as amended by section 307(b) of Pub. L. 106-554, provides the statutory authority for updating payment rates under the LTCH PPS. As discussed below, for cost reporting periods beginning on or after October 1, 2006, LTCHs that are not defined as new under § 412.23(e)(4), and that had not elected to be paid under 100 percent of the Federal rate are paid 100 percent of the adjusted Federal PPS rate. Therefore, because no portion of LTCHs' prospective payments will be based on reasonable cost concepts for cost reporting periods beginning on or after October 1, 
                            ( print page 25134)
                            2006, we are not proposing a rate-of-increase percentage for FY 2008 for LTCHs to be used under § 413.40. In addition, section 124 of Pub. L. 106-113 provides the statutory authority for updating all aspects of the payment rates for IPFs. Under this broad authority, IPFs that are not defined as new under § 412.426(c) will be paid under a blend methodology for cost reporting periods beginning on or after January 1, 2005, and before January 1, 2008. The methodology blends the estimated Federal per diem payment amount and a facility-specific payment amount. The portion of the IPF PPS payment that is based on reasonable cost principles is updated in accordance with 42 CFR Part 413, which uses section 1886(b)(3)(B)(ii) of the Act to determine the percentage increase in the rate-of-increase limits. For the reasonable cost-based portion of an IPF's PPS blended payments, we are proposing our current estimate of the excluded hospital market basket increase (3.4 percent) to update the target amounts. New IPFs are paid based on 100 percent of the Federal per diem payment amount. Currently, children's hospitals, cancer hospitals, and RNHCIs are the remaining three types of hospitals still reimbursed under the reasonable cost methodology. We are providing our current estimate of the FY 2008 IPPS operating market basket percentage increase (3.3 percent) to update the target limits for children's hospitals, cancer hospitals, and RNHCIs. Effective for cost reporting periods beginning on or after October 1, 2002, LTCHs have been paid under the LTCH PPS, which was implemented with a 5-year transition period for LTCHs not defined as new under § 412.23(e)(4) (hereafter referred to as “existing”). (See 67 FR 55954.) An existing LTCH could have elected to be paid at 100 percent of the adjusted Federal prospective rate at the start of any of its cost reporting periods during the transition period. During this transition period, if an existing LTCH did not elect to be paid at 100 percent of the adjusted Federal prospective payment rate, it received a PPS payment that consisted of a blend of its reasonable cost-based payment and the Federal prospective payment rate. For cost reporting periods beginning on or after October 1, 2006, no portion of a LTCH's PPS payments can be based on reasonable cost concepts. Consequently, there is no need to propose to update the target limit under § 413.40 effective October 1, 2007 for LTCHs. In the RY 2008 LTCH PPS proposed rule (72 FR 4791 through 4792), we recommended an update of 0.71 percent (that is, the latest estimate of the market basket rate-of-increase of 3.2 percent minus an adjustment factor of 2.49 percentage points for case-mix growth due to improved coding) to the LTCH PPS Federal rate for RY 2008. Effective for cost reporting periods beginning on or after January 1, 2005, IPFs are paid under the IPF PPS. IPF PPS payments are based on a Federal per diem rate that is derived from the sum of the average routine operating, ancillary, and capital costs for each patient day of psychiatric care in an IPF, adjusted for budget neutrality. For cost reporting periods beginning on or after January 1, 2005, and before January 1, 2008, existing IPFs (those not defined as “new” under § 412.426(c)) are paid based on a blend of the reasonable cost-based PPS payments and the Federal per diem base rate. For cost reporting periods beginning on or after January 1, 2008, existing IPFs will be paid based on 100 percent of the Federal per diem rate. For purposes of the update factor for FY 2008, the portion of the IPF PPS transitional blend payment based on reasonable costs would be determined by updating the IPF's TEFRA limit by the current estimate of the excluded hospital market basket, which is estimated to be 3.4 percent. The update factor of 4.3 percent to the Federal per diem rate for July 1, 2006 through June 30, 2007 was provided in the rate year (RY) 2007 IPF PPS final rule (71 FR 27046). The Federal per diem rate for RY 2008 will be updated in the RY 2008 update notice that is scheduled for publication in May 2007. IRFs are paid under the IRF PPS for cost reporting periods beginning on or after January 1, 2002. For cost reporting periods beginning on or after October 1, 2002 (FY 2003), and thereafter, the Federal prospective payments to IRFs are based on 100 percent of the adjusted Federal IRF prospective payment amount, updated annually. (See 69 FR 45721). Under section 1886(j)(3)(C) of the Act, the FY 2008 IRF PPS update will equal 3.3 percent based on the Global Insight, Inc.'s first quarter 2007 forecast with historical data through the fourth quarter of 2006. We expect that the market basket will be updated with more recent data to the extent the data are available. III. Secretary's Recommendation MedPAC is recommending an inpatient hospital update equal to the market basket rate of increase for FY 2008. MedPAC's rationale for this update recommendation is described in more detail below. Using the 2007 first quarter forecast from the Office of the Actuary of the FY 2008 market basket increase and an adjustment factor based on the FY 2008 President's Budget, we are recommending an update to the standardized amount of 2.65 percent (that is, the market basket rate-of-increase of 3.3 percent minus an adjustment factor of 0.65 percentage points). We are recommending that this same update factor apply to SCHs and MDHs. Our rationale for this recommended update is described below. In addition to making a recommendation for IPPS hospitals, in accordance with section 1886(e)(4)(A) of the Act, we are also recommending update factors for all other types of hospitals. Consistent with the President's budget, we are recommending an update based on the market basket increase for children's hospitals, cancer hospitals, and RNHCIs of 3.3 percent. For IPFs that are currently paid on a PPS blended payment basis, a portion of which is based on reasonable cost-principles and Federal prospective payment amounts, we are recommending an update factor of 3.4 percent for the portion of the payment that is based on reasonable costs. Consistent with the President's Budget, based on Global Insight Inc.'s 1st quarter 2007 forecast of the RPL market basket increase, we are recommending an update equal to the market basket increase of 3.2 percent for the Federal per diem payment amount. In the RY 2008 LTCH PPS proposed rule (72 FR 4791 through 4792), we recommended an update of 0.71 percent (that is, the most recent estimate of the market basket rate-of-increase of 3.2 percent minus an adjustment factor of 2.49 percentage points for case-mix growth due to improved coding) to the Federal rate for RY 2008. We will provide the final update in the LTCH final rule. Finally, consistent with the President's FY 2008 Budget, we are recommending that the Federal rate to the IRF PPS remain unchanged for FY 2008. For fiscal years prior to FY 2008, section 1886(e)(3) of the Act directed the Secretary to report to the Congress an initial estimate of his recommendation of an appropriate payment inflation update for inpatient hospital services for the upcoming fiscal year not later than March 1. Section 1886(d)(4)(C) of the Act further required the Secretary to include recommendations with respect to adjustments to the DRG weighting factors in the March 1 Report to Congress. In addition, sections 1886(e)(4)(A) and (e)(5)(B) of the Act require that the Secretary recommend update factors in each of the IPPS proposed and final rules, taking into account MedPAC's recommendation. Thus, the statute required the Secretary to make update recommendations in both a March 1 Report to Congress, and later in the IPPS proposed and final rules. Historically, the only difference between the recommendation we provided in the March 1 Report to Congress and the IPPS proposed rule was the use of a later estimate of the market basket increase for the proposed rule. Section 106(c) of Pub. L. 109-432 eliminated the requirement to make the Report to Congress recommending an update and adjustments to DRG weighting factors by March 1. In accordance with section 106(c) of Pub. L. 109-432, we are making the Secretary's only recommendation for an update factor in the IPPS rules. IV. MedPAC Recommendation for Assessing Payment Adequacy and Updating Payments in Traditional Medicare In its March 2007 Report to Congress, MedPAC assessed the adequacy of current payments and costs, and the relationship between payments and an appropriate cost base, utilizing an established methodology used by MedPAC in the past several years. MedPAC recommended an update to the hospital inpatient rates equal to the increase in the hospital market basket in FY 2008, concurrent with implementation of a quality incentive payment program. MedPAC also recommended that CMS put pressure on hospitals to control their costs rather than accommodate the current rate of cost growth. MedPAC noted that, notwithstanding negative overall Medicare margins, most of the indicators of Medicare payment adequacy to hospitals are positive, including beneficiaries' access to care, increased access to capital, and service volume increases. MedPAC also noted that this recommendation “should have no impact on beneficiary access to care and is not expected to affect providers' willingness and ability to provide care to Medicare beneficiaries.” 
                            ( print page 25135) *Response:*
                             We agree with MedPAC that hospitals should control costs rather than accommodate the current rate of growth. An update equal to less than the market basket will pressure hospitals to control their costs, consistent with MedPAC's recommendation. As MedPAC noted, rising hospital costs are resulting in margins for some hospitals that are below zero. As discussed in section II. of the preamble of this proposed rule, CMS is refining the DRGs to better account for severity illness and is basing the DRG weights on cost rather than charges. We believe that these refinements will better match Medicare payments to the cost of care and provide incentives for hospitals to be more efficient in controlling costs. For these reasons, we are recommending an inpatient hospital update equal to the market basket increase minus an adjustment factor of 0.65 percentage points for hospitals paid under the IPPS for FY 2008. We note that, because the operating and capital prospective payment systems remain separate, we are proposing to continue to use separate updates for operating and capital payments. The proposed update to the capital payment rate is discussed in section III. of the Addendum to this proposed rule.


# Footnotes

1.
    
                             Medicare Payment Advisory Commission: 
                            *Report to the Congress, Physician-Owned Specialty Hospitals*, March 2005, page viii. Back to Citation
 2.
    
                             Carter, Grace M. and Ginsburg, Paul: The Medicare Case Mix Index Increase, Medical Practice Changes, Aging and DRG Creep, Rand, 1985. Back to Citation
 3.
    
                             Review of Assumptions and Methods of the Medicare Trustees' Financial Projections; Technical Review Panel on the Medicare Trustees Reports, December 2000. Back to Citation
 4.
    
                             “Has DRG Creep Crept Up? Decomposing the Case Mix Index Change Between 1987 and 1988”; Carter, Newhouse, Relles ; R-4098-HCFA/ProPAC (1991). Back to Citation
 5.
    
                             Medicare Payment Advisory Commission: Report to the Congress, March 2006 (p. 52). Back to Citation
 6.
    
                             Medicare Payment Advisory Commission: Report to Congress on Physician-Owned Specialty Hospitals, March 2005, p. 42. Back to Citation
 7.
    
                             Carter, Paddock: Preliminary Analyses of Changes in Coding and Case Mix Under the Inpatient Rehabilitation Facility Prospective Payment System, RAND, 2004. Back to Citation
 8.
    
                             Maryland uses a July 1 to June 30 State fiscal year. Prior to FY 2003, Maryland had a 6-month lag in the data used to calculate the hospital base case-mix index and case-mix change. Maryland used 12 months data ending December even though the hospitals' rate year was July 1 to June 30. In FY 2003, Maryland moved to what it called “Real Time Case-Mix” and started using 12 months data ending June 30 to calculate case-mix index and case-mix change for a rate year beginning July 1. Back to Citation
 9.
    
                             The HSCRC informed us that it began using APR DRGs for this hospital to calculate the CMI and case-mix change to set the hospital's charge per case target (CPC) that is used in Maryland's all-payer ratesetting system for payment. However the HSCRC also compared the reasonableness of hospital rates and costs for this hospital relative to peer institutions using modified CMS DRGs to calculate CMI and case-mix change. This use of dual systems to calculate CMI and case-mix change made it difficult for the hospital to code aggressively in the first few years of using APR DRGs. Back to Citation
 10.
    
                             Medicare Payment Advisory Commission: 
                            *Report to the Congress: Physician-Owned Specialty Hospitals*, March 2005, p. 26. Back to Citation
 11.
    
                             Hackbarth, Glenn: MedPAC Comments on the IPPS Rule, June 12, 2006, page 2. Back to Citation
 12.
    
                             Foxman, B.: “Epidemiology of urinary tract infections: incidence, morbidity, and economic costs,” 
                            *The American Journal of Medicine,*
                             113 Suppl. 1A, pp. 5s-13s, 2002. Back to Citation
 13.
    
                             Safdar N.: Clinical and Economic Consequences of Ventilator-Associated Pneumonia: A Systematic Review, 
                            *Critical Care Medicine*, 2005, 33(10), pp. 2184-2193. Back to Citation
 14.
    
                             See the FY 1989 final rule (53 FR 38485, September 30, 1988), for the revision made for the discharges occurring in FY 1989; the FY 1990 final rule (54 FR 36552, September 1, 1989), for the FY 1990 revision; the FY 1991 final rule (55 FR 36126, September 4, 1990), for the FY 1991 revision; the FY 1992 final rule (56 FR 43209, August 30, 1991) for the FY 1992 revision; the FY 1993 final rule (57 FR 39753), September 1, 1992), for the FY 1993 revision; the FY 1994 final rule (58 FR 46278, September 1, 1993), for the FY 1994 revisions; the FY 1995 final rule (59 FR 45334, September 1, 1994), for the FY 1995 revisions; the FY 1996 final rule (60 FR 45782, September 1, 1995), for the FY 1996 revisions; the FY 1997 final rule (61 FR 46171, August 30, 1996), for the FY 1997 revisions; the FY 1998 final rule (62 FR 45966, August 29, 1997) for the FY 1998 revisions; the FY 1999 final rule (63 FR 40954, July 31, 1998), for the FY 1999 revisions; the FY 2001 final rule (65 FR 47064, August 1, 2000), for the FY 2001 revisions; the FY 2002 final rule (66 FR 39851, August 1, 2001), for the FY 2002 revisions; the FY 2003 final rule (67 FR 49998, August 1, 2002), for the FY 2003 revisions; the FY 2004 final rule (68 FR 45364, August 1, 2003), for the FY 2004 revisions; the FY 2005 final rule (69 FR 49848, August 11, 2004), for the FY 2005 revisions; the FY 2006 final rule (70 FR 47640, August 12, 2005), for the FY 2006 revisions; and the FY 2007 final rule (71 FR 47870) for the FY 2007 revisions. In the FY 2000 final rule (64 FR 41490, July 30, 1999), we did not modify the CC Exclusions List because we did not make any changes to the ICD-9-CM codes for FY 2000. Back to Citation
 15.
    
                             The original list of the ICD-9-CM procedure codes for the procedures we consider nonextensive procedures, if performed with an unrelated principal diagnosis, was published in Table 6C in section IV. of the Addendum to the FY 1989 final rule (53 FR 38591). As part of the FY 1991 final rule (55 FR 36135), the FY 1992 final rule (56 FR 43212), the FY 1993 final rule (57 FR 23625), the FY 1994 final rule (58 FR 46279), the FY 1995 final rule (59 FR 45336), the FY 1996 final rule (60 FR 45783), the FY 1997 final rule (61 FR 46173), and the FY 1998 final rule (62 FR 45981), we moved several other procedures from DRG 468 to DRG 477, and some procedures from DRG 477 to DRG 468. No procedures were moved in FY 1999, as noted in the final rule (63 FR 40962); in FY 2000 (64 FR 41496); in FY 2001 (65 FR 47064); or in FY 2002 (66 FR 39852). In the FY 2003 final rule (67 FR 49999) we did not move any procedures from DRG 477. However, we did move procedure codes from DRG 468 and place them in more clinically coherent DRGs. In the FY 2004 final rule (68 FR 45365), we moved several procedures from DRG 468 to DRGs 476 and 477 because the procedures are nonextensive. In the FY 2005 final rule (69 FR 48950), we moved one procedure from DRG 468 to 477. In addition, we added several existing procedures to DRGs 476 and 477. In the FY 2006 (70 FR 47317), we moved one procedure from DRG 468 and assigned it to DRG 477. In FY 2007, we moved one procedure from DRG 468 and assigned it to DRGs 479, 553, and 554. Back to Citation
 16.
    
                             The BBA was enacted on August 5, 1997, and required application of the rural floor beginning with the FY 1998 IPPS. See the following for a description and calculation of the IPPS standardized amounts since that time: 62 FR 46038-46043, August 29, 1997; 63 FR 41006-41010, July 31, 1998; 64 FR 41544-41549, July 30, 1999; 65 FR 47111-47116, August 1, 2000; 66 FR 39939-39946, August 1, 2001; 67 FR 50120-50126, August 1, 2002; 68 FR 45474-45480, August 1, 2003; 69 FR 49273-49282, August 11, 2004; 70 FR 47491-47498, August 12, 2005; 71 FR 59889-58980, October 11, 2006. Back to Citation
 17.
    
                             Institute of Medicine, “Performance Measurement: Accelerating Improvement,” December 1, 2005, available at 
                            *http://www.iom.edu/​CMS/​3809/​19805/​31310.aspx.* Back to Citation
 18.
    
                                         These figures represent 3.0 standard deviations from the mean of the log distribution of CCRs for all hospitals. Back to Citation


BILLING CODE 4120-01-P BILLING CODE 4120-01-C BILLING CODE 4120-01-C 
                            ( print page 25124) [FR Doc. 07-1920 Filed 4-13-07; 4:15 pm]