DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Medicare & Medicaid Services 

42 CFR Parts 412, 413, 440, 441, 482, 485, and 489 

[CMS-1498-P] 

RIN 0938-AP80 

Medicare Program; Proposed Changes to the Hospital Inpatient Prospective 

Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital 

Prospective Payment System and Proposed Fiscal Year 2011 Rates; Effective Date 

of Provider Agreements and Supplier Approvals; and Hospital Conditions of 

Participation for Rehabilitation and Respiratory Care Services 

Medicaid Program: Accreditation Requirements for Providers of Inpatient 

Psychiatric Services for Individuals under Age 21 

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 of acute care hospitals to 

implement changes arising from our continuing experience with these systems. In 

addition, in the Addendum to this proposed rule, we describe the proposed changes to the 

amounts and factors used to determine the rates for Medicare acute care hospital inpatient 

services for operating costs and capital-related costs. These proposed changes would be 

applicable to discharges occurring on or after October 1, 2010. We also are setting forth 

the proposed update to the rate-of-increase limits for certain hospitals excluded from the 

IPPS that are paid on a reasonable cost basis subject to these limits. The proposed 
CMS-1498-P 2 

updated rate-of-increase limits would be effective for cost reporting periods beginning on 

or after October 1, 2010. 

 We are proposing to update the payment policy and the annual payment rates for 

the Medicare prospective payment system (PPS) for inpatient hospital services provided 

by long-term care hospitals (LTCHs). In the Addendum to this proposed rule, we also set 

forth the proposed changes to the payment rates, factors, and other payment rate policies 

under the LTCH PPS. These proposed changes would be applicable to discharges 

occurring on or after October 1, 2010. 

 We are proposing changes affecting the Medicare conditions of participation for 

hospitals relating to the types of practitioners who may provide rehabilitation services 

and respiratory care services. 

 We are proposing changes affecting the determination of the effective date of 

provider agreements and supplier approvals under Medicare. 

 Finally, we are proposing to offer psychiatric hospitals, hospitals with inpatient 

psychiatric programs, and psychiatric facilities that are not hospitals increased flexibility 

in obtaining accreditation to participate in the Medicaid program. Psychiatric hospitals 

would have the choice of meeting the existing regulatory requirements to participate in 

Medicare as a psychiatric hospital or to obtaining accreditation from a national 

accrediting organization whose psychiatric hospital accrediting program has been 

approved by CMS. Hospitals with inpatient psychiatric programs would have the choice 

of meeting the existing regulatory requirements for participation in Medicare as a hospital 

or obtaining accreditation from a national accrediting organization whose hospital 
CMS-1498-P 3 

accreditation program has been approved by CMS. In addition, psychiatric facilities that 

are not hospitals would be afforded the flexibility in obtaining accreditation by a national 

accrediting organization whose program has been approved by CMS, or by any other 

accrediting organization with comparable standards that is recognized by the State. 

DATES: To be assured consideration, comments on this proposed rule must be 

received at one of the addresses provided below, no later than 5 p.m. Eastern Daylight 

Time (E.D.T.) on June 18, 2010. 

ADDRESSES: When commenting on issues presented in this proposed rule, 

please refer to file code CMS-1498-P. Because of staff and resource limitations, we 

cannot accept comments by facsimile (FAX) transmission. 

You may submit comments in one of four ways (please choose only one of the 

ways listed): 

1. Electronically. You may submit electronic comments on this regulation at 

http://www.regulations.gov. Follow the instructions for "Comment or Submission" and 

enter the file code CMS-1498-P to submit comments on this proposed rule. 

 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-1498-P, 

 P.O. Box 8011, 

 Baltimore, MD 21244-1850. 
CMS-1498-P 4 

 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-1498-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 either of the following addresses: 

 a. Room 445-G, Hubert H. Humphrey Building, 

 200 Independence Avenue, SW, 

 Washington, DC 20201. 

(Because access to the interior of the HHH 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 a proof of filing by stamping in 

and retaining an extra copy of the comments being filed.) 
CMS-1498-P 5 

b. 7500 Security Boulevard, 

Baltimore, MD 21244-1850. 

 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. 

 Comments mailed to the addresses indicated as appropriate for hand or courier 

delivery may be delayed and received after the comment period. 

 For information on viewing public comments, see the beginning of the 

Supplementary Information section. 

FOR FURTHER INFORMATION, CONTACT: 

Tzvi Hefter, (410) 786-4487, and Ing-Jye Cheng, (410) 786 4548, Operating 

Prospective Payment, MS-DRGs, Hospital Acquired Conditions (HAC), Wage Index, 

New Medical Service and Technology Add-On Payments, Hospital Geographic 

Reclassifications, Acute Care Transfers, Capital Prospective Payment, Excluded 

Hospitals, Direct and Indirect Graduate Medical Education Payments, Disproportionate 

Share Hospital (DSH), and Critical Access Hospital (CAH) Issues. 

Michele Hudson, (410) 786-4487, and Judith Richter, (410) 786-2590, 

Long-Term Care Hospital Prospective Payment System and MS-LTC-DRG Relative 

Weights Issues. 

Siddhartha Mazumdar, (410) 786-6673, Rural Community Hospital 

Demonstration Program Issues. 
CMS-1498-P 6 

 James Poyer, (410) 786-2261, Reporting of Hospital Quality Data for Annual 

Payment Update--Program Administration, Validation, and Reconsideration Issues. 

 Shaheen Halim (410) 786-0641, Reporting of Hospital Quality Data for Annual 

Payment Update--Measures Issues Except Hospital Consumer Assessment of Healthcare 

Providers and Systems 

Elizabeth Goldstein (41) 786-6665 Reporting of Hospital Quality Data for Annual 

Payment Update--Hospital Consumer Assessment of Healthcare Providers and Systems 

Measures Issues. 

 Marcia Newton, (410-786-5265) and CDR Scott Cooper (U.S. Public Health 

Service), (410) 786-9465, Hospital Conditions of Participation for Rehabilitation 

Services and Respiratory Therapy Care Issues. 

 Marilyn Dahl, (410) 786-8665, Provider Agreement and Supplier Approval 

Issues. 

 Melissa Harris, (410) 786-3397 or Adrienne Delozier, (410) 786-0278, 

Accreditation of Providers of Inpatient Psychiatric Services to Individuals under Age 21 

Issues. 

SUPPLEMENTARY INFORMATION: 

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 
CMS-1498-P 7 

as soon as possible after they have been received: http://www.regulations.gov. Follow 

the search instructions at that Web site to view public comments. 

Comments received timely will also be available for public inspection, 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 4:00 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 Web 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 

3M 3M Health Information System 

AAHKS American Association of Hip and Knee Surgeons 

AAMC Association of American Medical Colleges 

ACGME Accreditation Council for Graduate Medical Education 
CMS-1498-P 8 

AHA American Hospital Association 

AHIC American Health Information Community 

AHIMA American Health Information Management Association 

AHRQ Agency for Healthcare Research and Quality 

ALOS Average length of stay 

ALTHA Acute Long Term Hospital Association 

AMA American Medical Association 

AMGA American Medical Group Association 

AOA American Osteopathic Association 

APR DRG All Patient Refined Diagnosis Related Group System 

ARRA American Recovery and Reinvestment Act of 2009, Pub. L. 111-5 

ASC Ambulatory surgical center 

ASCA Administrative Simplification Compliance Act of 2002, Pub. L. 107-105 

ASITN American Society of Interventional and Therapeutic Neuroradiology 

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 

BIC Beneficiary Identification Code 

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 
CMS-1498-P 9 

CAH Critical access hospital 

CARE [Medicare] Continuity Assessment Record & Evaluation [Instrument] 

CART CMS Abstraction & Reporting Tool 

CBSAs Core-based statistical areas 

CC Complication or comorbidity 

CCR Cost-to-charge ratio 

CDAC [Medicare] Clinical Data Abstraction Center 

CDAD Clostridium difficile-associated disease 

CIPI Capital input 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 

COLA Cost-of-living adjustment 

CoP [Hospital] condition of participation 

CPI Consumer price index 

CRNA Certified Registered Nurse Anesthetist 

CY Calendar year 

DPP Disproportionate patient percentage 

DRA Deficit Reduction Act of 2005, Pub. L. 109-171 

DRG Diagnosis-related group 

DSH Disproportionate share hospital 
CMS-1498-P 10 

ECI Employment cost index 

EDB [Medicare] Enrollment Database 

EMR Electronic medical record 

FAH Federation of Hospitals 

FDA Food and Drug Administration 

FFY Federal fiscal year 

FHA Federal Health Architecture 

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 

HACs Hospital-acquired conditions 

HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems 

HCFA Health Care Financing Administration 

HCO High-cost outlier 

HCRIS Hospital Cost Report Information System 

HHA Home health agency 

HHS Department of Health and Human Services 

HICAN Health Insurance Claims Account Number 
CMS-1498-P 11 

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 

HPMP Hospital Payment Monitoring Program 

HSA Health savings account 

HSCRC [Maryland] Health Services Cost Review Commission 

HSRV Hospital-specific relative value 

HSRVcc Hospital-specific relative value cost center 

HQA Hospital Quality Alliance 

HQI Hospital Quality Initiative 

HwH Hospital-within-a-hospital 

ICD-9-CM International Classification of Diseases, Ninth Revision, 

Clinical Modification 

ICD-10-CM International Classification of Diseases, Tenth Revision, 

 Clinical Modification 

ICD-10-PCS International Classification of Diseases, Tenth Revision, Procedure 

 Coding System 

ICR Information collection requirement 

IHS Indian Health Service 
CMS-1498-P 12 

IME Indirect medical education 

I-O Input-Output 

IOM Institute of Medicine 

IPF Inpatient psychiatric facility 

IPPS [Acute care hospital] inpatient prospective payment system 

IRF Inpatient rehabilitation facility 

LAMCs Large area metropolitan counties 

LOS Length of stay 

LTC-DRG Long-term care diagnosis-related group 

LTCH Long-term care hospital 

MA Medicare Advantage 

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 
CMS-1498-P 13 

MIEA-TRHCA Medicare Improvements and Extension Act, Division B of 

 the Tax Relief and Health Care Act of 2006, Pub. L. 109-432 

MIPPA Medicare Improvements for Patients and Providers Act of 2008, 

 Pub. L. 110-275 

MMA Medicare Prescription Drug, Improvement, and Modernization Act 

of 2003, Pub. L. 108-173 

MMSEA Medicare, Medicaid, and SCHIP Extension Act of 2007, Pub. L. 110-173 

MPN Medicare provider number 

MRHFP Medicare Rural Hospital Flexibility Program 

MRSA Methicillin-resistant Staphylococcus aureus

MSA Metropolitan Statistical Area 

MS-DRG Medicare severity diagnosis-related group 

MS-LTC-DRG Medicare severity long-term care diagnosis-related group 

NAICS North American Industrial Classification System 

NALTH National Association of Long Term Hospitals 

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 

NP Nurse practitioner 

NQF National Quality Forum 
CMS-1498-P 14 

NTIS National Technical Information Service 

NTTAA National Technology Transfer and Advancement Act of 1991 

 (Pub. L. 104-113) 

NVHRI National Voluntary Hospital Reporting Initiative 

OACT [CMS'] Office of the Actuary 

OBRA 86 Omnibus Budget Reconciliation Act of 1996, Pub. L. 99-509 

OES Occupational employment statistics 

OIG Office of the Inspector General 

OMB Executive Office of Management and Budget 

OPM U.S. Office of Personnel Management 

O.R. Operating room 

OSCAR Online Survey Certification and Reporting [System] 

PA Physician assistant 

PIP Periodic interim payment 

PLI Professional liability insurance 

PMSAs Primary metropolitan statistical areas 

POA Present on admission 

PPACA Patient Protection and Affordable Care Act, Pub. L. 111-148 

PPI Producer price index 

PPS Prospective payment system 

PRM Provider Reimbursement Manual 

ProPAC Prospective Payment Assessment Commission 
CMS-1498-P 15 

PRRB Provider Reimbursement Review Board 

PRTFs Psychiatric residential treatment facilities 

PSF Provider-Specific File 

PS&R Provider Statistical and Reimbursement (System) 

QIG Quality Improvement Group, CMS 

QIO Quality Improvement Organization 

RCE Reasonable compensation equivalent 

RHC Rural health clinic 

RHQDAPU Reporting hospital quality data for annual payment update 

RNHCI Religious nonmedical health care institution 

RPL Rehabilitation psychiatric long-term care (hospital) 

RRC Rural referral center 

RTI Research Triangle Institute, International 

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 
CMS-1498-P 16 

SSN Social Security number 

SSO Short-stay outlier 

TEFRA Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-248 

TEP Technical expert panel 

TMA TMA [Transitional Medical Assistance], Abstinence Education, and QI 

[Qualifying Individuals] Programs Extension Act of 2007, Pub. L. 110-90 

UHDDS Uniform hospital discharge data set 

Table of Contents 

I. Background 

 A. Summary 

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

 2. Hospitals and Hospital Units Excluded from the IPPS 

 3. Long-Term Care Hospital Prospective Payment System (LTCH PPS) 

 4. Critical Access Hospitals (CAHs) 

 5. Payments for Graduate Medical Education (GME) 

 B. Provisions of the Patient Protection and Affordable Care Act 

(Pub. L. 111-148), as amended by the Health Care and Education Reconciliation Act of 

2010 (Pub. L. 111-152) 

 C. Major Content of This Proposed Rule 

 1. Proposed Changes to MS-DRG Classifications and Recalibrations of Relative 

Weights 

 2. Proposed Changes to the Hospital Wage Index for Acute Care Hospitals 
CMS-1498-P 17 

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

GME Costs 

 4. Proposed FY 2011 Policy Governing the IPPS for Capital-Related Costs 

 5. Proposed Changes to the Payment Rates for Certain Excluded Hospitals: 

Rate-of-Increase Percentages 

 6. Proposed Changes to the LTCH PPS 

 7. Proposed Changes Relating to Effective Date of Provider Agreements and 

Supplier Approvals 

 8. Proposed Changes to Medicare Conditions of Participation Affecting Hospital 

Rehabilitation Services and Respiratory Care Services

9. Proposed Changes to the Accreditation Requirements for Medicaid Providers 

of Inpatient Psychiatric Services for Individuals under Age 21 

 10. Determining Proposed Prospective Payment Operating and Capital Rates and 

Rate-of-Increase Limits for Acute Care Hospitals 

 11. Determining Proposed Prospective Payments Rates for LTCHs 

 12. Impact Analysis 

 13. Recommendation of Update Factors for Operating Cost Rates of Payment for 

Hospital Inpatient Services 

 14. Discussion of Medicare Payment Advisory Commission Recommendations 

E. Interim Final Rule with Comment Period That Implemented Certain 

Provisions of the ARRA Relating to Payments to LTCHs and LTCH Satellite Facilities 
CMS-1498-P 18 

 II. Proposed Changes to Medicare Severity Diagnosis-Related Group (MS-DRG) 

Classifications and Relative Weights 

 A. Background 

 B. MS-DRG Reclassifications 

 1. General 

 2. Yearly Review for Making MS-DRG Changes 

 C. Adoption of the MS-DRGs in FY 2008 

 D. Proposed FY 2011 MS-DRG Documentation and Coding Adjustment, 

Including the Applicability to the Hospital-Specific Rates and the Puerto Rico-Specific 

Standardized Amount 

1. Background on the Prospective MS-DRG Documentation and Coding 

Adjustments for FY 2008 and FY 2009 Authorized by Pub. L. 110-90 

 2. Prospective Adjustment to the Average Standardized Amounts Required by 

Section 7(b)(1)(A) of Pub. L. 110-90 

 3. Recoupment or Repayment Adjustments in FYs 2010 through 2012 Required 

by Pub. L. 110-90 

4. Retrospective Evaluation of FY 2008 Claims Data 

 5. Retrospective Analysis of FY 2009 Claims Data 

 6. Prospective Adjustment for FY 2010 and Subsequent Years Authorized by 

Section 7(b)(1)(A) of Pub. L. 110-90 and Section 1886(d)(3)(vi) of the Act 

 7. Recoupment or Repayment Adjustment for FY 2010 Authorized by Section 

7(b)(1)(B) of Pub. L. 110-90 
CMS-1498-P 19 

 8. Background on the Application of the Documentation and Coding Adjustment 

to the Hospital-Specific Rates 

 9. Proposed Documentation and Coding Adjustment to the Hospital-Specific 

Rates for FY 2011 and Subsequent Fiscal Years 

 10. Background on the Application of the Documentation and Coding 

Adjustment to the Puerto Rico-Specific Standardized Amount 

 11. Proposed Documentation and Coding Adjustment to the Puerto Rico-Specific 

Standardized Amount 

 E. Refinement of the MS-DRG Relative Weight Calculation 

 1. Background 

 a. Summary of FY 2009 Changes and Discussion for FY 2011 

 b. Summary of the RAND Corporation Study of Alternative Relative Weight 

Methodologies 

2. Proposals for FY 2011 and Timeline for Changes to the Medicare Cost Report 

 F. Preventable Hospital-Acquired Conditions (HACs), Including Infections 

 1. Background 

 a. Statutory Authority 

 b. HAC Selection 

c. Collaborative Process 

 d. Application of HAC Payment Policy to MS-DRG Classifications 

 e. Public Input Regarding Selected and Potential Candidate HACs 

 f. POA Indicator Reporting 
CMS-1498-P 20 

 2. Proposed HAC Conditions for FY 2011 

 3. RTI Program Evaluation Summary 

 a. Background 

 b. Preliminary RTI Analysis on POA Indicator Reporting Across Medicare 

Discharges 

 c. Preliminary RTI Analysis on POA Indicator Reporting of Current HACs 

 d. Preliminary RTI Analysis of Frequency of Discharges and POA Indicator 

Reporting for Current HACs 

 e. Preliminary RTI Analysis of Circumstances When Application of HAC 

Provisions Would Not Result in MS-DRG Reassignment for Current HACs 

 f. Preliminary RTI Analysis of Coding Changes for HAC-Associated Secondary 

Diagnoses for Current HACs 

 g. Preliminary RTI Analysis of Estimated Net Savings for Current HACs 

 h. Previously Considered Candidate HACs—Preliminary RTI Analysis of 

Frequency of Discharges and POA Indicator Reporting 

 i. Current and Previously Considered Candidate HACs—RTI Report on 

Evidence-Based Guidelines 

 j. Proposals Regarding Current HACs and Previously Considered Candidate 

HACs 

 G. Proposed Changes to Specific MS-DRG Classifications 

 1. Pre-Major Diagnostic Categories (MDCs 
CMS-1498-P 21 

 a. Postsurgical Hypoinsulinemia (MS-DRG 008 (Simultaneous Pancreas/Kidney 

Transplant) 

 b. Bone Marrow Transplants 

 2. MDC 1 (Nervous System): Administration of Tissue Plasminogen Activator 

(tPA) (rtPA) 

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

Fluorescence Vascular Angiography (IFVA) and X-Ray Coronary Angiography in 

Coronary Artery Bypass Graft Surgery 

a. New MS-DRGs for Intraoperative Fluorescence Vascular Angiography (IFVA) 

with CABG 

 b. New MS-DRG for Intraoperative Angiography, by any Method, with CABG 

 c. New Procedure Codes 

 d. MS-DRG Reassignment of Intraoperative Fluorescence Vascular Angiography 

(IFVA) 

 4. MDC 6 (Diseases and Disorders of the Digestive System): Gastrointestinal 

Stenting 

 5. MDC 8 (Diseases and Disorders of the Musculoskeletal System and 

Connective Tissue): Pedicle-Based Dynamic Stabilization 

 6. MDC 15 (Newborns and Other Neonates with Conditions Originating in the 

Perinatal Period) 

 a. Discharges/Transfers of Neonates to a Designated Cancer Center or a 

Children's Hospital 
CMS-1498-P 22 

 b. Vaccination of Newborns 

 7. Medicare Code Editor (MCE) Changes 

 a. Unacceptable Principal Diagnosis Edit: Addition of Code for Gastroparesis 

 b. Open Biopsy Check Edit 

 c. Noncovered Procedure Edit 

 8. Surgical Hierarchies 

 9. Complication or Comorbidity (CC) Exclusions List 

 a. Background 

 b. Proposed CC Exclusions List for FY 2011 

 10. Review of Procedure Codes in MS-DRGs 981 through 983, 984 through 986, 

and 987 through 989 

 a. Moving Procedure Codes from MS-DRGs 981 through 983 or MS-DRGs 987 

through 989 to MDCs 

b. Reassignment of Procedures among MS-DRGs 981 through 983, 984 through 

986, and 987 through 989 

c. Adding Diagnosis or Procedure Codes to MDCs 

 11. Changes to the ICD-9-CM Coding System, Including Discussion of the 

Replacement of the ICD-9-CM System with the ICD-10-CM and ICD-10-PCS Systems 

in FY 2014 

 a. ICD-9-CM Coding System 

 b. Code Freeze 
CMS-1498-P 23 

 c. Processing of 25 Diagnosis Codes and 25 Procedure Codes on Hospital 

Inpatient Claims 

H. Recalibration of MS-DRG Weights 

I. 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 2011 Status of Technologies Approved for FY 2010 Add-On Payments 

 a. Spiration® IBV® Valve System 

 b. CardioWestTM Temporary Total Artificial Heart System (CardioWestTM 

TAH-t) 

 4. FY 2011 Applications for New Technology Add-On Payments 

a. Auto Laser Interstitial Thermal Therapy (AutoLITTTM) System 

 b. LipiScanTM Coronary Imaging System 

 c. LipiScanTM Coronary Imaging System with Intravascular Ultrasound (IVUS) 

III. Proposed Changes to the Hospital Wage Index for Acute Care Hospitals 

 A. Background 

 B. Wage Index Reform 

 1. Wage Index Study Required under the MIEA-TRHCA 

 a. Legislative Requirement 

 b. Interim and Final Reports on Results of Acumen’s Study 
CMS-1498-P 24 

 2. FY 2009 Policy Changes in Response to Requirements under Section 106(b) of 

the MIEA-TRHCA 

 a. Reclassification Average Hourly Wage Comparison Criteria 

 b. Budget Neutrality Adjustment for the Rural and Imputed Floors 

 C. Core-Based Statistical Areas for the Hospital Wage Index 

 D. Proposed Occupational Mix Adjustment to the Proposed FY 2011 Wage Index 

 1. Development of Data for the Proposed FY 2011 Occupational Mix Adjustment 

Based on the 2007-2008 Occupational Mix Survey 

 2. New 2010 Occupational Mix Survey for the FY 2013 Wage Index 

 3. Calculation of the Proposed Occupational Mix Adjustment for FY 2011 

 E. Worksheet S-3 Wage Data for the Proposed FY 2011 Wage Index 

 1. Included Categories of Costs 

 2. Excluded Categories of Costs 

 3. Use of Wage Index Data by Providers Other Than Acute Care Hospitals under 

the IPPS 

 F. Verification of Worksheet S-3 Wage Data 

 G. Method for Computing the Proposed FY 2011 Unadjusted Wage Index 

 H. Analysis and Implementation of the Proposed Occupational Mix Adjustment 

and the Proposed FY 2011 Occupational Mix Adjusted Wage Index 

 I. Revisions to the Wage Index Based on Hospital Redesignations and 

Reclassifications 

 1. General 
CMS-1498-P 25 

 2. Effects of Reclassification/Redesignation 

 3. FY 2011 MGCRB Reclassifications 

 a. FY 2011 Reclassification Requirements and Approvals 

 b. Applications for Reclassifications for FY 2012 

 c. Appeals of MGCRB Denials of Withdrawals and Terminations 

 4. Redesignations of Hospitals under Section 1886(d)(8)(B) of the Act 

 5. Reclassifications under Section 1886(d)(8)(B) of the Act 

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

 J. Proposed FY 2011 Wage Index Adjustment Based on Commuting Patterns of 

Hospital Employees 

 K. Process for Requests for Wage Index Data Corrections 

 L. Labor-Market Share for the Proposed FY 2011 Wage Index 

 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 

 a. Overview 

 b. Hospital Quality Data Reporting under Section 501(b) of Pub. L. 108-173 

 c. Hospital Quality Data Reporting under Section 5001(a) of Pub. L. 109-171 

 2. Retirement of RHQDAPU Program Measures 

 a. Considerations in Retiring Quality Measures from the RHQDAPU Program 
CMS-1498-P 26 

 b. Proposed Retirement of Quality Measures under the RHQDAPU Program for 

the FY 2011 Payment Determination and Subsequent Years 

 3. Proposed Expansion Plan for Quality Measures for the FY 2012, FY 2013, and 

FY 2014 Payment Determinations 

 a. Considerations in Expanding and Updating Quality Measures under the 

RHQDAPU Program 

 b. Proposed RHQDAPU Program Quality Measures for the FY 2012 Payment 

Determination 

 c. Proposed RHQDAPU Program Quality Measures for the FY 2013 Payment 

Determination 

 d. Proposed RHQDAPU Program Quality Measures for the FY 2014 Payment 

Determination 

 4. Possible New Quality Measures for Future Years 

 5. Form, Manner, and Timing of Quality Data Submission 

 a. Proposed RHQDAPU Program Requirements for FY 2012, FY 2013, and 

FY 2014 

 b. Additional Proposed RHQDAPU Program Procedural Requirements for 

FY 2012, FY 2013, and FY 2014 Payment Determinations 

 6. RHQDAPU Program Disaster Extensions and Waivers 

 7. Proposed Chart Validation Requirements for Chart–Abstracted Measures 

 a. Proposed Chart Validation Requirements and Methods for the FY 2012 

Payment Determination 
CMS-1498-P 27 

 b. Proposed Supplements to the Chart Validation Process for the FY 2013 

Payment Determination and Subsequent Years 

 8. Data Accuracy and Completeness Acknowledgement Requirements for the 

FY 2012 Payment Determination and Subsequent Years 

 9. Proposed Public Display Requirements for the FY 2012 Payment 

Determination and Subsequent Years 

 10. Proposed Reconsideration and Appeal Procedures for the FY 2011 Payment 

Determination 

 11. Proposed RHQDAPU Program Withdrawal Deadlines 

 12. Electronic Health Records (EHRs) 

 a. Background 

 b. EHR Testing of Quality Measures Submission 

 c. HITECH Act EHR Provisions 

 13. Qualification of Registries for RHQDAPU Data Submission 

 B. Payment for Transfers of Cases from Medicare Participating Acute Care 

Hospitals to Nonparticipating Hospitals and CAHs 

 1. Background 

 2. Proposed Policy Change 

 C. Technical Change to Regulations 

 D. Medicare-Dependent, Small Rural Hospitals (MDHs): Change to Criteria 

 1. Background 

 2. Medicare-Dependency: Counting Medicare Inpatients 
CMS-1498-P 28 

 E. Rural Referral Centers (RRCs) 

 1. Case-Mix Index (CMI) 

 2. Discharges 

 F. Indirect Medical Education (IME) Adjustment 

1. Background 

 2. IME Adjustment Factor for FY 2011 

 3. IME-Related Changes in Other Sections of this Proposed Rule 

 G. Payment Adjustment for Medicare Disproportionate Share Hospitals (DSHs): 

Supplemental Security Income (SSI) Fraction 

 1. Background 

2. CMS’ Current Data Matching Process for the SSI Fraction 

3. Baystate Medical Center v. Leavitt Court Decision 

4. CMS’ Proposed Process for Matching Medicare and SSI Eligibility Data 

a. Inclusion of Stale Records and Forced Pay Records in the SSI Eligibility Data 

Files 

b. Use of SSNs in the Revised Match Process 

 c. Timing of the Match 

 5. CMS Ruling 

 6. Clarification of Language on Inclusion of Medicare Advantage Days in the SSI 

Fraction of the Medicare DSH Calculation 

 H. Payments for Direct Graduate Medical Education (GME) Costs 

 1. Background 
CMS-1498-P 29 

 2. Identifying “Approved Medical Residency Programs” 

 a. Residents in Approved Medical Residency Programs 

 b. Determining Whether an Individual Is a Resident or a Physician 

 c. Formal Enrollment and Participation in a Program 

 3. Electronic Submission of Affiliation Agreements 

I. Certified Registered Nurse Anesthetist (CRNA) Services Furnished in Rural 

Hospitals and CAHs 

 J. Rural Community Hospital Demonstration Program 

V. Proposed Changes to the IPPS for Capital-Related Costs 

 A. Overview 

 B. Exception Payments 

 C. New Hospitals 

 D. Hospitals Located in Puerto Rico 

 E. Proposed Changes for FY 2011: MS-DRG Documentation and Coding 

Adjustment 

 1. Background on the Prospective MS-DRG Documentation and Coding 

Adjustments for FY 2008 and FY 2009 

2. Retrospective Evaluation of FY 2008 Claims Data 

3. Retrospective Analysis of FY 2009 Claims Data 

4. Proposed Prospective MS-DRG Documentation and Coding Adjustment to the 

National Capital Federal Rate for FY 2011 and Subsequent Years 
CMS-1498-P 30 

 5. Proposed Documentation and Coding Adjustment to the Puerto Rico-Specific 

Capital Rate 

 F. Other Proposed Changes for FY 2011 

VI. Proposed Changes for Hospitals Excluded from the IPPS 

 A. Excluded Hospitals 

 B. Critical Access Hospitals (CAHs) 

 1. Background 

2. CAH Optional Method Election for Payment of Outpatient Services 

 3. Costs of Provider Taxes as Allowable Costs for CAHs 

 a. Background and Statutory Basis 

 b. Proposed Clarification of Payment Policy for Provider Taxes 

VII. Proposed Changes to the Long-Term Care Hospital Prospective Payment System 

(LTCH PPS) for FY 2011 

 A. Background of the LTCH PPS 

 1. Legislative and Regulatory Authority 

 2. Criteria for Classification as a LTCH 

 a. Classification as a LTCH 

 b. Hospitals Excluded from the LTCH PPS 

 3. Limitation on Charges to Beneficiaries 

 4. Administrative Simplification Compliance Act (ASCA) and Health Insurance 

Portability and Accountability Act (HIPAA) Compliance 
CMS-1498-P 31 

 B. Proposed Medicare Severity Long-Term Care Diagnosis-Related Group 

(MS-LTC-DRG) Classifications and Relative Weights 

 1. Background 

 2. Patient Classifications into MS-LTC-DRGs 

 a. Background 

 b. Proposed Changes to the MS-LTC-DRGs for FY 2011 

 3. Development of the Proposed FY 2011 MS-LTC-DRG Relative Weights 

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

 b. Development of the Proposed MS-LTC-DRG Relative Weights for FY 2011 

 c. Data 

 d. Hospital-Specific Relative Value (HSRV) Methodology 

 e. Treatment of Severity Levels in Developing the Proposed MS-LTC-DRG 

Relative Weights 

 f. Low-Volume MS-LTC-DRGs 

 g. Steps for Determining the Proposed RY 2011 MS-LTC-DRG Relative Weights 

 C. Proposed Changes to the LTCH Payment Rates and Other Proposed Changes 

to the FY 2011 LTCH PPS 

 1. Overview of Development of the LTCH Payment Rates 

 2. Market Basket for LTCHs Reimbursed under the LTCH PPS 

 a. Overview 

 b. Market Basket under the LTCH PPS for FY 2011 

 c. Proposed Market Basket Update for LTCHs for FY 2011 
CMS-1498-P 32 

 d. Proposed Labor-Related Share under the LTCH PPS for FY 2011 

 3. Proposed Adjustment for Changes in LTCHs’ Case-Mix Due to Changes in 

Documentation and Coding Practices That Occurred in a Prior Period 

 a. Background 

 b. Evaluation of FY 2009 Claims Data 

 c. Proposed FY 2011 Documentation and Coding Adjustment 

 D. Proposed Change in Terminology from “Rate Year” to “Fiscal Year” and 

Other Proposed Changes 

VIII. Determination of Effective Date of Provider Agreements and Supplier Approvals 

 A. Background 

 B. Departmental Appeals Board Decision 

 C. Proposed Revisions to Regulations 

IX. Proposed Changes to Medicare Conditions of Participation Affecting Hospital 

Rehabilitation Services and Respiratory Care Services 

X. Proposed Changes to the Accreditation Requirements for Medicaid Providers of 

Inpatient Psychiatric Services for Individuals under Age 21 

 A. Background 

 B. Proposed Revision of Policy and Regulations 

XI. MedPAC Recommendations 

XII. Other Required Information 

 A. Requests for Data from the Public 

 B. Collection of Information Requirements 
CMS-1498-P 33 

 1. Legislative Requirement for Solicitation of Comments 

 2. Requirements in Regulation Text 

a. ICRs Regarding Withdrawing an Application, Terminating an Approved 

3 Year Reclassification, or Canceling a Previous Withdrawal or Termination (Proposed 

Revised §412.273)

b. ICRs Regarding Condition of Participation: Respiratory Care Services 

(§482.57) 

 3. Additional Information Collection Requirements 

 a. Present on Admission (POA) Indicator Reporting 

 b. Add-On Payments for New Services and Technologies 

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

 d. Occupational Mix Adjustment to the FY 2011 Index (Hospital Wage Index 

Occupational Mix Survey) 

 e. Hospital Applications for Geographic Reclassifications by the MGCRB 

f. Direct GME Payments: General Requirements 

C. Response to 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, 2010 

I. Summary and Background 
CMS-1498-P 34 

II. Proposed Changes to the Prospective Payment Rates for Hospital Inpatient Operating 

Costs for Acute Care Hospitals for FY 2011 

 A. Calculation of the Adjusted Standardized Amount 

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

 C. Proposed MS-DRG Relative Weights 

 D. Calculation of the Proposed Prospective Payment Rates 

III. Proposed Changes to Payment Rates for Acute Care Hospital Inpatient 

Capital-Related Costs for FY 2011 

 A. Determination of Federal Hospital Inpatient Capital-Related Prospective 

Payment Rate Update 

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

for FY 2011 

 C. Capital Input Price Index 

IV. Proposed Changes to Payment Rates for Certain Excluded Hospitals: 

Rate-of-Increase Percentages 

V. Proposed Changes to the Payment Rates for the LTCH PPS for FY 2011 

 A. Proposed LTCH PPS Standard Federal Rate for FY 2011 

 B. Proposed Adjustment for Area Wage Levels under the LTCH PPS for 

FY 2011 

 C. Proposed Adjustment for LTCH PPS High-Cost Outlier (HCO) Cases 

 D. Computing the Proposed Adjusted LTCH PPS Federal Prospective Payments 

for FY 2011 
CMS-1498-P 35 

VI. Tables 

 Table 1A.—Proposed National Adjusted Operating Standardized Amounts, 

Labor/Nonlabor (68.8 Percent Labor Share/31.2 Percent Nonlabor Share If Wage Index 

Is Greater Than 1) 

 Table 1B.—Proposed 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.—Proposed Adjusted Operating Standardized Amounts for Puerto Rico, 

Labor/Nonlabor 

 Table 1D.—Proposed Capital Standard Federal Payment Rate 

 Table 1E.—Proposed LTCH Standard Federal Prospective Payment Rate 

 Table 2.—Acute Care Hospitals Case-Mix Indexes for Discharges Occurring in 

Federal Fiscal Year 2009; Proposed Hospital Wage Indexes for Federal Fiscal Year 2011; 

Hospital Average Hourly Wages for Federal Fiscal Years 2009 (2005 Wage Data), 2010 

(2006 Wage Data), and 2011 (2007 Wage Data); and 3-Year Average of Hospital 

Average Hourly Wages 

 Table 3A.—FY 2011 and 3-Year Average Hourly Wage for Acute Care Hospitals 

in Urban Areas by CBSA 

 Table 3B.—FY 2011 and 3-Year Average Hourly Wage for Acute Care Hospitals 

in Rural Areas by CBSA 

 Table 4A.—Proposed Wage Index and Capital Geographic Adjustment Factor 

(GAF) for Acute Care Hospitals in Urban Areas by CBSA and by State--FY 2011 
CMS-1498-P 36 

 Table 4B.—Proposed Wage Index and Capital Geographic Adjustment Factor 

(GAF) for Acute Care Hospitals in Rural Areas by CBSA and by State--FY 2011 

 Table 4C.—Proposed Wage Index and Capital Geographic Adjustment Factor 

(GAF) for Acute Care Hospitals That Are Reclassified by CBSA and by State--FY 2011 

 Table 4D-1.—Proposed Rural Floor Budget Neutrality Factors for Acute Care 

Hospitals--FY 2011 

 Table 4D-2.—Urban Areas with Acute Care Hospitals Receiving the Proposed 

Statewide Rural Floor or Imputed Floor Wage Index--FY 2011 

 Table 4E.--Urban CBSAs and Constituent Counties for Acute Care 

Hospitals--FY 2011 

 Table 4F.—Proposed Puerto Rico Wage Index and Capital Geographic 

Adjustment Factor (GAF) for Acute Care Hospitals by CBSA--FY 2011 

Table 4J.—Proposed Out-Migration Adjustment for Acute Care Hospitals—

FY 2011 

 Table 5.--List of Medicare Severity Diagnosis-Related Groups (MS-DRGs), 

Relative Weighting Factors, and Geometric and Arithmetic Mean Length of 

Stay--FY 2011 

 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 
CMS-1498-P 37 

 Table 6F.--Revised Procedure Code Titles 

 Table 6G.--Additions to the CC Exclusions List (Available through the Internet 

on the CMS Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS/) 

 Table 6H.--Deletions from the CC Exclusions List (Available 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 (Available through 

the Internet on the CMS Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS/) 

 Table 6K.--Complication and Comorbidity (CC) List (Available through the 

Internet on the CMS Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS/) 

 Table 7A.--Medicare Prospective Payment System Selected Percentile Lengths of 

Stay: FY 2009 MedPAR Update—December 2009 GROUPER V27.0 MS-DRGs 

 Table 7B.--Medicare Prospective Payment System Selected Percentile Lengths of 

Stay: FY 2009 MedPAR Update—December 2009 GROUPER V28.0 MS-DRGs 

 Table 8A.—Proposed Statewide Average Operating Cost-to-Charge Ratios 

(CCRs) for Acute Care Hospitals—March 2009 

 Table 8B.—Proposed Statewide Average Capital Cost-to-Charge Ratios (CCRs) 

for Acute Care Hospitals—March 2009 

 Table 8C.—Proposed Statewide Average Total Cost-to-Charge Ratios (CCRs) for 

LTCHs--March 2009 
CMS-1498-P 38 

 Table 9A.--Hospital Reclassifications and Redesignations--FY 2011 

 Table 9C.--Hospitals Redesignated as Rural under Section 1886(d)(8)(E) of the 

Act--FY 2011 

 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 Medicare 

Severity Diagnosis-Related Groups (MS-DRGs)—March 2009 

 Table 11.—Proposed MS-LTC-DRGs, Relative Weights, Geometric Average 

Length of Stay, Short-Stay Outlier Threshold, and IPPS Comparable Threshold for 

Discharges Occurring from October 1, 2010 through September 30, 2011 under the 

LTCH PPS 

 Table 12A.—Proposed LTCH PPS Wage Index for Urban Areas for Discharges 

Occurring from October 1, 2010 through September 30, 2011 

 Table 12B.—Proposed LTCH PPS Wage Index for Rural Areas for Discharges 

Occurring from October 1, 2010 through September 30, 2011 

Appendix A--Regulatory Impact Analysis

I. Overall Impact 

II. Objectives of the IPPS 

III. Limitations of Our Analysis 

IV. Hospitals Included in and Excluded From the IPPS 

V. Effects on Hospitals and Hospital Units Excluded from the IPPS 
CMS-1498-P 39 

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 MS-DRG Reclassifications and 

Relative Cost-Based Weights (Column 1) 

 D. Effects of the Application of Recalibration Budget Neutrality (Column 2) 

 E. Effects of Proposed Wage Index Changes (Column 3) 

 F. Application of the Wage Budget Neutrality Factor (Column 4) 

 G. Combined Effects of Proposed MS-DRG and Wage Index Changes 

(Column 5) 

 H. Effects of MGCRB Reclassifications (Column 6) 

 I. Effects of the Proposed Rural Floor and Imputed Floor, Including Application 

of Budget Neutrality at the State Level (Column 7) 

 J. Effects of the Proposed Wage Index Adjustment for Out-Migration (Column 8) 

 K. Effects of All Proposed Changes Prior to Documentation and Coding (Or 

CMI) Adjustment (Column 9) 

 L. Effects of All Proposed Changes with CMI Adjustment (Column 10) 

 M. Effects of Proposed Policy on Payment Adjustments for Low-Volume 

Hospitals 

 N. Impact Analysis of Table II 

VII. Effects of Other Proposed Policy Changes 
CMS-1498-P 40 

 A. Effects of Proposed Policy on HACs, Including Infections 

 B. Effects of Proposed Policy Changes Relating to New Medical Service and 

Technology Add-On Payments 

 C. Effects of Proposed Requirements for Hospital Reporting of Quality Data for 

Annual Hospital Payment Update 

 D. Effects of Proposed Policy on Payment for Transfer Cases from Medicare 

Participating Hospitals to Nonparticipating Hospitals and CAHs 

 E. Effects of Proposed Change in Criteria for MDHs 

 F. Effects of Proposed Change Relating to Payment Adjustment for 

Disproportionate Share Hospitals 

 G. Effects of Proposed Changes Relating to Payments for IME and Direct GME 

1. Identifying “Approved Medical Residency Programs” 

2. Submission of Electronic Affiliation Agreements 

 H. Effects of Proposed Changes Relating to CRNA Services Furnished in Rural 

Hospitals and CAHs 

 I. Effects of Implementation of Rural Community Hospital Demonstration 

Program 

 J. Effects of Proposed Changes Relating to CAHs 

 1. CAH Optional Method of Payment for Outpatient Services 
CMS-1498-P 41 

 2. Consideration of Costs of Provider Taxes as Allowable Costs for CAHs 

 K. Effects of Proposed Policy Relating to Effective Date of Provider Agreements 

and Supplier Approvals 

 L. Effects of Proposed Changes Relating to Hospital Rehabilitation Services and 

Respiratory Care Services Conditions of Participation 

VIII. Effects of Proposed Changes in the Capital IPPS 

 A. General Considerations 

 B. Results 

IX. Effects of Proposed Payment Rate Changes and Proposed Policy Changes under the 

LTCH PPS 

 A. Introduction and General Considerations 

 B. Impact on Rural Hospitals 

 C. Anticipated Effects of Proposed LTCH PPS Payment Rate Change and 

Proposed Policy Changes 

 D. Effect on the Medicare Program 

 E. Effect on Medicare Beneficiaries 

X. Effects of Proposed Policy Changes Relating to Accreditation Requirements for 

Medicaid Providers of Inpatient Psychiatric Services to Individuals under Age 21 

XI. Alternatives Considered 

XII. Overall Conclusion 

 A. Acute Care Hospitals 

 B. LTCHs 
CMS-1498-P 42 

XIII. Accounting Statements 

 A. Acute Care Hospitals 

 B. LTCHs 

XIV. 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 2011 

 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 predetermined, specific rates for 

each hospital discharge. Discharges are classified according to a list of diagnosis-related 

groups (DRGs). 
CMS-1498-P 43 

 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. 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 
CMS-1498-P 44 

payment is designed to protect the hospital from large financial losses due to unusually 

expensive cases. Any eligible outlier payment 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 in whole or in part based on 

their hospital-specific rate based on their costs in a base year. For example, sole 

community hospitals (SCHs) receive the higher of a hospital-specific rate based on their 

costs in a base year (the highest of FY 1982, FY 1987, FY 1996, or FY 2006) or the IPPS 

Federal rate based on the standardized amount. Through and including FY 2006, a 

Medicare-dependent, small rural hospital (MDH) received the higher of the Federal rate 

or the Federal rate plus 50 percent of the amount by which the Federal rate is exceeded 

by the higher of its FY 1982 or FY 1987 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 higher of the Federal rate or the Federal rate plus 75 percent of the 

amount by which the Federal rate is exceeded by the highest of its FY 1982, FY 1987, or 

FY 2002 hospital-specific rate. SCHs are the sole source of care in their areas, and 

MDHs are a major source of care for Medicare beneficiaries in their areas. Specifically, 

section 1886(d)(5)(D)(iii) of the Act defines an SCH as a hospital that is located more 

than 35 road miles from another hospital or that, by reason of factors such as isolated 

location, weather conditions, travel conditions, or absence of other like hospitals (as 

determined by the Secretary), is the sole source of hospital inpatient services reasonably 
CMS-1498-P 45 

available to Medicare beneficiaries. In addition, certain rural hospitals previously 

designated by the Secretary as essential access community hospitals are considered 

SCHs. Section 1886(d)(5)(G)(iv) of the Act defines an MDH as a hospital that is located 

in a rural area, has not more than 100 beds, is not an SCH, and has a high percentage of 

Medicare discharges (not less than 60 percent of its inpatient days or discharges in its 

cost reporting year beginning in FY 1987 or in two of its three most recently settled 

Medicare cost reporting years). Both of these categories of hospitals are afforded this 

special payment protection in order to maintain access to services for beneficiaries. 

 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 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; 
CMS-1498-P 46 

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 (BBA, Pub. L. 105-33), the Medicare, Medicaid and SCHIP [State Children's 

Health Insurance Program] Balanced Budget Refinement Act of 1999 (BBRA, 

Pub. L. 106-113), and the Medicare, Medicaid, and SCHIP Benefits Improvement and 

Protection Act of 2000 (BIPA, 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)). (We note that the annual updates to the LTCH PPS are now included as 

part of the IPPS annual update document. Updates to the IRF PPS and IPF PPS are 

issued as separate documents.) Children's hospitals, cancer hospitals, and RNHCIs 

continue to be paid solely under a reasonable cost-based system subject to a 

rate-of-increase ceiling on inpatient operating costs per discharge. 

 The existing regulations governing payments to excluded hospitals and hospital 

units are located in 42 CFR Parts 412 and 413. 

3. Long-Term Care Hospital Prospective Payment System (LTCH PPS) 

 The Medicare prospective payment system (PPS) for LTCHs applies to hospitals 

described in section 1886(d)(1)(B)(iv) effective for cost reporting periods beginning on 

or after October 1, 2002. The LTCH PPS was established under the authority of sections 

123(a) and (c) of Pub. L. 106-113 and section 307(b)(1) of Pub. L. 106-554 (as codified 

under section 1886(m)(1) of the Act). During the 5-year (optional) transition period, a 

LTCH’s payment under the PPS was based on an increasing proportion of the LTCH 
CMS-1498-P 47 

Federal rate with a corresponding decreasing proportion based on reasonable cost 

principles. Effective 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. Beginning 

October 1, 2009, we issue the annual updates to the LTCH PPS in the same documents 

that update the IPPS (73 FR 26797 through 26798). 

4. Critical Access Hospitals (CAHs) 

 Under sections 1814(l), 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 are generally 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. 

5. 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 Patient Protection and Affordable Care Act (Pub. L. 111-148), as 

amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152)
CMS-1498-P 48 

 On March 23, 2010, the Patient Protection and Affordable Care Act (PPACA), 

Pub. L. 111-148 was enacted. Following the enactment of Pub. L. 111-148, the Health 

Care and Education Reconciliation Act of 2010, Public L. 111-152 (enacted on 

March 30, 2010), amended certain provisions of Pub. L. 111-148. A number of the 

provisions of Pub. L. 111-148, as amended by Pub. L. 111-152, affect the IPPS and the 

LTCH PPS and the providers and suppliers addressed in this proposed rule. However, 

due to the timing of the passage of the legislation, we are unable to address those 

provisions in this proposed rule. Therefore, the proposed policies and payment rates in 

this proposed rule do not reflect the new legislation. We plan to issue separate 

documents in the Federal Register addressing the provisions of Pub. L. 111-148, as 

amended, that affect our proposed policies and payment rates for FY 2011 under the IPPS 

and the LTCH PPS. In addition, we plan to issue further instructions implementing the 

provisions of Pub. L. 111-148, as amended, that affect the policies and payment rates for 

FY 2010 under the IPPS and for RY 2010 under the LTCH PPS. 

C. Major Content 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 of acute care hospitals in FY 2011. 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. 

 In addition, in this proposed rule, we are setting forth proposed changes to the 

payment rates, factors, and other payment rate policies under the LTCH PPS for 
CMS-1498-P 49 

FY 2011. We note that because the annual update of payment rates for the LTCH PPS 

will now take place on the same schedule and in the same publication as for the IPPS, for 

the sake of clarity, in section VII.D. of this proposed rule, we are proposing to use “fiscal 

year (FY)” instead of “rate year (RY) when referring to updates and changes to the 

LTCH PPS to be effective October 1, 2010. Therefore, throughout this proposed rule, we 

are using the phrase “fiscal year (FY)” in referring to proposed updates and changes to 

the LTCH PPS. 

 Below is a summary of the major changes that we are proposing to make: 

1. Proposed Changes to MS-DRG Classifications and Recalibrations of Relative Weights 

 In section II. of the preamble of this proposed rule, we included-- 

● Proposed changes to MS-DRG classifications based on our yearly review. 

● Proposed application of the documentation and coding adjustment to 

hospital-specific rates for FY 2011 resulting from implementation of the MS-DRG 

system. 

● A discussion of the Research Triangle International, Inc. (RTI) and RAND 

Corporation reports and recommendations relating to charge compression. 

● Proposed recalibrations of the MS-DRG relative weights. 

 We also presented a listing and discussion of hospital-acquired conditions 

(HACs), including infections, that are subject to the statutorily required quality 

adjustment in MS-DRG payments for FY 2011. 

 We discuss the FY 2011 status of two new technologies approved for add-on 

payments for FY 2010 and presented our evaluation and analysis of the FY 2011 
CMS-1498-P 50 

applicants for add-on payments for high-cost new medical services and technologies 

(including public input, as directed by Pub. L. 108-173, obtained in a town hall meeting). 

2. Proposed Changes to the Hospital Wage Index for Acute Care Hospitals 

 In section III. of the preamble to this proposed rule, we are proposing revisions to 

the wage index for acute care hospitals and the annual update of the wage data. Specific 

issues addressed include the following: 

● Budget neutrality for the rural floor and imputed floor. 

● Changes to titles and principal cities of CBSA designations. 

● The proposed FY 2011 wage index update using wage data from cost reporting 

periods beginning in FY 2007. 

● Analysis and implementation of the proposed FY 2011 occupational mix 

adjustment to the wage index for acute care hospitals, including discussion of the 2010 

occupational mix survey. 

● Proposed revisions to the wage index for acute care hospitals based on hospital 

redesignations and reclassifications. 

● The proposed adjustment to the wage index for acute care hospitals for 

FY 2011 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 used to compute the 

proposed FY 2011 hospital wage index. 

● Determination of the labor-related share for the proposed FY 2011 wage index. 
CMS-1498-P 51 

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

Costs 

 In section IV. of the preamble of this proposed rule, we discussed a number of the 

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. 

● Payment for transfer cases from Medicare participating hospitals to 

nonparticipating hospitals and CAHs. 

● A change to the definition criteria for MDHs. 

● The proposed updated national and regional case-mix values and discharges for 

purposes of determining RRC status. 

● The statutorily required IME adjustment factor for FY 2011. 

● The proposed policy change relating to the determination of the SSI ratio of the 

Medicare fraction in the formula for determining the payment adjustments for 

disproportionate share hospitals. 

● A proposed clarification of “approved medical residency programs” policies 

relating to payment for IME and direct GME and our proposal to accept the electronic 

submission of Medicare GME affiliation agreements. 

● Proposed policy change for payments for services furnished by certified 

registered nurse anesthetists (CRNAs) in rural hospitals and CAHs. 

● Discussion of the status of the Rural Community Hospital Demonstration 

Program. 
CMS-1498-P 52 

4. Proposed FY 2011 Policy Governing the IPPS for Capital-Related Costs 

 In section V. of the preamble to this proposed rule, we discussed the proposed 

payment policy requirements for capital-related costs and capital payments to hospitals 

for FY 2011 and the proposed MS-DRG documentation and coding adjustment for 

FY 2011. 

5. Proposed Changes to the Payment Rates for Certain Excluded Hospitals: 

Rate-of-Increase Percentages 

 In section VI. of the preamble of this proposed rule, we discussed-- 

● Proposed changes to payments to excluded hospitals. 

● Proposed changes relating to the election by CAHs of the optional method of 

payment for outpatient services 

● Proposed clarification of the policies on costs of provider taxes as allowable 

costs for CAHs. 

6. Proposed Changes to the LTCH PPS 

 In section VII. of the preamble of this proposed rule, we set forth proposed 

changes to the payment rates, factors, and other payment rate policies under the LTCH 

PPS for FY 2011, including the annual update of the MS-LTC-DRG classifications and 

relative weights for use under the LTCH PPS for FY 2011 and the proposed MS-DRG 

documentation and coding adjustment for FY 2011. 

7. Proposed Changes Relating to Effective Date of Provider Agreements and Supplier 

Approvals 
CMS-1498-P 53 

In section VIII. of the preamble of this proposed rule, we set forth our proposed 

change in policies for determining the effective date of provider agreements and supplier 

approvals and to make changes to assure that accredited and nonaccredited facilities are 

treated in the same manner in determining this effective date. 

8. Proposed Changes to Medicare Conditions of Participation Affecting Hospital 

Rehabilitation Services and Respiratory Care Services

 In section IX. of the preamble of this proposed rule, we are proposing changes to 

the Medicare conditions of participation regarding which practitioners are allowed to 

order rehabilitation and respiratory care services in the hospital setting. 

9. Proposed Changes to the Accreditation Requirements for Medicaid Providers of 

Inpatient Psychiatric Services for Individuals under Age 21 

 In section X. of the preamble of this proposed rule, we are proposing to remove 

the requirement for accreditation by The Joint Commission of psychiatric hospitals and 

hospitals with inpatient psychiatric programs. Hospitals with inpatient psychiatric 

programs would be afforded the flexibility in obtaining accreditation by a national 

accrediting organization whose hospital accrediting program has been approved by CMS, 

and psychiatric rehabilitation treatment facilities would be afforded flexibility in 

obtaining accreditation by a national accrediting organization whose program has been 

approved by CMS, or by any other accrediting organization with comparable standards 

that is recognized by the State. 

10. Determining Proposed Prospective Payment Operating and Capital Rates and 

Rate-of-Increase Limits for Acute Care Hospitals 
CMS-1498-P 54 

 In the Addendum to this proposed rule, we set forth proposed changes to the 

amounts and factors for determining the proposed FY 2011 prospective payment rates for 

operating costs and capital-related costs for acute care hospitals. We also are establishing 

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 2011 for certain hospitals excluded from the IPPS. 

11. Determining Proposed Prospective Payment Rates for LTCHs 

 In the Addendum to this proposed rule, we set forth proposed changes to the 

amounts and factors for determining the proposed FY 2011 prospective standard Federal 

rate. We also are establishing the proposed adjustments for wage levels, the labor-related 

share, the cost-of-living adjustment, and high-cost outliers, including the fixed-loss 

amount, and the LTCH cost-to-charge ratios (CCRs) under the LTCH PPS. 

12. 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 acute care hospitals and LTCHs. 

13. Recommendation of Update Factors for Operating Cost Rates of Payment for 

Hospital Inpatient Services 

 In Appendix B of this proposed rule, as required by sections 1886(e)(4) and (e)(5) 

of the Act, we provide our recommendations of the appropriate percentage changes for 

FY 2011 for the following: 
CMS-1498-P 55 

● A single average standardized amount for all areas for hospital inpatient 

services paid under the IPPS for operating costs of acute care hospitals (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 certain hospitals excluded from the IPPS. 

● The standard Federal rate for hospital inpatient services furnished by LTCHs. 

14. 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 2010 

recommendations concerning hospital inpatient payment policies address the update 

factor for hospital inpatient operating costs and capital-related costs under the IPPS, for 

hospitals and distinct part hospital units excluded from the IPPS. We address these 

recommendations in Appendix B of this proposed rule. For further information relating 

specifically to the MedPAC March 2008 report or to obtain a copy of the report, contact 

MedPAC at (202) 220-3700 or visit MedPAC's Web site at: http://www.medpac.gov. 

E. Interim Final Rule with Comment Period That Implemented Certain Provisions of the 

ARRA Relating to Payments to LTCHs and LTCH Satellite Facilities

 Section 4302 of the American Recovery and Reinvestment Act of 2009 (ARRA, 

Pub. L. 111-5) included several amendments to section 114 of Pub. L. 110-173 

(MMSEA) relating to payments to LTCHs and LTCH satellite facilities that were 

discussed under section X. of the FY 2010 IPPS/RY 2010 LTCH PPS final rule 
CMS-1498-P 56 

(74 FR 43976 through 43990). These amendments are effective as if they were enacted 

as part of section 114 of Pub. L. 110-173 (MMSEA). We issued instructions to the fiscal 

intermediaries and Medicare administrative contractors (MACs) to interpret these 

amendments (Change Request 6444). In section XI. of the FY 2010/RY 2010 LTCH PPS 

final rule (74 FR 43990), we implemented the provisions of section 4302 of 

Pub. L. 111-5 through an interim final rule with comment period. We will respond to the 

public comments that we received in a timely manner on this interim final rule with 

comment period and finalize the interim final rule with any necessary modification in the 

final rule for this proposed rule. 

II. Proposed Changes to Medicare Severity Diagnosis-Related Group (MS-DRG) 

Classifications and Relative Weights 

A. Background

 Section 1886(d) of the Act specifies that the Secretary shall establish a 

classification system (referred to as DRGs) for inpatient discharges and adjust payments 

under the IPPS based on appropriate weighting factors assigned to each DRG. Therefore, 

under the IPPS, we pay for inpatient hospital services on a rate per discharge basis that 

varies according to the DRG to which a beneficiary's stay is assigned. The formula used 

to calculate payment for a specific case multiplies an individual hospital's payment rate 

per case by the weight of the DRG to which the case is assigned. Each DRG weight 

represents the average resources required to care for cases in that particular DRG, relative 

to the average resources used to treat cases in all DRGs. 
CMS-1498-P 57 

 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. MS-DRG Reclassifications

1. General 

 As discussed in the preamble to the FY 2008 IPPS final rule with comment period 

(72 FR 47138), we focused 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 severity of 

illness into account 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 other DRGs across 

13 different clinical areas involving nearly 1.7 million cases. As described in more detail 

below, these refinements were intermediate steps towards comprehensive reform of both 

the relative weights and the DRG system as we undertook further study. For FY 2008, 

 

1

 Medicare Payment Advisory Commission: Report to the Congress, Physician-Owned 

Specialty Hospitals, March 2005, page viii. 
CMS-1498-P 58 

we adopted 745 new Medicare Severity DRGs (MS-DRGs) to replace the CMS DRGs. 

We refer readers to section II.D. of the FY 2008 IPPS final rule with comment period for 

a full detailed discussion of how the MS-DRG system, based on severity levels of illness, 

was established (72 FR 47141). 

 Currently, cases are classified into MS-DRGs for payment under the IPPS based 

on the following information reported by the hospital: the principal diagnosis, up to eight 

additional diagnoses, and up to six procedures performed during the stay. (We refer 

readers to section II.G.11.c. of this proposed rule for a discussion of our efforts to 

increase our internal systems capacity to process diagnosis and procedures on hospital 

claims to 25 diagnosis codes and 25 procedure codes prior to the use of the International 

Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) for 

diagnosis coding and the International Classification of Diseases, 10th Revision, 

Procedure Coding System (ICD-10 PCS) for inpatient hospital procedure coding, 

effective October 1, 2013.) In a small number of MS-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) prior to October 1, 2013. 

We refer readers to section II.G.11.b. of this proposed rule for a reference to the 

replacement of ICD-9-CM, Volumes 1 and 2, including the Official ICD-9-CM 

Guidelines for Coding and Reporting, Volume 3, with the ICD-10-CM and ICD-10-PCS, 

including the Official ICD-10-CM and ICM-10-PCS Guidelines for Coding and 

Reporting, effective October 1, 2013 (FY 2014). 
CMS-1498-P 59 

 The process of developing the MS-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 formulated by physician panels to 

ensure 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 MS-DRG could contain patients in different MDCs. 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 2010, cases are assigned to one 

of 746 MS-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 
CMS-1498-P 60 

 Major Diagnostic Categories (MDCs) 

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 an MS-DRG. However, under the most recent version of 

the Medicare GROUPER (Version 27.0), there are 13 MS-DRGs to which cases are 

directly assigned on the basis of ICD-9-CM procedure codes. These MS-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 tracheostomies. Cases are assigned to these MS-DRGs before they are 

classified to an MDC. The table below lists the 13 current pre-MDCs. 

Pre-Major Diagnostic Categories (Pre-MDCs) 

MS-DRG 001 Heart Transplant or Implant of Heart Assist System with MCC 

MS-DRG 002 Heart Transplant or Implant of Heart Assist System without MCC 

MS-DRG 003 ECMO or Tracheostomy with Mechanical Ventilation 96+ Hours 

or Principal Diagnosis Except for Face, Mouth, and Neck 

Diagnosis with Major O.R. 

MS-DRG 004 Tracheostomy with Mechanical Ventilation 96+ Hours or 

Principal Diagnosis Except for Face, Mouth, and Neck Diagnosis 

with Major O.R. 

MS-DRG 005 Liver Transplant with MCC or Intestinal Transplant 

MS-DRG 006 Liver Transplant without MCC 

MS-DRG 007 Lung Transplant 

MS-DRG 008 Simultaneous Pancreas/Kidney Transplant 

MS-DRG 009 Bone Marrow Transplant 
CMS-1498-P 61 

Pre-Major Diagnostic Categories (Pre-MDCs) 

MS-DRG 010 Pancreas Transplant 

MS-DRG 011 Tracheostomy for Face, Mouth, and Neck Diagnoses with MCC 

MS-DRG 012 Tracheostomy for Face, Mouth, and Neck Diagnoses with CC 

MS-DRG 013 Tracheostomy for Face, Mouth, and Neck Diagnoses without 

CC/MCC 

 Once the MDCs were defined, each MDC was evaluated to identify those 

additional patient characteristics that would have a consistent effect on hospital resource 

consumption. 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) or a major complication 

or comorbidity (MCC). 

 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 MS-DRG assignment for certain 

principal diagnoses. An example is extracorporeal shock wave lithotripsy for patients 

with a principal diagnosis of urinary stones. Lithotripsy procedures are not routinely 

performed in an operating room. Therefore, lithotripsy codes are not classified as O.R. 

procedures. However, our clinical advisors believe that patients with urinary stones who 
CMS-1498-P 62 

undergo extracorporeal shock wave lithotripsy should be considered similar to other 

patients who undergo O.R. procedures. Therefore, we treat this group of patients similar 

to patients undergoing O.R. procedures. 

 Once the medical and surgical classes for an MDC were formed, each diagnosis 

class was evaluated to determine if complications or comorbidities would consistently 

affect hospital resource consumption. Each diagnosis was categorized into one of three 

severity levels. These three levels include a major complication or comorbidity (MCC), a 

complication or comorbidity (CC), or a non-CC. Physician panels classified each 

diagnosis code based on a highly iterative process involving a combination of statistical 

results from test data as well as clinical judgment. As stated earlier, we refer readers to 

section II.D. of the FY 2008 IPPS final rule with comment period for a full detailed 

discussion of how the MS-DRG system was established based on severity levels of 

illness (72 FR 47141). 

 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 an 

MS-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 

MS-DRG by the Medicare GROUPER software program. The GROUPER program was 

developed as a means of classifying each case into an MS- DRG on the basis of the 
CMS-1498-P 63 

diagnosis and procedure codes and, for a limited number of MS-DRGs, demographic 

information (that is, sex, age, and discharge status). 

 After cases are screened through the MCE and assigned to an MS-DRG by the 

GROUPER, the PRICER software calculates a base MS-DRG payment. The PRICER 

calculates the payment for each case covered by the IPPS based on the MS-DRG relative 

weight and additional factors associated with each hospital, such as IME and DSH 

payment adjustments. These additional factors increase the payment amount to hospitals 

above the base MS-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 MS-DRG classification changes and to recalibrate the MS-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. 
CMS-1498-P 64 

As we indicated above, for FY 2008, we made significant improvements in the 

DRG system to recognize severity of illness and resource usage by adopting MS-DRGs 

that were reflected in the FY 2008 GROUPER, Version 25.0, and were effective for 

discharges occurring on or after October 1, 2007. Our MS-DRG analysis for the 

FY 2009 final rule was based on data from the March 2008 update of the FY 2007 

MedPAR file, which contained hospital bills received through March 31, 2008, for 

discharges occurring through September 30, 2007. For this proposed rule, for FY 2011, 

our MS-DRG analysis is based on data from the September 2009 update of the FY 2009 

MedPAR file, which contains hospital bills received through September 30, 2009, for 

discharges occurring through September 30, 2009. 
CMS-1498-P 65 

2. Yearly Review for Making MS-DRG Changes 

 Many of the changes to the MS-DRG classifications we make annually are the 

result of specific issues brought to our attention by interested parties. We encourage 

individuals with comments about MS-DRG classifications to submit these comments no 

later than early December of each year 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 the MS-DRG recalibration process, comments 

about MS-DRG classification issues should be submitted 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 MS-DRGs was, and will likely continue to be, 

highly iterative, involving a combination of statistical results from test data combined 

with clinical judgment. In the FY 2008 IPPS final rule (72 FR 47140 through 47189), we 

described in detail the process we used to develop the MS-DRGs that we adopted for 

FY 2008. In addition, in deciding whether to make further modification to the MS-DRGs 

for particular circumstances brought to our attention, we considered 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 MS-DRG. We evaluated patient 

care costs using average charges and lengths of stay as proxies for costs and relied on the 

judgment of our medical advisors to decide whether patients are clinically distinct or 

similar to other patients in the MS-DRG. In evaluating resource costs, we considered 
CMS-1498-P 66 

both the absolute and percentage differences in average charges between the cases we 

selected for review and the remainder of cases in the MS-DRG. We also considered 

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 considered the number of patients who 

will have a given set of characteristics and generally preferred not to create a new 

MS-DRG unless it would include a substantial number of cases. 

C. Adoption of the MS-DRGs in FY 2008

 In the FY 2006, FY 2007, and FY 2008 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; 71 FR 47881 through 47939; and 

72 FR 47140 through 47189). 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). 

Based on public comments received on the FY 2007 IPPS proposed rule, we decided not 

to adopt the CS DRGs. In the FY 2007 IPPS final rule (71 FR 47906 through 47912), we 
CMS-1498-P 67 

discussed several concerns raised by commenters regarding the proposal to adopt 

CS DRGs. We acknowledged the many comments suggesting the logic of Medicare's 

DRG system should continue to remain in the public domain as it has since the inception 

of the PPS. We also acknowledged concerns about the impact on hospitals and software 

vendors of moving to a proprietary system. Several commenters suggested that CMS 

refine the existing DRG classification system to preserve the many policy decisions that 

were made over the last 20 years and were already incorporated into the DRG system, 

such as complexity of services and new device technologies. Consistent with the 

concerns expressed in the public comments, this option had the advantage of using the 

existing DRGs as a starting point (which was already familiar to the public) and retained 

the benefit of many DRG decisions that were made in recent years. We stated our belief 

that the suggested approach of incorporating severity measures into the existing DRG 

system was a viable option that would be evaluated. 

Therefore, 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 contained 1,666,476 cases and represented a 

number of body systems. In creating these 20 new DRGs, we deleted 8 existing DRGs 

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. 
CMS-1498-P 68 

In the FY 2007 IPPS final rule (71 FR 47898), 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 CMS 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 in connection 

with adopting severity DRGs. We describe below the progress we have made on these 

two initiatives and our actions for FYs 2008, 2009, and 2010, and our proposals for 

FY 2011 based on our continued analysis of reform of the DRG system. We note that the 

adoption of the MS-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 DSH payment adjustments. 

We discuss these implications for FY 2011 in other sections of this preamble and in the 

Addendum to this proposed rule. 

In the FY 2007 IPPS proposed rule, we discussed MedPAC’s recommendations to 

move to a cost-based HSRV weighting methodology using HSRVs beginning with the 

FY 2007 IPPS proposed rule for determining the DRG relative weights. Although we 

proposed to adopt the HSRV weighting methodology for FY 2007, we decided not to 

adopt the proposed methodology in the final rule after considering the public comments 

we received on the proposal. Instead, in the FY 2007 IPPS final rule, we adopted a 

cost-based weighting methodology without the HSRV portion of the proposed 
CMS-1498-P 69 

methodology. The cost-based weights were 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 HSRV-based methodology as well as 

other issues brought to our attention related to the cost-based weighting methodology 

adopted in the FY 2007 final rule. There was significant concern in the public comments 

that our cost-based weighting methodology does not adequately account for charge 

compression--the practice of applying a higher percentage charge markup over costs to 

lower cost items and services and a lower percentage charge markup over costs to higher 

cost items and services. 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) 

which we then applied to charges on the Medicare claims to determine the cost-based 

weights. The commenters were concerned about potential distortions to the cost-based 

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 (RTI) 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 reports and 

how hospitals report charges on individual claims. Further, as part of its study of 

alternative DRG systems, the RAND Corporation analyzed the HSRV cost-weighting 

methodology. We refer readers to section II.E. of the preamble of this proposed rule for 
CMS-1498-P 70 

discussion of the issue of charge compression and the cost-weighting methodology for 

FY 2011. 

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 

prospective payment system based on grouping cases will always present some 

opportunities for providers to specialize in cases they believe have higher margins, we 

believe that the changes we have adopted and the continuing reforms we are proposing to 

make in this proposed rule for FY 2011 will improve payment accuracy and reduce 

financial incentives to create specialty hospitals. 

We refer readers to section II.D. of the FY 2008 IPPS final rule with comment 

period for a full discussion of how the MS-DRG system was established based on 

severity levels of illness (72 FR 47141). 
CMS-1498-P 71 

D. Proposed FY 2011 MS-DRG Documentation and Coding Adjustment, Including the 

Applicability to the Hospital-Specific Rates and the Puerto Rico-Specific Standardized 

Amount

1. Background on the Prospective MS-DRG Documentation and Coding Adjustments for 

FY 2008 and FY 2009 Authorized by Pub. L. 110-90 

 As we discussed earlier in this preamble, we adopted the MS-DRG patient 

classification system for the IPPS, effective October 1, 2007, to better recognize severity 

of illness in Medicare payment rates for acute care hospitals. The adoption of the 

MS-DRG system resulted in the expansion of the number of DRGs from 538 in FY 2007 

to 745 in FY 2008. (Currently, there are 746 DRGs for FY 2010; there would be 747 

DRGs in FY 2011, with our proposals in this proposed rule to delete one MS-DRG and to 

create two new MS-DRGs.) By increasing the number of MS-DRGs and more fully 

taking into account patients’ severity of illness in Medicare payment rates for acute care 

hospitals, MS-DRGs encourage hospitals to improve their documentation and coding of 

patient diagnoses. In the FY 2008 IPPS final rule with comment period (72 FR 47175 

through 47186), we indicated that the adoption of the MS-DRGs had the potential to lead 

to increases in aggregate payments without a corresponding increase in actual patient 

severity of illness due to the incentives for additional documentation and coding. In that 

final rule with comment period, we exercised our authority under 

section 1886(d)(3)(A)(vi) of the Act, which authorizes us to maintain budget neutrality 

by adjusting the national standardized amount, to eliminate the estimated effect of 

changes in coding or classification that do not reflect real changes in case-mix. Our 
CMS-1498-P 72 

actuaries estimated that maintaining budget neutrality required an adjustment of 

-4.8 percent to the national standardized amount. We provided for phasing in this 

-4.8 percent adjustment over 3 years. Specifically, we established prospective 

documentation and coding adjustments of -1.2 percent for FY 2008, -1.8 percent for 

FY 2009, and -1.8 percent for FY 2010. 

 On September 29, 2007, Congress enacted the TMA [Transitional Medical 

Assistance], Abstinence Education, and QI [Qualifying Individuals] Programs Extension 

Act of 2007, Pub. L. 110-90. Section 7(a) of Pub. L. 110-90 reduced the documentation 

and coding adjustment made as a result of the MS-DRG system that we adopted in the 

FY 2008 IPPS final rule with comment period to -0.6 percent for FY 2008 and 

-0.9 percent for FY 2009. Section 7(a) of Pub. L. 110-90 did not adjust the FY 2010 

-1.8 percent documentation and coding adjustment promulgated in the FY 2008 IPPS 

final rule with comment period. To comply with section 7(a) of Pub. L. 110-90, we 

promulgated a final rule on November 27, 2007 (72 FR 66886) that modified the IPPS 

documentation and coding adjustment for FY 2008 to -0.6 percent, and revised the 

FY 2008 payment rates, factors, and thresholds accordingly. These revisions were 

effective on October 1, 2007. 

 For FY 2009, section 7(a) of Pub. L. 110-90 required a documentation and coding 

adjustment of -0.9 percent instead of the -1.8 percent adjustment established in the 

FY 2008 IPPS final rule with comment period. As discussed in the FY 2009 IPPS final 

rule (73 FR 48447) and required by statute, we applied a documentation and coding 

adjustment of -0.9 percent to the FY 2009 IPPS national standardized amount. The 
CMS-1498-P 73 

documentation and coding adjustments established in the FY 2008 IPPS final rule with 

comment period, as amended by Pub. L. 110-90, are cumulative. As a result, the 

-0.9 percent documentation and coding adjustment for FY 2009 was in addition to the 

-0.6 percent adjustment for FY 2008, yielding a combined effect of -1.5 percent. 

2. Prospective Adjustment to the Average Standardized Amounts Required by 

Section 7(b)(1)(A) of Pub. L. 110-90 

 Section 7(b)(1)(A) of Pub. L. 110-90 requires that, if the Secretary determines 

that implementation of the MS–DRG system resulted in changes in documentation and 

coding that did not reflect real changes in case-mix for discharges occurring during FY 

2008 or FY 2009 that are different than the prospective documentation and coding 

adjustments applied under section 7(a) of Pub. L. 110-90, the Secretary shall make an 

appropriate adjustment under section 1886(d)(3)(A)(vi) of the Act. Section 

1886(d)(3)(A)(vi) of the Act authorizes adjustments to the average standardized amounts 

for subsequent fiscal years in order to eliminate the effect of such coding or classification 

changes. These adjustments are intended to ensure that future annual aggregate IPPS 

payments are the same as the payments that otherwise would have been made had the 

prospective adjustments for documentation and coding applied in FY 2008 and FY 2009 

reflected the change that occurred in those years. 

3. Recoupment or Repayment Adjustments in FYs 2010 through 2012 Required by 

Pub. L. 110-90 

 If, based on a retroactive evaluation of claims data, the Secretary determines that 

implementation of the MS–DRG system resulted in changes in documentation and coding 
CMS-1498-P 74 

that did not reflect real changes in case-mix for discharges occurring during FY 2008 or 

FY 2009 that are different from the prospective documentation and coding adjustments 

applied under section 7(a) of Pub. L. 110-90, section 7(b)(1)(B) of Pub. L. 110-90 

requires the Secretary to make an additional adjustment to the standardized amounts 

under section 1886(d) of the Act. This adjustment must offset the estimated increase or 

decrease in aggregate payments for FYs 2008 and 2009 (including interest) resulting 

from the difference between the estimated actual documentation and coding effect and 

the documentation and coding adjustment applied under section 7(a) of Pub. L. 110-90. 

This adjustment is in addition to making an appropriate adjustment to the standardized 

amounts under section 1886(d)(3)(A)(vi) of the Act as required by section 7(b)(1)(A) of 

Pub. L. 110-90. That is, these adjustments are intended to recoup (or repay) spending in 

excess of (or less than) spending that would have occurred had the prospective 

adjustments for changes in documentation and coding applied in FY 2008 and FY 2009 

precisely matched the changes that occurred in those years. Pub. L. 110-90 requires that 

the Secretary make these recoupment or repayment adjustments for discharges occurring 

during FYs 2010, 2011, and 2012. 

4. Retrospective Evaluation of FY 2008 Claims Data 

 In order to implement the requirements of section 7 of Pub. L. 110-90, we 

indicated in the FY 2009 IPPS final rule (73 FR 48450) that we planned a thorough 

retrospective evaluation of our claims data. We stated that the results of this evaluation 

would be used by our actuaries to determine any necessary payment adjustments to the 

standardized amounts under section 1886(d) of the Act to ensure the budget neutrality of 
CMS-1498-P 75 

the MS-DRGs implementation for FY 2008 and FY 2009, as required by law. In the 

FY 2009 IPPS proposed rule (73 FR 23541 through 23542), we described our preliminary 

plan for a retrospective analysis of inpatient hospital claims data and invited public input 

on our proposed methodology. 

 In that proposed rule, we indicated that we intended to measure and corroborate 

the extent of the overall national average changes in case-mix for FY 2008 and FY 2009. 

We expected that the two largest parts of this overall national average change would be 

attributable to underlying changes in actual patient severity of illness and to 

documentation and coding improvements under the MS-DRG system. In order to 

separate the two effects, we planned to isolate the effect of shifts in cases among base 

DRGs from the effect of shifts in the types of cases within-base DRGs. 

 The MS-DRGs divide the base DRGs into three severity levels (with MCC, with 

CC and without CC); the previously used CMS DRGs had only two severity levels (with 

CC and without CC). Under the CMS DRG system, the majority of hospital discharges 

had a secondary diagnosis which was on the CC list, which led to the higher severity 

level. The MS-DRGs significantly changed the code lists of what was classified as an 

MCC or a CC. Many codes that were previously classified as a CC are no longer 

included on the MS-DRG CC list because the data and clinical review showed these 

conditions did not lead to a significant increase in resource use. The addition of a new 

level of high severity conditions, the MCC list, also provided a new incentive to code 

more precisely in order to increase the severity level. We anticipated that hospitals 

would examine the MS-DRG MCC and CC code lists and then work with physicians and 
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coders on documentation and coding practices so that coders could appropriately assign 

codes from the highest possible severity level. We note that there have been numerous 

seminars and training sessions on this particular coding issue. The topic of improving 

documentation practices in order to code conditions on the MCC list was also discussed 

extensively by participants at the March 11-12, 2009 ICD-9-CM Coordination and 

Maintenance Committee meeting. Participants discussed their hospitals’ efforts to 

encourage physicians to provide more precise documentation so that coders could 

appropriately assign codes that would lead to a higher severity level. Because we 

expected most of the documentation and coding changes under the MS-DRG system 

would occur in the secondary diagnoses, we believed that the shifts among base DRGs 

were less likely to be the result of the MS-DRG system and the shifts within-base DRGs 

were more likely to be the result of the MS-DRG system. We also anticipated evaluating 

data to identify the specific MS-DRGs and diagnoses that contributed significantly to the 

documentation and coding payment effect and to quantify their impact. This step entailed 

analysis of the secondary diagnoses driving the shifts in severity within specific base 

DRGs. 

 In that same proposed rule, we also stated that, while we believed that the data 

analysis plan described previously would produce an appropriate estimate of the extent of 

case-mix changes resulting from documentation and coding changes, we might decide, if 

feasible, to use historical data from our Hospital Payment Monitoring Program (HPMP) 

to corroborate the within-base DRG shift analysis. The HPMP is supported by the 

Medicare Clinical Data Abstraction Center (CDAC). 
CMS-1498-P 77 

 In the FY 2009 IPPS proposed rule, we solicited public comments on the analysis 

plans described above, as well as suggestions on other possible approaches for 

performing a retrospective analysis to identify the amount of case-mix changes that 

occurred in FY 2008 and FY 2009 that did not reflect real increases in patients' severity 

of illness. 

 A few commenters, including MedPAC, expressed support for the analytic 

approach described in the FY 2009 IPPS proposed rule. A number of other commenters 

expressed concerns about certain aspects of the approach and/or suggested alternate 

analyses or study designs. In addition, one commenter recommended that any 

determination or retrospective evaluation by the actuaries of the impact of the MS-DRGs 

on case-mix be open to public scrutiny prior to the implementation of the payment 

adjustments beginning in FY 2010. 

 We took these comments into consideration as we developed our proposed 

analysis plan and in the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule (74 FR 24092 

through 24101) solicited public comment on our methodology and analysis. For the 

FY 2010 IPPS/RY 2010 LTCH PPS proposed rule, we performed a retrospective 

evaluation of the FY 2008 data for claims paid through December 2008. Based on this 

evaluation, our actuaries determined that implementation of the MS–DRG system 

resulted in a 2.5 percent change due to documentation and coding that did not reflect real 

changes in case-mix for discharges occurring during FY 2008 

 In the analysis of data for that proposed rule, we found that the within-base DRG 

increases were almost entirely responsible for the case-mix change, supporting our 
CMS-1498-P 78 

conclusion that the 2.5 percent estimate was an accurate reflection of the FY 2008 effect 

of changes in documentation and coding under the MS-DRG system. In fact, almost 

every base DRG that was split into different severity levels under the MS-DRG system 

experienced increases in the within-base DRGs. We then further analyzed the changes in 

the within-base DRGs to determine which MS-DRGs had the highest contributions to this 

increase. The results of the analysis for the proposed rule provided additional support for 

our conclusion that the proposed 2.5 percent estimate accurately reflected the FY 2008 

increases in documentation and coding under the MS-DRG system. While we attempted 

to use the CDAC data to distinguish real increase in case-mix growth from 

documentation and coding in the overall case-mix number, we found aberrant data and 

significant variation across the FY 1999 through FY 2007 analysis period. It was not 

possible to distinguish changes in documentation and coding from changes in real 

case-mix in the CDAC data. Therefore, we concluded that the CDAC data would not 

support analysis of real case-mix growth that could be used in our retrospective 

evaluation of the FY 2008 claims data. 

 In the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43768 through 

43772), we responded to comments on our methodology for the retrospective evaluation 

of FY 2008 claims data. Commenters raised concerns that CMS' estimate in the proposed 

rule did not fully consider other potential causes of increased case-mix, such as patients 

requiring less complex services receiving care in other settings and “healthier” patients 

enrolling in Medicare Advantage plans in increasing numbers. Other commenters 

indicated that factors such as the changes in the CC/MCC definitions, limitations on the 
CMS-1498-P 79 

number of codes used by CMS for payment and ratesetting, resequencing of secondary 

diagnoses, the transition to the cost-based weights, less use of "not otherwise specified" 

codes, and increases in real case-mix due to health reform efforts also resulted in an 

inaccurate documentation and coding analysis. One commenter indicated that, of the 

overall case-mix increase, 1.0 percent to 1.5 percent is “real” case-mix increase, while 1.0 

percent to 1.5 percent is due to documentation and coding or other increases. 

 In considering these comments concerning historical real case-mix, in the 

FY 2010 final rule, we calculated overall increases in case-mix for the period from 

FY 2000 to FY 2007 using the cases from each year and the GROUPER and relative 

weights applicable for each year. The results are shown in the following chart: 

Overall Case-Mix Increases for FY 2000 to FY 2007 

Year 

Overall Case-Mix 

Change From Prior 

Year (in percent) 

FY 2000 -0.7%

FY 2001 -0.4%

FY 2002 1.0%

FY 2003 1.4%

FY 2004 1.0%

FY 2005 0.9%

FY 2006 1.2%

FY 2007 -0.2%

 Overall case-mix growth is predominately comprised of three factors: real 

case-mix growth; a documentation and coding effect; and a measurement effect. Under 

the reasonable assumption that there has been a relatively small measurement effect in 

those years, the assertion that there is a historical pattern of steady annual increases of 
CMS-1498-P 80 

1.2 to 1.3 percent in real case-mix implies that the documentation and coding effect in 

many of those years was negative. For example, as discussed in that rule (74 FR 43769), 

we estimated a recent measurement effect of +0.3 percent. The overall case-mix growth 

of -0.2 percent in FY 2007 net of a measurement effect of +0.3 percent results in growth 

of +0.1 percent. A real case-mix growth of +1.2 percent in FY 2007, therefore, implies a 

negative documentation and coding effect of approximately -1.1 percent. It is not 

obvious why documentation and coding would have had such a large negative effect in 

FY 2007, or in any other year where the overall case-mix change is significantly less than 

the commenter’s claimed average annual trend, calling into question the assertion that 

real case-mix growth is a steady 1.2 to 1.3 percent per year. 

 In the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43770 through 

43771), we indicated that our estimate of the overall case-mix growth for FY 2008 based 

on more recent data than the data used in the FY 2010 proposed rule was 2.0 percent, still 

less than our actuaries’ estimate of a 2.5 percent documentation and coding increase. 

With respect to the concerns raised by commenters about our finding of negative real 

case-mix growth in FY 2008, a finding of negative real case-mix growth is consistent 

with the fact that, in some years, overall case-mix growth has been negative, as shown in 

the chart presented above in this response. 

5. Retrospective Analysis of FY 2009 Claims Data 

We performed the same analysis for FY 2009 claims data using the same 

methodology as we did for FY 2008 claims in the FY 2010 final rule. We first divided 

the case-mix index (CMI) obtained by grouping the FY 2009 claims data through the 
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FY 2009 GROUPER (Version 26.0) by the CMI obtained by grouping these same 

FY 2009 claims through the FY 2007 GROUPER (Version 24.0). This resulted in a 

value of 1.056. Because these cases are the same FY 2009 cases grouped using the 

Versions 24.0 and 26.0 of the GROUPER, we attribute this increase primarily to two 

factors: (1) the effect of changes in documentation and coding under the MS-DRG 

system; and (2) the measurement effect from the calibration of the GROUPER. We 

estimated the measurement effect from the calibration of the GROUPER by dividing the 

CMI obtained by grouping cases in the FY 2007 claims data through the FY 2009 

GROUPER by the CMI obtained by grouping cases in these same claims through the 

FY 2007 GROUPER. This resulted in a value of 1.0019. In order to isolate the 

documentation and coding effect, we then divided the combined effect of the changes in 

documentation and coding and measurement (1.056) by the measurement effect (1.0019) 

to yield 1.054. Therefore, our estimate of the documentation and coding increase that did 

not reflect real changes in case-mix for discharges was 5.4 percent. 

We then sought to corroborate this 5.4 percent estimate by examining the 

increases in the within-base DRGs as compared to the increases in the across base DRGs 

as described earlier in our analysis plan. In other words, we looked for improvements in 

code selection that would lead to a secondary diagnosis increasing the severity level to 

either a CC or an MCC level. We found that the within-base DRG increases were almost 

entirely responsible for the case mix change, supporting our conclusion that the 

5.4 percent estimate was an accurate reflection of the FY 2009 effect of changes in 

documentation and coding under the MS-DRG system. We then further analyzed the 
CMS-1498-P 82 

changes in the within-base DRGs to determine which MS-DRGs had the highest 

contributions to this increase. The results of the analysis for the proposed rule provided 

additional support for our conclusion that the proposed 5.4 percent estimate accurately 

reflected the FY 2009 increases in documentation and coding under the MS-DRG system. 

As reflected in the above chart, for short-term acute care hospitals, SCHs, and 

MDHs, there is an 8 percentage point increase in the discharge severity with MCCs from 

20 percent to 28 percent, and a corresponding decrease of 8 percentage points in 

discharge severity without CC/MCC from 57 percent to 49 percent. 

Consistent with the expectations of our medical coding experts concerning areas 

with potential for documentation and coding improvements, the top contributors were 

heart failure, chronic obstructive pulmonary disease, and simple pneumonia and pleurisy. 

Heart failure is a very common secondary diagnosis among Medicare hospital 

admissions. The heart failure codes are assigned to all three severity levels. Some codes 
CMS-1498-P 83 

are classified as non-CCs, while other codes are on the CC and MCC lists. By changing 

physician documentation to more precisely identify the type of heart failure, coders are 

able to appropriately change the severity level of cases from the lowest level (non-CC) to 

a higher severity level (CC or MCC). This point was stressed repeatedly at the 

March 11-12, 2009 ICD-9-CM Coordination and Maintenance Committee meeting as 

coders discussed their work with physicians on this coding issue. Many of the 

participants indicated that additional work was still needed with their physicians in order 

to document conditions in the medical record more precisely. 

 The results of the analysis for the proposed rule provided additional support for 

our conclusion that the proposed 5.4 percent estimate accurately reflected the FY 2009 

increases in documentation and coding under the MS-DRG system. 

 As in prior years, the FY 2008 and FY 2009 MedPAR files are available to the 

public to allow independent analysis of the FY 2008 and FY 2009 documentation and 

coding effect. Interested individuals may still order these files through the Web site at: 

http://www.cms.hhs.gov/LimitedDataSets/ by clicking on MedPAR Limited Data Set 

(LDS)-Hospital (National). This Web page describes the file and provides directions and 

further detailed instructions for how to order. 

 Persons placing an order must send the following: a Letter of Request, the LDS 

Data Use Agreement and Research Protocol (refer to the Web site for further 

instructions), the LDS Form, and a check for $3,655 to: 

 Mailing address if using the U.S. Postal Service: 

 Centers for Medicare & Medicaid Services, 
CMS-1498-P 84 

 RDDC Account, 

 Accounting Division, 

 P.O. Box 7520, 

 Baltimore, MD 21207-0520. 

 Mailing address if using express mail: 

 Centers for Medicare & Medicaid Services, 

 OFM/Division of Accounting – RDDC, 

 7500 Security Boulevard, C3-07-11, 

 Baltimore. MD 21244-1850. 

6. Prospective Adjustment for FY 2010 and Subsequent Years Authorized by Section 

7(b)(1)(A) of Pub. L. 110-90 and Section 1886(d)(3)(vi) of the Act 

 Based on our evaluation of FY 2008 Medicare claims data that were most current 

at the time of the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule, the estimated 

2.5 percent change in FY 2008 case-mix due to changes in documentation and coding 

that did not reflect real changes in case-mix for discharges occurring during FY 2008 

exceeded the -0.6 percent prospective documentation and coding adjustment applied 

under section 7(a) of Pub. L. 110-90 by 1.9 percentage points. Under section 7(b)(1)(A) 

of Pub. L. 119-90, the Secretary is required to make an appropriate adjustment under 

section 1886(d)(3)(A)(vi) of the Act to the average standardized amounts for subsequent 

fiscal years in order to eliminate the full effect of the documentation and coding changes 

on future payments. As we have consistently stated since the initial implementation of 

the MS-DRG system, we do not believe it is appropriate for expenditures to increase due 
CMS-1498-P 85 

to MS-DRG-related changes in documentation and coding that do not reflect real changes 

in case-mix. 

 We also estimated in the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule that 

the additional change in case-mix due to changes in documentation and coding that do 

not reflect real changes in case-mix for discharges occurring during FY 2009 was 

2.3 percent, which would exceed by 1.4 percentage points the -0.9 percent prospective 

documentation and coding adjustment for FY 2009 applied under section 7(a) of 

Pub. L. 100-90. We had the statutory authority to adjust the FY 2010 rates for this 

estimated 1.4 percentage point increase. However, given that Pub. L. 100-90 requires a 

retrospective claims evaluation for the additional adjustments (as described in section 

II.D.3. of this preamble), we stated in the FY 2010 IPPS/RY 2010 LTCH PPS proposed 

rule and final rule (74 FR 24096 and 43772, respectively) that we believed our evaluation 

of the extent of the overall national average changes in case-mix for FY 2009 should also 

be based on a retrospective evaluation of all FY 2009 claims data. Because we did not 

receive all FY 2009 claims data prior to publication of the FY 2010 final rule, we 

indicated we would address any difference between the additional increase in FY 2009 

case-mix due to changes in documentation and coding that did not reflect real changes in 

case-mix for discharges occurring during FY 2009 and the -0.9 percent prospective 

documentation and coding adjustment applied under section 7(a) of Pub. L. 110-90 in the 

FY 2011 rulemaking cycle. 

 In the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule (74 FR 24096), we 

solicited public comment on the proposed -1.9 percent prospective adjustment to the 
CMS-1498-P 86 

standardized amounts under section 1886(d) of the Act to address the effects of 

documentation and coding changes unrelated to changes in real case-mix in FY 2008. In 

addition, we solicited public comments on addressing in the FY 2011 rulemaking cycle 

any differences between the increase in FY 2009 case-mix due to changes in 

documentation and coding changes that do not reflect real changes in case-mix for 

discharges occurring during FY 2009 and the -0.9 percent prospective documentation and 

coding adjustment applied under section 7(a) of Pub. L. 110-90. In response to the 

proposed rule, MedPAC summarized its comments on when CMS should reduce payment 

rates to prevent further overpayments and to recover overpayments occurring in 2008 and 

2009 as follows: "We support CMS’s proposal to reduce IPPS payments in 2010 by 

1.9 percent to prevent further overpayments. While we and the CMS actuaries believe 

that a 1.9 percent reduction will not fully prevent overpayments from continuing in 2010, 

this is a reasonable first step toward reducing overpayments.” Most of the other 

commenters opposed the proposed -1.9 percent prospective FY 2010 adjustment for 

FY 2008 documentation and coding increases, but supported the proposal not to apply a 

FY 2010 prospective adjustment for estimated FY 2009 documentation and coding 

increases. Many commenters expressed concern over the financial impact of the 

proposed -1.9 percent adjustment and the methodology for calculating the adjustment. 

Other commenters recommended that CMS seek to extend the timeframe beyond 2 years 

to phase in the estimated -6.6 percent adjustment to the standardized amount. 

 In the final FY 2010 IPPS/RY 2010 LTCH PPS rule in response to these 

commenters, we indicated that we fully understood that our proposed adjustment of 
CMS-1498-P 87 

-1.9 percent would reduce the increase in payments that affected hospitals would have 

received in FY 2009 in the absence of the adjustment. We explained that, although we 

are required to make an prospective adjustment to eliminate the full effect of coding or 

classification changes that did not reflect real changes in case-mix for discharges 

occurring during FY 2008, we believed we had some discretion regarding when to 

implement this adjustment. Section 7(b)(1)(A) of Pub. L. 110-90 requires that if the 

Secretary determines that implementation of the MS-DRG system resulted in changes in 

documentation and coding that did not reflect real changes in case-mix for discharges 

occurring during FY 2008 or FY 2009 that are different than the prospective 

documentation and coding adjustments applied under section 7(a) of Pub. L. 110-90, the 

Secretary shall make an “appropriate” adjustment under section 1886(d)(3)(A)(vi) of the 

Act. 

 Thus, we determined that it would be appropriate to postpone adopting 

documentation and coding adjustments as authorized under section 7(a) of Pub. L. 110-90 

and section 1886(d)(3)(A)(vi) of the Act until a full analysis of case-mix changes could 

be completed. We indicated that while we had the statutory authority to make this 

-1.9 percent prospective adjustment entirely in FY 2010, we believed it would be prudent 

to wait until we had completed data on the magnitude of the documentation and coding 

effect in FY 2009. Specifically, we stated that if the documentation and coding effect 

were to be less in FY 2009 than our then-current estimates, it could lessen the anticipated 

adjustment that we had estimated we would have had to make for FY 2008 and FY 2009 

combined. We indicated that, in future rulemaking, we would consider applying a 
CMS-1498-P 88 

prospective adjustment based upon a complete analysis of FY 2008 and FY 2009 claims 

data, beginning in FY 2011. We indicated that we intended to address any difference 

between the increase in FY 2009 case-mix due to changes in documentation and coding 

that did not reflect real changes in case-mix for discharges occurring during FY 2009 and 

the -0.9 percent prospective documentation and coding adjustment applied under 

section 7(a) of Pub. L. 110-90 in the FY 2011 rulemaking cycle. 

 After analysis of the FY 2009 claims data, we have found a total prospective 

documentation and coding effect of 1.054. After accounting for the -0.6 percent and the 

-0.9 percent documentation and coding adjustments in FYs 2008 and 2009, we find a 

remaining documentation and coding effect of 3.9 percent. As we have discussed, an 

additional cumulative adjustment of -3.9 percent would be necessary to meet the 

requirements of section 7(b)(1)(A) of Pub. L. 110-90 to make an adjustment to the 

average standardized amounts in order to eliminate the full effect of the documentation 

and coding changes on future payments. Unlike section 7(b)(1)(B) of Pub. L. 110-90, 

section 7(b)(1)(A) does not specify when we must apply the prospective adjustment, but 

merely requires us to make an “appropriate” adjustment. Therefore, we believe we have 

some discretion as to the manner in which we apply the prospective adjustment of 

-3.9 percent. Applying the full prospective adjustment of -3.9 percent for FY 2011, in 

combination with the proposed recoupment adjustment of -2.9 percent, discussed below, 

would require an aggregate adjustment of -6.8 percent. As we discuss more fully below, 

it has been our practice to moderate payment adjustments when necessary to mitigate the 

effects of significant downward adjustments on hospitals, to avoid what could be 
CMS-1498-P 89 

widespread, disruptive effects of such adjustments on hospitals. As we also discuss 

below, we are required to implement the adjustment in section 7(b)(1)(B) of Pub. L. 

110-90 no later than FY 2012, and accordingly, we are proposing an adjustment under 

that section for FY 2011. Therefore, we believe it is appropriate to not implement any or 

all of the -3.9 percent prospective adjustment in FY 2011. Accordingly, we are not 

proposing a prospective adjustment under section 7(b)(1)(A) of Pub. L. 110-90 for 

FY 2011. We note that, as a result, payments in FY 2011 (and in each future year until 

we implement the requisite adjustment) will be 3.9 percent higher than they would have 

been if we had implemented an adjustment under section 7(b)(1)(A) of Pub. L. 110-90. 

 We are seeking public comment on our proposal not to apply in FY 2011 the 

-3.9 percent prospective adjustment to the average standardized amounts required under 

section 7(b)(1)(A) of Pub. L. 110-90 in order to eliminate the full effect of the 

documentation and coding changes on future payments. We note that this proposal 

would require us to apply the -3.9 percent adjustment in future payment years, which may 

be applied all at once in a single year or phased in over more than one year. We intend to 

update our analysis with FY 2009 data on claims paid through March 2009 for the 

FY 2011 IPPS/LTCH PPS final rule. 

7. Recoupment or Repayment Adjustment for FY 2010 Authorized by Section 7(b)(1)(B) 

of Pub. L. 110-90 

 As indicated in the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43773), 

we estimated a 2.5 percent change (estimated from analysis of more recent data for the 

FY2010 final rule than the data used for that proposed rule) due to documentation and 
CMS-1498-P 90 

coding that did not reflect real changes in case-mix for discharges occurring during 

FY 2008, exceeding the -0.6 percent prospective documentation and coding adjustment 

applied under section 7(a) of Pub. L. 110-90 by 1.9 percentage points. We stated that our 

actuaries had estimated that this 1.9 percentage point increase resulted in an increase in 

aggregate payments of approximately $2.2 billion. As described earlier, section 

7(b)(1)(B) of Pub. L. 110-90 requires an adjustment for discharges occurring in 

FYs 2010, 2011, and/or 2012 to offset the estimated amount of this increase in aggregate 

payments (including interest). Although section 7(b)(1)(B) of Pub. L. 110-90 requires us 

to make this adjustment in FYs 2010, 2011, and/or 2012, we have discretion as to when 

during this 3 year period we will apply the adjustment. 

 We did not propose to make an adjustment to the FY 2010 average standardized 

amounts to offset, in whole or in part, the estimated increase in aggregate payments for 

discharges occurring in FY 2008, but stated in the proposed rule that we intended to 

address this issue in future rulemaking. That is, we stated that we would address 

recouping the additional expenditures that occurred in FY 2008 as a result of the 

1.9 percentage point difference between the actual changes in documentation and coding 

that do not reflect real changes in case-mix (2.5 percent), and the -0.6 percent adjustment 

applied under Pub. L. 110-90 in FY 2011 and/or FY 2012, as required by law. We 

indicated that, while we had the statutory authority to make this -1.9 percent recoupment 

adjustment entirely in FY 2010, we were delaying the adjustment until FY 2011 and 

FY 2012 because we did not yet have any data on the magnitude of the documentation 

and coding effect in FY 2009. We stated that as we have the authority to recoup the 
CMS-1498-P 91 

aggregate effect of this 1.9 percentage point difference in FY 2008 IPPS payments in 

FY 2011 or FY 2012 (with interest), delaying this adjustment would have no effect on 

Federal budget outlays. We indicated that we intended to wait until we have a complete 

year of data on the FY 2009 documentation and coding effect before applying a 

recoupment adjustment for IPPS spending that occurred in FY 2008 or we estimate will 

occur in FY 2009. 

 As discussed above, section 7(b)(1)(B) of Pub. L. 110-90 requires the Secretary to 

make an adjustment to the standardized amounts under section 1886(d) of the Act to 

offset the estimated increase or decrease in aggregate payments for FY 2009 (including 

interest) resulting from the difference between the estimated actual documentation and 

coding effect and the documentation and coding adjustments applied under section 7(a) 

of Pub. L. 110-90. This determination must be based on a retrospective evaluation of 

claims data. In the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43774), we 

stated that because we would not receive all FY 2009 claims data prior to publication of 

the final rule, we would address any increase or decrease in FY 2009 payments in future 

rulemaking for FY 2011 and 2012 after we perform a retrospective evaluation of the 

FY 2009 claims data. At that time, our actuaries estimated that this adjustment would be 

approximately -3.3 percent. This reflected the difference between the estimated 4.8 

percent cumulative actual documentation and coding changes for FY 2009 (2.5 percent 

for FY 2008 and an additional 2.3 percent for FY 2009) and the cumulative -1.5 percent 

documentation and coding adjustments applied under section 7(a) of Pub. L. 110-90 

(-0.6 percent in FY 2008 and -0.9 percent in FY 2009). We noted that the actual 
CMS-1498-P 92 

adjustments were multiplicative and not additive. This estimated 4.8 percent cumulative 

actual documentation and coding changes for FY 2009 included the impact of the 

changes in documentation and coding first occurring in FY 2008 because we believed 

hospitals would continue these changes in documentation and coding in subsequent fiscal 

years. Consequently, we believed that these documentation and coding changes would 

continue to impact payments under the IPPS absent a prospective adjustment to account 

for the effect of these changes. 

 We note that, unlike the adjustment to the standardized amounts under section 

7(b)(1)(A) of Pub. L. 110-90 described earlier, any adjustment to the standardized 

amounts under section 7(b)(1)(B) of Pub. L. 110-90 would not be cumulative, but would 

be removed for subsequent fiscal years once we have offset the increase in aggregate 

payments for discharges for FY 2008 expenditures and FY 2009 expenditures, if any. 

 In the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule (74 FR 24096), we did 

not propose to offset the 1.9 percent increase in aggregate payments (including interest) 

for discharges occurring in FY 2008 resulting from the adoption of the MS-DRGs, but to 

instead address this issue in future rulemaking for FYs 2011 and 2012. 

 In response to the FY 2010 proposed rule, MedPAC stated in its comments on the 

adjustment to the standardized amounts under section 7(b)(1)(B) of Pub. L. 110-90: “In 

addition, it would be desirable for CMS to minimize year-to-year changes in payment 

adjustments it must make to recover overpayments that were made in 2008 and 2009. To 

achieve this goal, CMS should consider spreading the recovery of 2008 overpayments 

over 3 years, beginning in 2010.” Some commenters recommended that CMS seek to 
CMS-1498-P 93 

extend the timeframe beyond 2 years to phase in the estimated -6.6 percent adjustment to 

the standardized amount. The commenters asked CMS to seek necessary legislative 

action to accommodate such a policy. Most commenters expressed concern with the 

significant negative financial impacts that would be incurred by providers if CMS 

adopted that proposed -1.9 percent documentation and coding adjustment in FY 2010. 

The commenters cited providers’ already small or negative margins for Medicare 

payments, and requested that CMS not further reduce payments during the current period 

of economic instability and reduced State funding. Other commenters indicated that it 

would be appropriate to delay any adjustment to the standardized amounts under section 

7(b)(1)(B) of Pub. L. 110-90 until after CMS has the opportunity to fully examine the 

FY 2009 claims data. 

 In response to these comments in FY 2010, we indicated that we recognized that 

any adjustment to account for the documentation and coding effect observed in the 

FY 2008 and FY 2009 claims data may result in significant future payment reductions for 

providers. However, we indicated that we are required under section 7(b)(1)(B) of 

Pub. L. 110-90 to recapture the difference of actual documentation and coding effect in 

FY 2008 and FY 2009 that is greater than the prior adjustments. We agreed with the 

commenters who requested that CMS delay any adjustment and, for the reasons stated 

above, indicated that we expect to address this issue in this FY 2011 rulemaking. 

 As indicated in section II.D.4. of this preamble, the change due to documentation 

and coding that did not reflect real changes in case mix for discharges occurring during 

FY 2008 and FY 2009 exceeded the -0.6 and -0.9 percent prospective documentation and 
CMS-1498-P 94 

coding adjustment applied under section 7(a) of Public Law 110-90 for those 2 years 

respectively by 1.9 percentage points in FY 2008 and 3.9 percentage points in FY 2009. 

In total, this change exceeded the cumulative prospective adjustments by 5.8 percentage 

points. Our actuaries currently estimate that this 5.8 percentage point increase resulted in 

an increase in aggregate payments of approximately $6.9 billion. We note that there may 

be a need to actuarially adjust the recoupment adjustment to accurately reflect 

accumulated interest. Therefore, an aggregate adjustment of -5.8 percent in FYs 2011 

and 2012, subject to actuarial adjustment to reflect accumulated interest, is necessary in 

order to meet the requirements of section 7(b)(1)(B) of Pub. L. 110-90 to adjust the 

standardized amounts for discharges occurring in FYs 2010, 2011, and/or 2012 to offset 

the estimated amount of the increase in aggregate payments (including interest) in 

FYs 2008 and 2009. We intend to take into account the need to reflect accumulated 

interest in proposing a recoupment adjustment under section (b)(1)(B) of Pub. L. 110-90 

for FY 2012. We will invite comments on our proposal at that time. 

 It is often our practice to phase in rate adjustments over more than one year in 

order to moderate the effect on rates in any one year. Therefore, consistent with the 

policies we have adopted in many similar cases, we are proposing to make an adjustment 

to the standardized amount of -2.9 percent, representing approximately half of the 

aggregate adjustment required under section 7(b)(1)(B) of Pub. L. 110-90, for FY 2011. 

An adjustment of this magnitude allows us to moderate the effects on hospitals in one 

year while simultaneously making it possible to implement the entire adjustment within 

the timeframe required under section 7(b)(1)(B) of Pub. L. 110-90. As we have 
CMS-1498-P 95 

previously noted, unlike the prospective adjustment to the standardized amounts under 

section 7(b)(1)(A) of Pub. L. 110-90 described earlier, the recoupment or repayment 

adjustment to the standardized amounts under section 7(b)(1)(B) of Pub. L. 110-90 is not 

cumulative, but would be removed for subsequent fiscal years once we have offset the 

increase in aggregate payments for discharges for FY 2008 expenditures and FY 2009 

expenditures. In keeping with our practice of moderating payment adjustments wherever 

possible, we can anticipate that this proposal will have an additional, and significant, 

moderating effect on implementing the requirements of section 7(b)(1)(B) of Pub. L. 

110-90 for FY 2012. Specifically, an advantage of our proposal for FY 2011 is that we 

anticipate removing this proposed FY 2011 -2.9 percent adjustment from the rates in 

FY 2012, when it would also be necessary under current law to apply the remaining 

approximately -2.9 percent adjustment required by section 7(b)(1)(B) of Pub. L. 110-90. 

These two steps in FY 2012, restoring the FY 2011 -2.9 percent adjustment, and applying 

the remaining adjustment of approximately -2.9 percent, would effectively cancel each 

other out. The result would be an aggregate adjustment of approximately 0.0 percent 

(subject to the need to account for accumulated interest, as discussed above) under 

section 7(b)(1)(B) of Pub. L. 110-90 in FY 2012. However, while we are noting this 

anticipated effect of our FY 2011 proposal, we are not making a formal proposal for the 

further implementation of section 7(b)(1)(B) of Pub. L. 110-90 in FY 2012 in this 

proposed rule. 

 We are seeking public comment on our proposal to offset part of the total 

5.8 percent increase in aggregate payments (including interest) for discharges occurring 
CMS-1498-P 96 

in FY 2008 and FY 2009 resulting from the adoption of the MS-DRGs in FY 2011, 

noting that this proposal would result in a -2.9 percent adjustment to the standardized 

amount. We intend to update our analysis with FY 2009 data on claims paid through 

March 2009 for the FY 2011 IPPS/LTCH PPS final rule. 

FY 2011 MS-DRG Documentation and Coding Adjustment 

Required 

Prospective 

Adjustment for 

FYs 2008-2009 

Required 

Recoupment 

Adjustment for FYs 

2008-2009 

Total 

Adjustment 

Proposed 

Recoupment 

Adjustment 

for FY 2011 

Remaining 

Adjustment

FY 2011 

Proposal 

Amount of 

Adjustment 

-3.9 -5.8 -9.7 -2.9 -6.8 

8. Background on the Application of the Documentation and Coding Adjustment to the 

Hospital-Specific Rates 

 Under section 1886(d)(5)(D)(i) of the Act, 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; the updated hospital-specific rate based on 

FY 1996 costs per discharge; or the updated hospital-specific rate based on FY 2006 

costs per discharge. Under section 1886(d)(5)(G) of the Act, MDHs are paid based on 

the Federal national rate or, if higher, the Federal national rate plus 75 percent of the 

difference between the Federal national rate and the updated hospital-specific rate based 

on the greatest of the FY 1982, FY 1987, or FY 2002 costs per discharge. In the FY 2008 

IPPS final rule with comment period (72 FR 47152 through 47188), we established a 
CMS-1498-P 97 

policy of applying the documentation and coding adjustment to the hospital-specific 

rates. In that final rule with comment period, we indicated that because SCHs and MDHs 

use the same DRG system as all other hospitals, we believe they should be equally 

subject to the budget neutrality adjustment that we are applying for adoption of the 

MS-DRGs to all other hospitals. In establishing this policy, we relied on section 

1886(d)(3)(A)(vi) of the Act, which provides us with the authority to adjust “the 

standardized amount” to eliminate the effect of changes in coding or classification that do 

not reflect real change in case-mix. 

 However, in the final rule that appeared in the Federal Register on 

November 27, 2007 (72 FR 66886), we rescinded the application of the documentation 

and coding adjustment to the hospital-specific rates retroactive to October 1, 2007. In 

that final rule, we indicated that, while we still believe it would be appropriate to apply 

the documentation and coding adjustment to the hospital-specific rates, upon further 

review, we decided that the application of the documentation and coding adjustment to 

the hospital-specific rates is not consistent with the plain meaning of section 

1886(d)(3)(A)(vi) of the Act, which only mentions adjusting “the standardized amount” 

under section 1886(d) of the Act and does not mention adjusting the hospital-specific 

rates. 

 In the FY 2009 IPPS proposed rule (73 FR 23540), we indicated that we 

continued to have concerns about this issue. Because hospitals paid based on the 

hospital-specific rate use the same MS-DRG system as other hospitals, we believe they 

have the potential to realize increased payments from documentation and coding changes 
CMS-1498-P 98 

that do not reflect real increases in patients' severity of illness. In section 

1886(d)(3)(A)(vi) of the Act, Congress stipulated that hospitals paid based on the 

standardized amount should not receive additional payments based on the effect of 

documentation and coding changes that do not reflect real changes in case-mix. 

Similarly, we believe that hospitals paid based on the hospital-specific rates should not 

have the potential to realize increased payments due to documentation and coding 

changes that do not reflect real increases in patients' severity of illness. While we 

continue to believe that section 1886(d)(3)(A)(vi) of the Act does not provide explicit 

authority for application of the documentation and coding adjustment to the 

hospital-specific rates, we believe that we have the authority to apply the documentation 

and coding adjustment to the hospital-specific rates using our special exceptions and 

adjustment authority under section 1886(d)(5)(I)(i) of the Act. The special exceptions 

and adjustment provision authorizes us to provide “for such other exceptions and 

adjustments to [IPPS] payment amounts * * * as the Secretary deems appropriate.” In the 

FY 2009 IPPS final rule (73 FR 48448 through 48449), we indicated that, for the 

FY 2010 rulemaking, we planned to examine our FY 2008 claims data for hospitals paid 

based on the hospital-specific rate. We further indicated that if we found evidence of 

significant increases in case-mix for patients treated in these hospitals that do not reflect 

real changes in case-mix, we would consider proposing application of the documentation 

and coding adjustments to the FY 2010 hospital-specific rates under our authority in 

section 1886(d)(5)(I)(i) of the Act. 
CMS-1498-P 99 

 In response to public comments received on the FY 2009 IPPS proposed rule, we 

stated in the FY 2009 IPPS final rule that we would consider whether such a proposal is 

warranted for FY 2010. To gather information to evaluate these considerations, we 

indicated that we planned to perform analyses on FY 2008 claims data to examine 

whether there has been a significant increase in case-mix for hospitals paid based on the 

hospital-specific rate. If we found that application of the documentation and coding 

adjustment to the hospital-specific rates for FY 2010 is warranted, we indicated that we 

would include a proposal to do so in the FY 2010 IPPS proposed rule. 

9. Proposed Documentation and Coding Adjustment to the Hospital-Specific Rates for 

FY 2011 and Subsequent Fiscal Years 

 In the FY 2010 IPPS/RY 2010 LTCH proposed rule and final rule (74 FR 24098 

through 24100 and 74 FR 43775 through 43776, respectively), we discussed our 

performance of a retrospective evaluation of the FY 2008 claims data for SCHs and 

MDHs using the same methodology described earlier for other IPPS hospitals. We found 

that, independently for both SCHs and MDHs, the change due to documentation and 

coding that did not reflect real changes in case-mix for discharges occurring during 

FY 2008 slightly exceeded the proposed 2.5 percent result discussed earlier, but did not 

significantly differ from that result. 

 Again, for the FY 2010 proposed rule, we found that the within-base DRG 

increases were almost entirely responsible for the case-mix change. In that proposed 

rule, we presented two Figures to display our results. 
CMS-1498-P 100 

 Therefore, consistent with our statements in prior IPPS rules, we proposed to use 

our authority under section 1886(d)(5)(I)(i) of the Act to prospectively adjust the 

hospital-specific rates by the proposed -2.5 percent in FY 2010 to account for our 

estimated documentation and coding effect in FY 2008 that does not reflect real changes 

in case-mix. We proposed to leave this adjustment in place for subsequent fiscal years in 

order to ensure that changes in documentation and coding resulting from the adoption of 

the MS-DRGs do not lead to an increase in aggregate payments for SCHs and MDHs not 

reflective of an increase in real case-mix. The proposed -2.5 percent adjustment to the 

hospital-specific rates exceeded the -1.9 percent adjustment to the national standardized 

amount under section 7(b)(1)(A) of Pub. L. 110-90 because, unlike the national 

standardized rates, the FY 2008 hospital-specific rates were not previously reduced in 

order to account for anticipated changes in documentation and coding that do not reflect 

real changes in case-mix resulting from the adoption of the MS-DRGs. 

 In the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule (74 FR 24100), we 

solicited public comment on the proposed -2.5 percent prospective adjustment to the 

hospital-specific rates under section 1886(d)(5)(I)(i) of the Act and our proposal to 

address in the FY 2011 rulemaking cycle any changes in FY 2009 case-mix due to 

changes in documentation and coding that do not reflect real changes in case-mix for 

discharges occurring during FY 2009. We also indicated that we intended to update our 

analysis with FY 2008 data on claims paid through March 2008 [sic] for the FY 2010 

IPPS final rule. (We note that the March 2008 update claims paid data date in the 

proposed rule should have been March 2009.) 
CMS-1498-P 101 

 Consistent with our approach for IPPS hospitals discussed earlier, in the FY 2010 

IPPS/RY 2010 LTCH PPS final rule, we also delayed adoption of a documentation and 

coding adjustment to the hospital-specific rate until FY 2011. Similar to our approach for 

IPPS hospitals, we indicated that we would consider, through future rulemaking, phasing 

in the documentation and coding adjustment over an appropriate period. We also 

indicated that we would address, through future rulemaking, any changes in 

documentation and coding that do not reflect real changes in case-mix for discharges 

occurring during FY 2009. We noted that, unlike the national standardized rates, the 

FY 2009 hospital-specific rates were not previously reduced in order to account for 

anticipated changes in documentation and coding that do not reflect real changes in casemix resulting from the adoption of the MS-DRGs. However, as we noted earlier with 

regard to IPPS hospitals, if the estimated documentation and coding effect determined 

based on a full analysis of FY 2009 claims data is more or less than our current estimates, 

it would change, possibly lessen, the anticipated cumulative adjustments that we 

currently estimate we would have to make for the FY 2008 and FY 2009 combined 

adjustment. Therefore, we believed that it would be more prudent to delay 

implementation of the documentation and coding adjustment to allow for a more 

complete analysis of FY 2009 claims data for hospitals receiving hospital-specific rates. 
CMS-1498-P 102 

 Consistent with our analysis of IPPS hospitals, the two charts above show that we 

found after analysis of FY 2009 discharge data that the distribution of severity discharges 
CMS-1498-P 103 

for MDH and SCH both proportionally shifted from the without CC/MCC to with MCC 

category. Similarly, we found using a methodology consistent with our analysis of IPPS 

hospitals that, independently for both SCHs and MDHs, the change due to documentation 

and coding that did not reflect real changes in case-mix for discharges occurring during 

FY 2009 slightly exceeded the proposed 2.5 percent result discussed earlier, but did not 

significantly differ from that result 

As we have noted above, because SCHs and MDHs use the same MS-DRG 

system as all other hospitals, we believe they have the potential to realize increased 

payments from documentation and coding changes that do not reflect real increases in 

patients' severity of illness. Therefore, we believe they should be equally subject to a 

prospective budget neutrality adjustment that we are applying for adoption of the 

MS-DRGs to all other hospitals. We believe the documentation and coding estimates for 

all subsection (d) hospitals should be the same. While the findings for the documentation 

and coding effect for all IPPS hospitals are similar to the effect for SCHs and slightly 

different to the effect for MDHs, we continue to believe that this is the appropriate policy 

so as to neither advantage or disadvantage different types of providers. As we have also 

discussed above, our best estimate, based on the most recently available data, is that a 

cumulative adjustment of -5.4 percent is required to eliminate the full effect of the 

documentation and coding changes on future payments. Unlike the case of standardized 

amounts paid to IPPS hospitals, we have not made any previous adjustments to the 

hospital-specific rates paid to SCHs and MDHs to account for documentation and coding 

changes. Therefore, the entire -5.4 percent adjustment remains to be implemented. 
CMS-1498-P 104 

As discussed above, we are proposing to make an adjustment to the standardized 

amount for IPPS hospitals of -2.9 percent under section 7(b)(1)(B) of Pub. L. 110-90, for 

FY 2011. As we also discussed above, it has been our practice to moderate payment 

adjustments when necessary to mitigate the effects of significant downward adjustments 

on hospitals, to avoid what could be widespread, disruptive effects of such adjustments 

on hospitals. Because payments for non-SCH and non-MDH IPPS hospitals and SCHs 

and MDHs are determined on the basis of the same MS-DRG system, SCHs and MDHs 

have the potential to realize increased payments from documentation and coding changes 

that do not reflect real increases in patients' severity of illness. Therefore, in determining 

the level and pace of adjustments to account for such documentation and coding changes, 

we believe that it is important to maintain, as much as possible, both consistency and 

equity among these classes of hospitals. In addition, as in the case of the documentation 

and coding adjustment for non-SCH and non-MDH IPPS hospitals, we also believe that it 

is important to provide as much as possible for moderating the effects of adjustments on 

hospital payments. Therefore we are proposing an adjustment of -2.9 percent in FY 2011 

to the hospital-specific rates paid to SCHs and MDHs. This proposal is consistent with 

our proposed adjustment for IPPS hospitals in two ways. First, as in the case of the IPPS 

adjustment, we are not proposing to implement the entire adjustment that is warranted by 

our data (in this case, 5.4 percent) in one year. Second, we are maintaining consistency 

by proposing the same numerical level of adjustment for both groups of hospitals in 

FY 2011. While this proposed adjustment to the hospital-specific rates represents 

somewhat over half of the of the entire adjustment that is appropriate for SCHs and 
CMS-1498-P 105 

MDHs, it allows us to maintain complete consistency, at least for FY 2011, in the effects 

on the relevant classes of hospitals. Although the proposed adjustment for SCHs and 

MDHs is cumulative and prospective, as opposed to the noncumulative recoupment 

adjustment we are proposing for other IPPS hospitals, we believe that proposing equal 

numerical adjustments in this first year is the most appropriate means to maintain such 

consistency and equity at this time. We will continue, as much as possible, consistent 

with sections 7(b)(1) of Pub. L. 110-90 and section 1886(d)(5)(I)(i) of the Act, to take 

such consistency and equity into account in developing future proposals for 

implementing documentation and coding adjustments. 

We are seeking public comment on the proposed -2.9 percent prospective 

adjustment to hospital-specific rates under section 1886(d)(5)(I)(i) of the Act and 

addressing in future rule making cycles changes in FY 2008 and FY 2009 case-mix due 

to changes in documentation and coding that do not reflect real changes in case-mix for 

discharges occurring during FY 2008 and FY 2009, noting that our current estimates of 

the remaining adjustment is -2.5 percent. We intend to update our analysis with FY 2009 

data on claims paid through March 2009 for the FY 2011 IPPS/LTCH PPS final rule. 

10. Background on the Application of the Documentation and Coding Adjustment to the 

Puerto Rico-Specific Standardized Amount 

 Puerto Rico hospitals are paid based on 75 percent of the national standardized 

amount and 25 percent of the Puerto Rico-specific standardized amount. As noted 

previously, the documentation and coding adjustment we adopted in the FY 2008 IPPS 

final rule with comment period relied upon our authority under section 1886(d)(3)(A)(vi) 
CMS-1498-P 106 

of the Act, which provides the Secretary the authority to adjust “the standardized amounts 

computed under this paragraph'' to eliminate the effect of changes in coding or 

classification that do not reflect real changes in case-mix. Section 1886(d)(3)(A)(vi) of 

the Act applies to the national standardized amounts computed under section 1886(d)(3) 

of the Act, but does not apply to the Puerto Rico-specific standardized amount computed 

under section 1886(d)(9)(C) of the Act. In calculating the FY 2008 payment rates, we 

made an inadvertent error and applied the FY 2008 -0.6 percent documentation and 

coding adjustment to the Puerto Rico-specific standardized amount, relying on our 

authority under section 1886(d)(3)(A)(vi) of the Act. However, section 

1886(d)(3)(A)(vi) of the Act authorizes application of a documentation and coding 

adjustment to the national standardized amount and does not apply to the Puerto 

Rico specific standardized amount. In the FY 2009 IPPS final rule (73 FR 48449), we 

corrected this inadvertent error by removing the -0.6 percent documentation and coding 

adjustment from the FY 2008 Puerto Rico-specific rates. 

 While section 1886(d)(3)(A)(vi) of the Act is not applicable to the Puerto 

Rico-specific standardized amount, we believe that we have the authority to apply the 

documentation and coding adjustment to the Puerto Rico-specific standardized amount 

using our special exceptions and adjustment authority under section 1886(d)(5)(I)(i) of 

the Act. Similar to SCHs and MDHs that are paid based on the hospital-specific rate, we 

believe that Puerto Rico hospitals that are paid based on the Puerto Rico-specific 

standardized amount should not have the potential to realize increased payments due to 

documentation and coding changes that do not reflect real increases in patients' severity 
CMS-1498-P 107 

of illness. Consistent with the approach described for SCHs and MDHs, in the FY 2009 

IPPS final rule (73 FR 48449), we indicated that we planned to examine our FY 2008 

claims data for hospitals in Puerto Rico. We indicated in the FY 2009 IPPS proposed 

rule (73 FR 23541) that if we found evidence of significant increases in case-mix for 

patients treated in these hospitals, we would consider proposing application of the 

documentation and coding adjustments to the FY 2010 Puerto Rico-specific standardized 

amount under our authority in section 1886(d)(5)(I)(i) of the Act. 

11. Proposed Documentation and Coding Adjustment to the Puerto Rico-Specific 

Standardized Amount 

 For the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule, we performed a 

retrospective evaluation of the FY 2008 claims data for Puerto Rico hospitals using the 

same methodology described earlier for IPPS hospitals paid under the national 

standardized amounts under section 1886(d) of the Act. We found that, for Puerto Rico 

hospitals, the increase in payments for discharges occurring during FY 2008 due to 

documentation and coding that did not reflect real changes in case-mix for discharges 

occurring during FY 2008 was approximately 1.1 percent. When we calculated the 

within-base DRG changes and the across-base DRG changes for Puerto Rico hospitals, 

we found that responsibility for the case-mix change between FY 2007 and FY 2008 is 

much more evenly shared. Across-base DRG shifts accounted for 44 percent of the 

changes, and within-base DRG shifts accounted for 56 percent. Thus, the change in the 

percentage of discharges with an MCC was not as large as that for other IPPS hospitals. 

In Figure 4 in the FY 2010 proposed rule, we showed that, for Puerto Rico hospitals, 
CMS-1498-P 108 

there was a 3 percentage point increase in the discharges with an MCC from 22 percent to 

25 percent and a corresponding decrease of 3 percentage points from 58 percent to 55 

percent in discharges without a CC or an MCC. 

 In the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule (74 FR 24101), we 

solicited public comment on the proposed -1.1 percent prospective adjustment to the 

hospital-specific rates under section 1886(d)(5)(I)(i) of the Act and our intent to address 

in the FY 2011 rulemaking cycle any changes in FY 2009 case-mix due to changes in 

documentation and coding that did not reflect real changes in case-mix for discharges 

occurring during FY 2009. We also stated that we intended to update our analysis with 

FY 2008 data on claims paid through March 2009 for the FY 2010 IPPS final rule. 

 In the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43777), we indicated 

that, given these documentation and coding increases, consistent with our statements in 

prior IPPS rules, we would use our authority under section 1886(d)(5)(I)(i) of the Act to 

adjust the Puerto Rico-specific rate. However, in parallel to our decision to postpone 

adjustments to the Federal standardized amount, we indicated that we were adopting a 

similar policy for the Puerto Rico-specific rate for FY 2010 and would consider the 

phase-in of this adjustment over an appropriate time period through future rulemaking. 

The adjustment would be applied to the Puerto Rico-specific rate that accounts for 

25 percent of payments to Puerto Rico hospitals, with the remaining 75 percent based on 

the national standardized amount. Consequently, the overall reduction to the payment 

rates for Puerto Rico hospitals to account for documentation and coding changes will be 

slightly less than the reduction for IPPS hospitals paid based on 100 percent of the 
CMS-1498-P 109 

national standardized amount. We noted that, as with the hospital-specific rates, the 

Puerto Rico-specific standardized amount had not previously been reduced based on 

estimated changes in documentation and coding associated with the adoption of the 

MS-DRGs. However, as we note earlier for IPPS hospitals and hospitals receiving 

hospital-specific rates, if the estimated documentation and coding effect determined 

based on a full analysis of FY 2009 claims data is more or less than our current estimates, 

it would change, possibly lessen, the anticipated cumulative adjustments that we 

currently estimate we would have to make for the FY 2008 and FY 2009 combined 

adjustment. Therefore, we believed that it would be more prudent to delay 

implementation of the documentation and coding adjustment to allow for a more 

complete analysis of FY 2009 claims data for Puerto Rico hospitals. 

 Consistent with our approach for IPPS hospitals for FY 2010, we indicated that 

we would address in the FY 2011 rulemaking cycle any change in FY 2009 case-mix due 

to documentation and coding that did not reflect real changes in case-mix for discharges 

occurring during FY 2009. We noted that, unlike the national standardized rates, the 

FY 2009 hospital-specific rates were not previously reduced in order to account for 

anticipated changes in documentation and coding that do not reflect real changes in casemix resulting from the adoption of the MS-DRGs. 

As we have noted above, similar to SCHs and MDHs, hospitals in Puerto Rico use 

the same MS-DRG system as all other hospitals and we believe they have the potential to 

realize increased payments from documentation and coding changes that do not reflect 

real increases in patients' severity of illness. Therefore, we believe they should be 
CMS-1498-P 110 

equally subject to the prospective budget neutrality adjustment that we intend to apply to 

prospective payment rates for IPPS hospitals including SCHs and MDHs in order to 

eliminate the full effect of the documentation and coding changes associated with 

implementation of the MS-DRG system. 

In the above chart, consistent with our findings for IPPS hospitals, for Puerto Rico 

hospitals, there is a 4 percentage point increase in the discharge severity with MCCs from 

22 percent to 26 percent, and a corresponding decrease of 4 percentage points in 

discharge severity without CC/MCC from 58 percent to 54 percent. 

Using the same methodology we applied to estimate documentation and coding 

changes under IPPS for non-Puerto Rico hospitals, as we have also discussed above, our 

best estimate, based on the most recently available data, is that a cumulative adjustment 

of -2.4 percent is required to eliminate the full effect of the documentation and coding 

changes on future payments from the Puerto Rico-specific rate. Unlike the case of 
CMS-1498-P 111 

standardized amounts paid to IPPS hospitals, we have not made any previous adjustments 

to the hospital-specific rates paid to Puerto Rico hospitals to account for documentation 

and coding changes. Therefore, the entire -2.4 percent adjustment remains to be 

implemented. 

As we stated above, we believe it important to maintain both consistency and 

equity among all hospitals paid on the basis of the same MS-DRG system. At the same 

time, however, we recognize that the estimated cumulative impact on aggregate payment 

rates resulting from implementation of the MD-DRG system was smaller for Puerto Rico 

hospitals as compared to IPPS hospitals and SCHs and MDHs. We therefore are 

proposing an adjustment of -2.4 percent in FY 2011 to Puerto Rico-specific rate that 

accounts for 25 percent of payments to Puerto Rico hospitals, with the remaining 75 

percent based on the national standardized amount, which we are proposing to adjust as 

described above. Consequently, the overall reduction to rates for Puerto Rico hospitals to 

account for the documentation and coding changes will be slightly less than the reduction 

for IPPS hospitals based on 100 percent of the national standardized amount. We note 

that this proposed -2.4 percent prospective adjustment would eliminate the full effect of 

the documentation and coding changes on the portion of future payments to Puerto Rico 

hospitals based on the Puerto Rico-specific rate. We believe that this proposed 

adjustment is the most appropriate means to take into full account the effect of 

documentation and coding changes on payments, and to maintain equity as much as 

possible between hospitals paid on the basis of different prospective rates. One reason 

for proposing the full -2.4 percent adjustment for the Puerto Rico-specific rate in 
CMS-1498-P 112 

FY 2011 is to maintain equity as much as possible in the documentation and coding 

adjustments applied to various hospital rates in FY 2011. Because this proposed 

-2.4 percent adjustment represents the full adjustment that is warranted for the Puerto 

Rico-specific rate, we do not anticipate proposing any additional adjustments to the this 

rate for documentation and coding effects. 

We are seeking public comment on the proposed -2.4 percent prospective 

adjustment to Puerto Rico-specific standardized amount under section 1886(d)(5)(I)(i) of 

the Act. We intend to update our analysis with FY 2009 data on claim paid through 

March 2009 for the FY 2011 IPPS/LTCH PPS final rule. 

E. Refinement of the MS-DRG Relative Weight Calculation

1. Background 

In the FY 2009 IPPS final rule (73 FR 48450), we continued to implement 

significant revisions to Medicare’s inpatient hospital rates by completing our 3-year 

transition from charge-based relative weights to cost-based relative weights. Beginning 

in FY 2007, we implemented relative weights based on cost report data instead of based 

on charge information. We had initially proposed to develop cost-based relative weights 

using the hospital-specific relative value cost center (HSRVcc) methodology as 

recommended by MedPAC. However, after considering concerns expressed in the public 

comments we received on the proposal, we modified MedPAC’s methodology to exclude 

the hospital-specific relative weight feature. Instead, we developed national CCRs based 

on distinct hospital departments and engaged a contractor to evaluate the HSRVcc 

methodology for future consideration. To mitigate payment instability due to the 
CMS-1498-P 113 

adoption of cost-based relative weights, we decided to transition cost-based weights over 

3 years by blending them with charge-based weights beginning in FY 2007. (We refer 

readers to the FY 2007 IPPS final rule for details on the HSRVcc methodology and the 

3-year transition blend from charge-based relative weights to cost-based relative weights 

(71 FR 47882 through 47898).) 

 In FY 2008, we adopted severity-based MS-DRGs, which increased the number 

of DRGs from 538 to 745. Many commenters raised concerns as to how the transition 

from charge-based weights to cost-based weights would continue with the introduction of 

new MS-DRGs. We decided to implement a 2-year transition for the MS-DRGs to 

coincide with the remainder of the transition to cost-based relative weights. In FY 2008, 

50 percent of the relative weight for each DRG was based on the CMS DRG relative 

weight and 50 percent was based on the MS-DRG relative weight. 

 In FY 2009, the third and final year of the transition from charge-based weights to 

cost-based weights, we calculated the MS-DRG relative weights based on 100 percent of 

hospital costs. We refer readers to the FY 2007 IPPS final rule (71 FR 47882) for a more 

detailed discussion of our final policy for calculating the cost-based DRG relative 

weights and to the FY 2008 IPPS final rule with comment period (72 FR 47199) for 

information on how we blended relative weights based on the CMS DRGs and 

MS-DRGs. 

a. Summary of the RTI Study of Charge Compression and CCR Refinement 

 As we transitioned to cost-based relative weights, some commenters raised 

concerns about potential bias in the weights due to “charge compression,” which is the 
CMS-1498-P 114 

practice of applying a higher percentage charge markup over costs to lower cost items 

and services, and a lower percentage charge markup over costs to higher cost items and 

services. As a result, the cost-based weights would 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. To address this concern, in August 2006, we awarded a contract to 

RTI to study the effects of charge compression in calculating the relative weights and to 

consider methods to reduce the variation in the CCRs across services within cost centers. 

RTI issued an interim draft report in January 2007 with its findings on charge 

compression (which was posted on the CMS Web site at: 

http://www.cms.hhs.gov/reports/downloads/Dalton.pdf). In that report, RTI found that a 

number of factors contribute to charge compression and affect the accuracy of the relative 

weights. RTI’s findings demonstrated that charge compression exists in several CCRs, 

most notably in the Medical Supplies and Equipment CCR. 

 In its interim draft report, RTI offered a number of recommendations to mitigate 

the effects of charge compression, including estimating regression-based CCRs to 

disaggregate the Medical Supplies Charged to Patients, Drugs Charged to Patients, and 

Radiology cost centers, and adding new cost centers to the Medicare cost report, such as 

adding a “Devices, Implants and Prosthetics” line under “Medical Supplies Charged to 

Patients” and a “CT Scanning and MRI” subscripted line under “Radiology-Diagnostics”. 

Despite receiving public comments in support of the regression-based CCRs as a means 

to immediately resolve the problem of charge compression, particularly within the 

Medical Supplies and Equipment CCR, we did not adopt RTI's recommendation to create 
CMS-1498-P 115 

additional regression-based CCRs. (For more details on RTI’s findings and 

recommendations, we refer readers to the FY 2009 IPPS final rule (73 FR 48452).) RTI 

subsequently expanded its analysis of charge compression beyond inpatient services to 

include a reassessment of the regression-based CCR models using both outpatient and 

inpatient charge data. This interim report was made available in April 2008 during the 

public comment period on the FY 2009 IPPS proposed rule and can be found on RTI’s 

Web site at: http://www.rti.org/reports/cms/HHSM-500-2005-

0029I/PDF/Refining_Cost_to_Charge_Ratios_200804.pdf . The IPPS-specific chapters, 

which were separately displayed in the April 2008 interim report, as well as the more 

recent OPPS chapters, were included in the July 3, 2008 RTI final report entitled, 

“Refining Cost-to-Charge Ratios for Calculating APC [Ambulatory Payment 

Classification] and DRG Relative Payment Weights,” that became available at the time of 

the development of the FY 2009 IPPS final rule. The RTI final report can be found on 

RTI’s Web site at: http://www.rti.org/reports/cms/HHSM-500-2005-

0029I/PDF/Refining_Cost_to_Charge_Ratios_200807_Final.pdf. 

RTI’s final report found that, under the IPPS and the OPPS, accounting 

improvements to the cost reporting data reduce some of the sources of aggregation bias 

without having to use regression-based adjustments. In general, with respect to the 

regression-based adjustments, RTI confirmed the findings of its March 2007 report that 

regression models are a valid approach for diagnosing potential aggregation bias within 

selected services for the IPPS and found that regression models are equally valid for 

setting payments under the OPPS. 
CMS-1498-P 116 

 RTI also noted that cost-based weights are only one component of a final 

prospective payment rate. There are other rate adjustments (wage index, IME, and DSH) 

to payments derived from the revised cost-based weights, and the cumulative effect of 

these components may not improve the ability of final payment to reflect resource cost. 

RTI endorsed short-term regression-based adjustments, but also concluded that more 

refined and accurate accounting data are the preferred long-term solution to mitigate 

charge compression and related bias in hospital cost-based weights. For a more detailed 

summary of RTI’s findings, recommendations, and public comments we received on the 

report, we refer readers to the FY 2009 IPPS final rule (73 FR 48452 through 48453). 

b. Summary of the RAND Corporation Study of Alternative Relative Weight 

Methodologies 

One of the reasons that we did not implement regression-based CCRs at the time 

of the FY 2008 IPPS final rule with comment period was our inability to investigate how 

regression-based CCRs would interact with the implementation of MS-DRGs. In the 

FY 2008 final rule with comment period (72 FR 47197), we stated that we engaged the 

RAND Corporation as the contractor to evaluate the HSRV methodology in conjunction 

with regression-based CCRs, and that we would consider its analysis as we prepared for 

the FY 2009 IPPS rulemaking process. 

RAND evaluated six different methods that could be used to establish relative 

weights; CMS’ current relative weight methodology of 15 national CCRs and 

5 alternatives, including a method in which the 15 national CCRs are disaggregated using 

the regression-based methodology, and a method using hospital-specific CCRs for the 
CMS-1498-P 117 

15 cost center groupings. In addition, RAND analyzed our standardization 

methodologies that account for systematic cost differences across hospitals. The purpose 

of standardization is to eliminate systematic facility-specific differences in cost so that 

these cost differences do not influence the relative weights. Overall, RAND found that 

none of the methods it studied of calculating the relative weights represented a marked 

improvement in payment accuracy over the current method, and there was little 

difference across methods in their ability to predict cost at either the discharge-level or 

the hospital-level. In their regression analysis, RAND found that, after controlling for 

hospital payment factors, the relative weights are compressed (that is, understated). 

However, RAND also found that the hospital payment factors are overstated and increase 

more rapidly than cost. Therefore, while the relative weights are compressed, these 

payment factors offset the compression such that total payments to hospitals increase 

more rapidly than hospitals' costs. 

In the FY 2009 IPPS final rule (73 FR 48453 through 48457), we provided a 

summary of the RAND report and the public comments we received in response to the 

FY 2009 IPPS proposed rule. The report may be found on RAND's Web site at: 

http://www.rand.org/pubs/working_papers/WR560/. 

2. Proposals for FY 2011 and Timeline for Changes to the Medicare Cost Report 

In the FY 2009 IPPS final rule (73 FR 48458 through 48467), in response to the 

RTI's recommendations concerning cost report refinements, and because of RAND’s 

finding that regression-based adjustments to the CCRs do not significantly improve 

payment accuracy, we discussed our decision to pursue changes to the cost report to split 
CMS-1498-P 118 

the cost center for Medical Supplies Charged to Patients into one line for "Medical 

Supplies Charged to Patients" and another line for "Implantable Devices Charged to 

Patients." We acknowledged, as RTI had found, that charge compression occurs in 

several cost centers that exist on the Medicare cost report. However, as we stated in the 

final rule, we focused on the CCR for Medical Supplies and Equipment because RTI 

found that the largest impact on the MS-DRG relative weights could result from 

correcting charge compression for devices and implants. In determining what should be 

reported in these respective cost centers, we adopted the commenters’ recommendation 

that hospitals should use revenue codes established by AHA's National Uniform Billing 

Committee to determine what should be reported in the “Medical Supplies Charged to 

Patients” and the “Implantable Devices Charged to Patients” cost centers. 

When we developed the FY 2009 IPPS final rule, we considered all of the public 

comments we received both for and against adopting regression-based CCRs. Also 

noteworthy is RAND’s belief that regression-based CCRs may not significantly improve 

payment accuracy, and that it is equally, if not more, important to consider revisions to 

the current IPPS hospital payment factor standardization method in order to improve 

payment accuracy. For FY 2010, we solicited comments on improving the 

standardization process, although we did not make any changes to the standardization 

process for FY 2010. We also stated that we continued to believe that, ultimately, 

improved and more precise cost reporting is the best way to minimize charge 

compression and improve the accuracy of the cost weights. Accordingly, a new 

subscripted line 55.01 for Implantable Devices Charged to Patients was created in 
CMS-1498-P 119 

July 2009 as part of CMS’ Transmittal 20 update to the existing cost report Form 

CMS-2552-96. This new subscripted cost center is available for use for cost reporting 

periods beginning on or after May 1, 2009. 

With respect to the initiative to reform, update, and streamline the Medicare cost 

report, which has been the subject of many comments and our responses in the IPPS (and 

OPPS) Federal Register notices of rulemaking over the past several years, CMS is 

continuing to work on this project. The new draft hospital cost report Form 

CMS-2552-10 was published in the Federal Register on July 2, 2009, and was subject to 

a 60-day review and comment period, which ended August 31, 2009. CMS received 

numerous comments on the draft hospital cost report Form CMS-2552-10, specifically 

regarding the creation of new cost centers from which data would be ultimately used in 

the relative weights calculation, even though CMS had not proposed to add these cost 

centers. The public comments on the July 2, 2009 Federal Register notice will be 

addressed in detail in the Federal Register notice that will be issued to finalize Form 

CMS-2525-10. We now plan to issue the revised draft of the hospital cost report Form 

CMS-2552-10, which will include a standard cost center for Implantable Devices 

Charged to Patients, through a notice in the Federal Register, which will allow for a 30-

day comment period, in the spring or summer of 2010. However, in part in this IPPS 

proposed rule, we are providing a summary of the public comments received on the 

July 2, 2009 notice that specifically related to the relative weights and responding to 

those comments. Our responses to the comments in this IPPS proposed rule constitute 

our proposals for FY 2011 regarding the relative weights. 
CMS-1498-P 120 

Several commenters asked that CMS create cost centers to house the costs of 

magnetic resonance imaging (MRI), Computed Tomography (CT), nuclear medicine 

services, cardiac catheterization, drugs that require detailed coding, and 

magnetoencephalography (MEG). One commenter indicated, that in RTI’s July 2008 

report (http://www.rti.org/reports/cms/), RTI made an argument that CMS should create 

new standard cost centers in which hospitals would report the costs of MRI scans, CT 

scans, cardiac catheterization, and drugs that require detailed coding, in addition to the 

new cost center for “Implantable Devices Charged to Patients.” The commenter stated 

that these additional lines are needed to distinguish items and services that hospitals tend 

to markup differently within existing revenue centers, citing RTI’s finding that CT scans 

have a significantly higher markup than most other radiology services. The commenter 

indicated that when CMS uses the overall radiology department CCR to convert charges 

for CT scans to costs, it overestimates the cost of these services, resulting in overstated 

relative weights for MS-DRGs under the IPPS and for APCs under the OPPS that 

incorporate CT scanning. The commenter argued that having a separate cost center for 

each of these services would resolve the problem. The commenter also stated that, while 

CMS has done something similar with the creation of the cost center for high cost 

medical devices, making cost center changes for some services, but not others, where 

such changes are warranted could create additional distortion in the relative weights. The 

commenter further argued that cost center changes should be made for all service areas 

with significant volume where services with sizable differences in markup are currently 

combined in a single cost center. The commenter asserted that creating these cost centers 
CMS-1498-P 121 

should not create reporting burden for hospitals because the RTI report indicated that 

roughly one-third of the hospitals are already reporting costs for CT scans, MRI scans, 

and cardiac catheterization under the specific nonstandard cost centers currently available 

in the cost report. 

Another commenter also recommended the creation of the cost centers for CT 

scans, MRI scans, and nuclear medicine services, but for different reasons than the first 

commenter. Specifically, this commenter believed these new cost centers are necessary 

in order for the high capital costs to be appropriately allocated to these services and to be 

correctly reflected in the CCRs that are used in the establishment of the MS-DRG and 

APC payment rates for the services. The commenter stated that, under the existing cost 

report structure, some providers are allocating high capital costs for these services in a 

single radiology line, diluting the high capital costs associated with CT scans, MRI scans, 

and nuclear medicine services across all radiology services, including low cost services. 

Therefore, the commenter concluded that the resulting radiology CCRs that CMS applies 

to charges for CT scans, MRI scans, and nuclear medicine services to arrive at the 

relative costs used to set payment rates for both the IPPS and OPPS understate the cost of 

high cost radiology services and overstate the cost of low cost radiology services, 

resulting in payments that are too low for the high cost services. The commenter 

indicated that CMS should not only create these new costs centers but should also require 

all hospitals to use them, and should issue explicit instructions on how to report the costs 

of these services in the new standard cost centers. 
CMS-1498-P 122 

We agree that it is appropriate to create standard cost centers for CT scans, MRI 

scans, and cardiac catheterization and to require that hospitals report the costs and 

charges for these services under new cost centers on the revised Medicare cost report 

Form CMS 2552-10. As we discussed in the FY 2009 IPPS and CY 2009 OPPS 

proposed and final rules, RTI found that the costs and charges of CT scans, MRI scans, 

and cardiac catheterization differ significantly from the costs and charges of other 

services included in the standard associated cost center. RTI also concluded that both the 

IPPS and OPPS relative weights would better estimate the costs of those services if CMS 

were to add standard costs centers for CT scanning, MRIs, and cardiac catheterization in 

order for hospitals to report separately the costs and charges for those services and in 

order for CMS to calculate unique CCRs to estimate the cost from charges on claims 

data. 

In its analysis, RTI concluded that the estimated costs for CT scanning and MRI 

scans would decline significantly and that the estimated cost for cardiac catheterization 

would increase modestly if specific standard cost centers were used. RTI found that 

cardiac catheterization has very different cost inputs from most cardiac testing (for 

example, electrocardiograms or cardiac stress testing) captured in the 5300 

“Electrocardiology” cost center and that the accuracy of the CCR for both types of 

services, cardiac catheterization and other cardiac testing, would improve with creation of 

a standard cost center for cardiac catheterization. RTI also found that one-third of 

hospitals already report cardiac catheterization costs and charges separately through the 

available nonstandard cost center or through subscripted lines to the “Electrocardiology” 
CMS-1498-P 123 

cost center. Similarly, RTI found that approximately one-third of hospitals already 

separately report the costs for CT scanning and MRI scans on their Medicare cost report 

through subscripted lines and the available nonstandard cost centers. We believe the 

current prevalence of reporting for the nonstandard cost centers for these three services 

suggests a modest hospital burden required to adopt these cost centers. 

We discussed the possibility of creating standard cost centers for these three 

different services in our CY 2009 OPPS proposed and final rule with comment period 

(73 FR 41432 and 73 FR 68525) and solicited general comments on RTI’s 

recommendations. The commenters who objected to the creation of the standard cost 

centers for CT scanning and MRI scans largely did so based on RTI projected lower 

estimated costs for these services if CMS created these cost centers. The commenters 

suggested that the current CCRs for advanced imaging may reflect a misallocation of 

capital costs and requested that CMS not adopt separate cost centers or statistical 

adjustment simulating lower CCRs for CT scanning and MRI until CMS could 

understand how providers are allocating the extensive capital costs for these services to 

the revenue producing cost centers. We also received comments suggesting that the 

accuracy of estimated costs would improve with better allocation, potentially increasing 

the CCR as more capital cost would be appropriately allocated to both CT scanning and 

MRI and not spread across all services in the radiology cost center. We noted in the 

CY 2009 OPPS/ASC final rule with comment period (73 FR 68525) that our 

recommended allocation of moveable equipment costs in Worksheet A of the Medicare 

cost report is based on dollar value, and that it would be important to encourage improved 
CMS-1498-P 124 

accuracy of capital allocation through dollar value or direct assignment if we were to 

make these cost centers standard cost centers. At this time, we do not know the impact 

on CCRs and estimated costs of adopting standard cost centers specific to CT scanning 

and MRI. However, we believe that, because these areas constitute significant payment 

under both the IPPS and OPPS and because these are common imaging services already 

widely reported by hospitals, we are proposing to adopt new standard cost centers for 

CT scanning and MRI. We agree with those commenters who asserted that creation of 

standard cost centers for CT scanning and MRI would improve the accuracy of cost 

estimation for these services, in part by creating incentives for hospitals to more 

accurately allocate the capital and equipment associated with these services. 

With regard to cardiac catheterization, we received one comment on the CY 2009 

OPPS/ASC proposed rule suggesting that hospitals might find it difficult to allocate costs 

for these services to specific cost centers, especially for cardiac catheterization, and that 

allocated overhead costs would, in most cases, be an estimate (73 FR 68527). However, 

given the number of hospitals already reporting the nonstandard cost center for cardiac 

catheterization and the number subscripting these costs and charges (approximately 

50 percent, according to RTI’s July 2008 report (pages 71 and 72) at: 

http://www.rti.org/reports/cms/HHSM-500-2005-

0029I/PDF/Refining_Cost_to_Charge_Ratios_200807_Final.pdf), we believe that 

hospitals do allocate overhead costs to a cardiac catheterization-specific cost center. For 

these reasons, we are proposing to create standard cost centers for CT scanning, MRI, 

and cardiac catheterization in Form CMS 2552-10. 
CMS-1498-P 125 

We also received public comments on the cost report notice urging us to create 

standard cost centers for nuclear medicine services, for drugs that require detailed coding, 

and for MEG. We continue to believe that it is not appropriate to create standard cost 

centers for these three services. The Medicare cost report already contains standard cost 

center 4300 (Radioisotope) to capture the costs and charges for the radioisotopes used in 

nuclear medicine services, the items that may have significantly different costs and 

hospital markup than the supplies and equipment used in other radiology services. 

Moreover, the cost report already contains standard cost center 4100 (Diagnostic 

Radiology) in which the costs of staff, equipment, and supplies for diagnostic nuclear 

medicine services can be reported. Therefore, we continue to believe that creating a new 

standard cost center for nuclear medicine services is not necessary. We also continue to 

believe that it is not appropriate to create a standard cost center for drugs that require 

detailed coding. We refer readers to the CY 2009 OPPS/ASC final rule with comment 

period (73 FR 68655) for a detailed discussion on our final decision not to create this cost 

center. Finally, with respect to MEG services, the extremely low volume of claims for 

MEG services furnished to Medicare beneficiaries in the hospital outpatient setting and 

the extremely low number of hospitals that report these codes relative to the volumes we 

typically have considered in adding both standard and nonstandard cost centers to the 

cost report lead us to conclude that a specific cost center for MEG is not justified at this 

time. 

 There is typically a 3-year lag between the availability of the cost report data that 

we use to calculate the relative weights both under the IPPS and the OPPS and a given 
CMS-1498-P 126 

fiscal or calendar year. We expect the data from the proposed standard cost centers for 

CT scans, MRI, and cardiac catheterization respectively, should they be finalized, to be 

available for possible use in calculating the relative weights not earlier than 3 years after 

Form CMS-2552-10 becomes available. At that time, we would analyze the data and 

determine if it is appropriate to use those data to create distinct CCRs from these cost 

centers for use in the relative weights for the respective payment systems. If we decide to 

finalize these proposed new cost centers, the upcoming Federal Register notice that will 

finalize Form CMS-2552-10 will provide more information regarding the addition of 

these proposed new standard cost centers for CT scans, MRI, and cardiac catheterization, 

including the instructions for completing these cost centers on the new cost report. 

F. Preventable Hospital-Acquired Conditions (HACs), Including Infections

1. Background 

a. Statutory Authority 

 Section 1886(d)(4)(D) of the Act addresses certain hospital-acquired conditions 

(HACs), including infections. Section 1886(d)(4)(D) of the Act specifies that by 

October 1, 2007, the Secretary was required to select, in consultation with the Centers for 

Disease Control and Prevention (CDC), at least two conditions that: (a) are high cost, 

high volume, or both; (b) are assigned to a higher paying MS-DRG when present as a 

secondary diagnosis (that is, conditions under the MS-DRG system that are CCs or 

MCCs); and (c) could reasonably have been prevented through the application of 

evidence-based guidelines. Section 1886(d)(4)(D) of the Act also specifies that the list of 
CMS-1498-P 127 

conditions may be revised, again in consultation with CDC, from time to time as long as 

the list contains at least two conditions. 

 Section 1886(d)(4)(D)(iii) of the Act requires that hospitals, effective with 

discharges occurring on or after October 1, 2007, submit information on Medicare claims 

specifying whether diagnoses were present on admission (POA). Section 

1886(d)(4)(D)(i) of the Act specifies that effective for discharges occurring on or after 

October 1, 2008, Medicare no longer assigns an inpatient hospital discharge to a higher 

paying MS-DRG if a selected condition is not POA. Thus, if a selected condition that 

was not POA manifests during the hospital stay, it is considered a HAC and the case is 

paid as though the secondary diagnosis was not present. However, even if a HAC 

manifests during the hospital stay, if any nonselected CC/MCC appears on the claim, the 

claim will be paid at the higher MS-DRG rate. Under the HAC payment policy, all 

CCs/MCCs on the claim must be HACs in order to generate a lower MS-DRG payment. 

In addition, Medicare continues to assign a discharge to a higher paying MS-DRG if a 

selected condition is POA. 

The POA indicator reporting requirement and the HAC payment provision apply 

to IPPS hospitals only. Non-IPPS hospitals, including CAHs, LTCHs, IRFs, IPFs, cancer 

hospitals, children’s hospitals, hospitals in Maryland operating under waivers, rural 

health clinics, federally qualified health centers, RNHCIs, and Department of Veterans 

Affairs/Department of Defense hospitals, are exempt from POA reporting and the HAC 

payment provision. Throughout this section, the term “hospital” refers to an IPPS 

hospital. 
CMS-1498-P 128 

 The HAC provision found in section 1886(d)(4)(D) of the Act is part of an array 

of Medicare value-based purchasing (VBP) tools that we are using to promote increased 

quality and efficiency of care. Those tools include measuring performance, using 

payment incentives, publicly reporting performance results, applying national and local 

coverage policy decisions, enforcing conditions of participation, and providing direct 

support for providers through Quality Improvement Organization (QIO) activities. The 

application of VBP tools, such as this HAC provision, is transforming Medicare from a 

passive payer to an active purchaser of higher value health care services. We are 

applying these strategies for inpatient hospital care and across the continuum of care for 

Medicare beneficiaries. 

 These VBP tools are highly compatible with the underlying purposes as well as 

existing structural features of Medicare’s IPPS. Under the IPPS, hospitals are 

encouraged to treat patients efficiently because they receive the same DRG payment for 

stays that vary in length and in the services provided, which gives hospitals an incentive 

to avoid unnecessary costs in the delivery of care. In some cases, conditions acquired in 

the hospital do not generate higher payments than the hospital would otherwise receive 

for cases without these conditions. To this extent, the IPPS encourages hospitals to avoid 

complications. 

 However, the treatment of certain conditions can generate higher Medicare 

payments in two ways. First, if a hospital incurs exceptionally high costs treating a 

patient, the hospital stay may generate an outlier payment. Because the outlier payment 

methodology requires that hospitals experience large losses on outlier cases before outlier 
CMS-1498-P 129 

payments are made, hospitals have an incentive to prevent outliers. Second, under the 

MS-DRGs system that took effect in FY 2008 and that has been refined through 

rulemaking in subsequent years, certain conditions can generate higher payments even if 

the outlier payment requirements are not met. Under the MS-DRG system, there are 

currently 258 sets of MS-DRGs that are split into 2 or 3 subgroups based on the presence 

or absence of a CC or an MCC. The presence of a CC or MCC generally results in a 

higher payment. However, since we implemented the HAC provisions, if a secondary 

diagnosis acquired during a hospital stay is a HAC and no other CCs or MCCs are 

present, the hospital receives a payment under the MS-DRGs as if the HACs were not 

present. (We refer readers to section II.D. of the FY 2008 IPPS final rule with comment 

period for a discussion of DRG reforms (72 FR 47141).) 

b. HAC Selection 

 In the FY 2007 IPPS proposed rule (71 FR 24100), we sought public input 

regarding conditions with evidence-based prevention guidelines that should be selected in 

implementing section 1886(d)(4)(D) of the Act. The public comments we received were 

summarized in the FY 2007 IPPS final rule (71 FR 48051 through 48053). 

 In the FY 2008 IPPS proposed rule (72 FR 24716 through 24726), we sought 

public comment on conditions that we proposed to select. In the FY 2008 IPPS final rule 

with comment period (72 FR 47200 through 47218), we selected 8 categories to which 

the HAC payment provisions would apply. 

 In the FY 2009 IPPS proposed rule (73 FR 23547), we proposed several 

additional candidate HACs as well as refinements to the previously selected HACs. In 
CMS-1498-P 130 

the FY 2009 IPPS final rule (73 FR 48471), we expanded and refined several of the 

previously selected HACs, and we selected 2 additional categories of HACs. 

 In the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule (74 FR 24106), we 

proposed the addition of ICD-9-CM codes 813.46 (Torus fracture of ulna) and 813.47 

(Torus fracture of radius and ulna) to more precisely define the previously selected HAC 

category of Falls and Trauma. In the FY 2010 IPPS/RY 2010 LTCH PPS final rule 

(74 FR 43784), we finalized the addition of these codes. A complete list of the 10 current 

categories of HACs is included in section II.F.2. of this preamble. 

c. Collaborative Process 

 In establishing the HAC payment policy under section 1886(d)(4)(D) of the Act, 

our experts have worked closely with public health and infectious disease professionals 

from across the Department of Health and Human Services, including CDC, the Agency 

for Healthcare Research and Quality (AHRQ), and the Office of Public Health and 

Science (OPHS), to identify the candidate preventable HACs, review comments, and 

select HACs. CMS and CDC have also collaborated on the process for hospitals to 

submit a POA indicator for each diagnosis listed on IPPS hospital Medicare claims and 

on the payment implications of the various POA reporting options. As discussed below, 

we have also used rulemaking and Listening Sessions to receive public input. 

d Application of HAC Payment Policy to MS-DRG Classifications 

 As described above, in certain cases application of the HAC payment policy 

provisions can result in MS-DRG reassignment to a lower paying MS-DRG. The 

following diagram portrays the logic of the HAC payment policy provision as adopted in 
CMS-1498-P 131 

the FY 2008 IPPS final rule (72 FR 47200) and in the FY 2009 IPPS final rule 

(73 FR 48471): 

All Medicare Discharges

Discharges with HAC 

codes as secondary 

diagnoses

Discharges with no

HAC codes as 

secondary diagnoses

Discharges with HAC 

codes present on 

admission (POA)

Discharges with HAC 

codes not present on 

admission (POA)

Discharges where MSDRG is re-assigned

Discharges where MSDRG does not change

MS-DRG splits into 2 severity 

levels and HAC does not affect 

severity

MS-DRG does not split by 

severity

CC Exclusion 

List

MS-DRG

logic 

Other CCs/MCCs 

prevent reassignment
CMS-1498-P 132 

e. Public Input Regarding Selected and Potential Candidate HACs 

In the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule (74 FR 24104 through 

24106), we did not propose to add or remove categories of HACs. However, as we 

indicated in that proposed rule, we continue to encourage public dialogue about 

refinements to the HAC list. During and after the December 18, 2008 Listening Session, 

we received many oral and written stakeholder comments about both previously selected 

and potential candidate HACs. In response to the Listening Session, commenters 

strongly supported using information gathered from early experience with the HAC 

payment provision to inform maintenance of the HAC list and consideration of future 

potential candidate HACs. Commenters also emphasized the need for a robust program 

evaluation prior to modifying the HAC list. 

In response to the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule 

(74 FR 24106), commenters expressed strong support for a program evaluation prior to 

modifying the HAC list. We responded to these commenters and expressed our 

appreciation for the public’s support for our decision to undertake a program evaluation. 

We indicated that we planned to include updates and findings from the evaluation on 

CMS’ Hospital-Acquired Conditions and Present on Admission Indicator Web site 

available at: http://www.cms.hhs.gov/HospitalAcqCond/. We also responded to 

commenters regarding POA indicator reporting as well as to comments addressing other 

topics related to HACs and POA reporting (74 FR 43785). 
CMS-1498-P 133 

f. POA Indicator Reporting 

Collection of POA indicator data is necessary to identify which conditions were 

acquired during hospitalization for the HAC payment provision as well as for broader 

public health uses of Medicare data. Through Change Request No. 5679 (released on 

June 20, 2007), we issued instructions requiring IPPS hospitals to submit POA indicator 

data for all diagnosis codes on Medicare claims. We also issued Change Request 

No. 6086 (released on June 13, 2008) regarding instructions for processing non-IPPS 

claims. Specific instructions on how to select the correct POA indicator for each 

diagnosis code are included in the ICD-9-CM Official Guidelines for Coding and 

Reporting, available on the CDC Web site at: 

http://www.cdc.gov/nchs/data/icd9/icdguide09.pdf. Additional information regarding 

POA indicator reporting and application of the POA reporting options is available on the 

CMS Web site at: http://www.cms.hhs.gov/HospitalAcqCond. Historically we have not 

provided coding advice. Rather, we collaborate with the American Hospital Association 

(AHA) through the Coding Clinic for ICD-9-CM. We have been collaborating with the 

AHA to promote the Coding Clinic for ICD-9-CM as the source for coding advice about 

the POA indicator. 

There are five POA indicator reporting options, as defined by the ICD-9-CM 

Official Guidelines for Coding and Reporting: 
CMS-1498-P 134 

Indicator Descriptor 

Y Indicates that the condition was present on admission. 

W Affirms that the hospital has determined that, based on data and clinical 

judgment, it is not possible to document when the onset of the condition 

occurred. 

N Indicates that the condition was not present on admission. 

U Indicates that the documentation is insufficient to determine if the 

condition was present at the time of admission. 

1 Signifies exemption from POA reporting. CMS established this code as a 

workaround to blank reporting on the electronic 4010A1. A list of 

exempt ICD-9-CM diagnosis codes is available in the ICD-9-CM Official 

Guidelines for Coding and Reporting. 

 In the FY 2009 IPPS final rule (73 FR 48486 through 48487), we adopted as final 

our proposal to: (1) pay the CC/MCC MS-DRGs for those HACs coded with “Y” and 

“W” indicators; and (2) not pay the CC/MCC MS-DRGs for those HACs coded with “N” 

and “U” indicators. 

 Beginning on or after January 1, 2011, hospitals will begin reporting with the 

5010 format. The 5010 format removes the need to report a POA indicator of “1” for 

codes that are exempt from POA reporting. The POA indicator of “1” is being used 

because of reporting restrictions from the use of the 4010 format. Therefore, hospitals 

that begin reporting with the 5010 format on and after January 1, 2011, will no longer 

report a POA indicator of “1” for POA exempt codes. The POA field will instead be left 

blank for codes exempt from POA reporting. We are planning to issue CMS instructions 

on this reporting change. 

2. Proposed HAC Conditions for FY 2011 

As changes to diagnosis codes and new diagnosis codes are proposed and 

finalized for the list of CCs and MCCs, we will modify the list of selected HACs to 
CMS-1498-P 135 

reflect these changes. In Table 6A in the Addendum to this proposed rule, we have listed 

the proposed addition of five new ICD-9-CM diagnosis codes to replace existing 

ICD-9-CM code 999.6 (ABO incompatibility reaction) for FY 2011. ICD-9-CM code 

999.6 is currently the only code identified under the Blood Incompatibility HAC 

category. We are proposing to delete code 999.6 and form a new subcategory of 999.6 to 

identify new diagnoses relating to ABO incompatibility reaction due to transfusion of 

blood or blood products. These diagnoses meet the criteria for the Blood Incompatibility 

HAC category based on the predecessor code 999.6 being a selected HAC. 

As shown in Table 6C in the Addendum to this proposed rule, we are proposing 

that code 999.6 become invalid as a diagnosis code in FY 2011 with the creation of this 

new ICD-9-CM subcategory. This proposed new subcategory would allow room for 

expansion and the creation of the following new diagnosis codes: 

ICD-9-CM 

Code 

Code Descriptor Proposed 

CC/MCC 

Designation 

999.60 ABO incompatibility reaction, unspecified CC 

999.61 ABO incompatibility with hemolytic transfusion 

reaction not specified as acute or delayed 

CC 

999.62 ABO incompatibility with acute hemolytic 

transfusion reaction 

CC 

999.63 ABO incompatibility with delayed hemolytic 

transfusion reaction 

CC 

999.69 Other ABO incompatibility reaction CC 

 We are inviting public comments on the proposed adoption of the five ICD-9-CM 

diagnosis codes as CCs that are listed above, which, if finalized, would be added to the 

current HAC Blood Incompatibility category. 
CMS-1498-P 136 

 The following table lists the current HACs categories and the ICD-9-CM codes 

that identify the conditions that have been finalized through FY 2010. For FY 2011, we 

are proposing that these conditions continue to be subject to the HAC payment provision, 

with a proposed refinement to the codes to identify blood incompatibility as described 

above. 

HAC 

CC/MCC 

(ICD-9-CM Code) 

Foreign Object Retained After Surgery 998.4 (CC)

998.7 (CC)

Air Embolism 999.1 (MCC)

Blood Incompatibility 999.6 (CC)

Pressure Ulcer Stages III & IV 707.23 (MCC)

707.24 (MCC)

Falls and Trauma: 

 - Fracture 

 - Dislocation 

 - Intracranial Injury 

 - Crushing Injury 

 - Burn 

 - Electric Shock 

Codes within these ranges

on the CC/MCC list:

800-829

830-839

850-854

925-929

940-949

991-994

Catheter-Associated Urinary Tract Infection (UTI) 996.64 (CC)

Also excludes the following 

from acting as a CC/MCC:

112.2 (CC)

590.10 (CC)

590.11 (MCC)

590.2 (MCC)

590.3 (CC)

590.80 (CC)

590.81 (CC)

595.0 (CC)

597.0 (CC)

599.0 (CC)

Vascular Catheter-Associated Infection 999.31 (CC)
CMS-1498-P 137 

HAC 

CC/MCC 

(ICD-9-CM Code) 

Manifestations of Poor Glycemic Control 250.10-250.13 (MCC)

250.20-250.23 (MCC)

251.0 (CC)

249.10-249.11 (MCC)

249.20-249.21 (MCC)

Surgical Site Infections 

 Surgical Site Infection, Mediastinitis, Following 

Coronary Artery Bypass Graft (CABG) 

519.2 (MCC)

And one of the following 

procedure codes:

36.10–36.19

 Surgical Site Infection Following Certain Orthopedic 

Procedures 

996.67 (CC)

998.59 (CC)

And one of the following 

procedure codes: 81.01-

81.08, 81.23-81.24, 81.31-

81.38, 81.83, 81.85

 Surgical Site Infection Following Bariatric Surgery for 

Obesity 

Principal Diagnosis – 278.01

998.59 (CC)

And one of the following 

procedure codes: 44.38, 

44.39, or 44.95

Deep Vein Thrombosis and Pulmonary Embolism 

Following Certain Orthopedic Procedures 

415.11 (MCC)

415.19 (MCC)

453.40-453.42 (CC)

And one of the following 

procedure codes: 00.85-

00.87, 81.51-81.52, or 

81.54 

 We refer readers to section II.F.6. of the FY 2008 IPPS final rule with comment 

period (72 FR 47202 through 47218) and to section II.F.7. of the FY 2009 IPPS final rule 

(73 FR 48474 through 48486) for detailed analyses supporting the selection of each of 

these HACs. We invite public comments on our proposal that these conditions continue 

to be subject to the HAC payment provision, with a proposed refinement of the codes to 

identify blood incompatibility as described above. 
CMS-1498-P 138 

3. RTI Program Evaluation Summary 

a. Background 

On September 30, 2009, a contract was awarded to Research Triangle 

Incorporated (RTI) to evaluate the impact of the Hospital-Acquired Condition-Present on 

Admission (HAC-POA) provisions on the changes in the incidence of selected 

conditions, effects on Medicare payments, impacts on coding accuracy, unintended 

consequences, and infection and event rates. This is an intra-agency project with funding 

and technical support coming from CMS, OPHS, AHRQ, and CDC. The evaluation will 

also examine the implementation of the program and evaluate additional conditions for 

future selection. 

RTI’s evaluation of the HAC-POA provisions is divided into several parts, only 

some of which will be complete prior to the publication date of this proposed rule. 

Below we summarize the analyses that are complete. RTI’s analyses of POA indicator 

reporting, frequencies and net savings associated with current HACs, and frequencies of 

previously considered candidate HACs reflect MedPAR claims from October 2008 

through June 2009. In the final rule, we intend to update our summary of these analyses 

with additional data that have become available. 

b. Preliminary RTI Analysis on POA Indicator Reporting Across Medicare Discharges 

To better understand the impact of HACs on the Medicare program, it is 

necessary to first examine the incidence of POA indicator reporting across all eligible 

Medicare discharges. As mentioned previously, only IPPS hospitals are required to 

submit POA indicator data for all diagnosis codes on Medicare claims. Therefore, all 
CMS-1498-P 139 

non-IPPS hospitals were excluded, as well as providers in waiver States (Maryland) and 

territories other than Puerto Rico. 

Using MedPAR claims data from October 2008 through June 2009, RTI found a 

total of approximately 50.22 million secondary diagnoses across approximately 7.17 

million discharges. As shown in Chart A below, the majority of all secondary diagnoses 

(83.52 percent) were reported with a POA indicator of “Y,” meaning the condition was 

POA. 
CMS-1498-P 140 

CHART A.—POA CODE DISTRIBUTION ACROSS ALL SECONDARY 

DIAGNOSES 

 Number Percentage

Total Discharges in Final File 7,175,139

Total Number of Secondary Diagnoses Across Total 

Discharges 50,216,195 100.00

POA Indicator Description 

Y Condition present on admission 41,938,234 83.52

W Status cannot be clinically determined 12,547 0.02

N Condition not present on admission 3,440,815 6.85

U Documentation not adequate to determine 

if condition was present on admission 110,771 0.22

1 Exempted ICD-9-CM code 4,713,828 9.39

SOURCE: RTI Analysis of MedPAR IPPS Claims, October 2008 through June 2009. 

c. Preliminary RTI Analysis on POA Indicator Reporting of Current HACs 

Following the initial analysis of POA indicator reporting for all secondary 

diagnoses, RTI then evaluated POA indicator reporting for specific HAC-associated 

secondary diagnoses. The term “HAC-associated secondary diagnosis” refers to those 

diagnoses that are on the selected HAC list and were reported as a secondary diagnosis. 

Chart B below shows a summary of the HAC categories with the frequency in which 

each HAC was reported as a secondary diagnosis and the corresponding POA indicators 

assigned on the claims. It is important to note that, because more than one HACassociated diagnosis code can be reported per discharge (that is, on a single claim), the 

frequency of HAC-associated diagnosis codes may be more than the actual number of 

discharges that have a HAC-associated diagnosis code reported as a secondary diagnosis. 

Below we discuss the frequency of each HAC-associated diagnosis code and the POA 

indicators assigned to those claims. 
CMS-1498-P 141 

RTI analyzed the frequency of each reported HAC-associated secondary 

diagnosis (across all 7.17 million discharges) and the POA indicator assigned to the 

claim. Chart B below shows that the most frequently reported conditions were in the 

Falls and Trauma HAC category, with a total of 132,666 HAC-associated diagnosis codes 

being reported for that HAC category. Of these 132,666 diagnoses, 4,081 reported a 

POA indicator of “N” for not POA and 128,286 diagnoses reported a POA indicator of 

“Y” for POA. The lowest frequency appears in the Surgical Site Infection (SSI) 

Following Bariatric Surgery for Obesity HAC category with only 12 HAC-associated 

secondary diagnosis codes (and procedure codes) reported. 

CHART B.—POA STATUS OF CURRENT HACS: 

OCTOBER 2008 THROUGH JUNE 2009 

Not Present on Admission Present on Admission 

POA = N POA = U POA = Y POA = W 

Selected HAC Frequency 

as a 

Secondary 

Diagnosis No. Percent No. Percent No. Percent No. Percent 

1. Foreign Object 

Retained After 

Surgery (CC) 378 172 45.5 0 0.0 206 54.5 0 0.0 

2. Air Embolism 

(MCC) 29 23 79.3 0 0.0 6 20.7 0 0.0 

3. Blood 

Incompatibility 

(CC) 23 8 34.8 0 0.0 15 65.2 0 0.0 

4. Pressure Ulcer 

Stages III & IV 

(MCC) 80,190 944 1.2 56 0.1 79,165 98.7 25 0.0 

5. Falls and Trauma 

(MCC & CC) 132,666 4,081 3.1 232 0.2 128,286 96.7 67 0.1 

6. CatheterAssociated UTI 

(CC) 11,424 1,887 16.5 15 0.1 9,496 83.1 26 0.2 

7. Vascular 

Catheter-Associated 

Infection (CC) 5,470 2,091 38.2 19 0.3 3,348 61.2 12 0.2 

8. Poor Glycemic 

Control (MCC) 11,070 344 3.1 9 0.1 10,711 96.8 6 0.1 
CMS-1498-P 142 

Not Present on Admission Present on Admission 

POA = N POA = U POA = Y POA = W 

Selected HAC Frequency 

as a 

Secondary 

Diagnosis No. Percent No. Percent No. Percent No. Percent 

9A. Surgical Site 

Infection 

Mediastinitis CABG 

(CC) 29 21 72.4 0 0.0 8 27.6 0 0.0 

9B. Surgical Site 

Infection Following 

Bariatric Surgery for 

Obesity (CC) 12 10 83.3 0 0.0 2 16.7 0 0.0 

9B. Surgical Site 

Infection Following 

Certain Orthopedic 

Procedures (CC) 202 125 61.9 1 0.5 75 37.1 1 0.5 

10. Pulmonary 

Embolism & DVT 

Orthopedic (MCC) 2,706 2,029 75.0 15 0.6 647 23.9 15 0.6 

Total* 244,199 347 152 

* Discharges can appear in more than one row. The total figure is not adjusted for the 47 discharges with 

more than one HAC that appear as secondary diagnoses (15 of these discharges resulted in MS-DRG 

reassignment). 

We welcome public comments on these data that can provide insight into the 

accuracy of the data, using comparative data sets or analysis such as how aspects of the 

coding system might influence these data. 

As described earlier, in the FY 2009 IPPS final rule (73 FR 48486 through 

48487), we adopted as final our proposal to: (1) pay the CC/MCC MS-DRGs for those 

HACs coded with “Y” and “W” indicators; and (2) not pay the CC/MCC MS-DRGs for 

those HACs coded with “N” and “U” indicators. We also discussed the comments we 

received urging CMS to strongly consider changing the policy and to pay for those HACs 

assigned a POA indicator of “U” (documentation is insufficient to determine if the 

condition was present at the time of admission). We stated we would monitor the extent 

to which and under what circumstances the “U” POA reporting option is used. In the 
CMS-1498-P 143 

FY 2010 IPPS/RY 2010 LTCH PPS final rule, we also discussed and responded to 

comments regarding HACs coded with the “U” indicator (74 FR 43784 and 43785). As 

shown in Chart B above, RTI’s analysis provides some initial data on a total of 347 

HAC-associated secondary diagnoses reported with a POA indicator of “U”. Of those 

diagnoses, 232 (0.2 percent) were assigned to the Falls and Trauma HAC category. 

We continue to believe that better documentation will result in more accurate 

public health data. Because the RTI analysis is based on preliminary data, at this time we 

are not proposing to change our policy under which CMS does not pay at the higher 

CC/MCC amount when a selected HAC diagnosis code is reported with a POA indicator 

of "U." 

We encourage readers to further review the RTI detailed report which 

demonstrates the frequency of each individual HAC-associated diagnosis code within the 

HAC categories. For example, in the Foreign Object Retained After Surgery HAC 

category, there are two unique ICD-9-CM diagnosis codes to identify that condition: 

code 998.4 (Foreign body accidentally left during a procedure) and code 998.7 (Acute 

reaction to foreign substance accidentally left during a procedure). In the detailed RTI 

report, readers can view that code 998.4 was reported 368 times and code 998.7 was 

reported 10 times, for a total of 378 times, as shown in Chart B above. The RTI detailed 

report is available at the following Web site: http://www.rti.org/reports/cms/.
CMS-1498-P 144 

d. Preliminary RTI Analysis of Frequency of Discharges and POA Indicator Reporting 

for Current HACs 

 RTI further analyzed the effect of the HAC provision by studying the frequency 

in which a HAC-associated diagnosis was reported as a secondary diagnosis with a POA 

indicator of “N” or “U” and, of that number, how many resulted in MS-DRG 

reassignment. In Chart C below, Column A shows the number of discharges for each 

HAC category where the HAC-associated diagnosis was reported as a secondary 

diagnosis. For example, there were 29 discharges that reported Air Embolism as a 

secondary diagnosis. Column C shows the number of discharges for each HAC reported 

with a POA indicator of “N” or “U.” Continuing with the example of Air Embolism, the 

chart shows that, of the 29 reported discharges, 23 discharges (79.31 percent) had a POA 

indicator of “N” or “U” and was identified as a HAC discharge. There were a total of 

23 discharges to which the HAC policy applies and that could, therefore, have had an 

MS-DRG reassignment. Column E shows the number of discharges where an actual 

MS-DRG reassignment occurred. As shown in Column E, the number of discharges with 

an Air Embolism that resulted in actual MS-DRG reassignments is 12 (52.17 percent of 

the 23 discharges with a POA indicator of “N” or “U”). Thus, while there were 

23 discharges (79.31 percent of the original 29) with an Air Embolism reported with a 

POA indicator of “N” or “U” identified as a HAC discharge that could have caused MSDRG reassignment, the end result was 12 (52.17 percent) actual MS-DRG reassignments. 

There are a number of reasons why a selected HAC reported with a POA indicator of “N” 

or “U” will not result in MS-DRG reassignment. These reasons were illustrated with the 
CMS-1498-P 145 

diagram in section II.F.1.c. of this preamble and will be discussed in further detail in 

section II.F.3.e. of this preamble. 

 Chart C below also shows that, of the 216,764 discharges with a HAC-associated 

diagnosis as a secondary diagnosis, 3,038 discharges ultimately resulted in MS-DRG 

reassignment. As will be discussed below, there were 15 claims that resulted in 

MS-DRG reassignment where two HACs were reported on the same admission. The four 

HAC categories that had the most discharges resulting in MS-DRG reassignment were: 

(1) Falls and Trauma; (2) Pressure Ulcer Stages III & IV; (3) Pulmonary Embolism and 

DVT Orthopedic (Orthopedic PE/DVT); and (4) Catheter-Associated Urinary Tract 

Infection (UTI). Codes falling under the Falls and Trauma HAC category were the most 

frequently reported secondary diagnoses with 109,728 discharges. Of these 109,728 

discharges, 3,852 (3.51 percent) were coded as not POA and identified as HAC 

discharges. This category also contained the greatest number of discharges that resulted 

in an MS-DRG reassignment. Of the 3,852 discharges within this HAC category that 

were not POA, 1,476 (38.32 percent) resulted in an MS-DRG reassignment. 

 Of the 216,764 total discharges reporting HAC-associated diagnoses as a 

secondary diagnosis, 2,494 discharges were coded with a secondary diagnosis of 

Orthopedic PE/DVT. Of these 2,494 discharges, 1,892 (75.86 percent) were coded as not 

POA and identified as HAC discharges. This category contained the second greatest 

number of discharges resulting in an MS-DRG reassignment. Of the 1,892 discharges in 

this HAC category that were not POA, 845 discharges (44.66 percent) resulted in an 

MS-DRG reassignment. 
CMS-1498-P 146 

 The Pressure Ulcer Stages III & IV category had the second most frequently 

coded secondary diagnoses, with 76,014 discharges. Of these discharges, 960 (1.26 

percent) were coded as not POA and identified as HAC discharges. This category 

contained the third greatest number of discharges resulting in an MS-DRG reassignment. 

Of the 960 discharges in this HAC category that were not POA, 337 discharges (35.10 

percent) resulted in an MS-DRG reassignment. 

 The Catheter-Associated UTI category had the third most frequently coded 

secondary diagnoses, with 11,434 discharges. Of these discharges, 1,896 (16.60 percent) 

were coded as not POA and identified as HAC discharges. This category contained the 

fourth greatest number of discharges resulting in an MS-DRG reassignment. Of the 

1,896 discharges in this HAC category that were not POA, 197 discharges (10.39 

percent) resulted in a MS-DRG reassignment. 

 The remaining 6 HAC categories only had 183 discharges that ultimately resulted 

in MS-DRG reassignment. We note that, even in cases where a large number of HACassociated secondary diagnoses were coded as not POA, this finding did not necessarily 

translate into a large number of discharges that resulted in MS-DRG reassignment. For 

example, only 23 of the 2,107 Vascular Catheter-Associated Infection secondary 

diagnoses that were coded as not POA and identified as HAC discharges resulted in a 

MS-DRG reassignment. 

There were a total of 277 discharges with a HAC-associated secondary diagnosis 

reporting a POA indicator of “N” or “U” that were excluded from acting as a HAC 

discharge (subject to MS-DRG reassignment) due to the CC Exclusion List logic within 
CMS-1498-P 147 

the GROUPER. The CC Exclusion List identifies secondary diagnosis codes designated 

as a CC or MCC that are disregarded by the GROUPER logic when reported with certain 

principal diagnoses. For example, a claim with the principal diagnosis code of 250.83 

(Diabetes with other specified manifestations, type 1 [juvenile type], uncontrolled) and a 

secondary diagnosis code of 250.13 (Diabetes with ketoacidosis, type 1, [juvenile type], 

uncontrolled) with a POA indicator of “N” would result in the HAC-associated secondary 

diagnosis code 250.13 being ignored as a CC. According to the CC Exclusion List, code 

250.13 is excluded from acting as a CC when code 250.83 is the principal diagnosis. As 

a result, the HAC logic would not be applicable to that case. For a detailed discussion on 

the CC Exclusion List, we refer readers to section II.G.9. of this preamble. 

Discharges where the HAC logic was not applicable due to the CC Exclusion List 

occurred among the following 4 HAC categories: Pressure Ulcer Stages III and IV 

(29 cases), Falls and Trauma (206 cases), Catheter-Associated UTI (6 cases), Vascular 

Catheter-Associated Infection (3 cases), and Manifestations of Poor Glycemic Control 

(33 cases). Further information regarding the specific number of cases that were 

excluded for each HAC-associated secondary diagnosis code within each of the above 

mentioned HAC categories is also available. We refer readers to the RTI detailed report 

at the following Web site: http://www.rti.org/reports/cms/.

 In summary, Chart C below demonstrates that there were a total of 216,764 

discharges with a reported HAC-associated secondary diagnosis. Of the total 216,764 

discharges, 11,383 (5.25 percent) discharges were HACs reported with a POA indicator 
CMS-1498-P 148 

of “N” or “U” that were identified as a HAC discharge. Of these 11,383 discharges, the 

number of discharges resulting in MS-DRG reassignments was 3,038 (26.69 percent). 
CMS-1498-P 149 

CHART C.—DISCHARGE FREQUENCIES OF CURRENT CMS HACS 

OCTOBER 2008 THRUGH JUNE 2009 

Discharges With This 

Condition as 

Secondary Diagnosis 

Discharges Identified 

as a HAC 

Discharges That 

Change MS-DRG 

Due to HAC Selected HAC 

Category Number 

(Column 

A) 

Percent2 

(Column 

B) 

Number 

(Column 

C) 

Percent3 

(Column 

D) 

Number 

(Column 

E) 

Percent4 

(Column 

F) 

1. Foreign Object 

Retained After 

Surgery 378 0.01% 172 45.50% 40 23.26% 

2. Air Embolism 29 0.00% 23 79.31% 12 52.17% 

3. Blood 

Incompatibility 23 0.00% 8 34.78% 0 0.00% 

4. Pressure Ulcer 

Stages III & IV 76,041 1.06% 960 1.26% 337 35.10% 

a. Stage III 42,659 0.59% 726 1.70% 286 39.39% 

b. Stage IV 37,531 0.52% 245 0.65% 53 23.27% 

5. Falls and Trauma 109,728 1.53% 3,852 3.51% 1,476 38.32% 

a. Fracture 

98,624 1.37% 3,343 3.39% 1,267 37.90% 

b. Dislocation 

763 0.01% 19 2.49% 3 15.79% 

c. Intracranial 

Injury 10,469 0.15% 478 4.57% 213 44.56 

d. Crushing 

Injury 32 0% 1 3.13% 0 0 

e. Burn 

1,663 0.02% 33 1.98% 6 18.18% 

f. Electric Shock 

466 0.01% 8 1.72% 1 12.50% 

6. CatheterAssociated UTI 11,424 0.16% 1,896 16.60% 197 10.39% 

7. Vascular CatheterAssociated Infection 5,470 0.08% 2,107 38.52% 23 1.09% 

8. Poor Glycemic 

Control 10,937 0.15% 319 2.92% 98 30.72% 

9a. SSI Mediastinitis 

CABG 29 0.04% 21 72.41% 5 23.81% 
CMS-1498-P 150 

Discharges With This 

Condition as 

Secondary Diagnosis 

Discharges Identified 

as a HAC 

Discharges That 

Change MS-DRG 

Due to HAC Selected HAC 

Category Number 

(Column 

A) 

Percent2 

(Column 

B) 

Number 

(Column 

C) 

Percent3 

(Column 

D) 

Number 

(Column 

E) 

Percent4 

(Column 

F) 

9b. SSI Orthopedic 199 0.26% 123 61.81% 4 3.25% 

9c. SSI Bariatric 12 0.11% 10 83.33% 1 10.00% 

10. Pulmonary 

Embolism & DVT 

Orthopedic 2,494 0.84% 1,892 75.86% 845 44.66% 

Total1 216,764 11,383 5.25% 3,038 26.69% 1

 Discharges can appear in more than one row. The total figure is not adjusted for the 47 discharges with 

more than one HAC that appear as secondary diagnoses (15 of these resulted in MS-DRG reassignment). 

2

 Percent computed relative to total discharges “at risk” for MS-DRG reassignment. For HACs 1 – 8, this 

is 7,175,139. For HAC 9a, this is 73,184. For HAC 9b, this is 76,104. For HAC 9c, this is 10,445. For 

HAC 10, this is 296,405. 

3

 Percent computed relative to discharges with condition as a secondary diagnosis. 

4

 Percent computed relative to discharges with condition as a secondary diagnosis and identified as a HAC 

(that is, coded as not present on admission), as identified in the Column E. 

SOURCE: RTI Analysis of MedPAR IPPS Claims, October 2008 through June 2009. 

 An extremely small number of discharges had multiple HACs reported during the 

same stay. In reviewing the 7.17 million claims, RTI found 47 cases in which two HACs 

were reported on the same discharge. Chart D below summarizes these cases. There 

were eight cases in which a Falls and Trauma HAC was reported in addition to a Pressure 

Ulcer Stages III & IV HAC. Eighteen of the cases with two HACs involved Pressure 

Ulcer Stages III & IV and 15 cases involved Falls or Trauma. Other multiple HAC cases 

included 9 Catheter-Associated UTI cases and 5 Vascular Catheter-Associated Infection 

cases. 

 Some of these cases with multiple HACs reported had both HAC codes ignored in 

the MS-DRG assignment. Of these 47 claims, 32 did not receive higher payments based 

on the presence of one or both of these reported HACs and we describe these claims 
CMS-1498-P 151 

below in section II.F.3.f.(2) of this preamble. Depending on the MS-DRG to which the 

cases were originally assigned, ignoring the HAC codes would have led to a MS-DRG 

reassignment if there were no other MCCs or CCs reported, if the MS-DRG was 

subdivided into severity levels, and if the case were not already in the lowest severity 

level prior to ignoring the HAC codes. 

CHART D.—CLAIMS WITH MORE THAN ONE HAC SECONDARY 

DIAGNOSIS OCTOBER 2008 THROUGH JUNE 2009 

HAC 4. Pressure 

Ulcer Stages 

III & IV – 

MCC 

5. Falls and 

Trauma – 

MCC & CC 

6. CatheterAssociated 

UTI - CC 

7. Vascular 

CatheterAssociated 

Infection – 

CC 

2. Air Embolism – 

MCC 1

5. Falls and Trauma – 

MCC & CC 8

6. CatheterAssociated UTI – CC 2 3

7. Vascular CatheterAssociated Infection – 

CC 5 4 6

8. Poor Glycemic 

Control - MCC 1 1

9C. Surgical Site 

Infection Following 

Bariatric Surgery for 

Obesity – CC 2 1

10. Pulmonary 

Embolism & DVT 

Orthopedic – MCC 2 7 1 3

Total 18 15 9 5
CMS-1498-P 152 

e. Preliminary RTI Analysis of Circumstances When Application of HAC Provisions 

Would Not Result in MS-DRG Reassignment for Current HACs 

 As discussed in section II.F.1. and illustrated in the diagram in section II.F.1.c. of 

this preamble, there are instances when the MS-DRG assignment does not change even 

when a HAC-associated secondary diagnosis has a POA indicator of either “N” or “U.” 

In analyzing our claims data, RTI identified four main reasons why a MS-DRG 

assignment would not change despite the presence of a HAC. Those four reasons are 

described below and are shown in Chart E below. Column A shows the frequency of 

discharges that included a HAC-associated secondary diagnosis. Column B shows the 

frequency of discharges where the HAC-associated secondary diagnosis was coded as not 

POA and identified as a HAC discharge. Column C shows the frequency of discharges in 

which the HAC-associated secondary diagnosis coded as not POA resulted in a change in 

MS-DRG. Columns D, E, F, and G show the frequency of discharges in which the 

HAC-associated secondary diagnosis coded as not POA did not result in a change in MSDRG assignment. Columns D, E, F, and G are explained in more detail below. 

(1) Other MCCs/CCs Prevent Reassignment 

 Column D (Other MCC/CCs that Prevent Reassignment) in Chart E below 

indicates the number of cases reporting a HAC-associated secondary diagnosis code that 

did not have a MS-DRG reassignment because of the presence of other secondary 

diagnoses on the MCC or CC list. A claim that is coded with a HAC-associated 

secondary diagnoses and a POA status of either “N” or “U” may have other secondary 

diagnoses that are classified as an MCC or a CC. In such cases, the presence of these 
CMS-1498-P 153 

other MCC and CC diagnoses will still lead to the assignment of a higher severity level, 

despite the fact that the GROUPER software is disregarding the ICD-9-CM code that 

identifies the selected HAC in making the MS-DRG assignment for that claim. For 

example, there were 83 cases in which the ICD-9-CM codes for the Foreign Object 

Retained After Surgery HAC category were present, but the presence of other secondary 

diagnoses that were MCCs or CCs resulted in no change to the MS-DRG assignment. 

Chart E shows that a total of 6,074 cases did not have a change in the MS-DRG 

assignment because of the presence of other reported MCCs and CCs. 

(2) Two Severity Levels Where HAC Does Not Impact MS-DRG Assignment 

 Column E (Number of MS-DRGs with Two Severity Levels Where HAC Does 

Not Impact MS-DRG Assignment) shows the frequency with which discharges with a 

HAC as a secondary diagnosis coded as not POA did not result in an MS-DRG change 

because the MS-DRG is subdivided solely by the presence or absence of an MCC. A 

claim with a HAC and a POA indicator of either “N” or “U” may be assigned to an MSDRG that is subdivided solely by the presence or absence of an MCC. In such cases, 

removing a HAC ICD-9-CM CC code will not lead to further changes in the MS-DRG 

assignment. Examples of these MS-DRG subdivisions are shown in the footnotes to the 

chart and include the following examples: 

● MS-DRGs 100 and 101 (Seizures with or without MCC, respectively) 

● MS-DRGs 102 and 103 (Headaches with or without MCC, respectively) 

 The codes that fall under the HAC category of Foreign Object Retained After 

Surgery are CCs. If this case were assigned to a MS-DRG with an MCC subdivision 
CMS-1498-P 154 

such as MS-DRGs 100 and 101, the presence of the HAC code would not affect the MSDRG severity level assignment. In other words, if the Foreign Object Retained After 

Surgery code were the only secondary diagnosis reported, then the case would be 

assigned to MS-DRG 101. If the POA indicator was “N,” the HAC Foreign Object 

Retained After Surgery code would be ignored in the MS-DRG assignment logic. 

Despite the fact that the code was ignored, the case would still be assigned to the same, 

lower severity level MS-DRG. Therefore, there would be no impact on the MS-DRG 

assignment. 

 Column E in Chart E below shows that there were 1,446 cases where the HAC 

code was “N” or “U” and the MS-DRG assignment did not change because the case was 

already assigned to the lowest severity level. 

(3) No Severity Levels 

 Column F (Number of MS-DRGs with No Severity Levels) shows the frequency 

with which discharges with an HAC as a secondary diagnosis coded as not POA did not 

result in an MS-DRG change because the MS-DRG is not subdivided by severity levels. 

A claim with a HAC and a POA of “N” or “U” may be assigned to a MS-DRG with no 

severity levels. For instance, MS-DRG 311 (Angina Pectoris) has no severity level 

subdivisions; this MS-DRG is not split based on the presence of an MCC or a CC. If a 

patient assigned to this MS-DRG develops a secondary diagnosis such as a Stage III 

pressure ulcer after admission, the condition would be considered to be a HAC. The code 

for the Stage III pressure ulcer would be ignored in the MS-DRG assignment because the 

condition developed after the admission (the POA indicator was “N”). Despite the fact 
CMS-1498-P 155 

that the ICD-9-CM code for the HAC Stage III pressure ulcer was ignored, the MS-DRG 

assignment would not change. The case would still be assigned to MS-DRG 311. 

Chart E below shows that 818 cases reporting a HAC-associated secondary diagnosis did 

not undergo a change in the MS-DRG assignment based on the fact that the case was 

assigned to a MS-DRG that had no severity subdivisions (that is, the MS-DRG is not 

subdivided based on the presence or absence of an MCC or a CC, rendering the presence 

of the HAC irrelevant for payment purposes). 

(4) MS-DRG Logic 

Column G (MS-DRG Logic Issues) shows the frequency with which a HAC as a 

secondary diagnosis coded as not POA did not result in an MS-DRG change because of 

MS-DRG assignment logic. There were seven discharges where the HAC criteria were 

met and the HAC logic was applied, however, due to the structure of the MS-DRG logic, 

these cases did not result in MS-DRG reassignment. These cases may appear similar to 

those discharges where the MS-DRG is subdivided into two severity levels by the 

presence or absence of an MCC and did not result in MS-DRG reassignment; however, 

these discharges differ slightly in that the MS-DRG logic also considers specific 

procedures that were reported on the claim. In other words, for certain MS-DRGs, a 

procedure may be considered the equivalent of an MCC or CC. The presence of the 

procedure code dictates the MS-DRG assignment despite the presence of the HACassociated secondary diagnosis code with a POA indicator of “N” or “U”. 

For example, a claim with the principal diagnosis code of 441.1 (Thoracic 

aneurysm, ruptured) with HAC-associated secondary diagnosis code of 996.64 (Infection 
CMS-1498-P 156 

and inflammatory reaction due to indwelling urinary catheter) and diagnosis code 599.0 

(Urinary tract infection, site not specified), having POA indicators of “Y”, “N”, “N”, 

respectively, and procedure code 39.73 (Endovascular implantation of graft in thoracic 

aorta) results in an assignment to MS-DRG 237 (Major Cardiovascular Procedures with 

MCC or Thoracic Aortic Aneurysm Repair). In this case, the thoracic aortic aneurysm 

repair is what dictated the MS-DRG assignment and the presence of the HAC-associated 

secondary diagnosis code, 996.64, did not affect the MS-DRG assigned. Other examples 

of MS-DRGs that are subdivided in this same manner are as follows: 

● MS-DRG 029 (Spinal procedures with CC or Spinal Neurostimulators) 

● MS-DRG 129 (Major Head & Neck Procedures with CC/MCC or Major 

Device) 

● MS-DRG 246 (Percutaneous Cardiovascular Procedure with Drug-Eluting 

Stent with MCC or 4+ Vessels/Stents) 

Column G in the chart below shows that four of the seven cases that did not result 

in MS-DRG reassignment due to the MS-DRG logic were in the Catheter Associated UTI 

HAC category, one case was in the Foreign Body Retained after Surgery HAC Category, 

one case was in the Falls and Trauma HAC category, and one case was in the Vascular 

Catheter-Associated Infection HAC Category. 

 In conclusion, a total of 8,345 cases (6,074 + 1,446 + 818 + 7) did not have a 

change in MS-DRG assignment, regardless of the presence of a HAC. The reasons 

described above explain why only 3,038 cases had a change in MS-DRG assignment 

despite the fact that there were 11,383 HAC cases with a POA of “N” or “U.” 
CMS-1498-P 157 

CHART E.—REASONS HAC DID NOT CHANGE MS-DRG ASSIGNMENT 

OCTOBER 2008 THROUGH JUNE 2009 

HAC Discharges That Do Not Change MS-DRG 

Selected HAC 

Category 

Number of 

Discharges 

with This 

Condition 

as 

Secondary 

Diagnosis 

(Column A) 

Number of 

Discharges 

Identified 

as a HAC 

 (Column B 

Number of 

HAC 

Discharges 

That 

Change 

MS-DRG 

Due to 

HAC 

(Column C) 

Number of 

Other 

MCCs/CCs 

That 

Prevent 

Reassignment 

(Column D) 

Number of 

MS-DRGs 

with Two 

Severity 

Levels Where 

HAC Does 

Not Impact 

MS-DRG 

Assignment* 

(Column E) 

Number 

of MSDRGs 

with No 

Severity 

Levels 

(Column 

F) 

Other 

MS-DRG 

Logic 

Issues ** 

(Column 

G) 

1. Foreign 

Object Retained 

After Surgery – 

CC 378 172 40 83 42 6 1 

2. Air 

Embolism – 

MCC 29 23 12 9 0 2 0 

3. Blood 

IncompatibilityCC 23 8 0 4 3 1 0 

4. Pressure 

Ulcer Stages III 

& IV – MCC 76,041 960 337 481 0 142 0 

5. Falls and 

Trauma – MCC 

& CC 109,728 3,852 1,476 1,762 367 246 1 

6. CatheterAssociated 

UTI- CC 11,424 1,896 197 1,326 250 119 4 

7. Vascular 

CatheterAssociated 

Infection – CC 5,470 2,107 23 1,717 122 244 1 

8. Poor 

Glycemic 

Control – MCC 

& CC 10,937 319 98 187 1 33 0 

9A. Surgical 

Site Infection, 

Mediastinitis, 

Following 

Coronary 

Artery Bypass 

Graft (CABG) – 

MCC 29 21 5 13 0 3 0 
CMS-1498-P 158 

HAC Discharges That Do Not Change MS-DRG 

Selected HAC 

Category 

Number of 

Discharges 

with This 

Condition 

as 

Secondary 

Diagnosis 

(Column A) 

Number of 

Discharges 

Identified 

as a HAC 

 (Column B 

Number of 

HAC 

Discharges 

That 

Change 

MS-DRG 

Due to 

HAC 

(Column C) 

Number of 

Other 

MCCs/CCs 

That 

Prevent 

Reassignment 

(Column D) 

Number of 

MS-DRGs 

with Two 

Severity 

Levels Where 

HAC Does 

Not Impact 

MS-DRG 

Assignment* 

(Column E) 

Number 

of MSDRGs 

with No 

Severity 

Levels 

(Column 

F) 

Other 

MS-DRG 

Logic 

Issues ** 

(Column 

G) 

9B. Surgical 

Site Infection 

Following 

Certain 

Orthopedic 

Procedures – 

CC 199 123 4 68 48 3 0 

9C. Surgical 

Site Infection 

Following 

Bariatric 

Surgery for 

Obesity – CC 12 10 1 9 0 0 0 

10. Pulmonary 

Embolism & 

DVT 

Orthopedic – 

MCC & CC 2,494 1,892 845 415 613 19 0 

Total1 216,764 11,383 3,038 6,074 1446 818 7 

1

 Discharges can appear in more than one row. The total figure is not adjusted for the 47 discharges with 

more than one HAC that appear as secondary diagnoses (15 of these resulted in MS-DRG reassignment). 

*Examples where an HAC classified as a CC would not impact the DRG assignment if it were removed. 

The MS-DRG is subdivided by the presence or absence of an MCC. A CC would not impact this DRG 

assignment. 

 MS-DRGs 100 and 101 (Seizures with or without MCC, respectively) 

 MS-DRGs 102 and 103 (Headaches with or without MCC, respectively) 

**Cases where HAC did not change MS-DRG assignment because of the MS-DRG logic. 

 MS-DRG 029 (Spinal Procedures with CC or Spinal Neurostimulators) 

 MS-DRG 129 (Major Head & Neck Procedures with CC/MCC or Major Device) 

SOURCE: RTI Analysis of MedPAR IPPS Claims, October 2008 through June 2009 

f. Preliminary RTI Analysis of Coding Changes for HAC-Associated Secondary 

Diagnoses for Current HACs 

 In addition to studying claims from October 2008 through June 2009, RTI 

evaluated claims data from 2 years prior to determine if there were significant changes in 
CMS-1498-P 159 

the number of discharges with a HAC being reported as a secondary diagnosis. To 

provide consistency with the FY 2009 data studied, RTI examined claims using discharge 

dates from October 2006 through June 2007 (for FY 2007) and October 2007 through 

June 2008 (for FY 2008) and compared these data to the FY 2009 data. 

RTI’s analysis found that there was an increase in the reporting of secondary 

diagnoses that are currently designated as HACs from FY 2007 to FY 2008. The most 

significant increase was in the Falls and Trauma HAC category, with 108,397 discharges 

being reported in FY 2007, while 116,832 discharges were reported in FY 2008, an 

increase of 8,435 cases. 

However, the analysis found that there was a decrease in reported 

HAC-associated secondary diagnoses from FY 2008 to FY 2009. The most significant 

decrease was in the Falls and Trauma HAC category, with 116,832 discharges being 

reported in FY 2008, while 109,246 discharges were reported in FY 2009, a decrease of 

7,586 cases. We point out that because diagnosis codes for the Pressure Ulcer Stages III 

& IV HAC did not become effective until October 1, 2008, there are no data available for 

FY 2007 or FY 2008. 

We refer readers to the RTI detailed report for all the conditions in each fiscal 

year (FY 2007 through FY 2009) as described above at the following Web site: 

http://www.rti.org/reports/cms/. 
CMS-1498-P 160 

g. Preliminary RTI Analysis of Estimated Net Savings for Current HACs 

RTI determined preliminary estimates of the net savings generated by the HAC 

payment policy based on MedPAR claims from October 2008 through June 2009 for the 

9-month period. 

(1) Net Savings Estimation Methodology 

The payment impact of a HAC is the difference between the IPPS payment amount under 

the initially assigned MS-DRG and the amount under the reassigned MS-DRG. The 

amount for the reassigned MS-DRG appears on the MedPAR files. To construct this, 

RTI modeled the IPPS payments for each MS-DRG following the same approach that we 

use to model the impact of IPPS annual rule changes. Specifically, RTI replicated the 

payment computations carried out in the IPPS PRICER program using payment factors 

for IPPS providers as identified in various CMS downloaded files. The files used are as 

follows: 

● Version 26 of the Medicare Severity GROUPER software (applicable to 

discharges between October 1 2008 and September 30, 2009). IPPS MedPAR claims 

were run through this file to obtain needed HAC-POA output variables. 

● The FY 2009 MS-DRG payment weight file. This file includes the weights, 

geometric mean length of stay (GLOS), and the postacute transfer payment indicators. 

● CMS standardized operating and capital rates. Tables 1A through 1C, as 

downloaded from the Web site at: 

http://www.cms.hhs.gov/AcuteInpatientPPS/IPPS2009, include the full update and 
CMS-1498-P 161 

reduced update amounts, as well as the information needed to compute the blended 

amount for providers located in Puerto Rico. 

● The IPPS impact files for FY 2009, also as downloaded from the Web site at: 

http://www.cms.hhs.gov/AcuteInpatientPPS/IPPS2009/. This file includes the wage 

index and geographic adjustment factors, plus the provider type variable to identify 

providers qualifying for alternative hospital-specific amounts and their respective HSP 

rates. 

● The IPPS impact files for FY 2010, as downloaded from the Web site at: 

http://www.cms.hhs.gov/AcuteInpatientPPS/10FR/ . This file includes indirect medical 

education (IME) and disproportionate share (DSH) percent adjustments that were in 

effect as of March 2009. 

● CMS historical provider-specific files (PSF). This includes the indicator to 

identify providers subject to the full or reduced standardized rates and the applicable 

operating and capital cost-to-charge ratios. A SAS version was downloaded from the 

Web site at: http://www.cms.hhs.gov/ProspMedicareFeeSvcPmtGen/04_psf_SAS.asp. 

There were 50 providers with discharges in the final HAC analysis file that did not 

appear in the FY 2009 impact file, of which 11 also did not appear in the FY 2010 impact 

file. For these providers, we identified the geographic CBSA from the historical PSF and 

assigned the wage index using values from Tables 4A and 4C as downloaded from the 

Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS/IPPS2009/. For providers in 

the FY 2010 file but not the FY 2009 file, we used IME and DSH rates from FY 2010. 
CMS-1498-P 162 

The 11 providers in neither impact file were identified as non-IME and non-DSH 

providers in the historical PSF file. 

 The steps for estimating the HAC payment impact are as follows: 

 Step 1: Re-run the Medicare Severity GROUPER on all records in the analysis 

file. This is needed to obtain information on actual HAC-related MS-DRG reassignments 

in the file, and to identify the CCs and MCCs that contribute to each MS-DRG 

assignment. 

Step 2: Model the base payment and outlier amounts associated with the initial 

MS-DRG if the HAC were excluded using the computations laid out in the CMS file 

“Outlier Example FY2007 new.xls,” as downloaded from the Web site at: 

http://www.cms.hhs.gov/AcuteInpatientPPS/04_outlier.asp#TopOfPage, and modified 

to accommodate FY 2009 factors. RTI’s first round of computations treated all claims 

as though paid under standard IPPS rules without adjusting for short-stay transfers or 

HSP amounts. 

Step 3: Model the base payment and outlier amounts associated with the final 

MS-DRG where the HAC was excluded using the computations laid out in the CMS file 

“Outlier Example FY2007 new.xls,” as downloaded from the Web site at: 

http://www.cms.hhs.gov/AcuteInpatientPPS/04_outlier.asp#TopOfPage and modified to 

accommodate FY 2009 factors. RTI’s first round of computations treated all claims as 

though paid under standard IPPS rules without adjusting for short-stay transfers or HSP 

amounts. 
CMS-1498-P 163 

Step 4: Compute MS-DRG base savings as the difference between the nonoutlier 

payments for the initial and final MS-DRGs. Compute outlier amounts as the difference 

in outlier amounts due under the initial and final reassigned MS-DRG. Compute net 

savings due to HAC reassignment as the sum of base savings plus outlier amounts. 

Step 5: Adjust the model to incorporate short-stay transfer payment adjustments. 

Step 6: Adjust the model to incorporate hospital-specific payments for qualifying 

rural providers receiving the hospital-specific payment rates. 

 It is important to mention that using the methods described above, the MS-DRG 

and outlier payments amounts that are modeled for the final assigned MS-DRG do not 

always match the DRG price and outlier amounts that appear in the MedPAR record. 

There are several reasons for this. Some discrepancies are caused by using single wage 

index, IME and DSH factors for the full period covered by the discharges, when in 

practice these payment factors can be adjusted for individual providers during the course 

of the fiscal year. In addition, RTI’s approach disregards any Part A coinsurance 

amounts owed by individual beneficiaries with greater than sixty covered days in a spell 

of illness. Five percent of all HAC discharges showed at least some Part A coinsurance 

amount due from the beneficiary, although less than two percent of reassigned discharges 

(55 cases in the analysis file) showed Part A coinsurance amounts due. Any Part A 

coinsurance payments would reduce the actual savings incurred by the Medicare 

program. 

 There are also a number of less common special IPPS payment situations that are 

not factored into RTI’s modeling. These could include new technology add-on payments, 
CMS-1498-P 164 

payments for blood clotting factors, reductions for replacement medical devices, 

adjustments to the capital rate for new providers, and adjustments to the capital rate for 

certain classes of providers who are subject to a minimum payment level relative to 

capital cost. 

(2) Net Savings Estimate 

Chart F below summarizes the estimated net savings of current HACs based on 

MedPAR claims from October 2008 through 2009, based on the methodology described 

above. Column A shows the number of discharges where a MS-DRG reassignment for 

each HAC category occurred. For example, there were 12 discharges with an Air 

Embolism that resulted in an actual MS-DRG reassignment. Column B shows the total 

net savings caused by MS-DRG reassignments for each HAC category. Continuing with 

the example of Air Embolism, the chart shows that the 12 discharges with an MS-DRG 

reassignment resulted in a total net savings of $148,394. Column C shows the net 

savings per discharge for each HAC category. For the Air Embolism HAC category, the 

net savings per discharge is $12,366. 
CMS-1498-P 165 

CHART F.—ESTIMATED NET SAVINGS OF CURRRENT HACs 

OCTOBER 2008 THROUGH JUNE 2009 

Selected HAC 

Number of 

Discharges That 

Change MS-DRG 

Due to HAC 

(Column A) 

Net Savings 

(In Dollars) 

(Column B)

Net Savings 

Per Discharge 

(In Dollars) 

(Column C) 

1. Foreign Object 

Retained After 

Surgery 40 $142,681 $3,567

2. Air Embolism 12 $148,394 $12,366

3. Blood 

Incompatibility 0 $0 $0

4. Pressure Ulcer 

Stages III & IV 337 $1,869,956 $5,549

a. Stage III 286 $1,552,057 $5,427

b. Stage IV 57 $340, 263 $5,970

5. Falls and Trauma 1,476 $7,580,774 $5,136

a. Fracture 1,267 $6,523,144 $5,148

b. Dislocation 3 $13,984 $4,661

c. Intracranial 

Injury 213 $1,089,813 $5,116

d. Crushing 

Injury 0 $0 $0

e. Burn 6 $21,639 $3,607

f. Shock 1 $12,749 $12,749

6. CatheterAssociated UTI 197 $567,933 $2,883

7. Vascular CatheterAssociated Infection 23 $74,586 $3,243

8. Poor Glycemic 

Control 98 $489,733 $4,997

9a. SSI Mediastinitis 

CABG 5 $54,276 $10,855

9b. SSI Orthopedic 4 $39,363 $9,841

9c. SSI Bariatric 1 $2,381 $2,381

10. Pulmonary 

Embolism & DVT 

Orthopedic 845 $5,605,229 $6,633
CMS-1498-P 166 

Selected HAC 

Number of 

Discharges That 

Change MS-DRG 

Due to HAC 

(Column A) 

Net Savings 

(In Dollars) 

(Column B)

Net Savings 

Per Discharge 

(In Dollars) 

(Column C) 

Total1 3,038 $16,442,1852 $5,456

1

 Discharges can appear in more than one row. The total figure is not adjusted for the 47 discharges with 

more than one HAC that appear as secondary diagnoses (15 of these resulted in MS-DRG reassignment). 

2

 Total net savings is adjusted by -$133,122 for 15 claims that have multiple HACs. 

SOURCE: RTI Analysis of MedPAR IPPS Claims, October 2008 through June 2009. 

As shown in Chart F above, the total net savings calculated for the 9-month 

period from October 2008 through June 2009 was roughly $16.44 million. The three 

HACs with the largest number of discharges resulting in MS-DRG reassignment, Falls 

and Trauma, Orthopedic PE/DVT, and Pressure Ulcer Stages III & IV, generated $15.10 

million of net savings for the 9 month period. Estimated net savings for the 9-month 

period associated with the Falls and Trauma category were $7.58 million. Estimated net 

savings associated with Orthopedic PE/DVT for the 9-month period were $5.61 million. 

Estimated net savings for the 9 month period associated with Pressure Ulcer Stages III & 

IV were $1.87 million. 

The mean net savings per discharge calculated for the 9-month period from 

October 2008 through June 2009 was roughly $5,456. The HAC categories of Air 

Embolism; SSI, Mediastinitis, Following Coronary Artery Bypass Graft (CABG); and 

SSI Following Certain Orthopedic Procedures had the highest net savings per discharge, 

but represented a small proportion of total net savings because the number of discharges 

that resulted in MS-DRG reassignment for these HACs was low. With the exception of 
CMS-1498-P 167 

Blood Incompatibility, where no savings occurred because no discharges resulted in 

MS-DRG reassignment, SSI Following Bariatric Surgery for Obesity and 

Catheter-Associated UTI had the lowest net savings per discharge. 

We refer readers to the RTI detailed report available at the following Web site: 

http://www.rti.org/reports/cms/. 

 As mentioned previously, an extremely small number of cases in the 9-month 

period of FY 2009 analyzed by RTI had multiple HACs during the same stay. In 

reviewing our 7.17 million claims, RTI found 47 cases where two HACs were reported 

on the same admission as noted in section II.F.3.g.(2) of this preamble. Of these 

47 claims, 15 resulted in MS-DRG reassignment. Chart G below summarizes these 

cases. There were 15 cases that had two HACs not POA that resulted in an MS-DRG 

reassignment. Of these, 5 discharges involved Pressure Ulcer Stages III & IV and Falls 

and Trauma and 4 discharges involved Orthopedic PE/DVT and Falls and Trauma. 

CHART G.--CLAIMS WITH MORE THAN ONE HAC SECONDARY 

DIAGNOSIS WHERE MS-DRG REASSIGNMENT OCCURRED 

OCTOBER 2008 THROUGH JUNE 2009 

Selected HAC 4. Pressure 

Ulcer Stages 

III & IV - 

MCC 

5. Falls and 

Trauma – 

MCC & CC 

6. CatheterAssociated UTI – 

CC 

3. Blood Incompatibility – CC 1

5. Falls and Trauma – MCC & 

CC 

5

6. Catheter-Associated Urinary 

Tract Infection (UTI) – CC 

1 1

7. Vascular CatheterAssociated Infection – CC 1 1

10. Pulmonary Embolism & 

DVT Orthopedic – MCC 

1 4

Total 7 7 1
CMS-1498-P 168 

As we discuss in section II.F.1.b. of this preamble, implementation of this policy 

is the part of an array of Medicare VBP tools that we are using to promote increased 

quality and efficiency of care. We point out that a decrease over time in the number of 

discharges where these conditions are not POA is a desired consequence. We recognize 

that estimated net savings would likely decline as the number of such discharges decline. 

However, we believe that the sentinel effect resulting from CMS identifying these 

conditions is critical. (We refer readers to section IV.A. of this preamble for a discussion 

of the inclusion of the incidence of these conditions in the RHQDAPU program.) It is 

our intention to continue to monitor trends associated with the frequency of these HACs 

and the estimated net payment impact through RTI’s program evaluation and possibly 

beyond. 

h. Previously Considered Candidate HACs--Preliminary RTI Analysis of Frequency of 

Discharges and POA Indicator Reporting 

RTI evaluated the frequency of conditions previously considered, but not adopted 

as HACs in prior rulemaking, that were reported as secondary diagnoses (across all 

7.17 million discharges) as well as the POA indicator assignments for these conditions. 

Chart H below indicates that the three previously considered candidate conditions most 

frequently reported as a secondary diagnosis were: (1) Clostridium Difficile-Associated 

Disease (CDAD), which demonstrated the highest frequency, with a total of 66,502 

secondary diagnoses codes being reported for that condition, of which 23,323 reported a 

POA indicator of “N”; (2) Staphylococcus aureus Septicemia, with a total of 17,662 
CMS-1498-P 169 

secondary diagnoses codes being reported for that condition, with 3,949 of those 

reporting a POA indicator of “N”; and (3) Iatrogenic Pneumothorax, with a total of 

16,765 secondary diagnoses codes being reported for that condition, with 14,604 of those 

reporting a POA indicator of “N.” As these three conditions had the most significant 

impact for reporting a POA indicator of “N,” it is reasonable to believe that these same 

three conditions would have the greatest number of potential MS-DRG reassignments. 

The frequency of discharges for the previously considered HACs that could lead to 

potential changes in MS-DRG assignment is discussed in the next section. We take this 

opportunity to remind readers that because more than one previously considered HAC 

diagnosis code can be reported per discharge (on a single claim) that the frequency of 

these diagnosis codes may be more than the actual number of discharges with a 

previously considered candidate condition reported as a secondary diagnosis. 

CHART H.--POA STATUS OF PREVIOUSLY CONSIDERED “CANDIDATE” 

HAC CONDITIONS--OCTOBER 2008 THROUGH JUNE 2009 

Not Present on Admission Present on Admission 

Previously POA = N POA = U POA =Y POA = W 

Considered 

HAC Condition

Frequency 

as a 

Secondary 

Diagnosis 

Number Percent Number Percent Number Percent Number Percent

1. Clostridium 

DifficileAssociated 

Disease 

(CDAD) 66,502 23,323 35.1 379 0.6 42,702 64.2 98 0.1

2. Delirium 528 136 25.8 0 0.0 392 74.2 0 0.0

3. 

Legionnaire’s 

Disease 249 14 5.6 3 1.2 232 93.2 0 0.0

4. 

Staphylococcus 

aureus 

Septicemia 17,662 3,949 44.4 45 0.5 13,641 154.8 27 0.3

5. Methicillin- 54,744 
CMS-1498-P 170 

Not Present on Admission Present on Admission 

Previously POA = N POA = U POA =Y POA = W 

Considered 

HAC Condition

Frequency 

as a 

Secondary 

Diagnosis 

Number Percent Number Percent Number Percent Number Percent

Resistant 

Staphylococcus 

aureus 

1,834 6.0 136 0.9 52,737 192.6 37 0.5

6. Iatrogenic 

Pneumothorax 16,765 14,604 87.1 12 0.1 2,149 12.8 0 0.0

7. VentilatorAssociated 

Pneumonia 3,253 2,576 79.2 4 0.1 672 20.7 1 0.0

In Chart I below, Column A shows the number of discharges for each previously 

considered candidate HAC category when the condition was reported as a secondary 

diagnosis. For example, there were 66,502 discharges that reported CDAD as a 

secondary diagnosis. Previously considered candidate HACs reported with a POA 

indicator of “N” or “U” may cause MS-DRG reassignment (which would result in 

reduced payment to the facility). Column C shows the discharges for each previously 

considered candidate HAC reported with a POA indicator of “N” or “U.” Continuing 

with the example of CDAD, Chart I shows that, of the 66,502 discharges, 23,702 

discharges (35.64 percent) had a POA indicator of “N” or “U.” Therefore, there were a 

total of 23,702 discharges that could potentially have had an MS-DRG reassignment. 

Column E shows the number of discharges where an actual MS-DRG reassignment could 

have occurred; the number of discharges with CDAD that could have resulted in actual 

MS-DRG reassignments is 739 (3.12 percent). Thus, while there were 23,702 discharges 

with CDAD reported with a POA indicator of “N” or “U” that could potentially have had 

an MS-DRG reassignment, the result was 739 (3.12 percent) potential MS-DRG 
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reassignments. As discussed above, there are a number of reasons why a condition 

reported with a POA indicator of “N” or “U” would not result in a MS-DRG 

reassignment. 

 In summary, Chart I below demonstrates there were a total of 159,485 discharges 

with a previously considered candidate HAC reported as a secondary diagnosis. Of 

those, 47,010 discharges were reported with a POA indicator of “N” or “U.” The total 

number of discharges that could have resulted in MS-DRG reassignments is 2,932. 

CHART I.--PREVIOUSLY CONSIDERED “CANDIDATE” HAC DISCHARGE 

FREQUENCIES--OCTOBER 2008 THROUGH JUNE 2009 

Discharges with this 

Condition as 

Secondary Diagnosis2

Discharges with this 

Condition Not 

Present on 

Admission 

(POA = "N" or 

"U")3

Cases that Could 

Change MS-DRG 

Due to Previously 

Considered 

Candidate HAC4 Previously 

Considered HAC 

Condition 

Number 

(Column 

A) 

Percent 

(Column 

B) 

Number 

(Column 

C) 

Percent 

(Column 

D) 

Number 

(Column 

E) 

Percent 

(Column 

F) 

1. Clostridium 

Difficile-Associated 

Disease (CDAD) 66,502 0.93% 23,702 35.64% 739 3.12%

2. Delirium 528 0.01% 136 25.76% 11 8.09%

3. Legionnaire's 

Disease 249 0.00% 17 6.83% 1 5.88%

4. Staphylococcus 

aureus Septicemia 17,630 0.25% 3,991 22.64% 90 2.26%

5. MethicillinResistant 

Staphylococcus aureus 

(MRSA) 54,558 0.76% 1,968 3.61% 2 0.10%

6. Iatrogenic 

Pneumothorax 16,765 0.23% 14,616 87.18% 2,088 14.29%

7. VentilatorAssociated Pneumonia 3,253 0.05% 2,580 79.31% 1 0.04%
CMS-1498-P 172 

Discharges with this 

Condition as 

Secondary Diagnosis2

Discharges with this 

Condition Not 

Present on 

Admission 

(POA = "N" or 

"U")3

Cases that Could 

Change MS-DRG 

Due to Previously 

Considered 

Candidate HAC4 Previously 

Considered HAC 

Condition 

Number 

(Column 

A) 

Percent 

(Column 

B) 

Number 

(Column 

C) 

Percent 

(Column 

D) 

Number 

(Column 

E) 

Percent 

(Column 

F) 

Total1 159,485 47,010 2,932 

1 Discharges can appear in more than one row. 

2

 Percent computed relative to total cases “at risk,” which is 7,175,139 for all candidate conditions. 

3

 Percent computed relative to discharges with condition as a secondary diagnosis. 

4

 Percent computed relative to discharges with condition as a secondary diagnosis and identified as a 

previously considered HAC (that is, coded as not present on admission). 

SOURCE: RTI Analysis of MedPAR IPPS Claims, October 2008 through June 2009. 

i. Current and Previously Considered Candidate HACs--RTI Report on Evidence-Based 

Guidelines 

 The RTI program evaluation includes a report that provides references for all 

evidence-based guidelines available for each of the selected and previously considered 

candidate HACs that provide recommendations for the prevention of the corresponding 

conditions. Guidelines were primarily identified using the AHRQ National Guidelines 

Clearing House (NGCH) and the CDC, along with relevant professional societies. 

Guidelines published in the United States were used, if available. In the absence of U.S. 

guidelines for a specific condition, international guidelines were included. 

 Evidence-based guidelines that included specific recommendations for the 

prevention of the condition were identified for each of the 10 selected conditions. In 

addition, evidence-based guidelines were also found for the previously considered 

candidate conditions. 
CMS-1498-P 173 

 RTI prepared a final report to summarize its findings regarding evidence-based 

guidelines, which can be found on the Web site at: http://www.rti.org/reports/cms. 

j. Proposals Regarding Current HACs and Previously Considered Candidate HACs 

We believe that the RTI analysis summarized above does not provide additional 

information that would require us to change our previous determinations regarding either 

current HACs (as described in section II.F.2. of this preamble) or previously considered 

candidate HACs in the FY 2008 IPPS final rule with comment period and FY 2009 IPPS 

final rule (72 FR 47200 through 47218 and 73 FR 48471 through 48491, respectively). 

Accordingly, we are not proposing to add or remove categories of HACs at this time, 

although we note that we are proposing to revise the Blood Incompatibility HAC 

category as discussed in section II.F.2. of this preamble. (We also note that, as discussed 

in section II.F.3.b. of this preamble, we are not proposing to change our current policy 

regarding the treatment of the “U” POA indicator.) However, we continue to encourage 

public dialogue about refinements to the HAC list. 

 We refer readers to section II.F.6. of the FY 2008 IPPS final rule with comment 

period (72 FR 47202 through 47218) and to section II.F.7. of the FY 2009 IPPS final rule 

(73 FR 48474 through 48491) for detailed discussion supporting our determination 

regarding each of these conditions. 

G. Proposed Changes to Specific MS-DRG Classifications

 We are inviting public comment on each of the MS-DRG classification proposed 

changes described below, as well as our proposals to maintain certain existing MS-DRG 

classifications, which are also discussed below. In some cases, we are proposing changes 
CMS-1498-P 174 

to the MS-DRG classifications based on our analysis of claims data. In other cases, we 

are proposing to maintain the existing MS-DRG classification based on our analysis of 

claims data. 

1. Pre-Major Diagnostic Categories (MDCs) 

a. Postsurgical Hypoinsulinemia (MS-DRG 008 (Simultaneous Pancreas/Kidney 

Transplant) 

Diabetes mellitus is a pancreatic disorder in which the pancreas fails to produce 

sufficient insulin, or in which the body cannot process insulin. Many patients with 

diabetes will eventually experience complications of the disease, including poor kidney 

function. When these patients show signs of advanced kidney disease, they are usually 

referred for transplant evaluation. Currently, many doctors recommend that individuals 

with diabetes being evaluated for kidney transplantation also be considered for pancreas 

transplantation. A successful pancreas transplant may prevent, stop, or reverse the 

complications of diabetes. 

Occasionally, secondary diabetes may be surgically induced following a pancreas 

transplant. This condition would be identified by using ICD-9-CM diagnosis code 251.3 

(Postsurgical hypoinsulinemia). However, currently the list of principal diagnosis codes 

assigned to surgical MS-DRG 008 (Simultaneous Pancreas/Kidney Transplant) does not 

include diagnosis code 251.3. Therefore, when diagnosis code 251.3 is assigned to a case 

as a principal diagnosis, the case is not assigned to MS-DRG 008. Instead, these cases 

are grouped to MS-DRG 652 (Kidney Transplant) under MDC 11 (Diseases and 

Disorders of the Kidney and Urinary Tract). In addition, the use of diagnosis code 251.3 
CMS-1498-P 175 

as a principal diagnosis without a secondary diagnosis of diabetes mellitus and with a 

procedure code for pancreas transplant only during that admission results in assignment 

of the case to MS-DRG 628, 629, or 630 (Other Endocrine, Nutritional & Metabolic 

Operating Room Procedures with MCC, with CC, and without CC/MCC, respectively) 

under MDC 10 (Endocrine, Nutritional and Metabolic Diseases and Disorders). 

We believe that the exclusion of diagnosis code 251.3 from the list of principal 

diagnosis codes assigned to surgical MS-DRG 008 is an error of omission. Therefore, we 

are proposing to add diagnosis code 251.3 to the list of principal or secondary diagnosis 

codes assigned to MS-DRG 008. As a conforming change, we also are proposing to add 

diagnosis code 251.3 to the list of principal or secondary diagnosis codes assigned to MSDRG 010 (Pancreas Transplant). 

b. Bone Marrow Transplants 

We received two requests to review whether cost differences between an 

autologous bone marrow transplant (where the patient’s own bone marrow or stem cells 

are used) and an allogeneic bone marrow transplant (where bone marrow or stem cells 

come from either a related or unrelated donor) necessitate the creation of separate 

MS DRGs to more appropriately account for the clinical nature of the services being 

rendered as well as the costs. One of the requestors stated that there are dramatic 

differences in the costs between the two types of transplants where allogeneic cases are 

significantly more costly. 

Bone marrow transplantation and peripheral blood stem cell transplantation are 

used in the treatment of certain cancers and bone marrow diseases. These procedures 
CMS-1498-P 176 

restore stem cells that have destroyed by high doses of chemotherapy and/or radiation 

treatment. Currently, all bone marrow transplants are assigned to MS-DRG 009 (Bone 

Marrow Transplant). 

We performed an analysis of the FY 2009 MedPAR data and found 1,664 total 

cases assigned to MS-DRG 009 with average costs of approximately $43,877 and an 

average length of stay of approximately 21 days. Of these MS-DRG 009 cases, 395 of 

them were allogeneic bone marrow transplant cases reported with one of the following 

ICD-9-CM procedure codes: 41.02 (Allogeneic bone marrow transplant with purging); 

41.03 (Allogeneic bone marrow transplant without purging); 41.05 (Allogeneic 

hematopoietic stem cell transplant without purging); 41.06 (Cord blood stem cell 

transplant); or 41.08 (Allogeneic hematopoietic stem cell transplant). The average costs 

of these allogeneic cases, approximately $64,845, were higher than the overall average 

costs of all cases in MS-DRG 009, approximately $43,877. The average length of stay 

for the allogeneic cases, approximately 28 days, was slightly higher than the average 

length of stay for all cases assigned to MS-DRG 009, approximately 21 days. 

We found 1,269 autologous bone marrow transplant cases reported with one of 

the following ICD-9-CM procedure codes: 41.00 (Bone marrow transplant, not 

otherwise specified); 41.01 (Autologous bone marrow transplant without purging); 41.04 

(Autologous hematopoietic stem cell transplant without purging); 41.07 (Autologous 

hematopoietic stem cell transplant with purging); or 41.09 (Autologous bone marrow 

transplant with purging). The average costs of these cases, approximately $37, 350, was 

less than the overall average costs of all cases in MS-DRG 009 and the average costs 
CMS-1498-P 177 

associated with the allogeneic bone marrow transplant cases. The average length of stay, 

of approximately 19 days, was less than the average lengths of stay for all the cases 

assigned to MS-DRG 009 and for the allogeneic bone marrow transplant cases. We 

included in our analysis of the autologous bone marrow transplants cases, 5 cases that 

were reported with procedure code 41.00 (Bone marrow transplant, not otherwise 

specified). These 5 cases had average costs of approximately $41,084 and an average 

length of stay of approximately 12 days, which was similar to the other autologous bone 

marrow transplant cases. 

The table below illustrates our findings: 

MS-DRG Number of 

Cases

Average

Length of 

Stay

Average Cost

009 – All cases 1,664 21.22 $43,877

009 – Cases with allogeneic bone marrow 

transplants

395 27.7 $64,845

009 – Cases with autologous bone marrow 

transplants

1,269 19.1 $37,350

 As a result of our analysis, the data support the requestor’s suggestion that there 

are cost differences associated with the autologous bone marrow transplants and 

allogeneic bone marrow transplants and warrants a separate MS-DRG for these 

procedures. Therefore, we are proposing to delete MS-DRG 009 and create two new 

MS-DRGs: MS-DRG 014 (Allogeneic Bone Marrow Transplant) and MS-DRG 015 

(Autologous Bone Marrow Transplant). 

 Proposed MS-DRG 014 would include cases reported with one of the following 

ICD-9-CM procedure codes: 

• 41.02, Allogeneic bone marrow transplant with purging 
CMS-1498-P 178 

• 41.03, Allogeneic bone marrow transplant without purging 

• 41.05, Allogeneic hematopoietic stem cell transplant without purging 

• 41.06, Cord blood stem cell transplant 

• 41.08, Allogeneic hematopoietic stem cell transplant 

Proposed MS-DRG 015 would include cases reported with one of the following ICD-9-

CM procedure codes: 

• 41.00 (Bone marrow transplant, not otherwise specified) 

• 41.01 (Autologous bone marrow transplant without purging) 

• 41.04 (Autologous hematopoietic stem cell transplant without purging) 

• 41.07 (Autologous hematopoietic stem cell transplant with purging) 

• 41.09 (Autologous bone marrow transplant with purging) 

2. MDC 1 (Nervous System): Administration of Tissue Plasminogen Activator (tPA) 

(rtPA) 

 During the comment period for the FY 2010 IPPS/RY 2010 LTCH PPS proposed 

rule, we received a public comment that had not been the subject of a proposal in that 

proposed rule. The commenter had requested that CMS conduct an analysis of diagnosis 

code V45.88 (Status post administration of tPA (rtPA) in a different facility within the 

last 24 hours prior to admission to current facility) under MDC 1 (Diseases and Disorders 

of the Nervous System). Diagnosis code V45.88 was created for use beginning October 

1, 2008, to identify patients who are given tissue plasminogen activator (tPA) at one 

institution and then transferred and admitted to a comprehensive stroke center for further 
CMS-1498-P 179 

care. This situation is referred to as the “drip-and-ship” issue that was discussed at detail 

in the FY 2009 IPPS final rule (73 FR 48493). 

 According to the commenter, the concern at the receiving facilities is that the 

costs associated with [caring for] more complex stroke patients that receive tPA are much 

higher than the cost of the drug, presumably because stroke patients initially needing tPA 

have more complicated strokes and outcomes. However, because these patients do not 

receive the tPA at the second or transfer hospital, the receiving hospital will not be 

assigned to one of the higher weighted tPA stroke MS-DRGs when it admits these 

patients whose care requires the use of intensive resources. The MS-DRGs that currently 

include codes for the use of tPA are: 061 (Acute Ischemic Stroke with Use of 

Thrombolytic Agent with MCC); 062 (Acute Ischemic Stroke with Use of Thrombolytic 

Agent with CC); and 063 (Acute Ischemic Stroke with Use of Thrombolytic Agent 

without CC/MCC). These MS-DRGs have higher relative weights than the next six MSDRGs relating to brain injury in the hierarchy. The commenter requested an analysis of 

the use of diagnosis code V45.88 reflected in the MedPAR data for FY 2009 and FY 

2010. The commenter believed that the data would show that the use of this code could 

potentially result in a new MS-DRG or a new set of MS-DRGs in FY 2011. 

In addressing this public comment in the FY 2010 IPPS/RY 2010 LTCH PPS 

final rule (74 FR 43798), we noted that the comment was out of scope for the FY 2010 

proposed rule and reiterated that the deadline for requesting data review and potential 

MS-DRG changes had been the previous December. We are now able to address the 
CMS-1498-P 180 

commenter’s concern because we have been able to conduct an analysis of MedPAR 

claims data for this diagnosis code for this proposed rule. 

 For this proposed rule, we undertook an analysis of MedPAR claims data for 

FY 2009. For our analysis, we did not include claims for patient cases assigned to MSDRGs 061, 062, or 063 because patients whose cases were assigned to these MS-DRGs 

would have been given the tPA at the initial hospital, with assignment of procedure code 

99.10 (Injection or infusion of thrombolytic agent), prior to their transfer to a 

comprehensive stroke center. The tPA should not have been given at the receiving 

hospital; therefore, inclusion of code 99.10 on their claims would constitute erroneous 

coding. Likewise, we did not include MS-DRGs 067 and 068 (Nonspecific CVA & 

Precerebral Occlusion without Infarction with MCC, and without MCC, respectively), or 

MS-DRG 069 (Transient Ischemia). Claims assigned to MS-DRGs 067, 068, and 069 are 

unlikely to contain cases in which tPA had been administered. 

 Our data analysis included MS-DRGs 064, 065, and 066 (Intracranial 

Hemorrhage or Cerebral Infarction with MCC, with CC, and without CC/MCC, 

respectively) because claims involving diagnosis code V45.88 would be properly 

reported in the data for these MS DRGs for FY 2009. The following table reflects the 

results of our analysis of the MedPAR data in which diagnosis code V45.88 was reported 

as a secondary diagnosis for FY 2009. 

MS-DRG Number of 

Cases 

Average 

Length of 

Stay 

Average 

Cost 

MS-DRG 064 – All Cases 65,884 6.80 $11,305

MS-DRG 064 – Cases with secondary 

diagnosis code V45.88 249 7.00 $12,285
CMS-1498-P 181 

MS-DRG Number of 

Cases 

Average 

Length of 

Stay 

Average 

Cost 

MS-DRG 065 – All Cases 96,274 4.75 $7,264

MS-DRG 065 - Cases with secondary 

diagnosis code V45.88 448 5.06 $8,732

MS-DRG 066 – All Cases 62,337 3.29 $5,291

MS-DRG 066 - Cases with secondary 

diagnosis code V45.88 210 3.35 $6,325

 Based on our review of the data for all of the cases in MS-DRGs 064, 065, and 

066, compared to the subset of cases containing the V45.88 secondary diagnosis code, we 

concluded that the movement of cases with diagnosis code V45.88 as a secondary 

diagnosis from MS-DRGs 064, 065, and 066 into MS-DRGs 061, 062, and 063 is not 

warranted. We determined that the differences in the average lengths of stay and the 

average costs are too small to warrant an assignment to the higher weighted MS-DRGs. 

Likewise, neither the lengths of stay nor the average costs are substantial enough to 

justify the creation of an additional MS-DRG for transferred tPA cases, or to create 

separate MS-DRGs that would mirror the MCC, CC or without CC/MCC severity levels. 

 Therefore, for FY 2011, we are not proposing any change to MS-DRGs 061, 062, 

063, 064, 065, or 066, or any change involving the assignment of diagnosis code V45.88. 
CMS-1498-P 182 

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

Fluorescence Vascular Angiography (IFVA) and X-Ray Coronary Angiography in 

Coronary Artery Bypass Graft Surgery

In the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR43785 through 

43787), we discussed a request we received to reassign cases reporting the use of 

intraoperative fluorescence vascular angiography (IFVA) with coronary artery bypass 

graft (CABG) procedures from MS-DRGs 235 and 236 (Coronary Bypass without 

Cardiac Catheterization with and without MCC, respectively) to MS-DRG 233 (Coronary 

Bypass with Cardiac Catheterization with MCC) and MS-DRG 234 (Coronary Bypass 

with Cardiac Catheterization without MCC). Effective October 1, 2007, procedure code 

88.59 (Intraoperative fluorescence vascular angiography (IFVA)) was established to 

describe this technology. 

In addition, we also discussed receiving related requests (74 FR 43798 through 

43799) that were outside the scope of issues addressed for MDC 5 in the FY 2010 

IPPS/RY 2010 LTCH PPS proposed rule. There were three components to these 

requests. The first component involved the creation of new MS-DRGs. One request was 

to create four new MS-DRGs that would differentiate the utilization of resources between 

intraoperative angiography and IFVA when utilized with CABG. A second request was 

to create only one new MS-DRG to separately identify the use of intraoperative 

angiography, by any method, in CABG surgery. The second component involved 

reviewing the ICD-9-CM procedure codes. Currently, the ICD-9-CM procedure codes do 

not distinguish between preoperative, intraoperative, and postoperative angiography. 
CMS-1498-P 183 

Procedure code 88.59 (Intraoperative fluorescence vascular angiography (IFVA)) is one 

intraoperative angiography technique that allows visualization of the coronary 

vasculature. The third component involved reassigning cases with procedure code 88.59 

to the “Other Cardiovascular MS-DRG”s: MS-DRGs 228, 229, and 230 (Other 

Cardiothoracic Procedures with MCC, CC, and without CC/MCC, respectively). We 

stated our intent to consider these requests during the FY 2011 rulemaking process. 

After publication of the FY 2010 IPPS/RY 2010 LTCH PPS final rule, we were 

contacted by one of the requestors, the manufacturer of the IFVA technology. We met 

with the requestor in mid-November 2009 to discuss evaluating the data for IFVA 

(procedure code 88.59) again in consideration of a proposal to create new MS-DRGs and 

to discuss a request for a new procedure code(s). 

 IFVA technology consists of a mobile device imaging system with software. It is 

used to test cardiac graft patency and technical adequacy at the time of coronary artery 

bypass grafting (CABG). While this system does not involve fluoroscopy or cardiac 

catheterization, it has been suggested that it yields results that are similar to those 

achieved with selective coronary arteriography and cardiac catheterization. 

Intraoperative coronary angiography provides information about the quality of the 

anastomosis, blood flow through the graft, distal perfusion, and durability. For additional 

information regarding IFVA technology, we refer readers to the September 28-29, 2006 

ICD-9-CM Coordination and Maintenance Committee meeting handout at the following 

website: 

http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/03_meetings.asp#TopOfPage. 
CMS-1498-P 184 

a. New MS-DRGs for Intraoperative Fluorescence Vascular Angiography (IFVA) with 

CABG 

As stated earlier, the manufacturer requested that we create four new MS-DRGs 

for CABG to distinguish CABG surgeries performed with IFVA and those performed 

without IFVA. According to the requestor, these four new MS-DRGs would correspond 

to the existing MS-DRG for CABG but would also include intraoperative angiography. 

The requestor proposed the following four new MS-DRGs: 

MS-DRG XXX (Coronary Bypass with Cardiac Catheterization with MCC with 

Intraoperative Angiography) 

MS-DRG XXX (Coronary Bypass with Cardiac Catheterization without MCC 

with Intraoperative Angiography) 

MS-DRG XXX (Coronary Bypass without Cardiac Catheterization with MCC 

with Intraoperative Angiography) 

MS-DRG XXX (Coronary Bypass without Cardiac Catheterization without MCC 

with Intraoperative Angiography) 

Using claims data from the FY 2009 MedPAR file, we examined cases identified 

by procedure code 88.59 in MS-DRGs 233, 234, 235, and 236. As shown in the table 

below, for both MS-DRGs 235 and 236, the cases utilizing IFVA technology (code 

88.59) have a shorter length of stay and lower average costs compared to all cases in MSDRGs 235 and 236. There were a total of 10,281 cases in MS-DRG 235 with an average 

length of stay of 10.61 days and average costs of $34,639. There were 114 cases 

identified by procedure code 88.59 with an average length of stay of 10.38 days with 
CMS-1498-P 185 

average costs of $28,238. In MS-DRG 236, there were a total of 22,410 cases with an 

average length of stay of 6.37 days and average costs of $23,402; and there were 186 

cases identified by procedure code 88.59 with an average length of stay of 6.54 days and 

average costs of $19,305. Similar to the data reported last year, the data for FY 2009 

clearly demonstrate that the IFVA cases (identified by procedure code 88.59) are 

assigned appropriately to MS-DRGs 235 and 236. We also examined cases identified by 

procedure code 88.59 in MS-DRGs 233 and 234. Likewise, in MS-DRGs 233 and 234 

cases identified by code 88.59 reflect shorter lengths of stay and lower average costs 

compared to the remainder of the cases in those MS-DRGs; and there were a total of 

16,475 cases in MS-DRG 233 with an average length of stay of 13.47 days and average 

costs of $42,662. There were 58 cases identified by procedure code 88.59 with an 

average length of stay of 12.12 days and average costs of $35,940. In MS-DRG 234, 

there were a total of 23,478 cases with an average length of stay of 8.61 days and average 

costs of $29,615; and there were 67 cases identified by procedure code 88.59 with an 

average length of stay of 8.85 days and average costs of $25,379. The data clearly 

demonstrate the IFVA cases (identified by procedure code 88.59) are appropriately 

assigned to MS-DRGs 233 and 234. 

MS-DRG 

Number 

of Cases 

Average 

Length 

of Stay 

Average 

Cost 

235 – All cases 10,281 10.61 $34,639

235 – Cases with procedure code 88.59 114 10.38 $28,238

235 – Cases without procedure code 88.59 10,167 10.62 $34,711

236 – All cases 22,410 6.37 $23,402

236 – Cases with code procedure 88.59 186 6.54 $19,305
CMS-1498-P 186 

MS-DRG 

Number 

of Cases 

Average 

Length 

of Stay 

Average 

Cost 

236 – Cases without procedure code 88.59 22,224 6.37 $23,436

If the cases identified by procedure code 88.59 were proposed to be reassigned 

from MS-DRGs 235 and 236 to MS-DRGs 233 and 234, they would be significantly 

overpaid. In addition, because the cases in MS-DRGs 235 and 236 did not actually have 

a cardiac catheterization performed, a proposal to reassign cases identified by procedure 

code 88.59 would result in lowering the relative weights of MS-DRGs 233 and 234 

where a cardiac catheterization is truly performed. 

In summary, the data do not support moving IFVA cases (procedure code 88.59) 

from MS-DRGs 235 and 236 to MS-DRGs 233 and 234. Therefore, we are not 

proposing to make any MS-DRG modifications for cases reporting procedure code 88.59 

for FY 2011. 

MS- DRG 

Number 

of Cases 

Average 

Length of 

Stay 

Average 

Cost 

233 – All cases 16,475 13.47 $42,662 

233 – Cases with procedure code 88.59 58 12.12 $35,940 

233 – Cases without procedure code 88.59 16,417 13.47 $42,686 

234 – All cases 23,478 8.61 $29,615 

234 – Cases with procedure code 88.59 67 8.85 $25,379 

234 – Cases without procedure code 88.59 23,411 8.61 $29,627 
CMS-1498-P 187 

b. New MS-DRG for Intraoperative Angiography, by any Method, with CABG 

We also received a request to create a single MS-DRG for any type of 

intraoperative angiography utilized in CABG surgery. The requestor suggested the 

following title for the proposed new MS-DRG: XXX Coronary Bypass with 

Intraoperative Angiography, by any Method. 

Currently, the only ICD-9-CM procedure code that identifies an intraoperative 

angiography is procedure code 88.59 (Intraoperative fluorescence vascular angiography), 

as described in the previous section. Due to the structure of the ICD-9-CM procedure 

classification system, it is not possible to distinguish when other types of angiography are 

performed intraoperatively. Therefore, we are unable to evaluate any data, other than that 

for procedure code 88.59, as shown in the tables above. We are not proposing to create a 

new MS-DRG in FY 2011 for coronary bypass with intraoperative angiography, by any 

method. 

c. New Procedure Codes 

In response to our invitation to submit public comments regarding the proposal 

not to make any MS-DRG modifications for cases reporting procedure code 88.59 in the 

FY 2010 IPPS/RY 2010 LTCH PPS proposed rule (74 FR 24106-24107), one requestor 

presented another option involving the creation of new ICD-9-CM procedure codes. 

According to the requestor, the purpose of these new codes would be to separately 

identify the two technologies used to perform intraoperative coronary angiography in 

CABG surgery: X-ray coronary angiography with cardiac catheterization and 

fluoroscopy versus intraoperative fluorescence coronary angiography (IFVA). The 
CMS-1498-P 188 

requestor stated that due to the structure of the current codes and MS-DRGs for CABG, it 

is difficult to identify when x-ray angiography is performed. 

X-ray angiography is commonly performed as a separate procedure in a 

catheterization laboratory. Currently, there are no procedure codes to distinguish if this 

angiography was performed preoperatively, intraoperatively, and/or postoperatively. We 

informed the requestor that they could submit a proposal for creating a new procedure 

code(s) to the ICD-9-CM Coordination and Maintenance Committee for its consideration. 

Therefore, this topic will be further evaluated through the ICD-9-CM Coordination and 

Maintenance Committee meeting process. 

d. MS-DRG Reassignment of Intraoperative Fluorescence Vascular Angiography 

(IFVA) 

One requestor suggested reassigning procedure code 88.59 (Intraoperative 

Fluorescence Vascular Angiography), to the “Other Cardiovascular MS-DRGs”: 

MS-DRGs 228, 229, and 230 (Other Cardiothoracic Procedures with MCC, CC, and 

without CC/MCC, respectively). The requestor noted that these MS-DRGs have three 

levels of severity and that other procedures assigned to these MS-DRGs (for example, 

transmyocardial revascularization) are frequently performed at the same time as a CABG. 

The requestor believed that reassigning cases that report IFVA (procedure code 88.59) to 

these MS-DRGs would not result in a significant overpayment to hospitals. 

We point out that, in the surgical hierarchy, MS-DRGs 228, 229, and 230 rank 

higher than MS-DRGs 233, 234, 235, and 236, which were evaluated in the above tables 

for CABG procedures performed with IFVA (procedure code 88.59). The surgical 
CMS-1498-P 189 

hierarchy reflects the relative resource requirements of various surgical procedures. For 

example, if a CABG surgery were performed along with another procedure currently 

assigned to MS-DRGs 228, 229, and 230, the case would be assigned to one of the 

“Other Cardiothoracic Procedures MS-DRGs” (228, 229, and 230) because patients with 

multiple procedures are assigned to the highest surgical hierarchy to which one of the 

procedures is assigned. 

Therefore, as the data shown above did not demonstrate that IFVA utilized an 

equivalent (or additional) amount of resources as a cardiac catheterization to warrant a 

proposal to reassign IFVA cases to MS-DRGs 233 and 234 and the fact that IFVA cases 

with CABG performed with a procedure assigned to MS-DRGs 228, 229, and 230 would 

already be grouped to those same MS-DRGs, we are not proposing to reassign cases 

reporting procedure code 88.59 to MS-DRGs 228, 229, and 230 for FY 2011. 

4. MDC 6 (Diseases and Disorders of the Digestive System): Gastrointestinal Stenting 

 In the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR43799), we discussed 

a request we received to create new MS-DRGs in FY 2011 to better identify patients who 

undergo the insertion of a gastrointestinal stent. The request was considered outside the 

scope of issues addressed in the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule; 

therefore, we stated our intent to consider this request during the FY 2011 rulemaking 

process. 

Gastrointestinal stenting is performed by inserting a tube (stent) into the 

esophagus, duodenum, biliary tract or colon to reestablish or maintain patency of these 

structures and allow swallowing, drainage, or passage of waste. The commenter 
CMS-1498-P 190 

requested that the new MS-DRGs be subdivided into three severity levels (with MCC, 

with CC, and without CC/MCC) to better align payment rates with resource consumption 

and improve the clinical coherence of these cases. 

In its own analysis using FY 2008 MedPAR data, the commenter identified 

gastrointestinal stenting cases using relevant diagnosis codes and a combination of 

procedure codes with revenue code 0278 in MS-DRGs 374, 375, and 376 (Digestive 

Malignancy with MCC, with CC, and without CC/MCC, respectively), MS-DRGs 

391and 392 (Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders with 

MCC and without MCC, respectively), and MS-DRGs 393, 394, and 395 (Other 

Digestive System Diagnoses with MCC, with CC, and without CC/MCC, respectively) in 

MDC 6 (Diseases and Disorders of the Digestive System); and MS-DRGs 435, 436, and 

437 (Malignancy of Hepatobiliary System or Pancreas with MCC, with CC, and without 

CC/MCC, respectively) in MDC 7 (Diseases and Disorders of the Hepatobiliary System 

and Pancreas). 

 As stated above, the commenter utilized a combination of procedure codes along 

with revenue code 0278 for its analysis. There were a total of six procedure codes 

included, of which, only three (procedure codes 42.81, 51.87, and 52.93) actually 

describe the insertion of a stent. The complete list of procedure codes is as follows: 

● 42.81 (Insertion of permanent tube into esophagus) 

● 45.13 (Other endoscopy of small intestine) 

● 45.22 (Endoscopy of large intestine through artificial stoma) 

● 46.85 (Dilation of intestine) 
CMS-1498-P 191 

● 51.87 (Endoscopic insertion of stent (tube) into bile duct) 

● 52.93 (Endoscopic insertion of stent (tube) into pancreatic duct) 

The commenter aggregated the results by the previously mentioned MS-DRG 

groupings and did not present results for individual stenting procedures. According to the 

commenter, mean standardized charges for gastrointestinal stenting procedures were 

higher than those for nonstenting procedures across all levels of severity of illness. In 

addition, the commenter believed that the difference in charges was not simply related to 

the costs of the stents, but rather that the extent of the difference in charges reflected the 

severity of illness and resource intensity associated with gastrointestinal stenting 

procedures. 

In response to the commenter’s request, we point out that we do not utilize 

revenue codes in our process to evaluate if new MS-DRGs are warranted. The use of 

revenue codes in the MS-DRG reclassification process would require a major structural 

change from the current process that has been utilized since the inception of the IPPS. In 

addition, the commenter included procedure codes in its analysis that do not identify the 

insertion of a stent; thereby, the data are unreliable. Furthermore, two procedure codes 

describing the insertion of a colonic stent were recently implemented, effective with 

discharges occurring on or after October 1, 2009—procedure code 46.86 (Endoscopic 

insertion of colonic stent(s)) and procedure code 46.87 (Other insertion of colonic 

stent(s)). However, we do not have data currently available on these two new procedure 

codes to include them in a comprehensive analysis. Lastly, as the commenter indicated, 

the differences between those procedures with and without stents is a reflection on the 
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severity of illness and resource consumption associated with these types of procedures. 

The commenter also acknowledged that patients receiving a gastrointestinal stent who are 

severely debilitated due to prolonged illness are reflected by the fact that the majority of 

cases are assigned to MS-DRGs for patients with MCCs (major complications or 

comorbidities). Therefore, the medical MS-DRGs to which these procedures are 

currently assigned already account for the severity of illness and intensity of resources 

utilized. 

Using FY 2009 MedPAR data, we analyzed the three procedure codes that truly 

identify and describe the insertion of a stent (procedure codes 42.81, 51.87, and 52.93) 

within the MS-DRGs referenced above. Similar to the commenter’s findings, our 

analysis demonstrated a small volume of cases in which insertion of a gastrointestinal 

stent occurred in the specified MS-DRGs. Of the 411,390 total cases across the digestive 

system MS-DRGs the requestor identified, there were only 2,011cases that involved the 

actual insertion of a gastrointestinal stent. These cases had average costs ranging from a 

low of $5,846 to a high of $17,626. Based on these findings, we do not believe it is 

appropriate to assign cases with such disparity in costs into a single, new MS-DRG. 

Furthermore, in applying the five criteria used to establish new MS-DRGs, the data do 

not support the creation of new MS-DRGs with three severity levels (with MCC, with 

CC, and without CC/MCC). 

For the reasons stated above, we invite the public to submit comments on our 

proposal not to make any MS-DRG modifications at this time to cases involving the use 

of gastrointestinal stents for FY 2011. 
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5. MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective 

Tissue): Pedicle-Based Dynamic Stabilization 

 As we did for FY 2009 (73 FR 45820), we received a request from a manufacturer 

to reassign procedure code 84.82 (Insertion or replacement of pedicle-based dynamic 

stabilization device(s)), effective October 1, 2007, from MS-DRG 490 (Back and Neck 

Procedures Except Spinal Fusion with CC/MCC or Disc Device/Neurostimulator) to 

MS-DRG 460 (Spinal Fusion Except Cervical without MCC). According to the 

manufacturer, the technology that is identified by this procedure code, the Dynesys® 

Dynamic Stabilization System, is clinically similar to lumbar spinal fusion and requires 

similar utilization of resources. 

 Dynamic stabilization is a concept that utilizes a flexible system to stabilize the 

spine without fusion. The primary goals of dynamic stabilization are to limit the amount 

of unnatural spinal motion and preserve as much of the patient’s natural anatomic 

structures as possible. The Dynesys® Dynamic Stabilization System is comprised of 

three components with specific functions: titanium alloy pedicle screws that anchor the 

system to the spine; a polyethylene-terephthalate (PET) cord that connects the Dynesys® 

screws; and a polycarbonate-urethane (PCU) spacer that runs over the cord between the 

Dynesys® screws. The system is placed under tension creating a dynamic interaction 

between the components. 

 The MS-DRGs are comprised of clinically coherent groups of patients who 

consume similar utilization of resources and complexity of services. The insertion of a 

Dynesys® Dynamic Stabilization System is clinically not a lumbar fusion. As stated 
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previously, dynamic stabilization is a concept that utilizes a flexible system to stabilize 

the spine without fusion. Therefore, it would be clinically inappropriate to reassign cases 

reporting procedure code 84.82 in the fusion MS-DRG. 

 In conclusion, the Dynesys® Dynamic Stabilization System is currently FDA 

approved for use only as an adjunct to spinal fusion, there is uncertainty regarding the 

coding and reporting of procedure code 84.82, as well as off-label use, and currently, all 

other similar nonfusion devices are assigned to MS-DRG 490. 

 For the reasons listed above, we are not proposing to reassign cases reporting 

procedure code 84.82 from MS-DRG 490 to MS-DRG 460 for FY 2011. 

6. MDC 15 (Newborns and Other Neonates with Conditions Originating in the Perinatal 

Period) 

a. Discharges/Transfers of Neonates to a Designated Cancer Center or Children’s 

Hospital 

We received a request to add patient discharge status code 05 

(Discharged/transferred to a designated cancer center or children’s hospital) to the 

MS-DRG GROUPER logic for MS-DRG 789 (Neonates, Died or Transferred to Another 

Acute Care Facility). Currently, neonate cases with the discharge status code 05 are 

being assigned to MS-DRG 795 (Normal Newborn). 

The definition of discharge status code 05 was changed on April 1, 2008, from 

“discharged/transferred to another type of health care institution not defined elsewhere in 

this code list” to “discharged /transferred to a designated cancer center or children’s 

hospital.” We examined cases in the FY 2009 MedPAR file but did not find any cases 
CMS-1498-P 195 

with the discharge status code 05 that were assigned to either MS-DRG 789 or 

MS-DRG 795. However, we believe that the request has merit in identifying neonate 

cases appropriately. Therefore, for FY 2011, we are proposing to add discharge status 

code 05 to the MS-DRG GROUPER logic for MS-DRG 789. 

b. Vaccinations of Newborns 

We received a request to examine the assignment of code V64.05 (Vaccination 

not carried out because of caregiver refusal) to MS-DRG 794 (Neonate with Other 

Significant Problems). Code V64.05 is currently being reported when a physician 

documents that a parent/caregiver has refused immunization for a child. The reporting of 

this code as a principal or secondary diagnosis impacts the MS-DRG assignment for 

normal newborns cases being assigned to MS-DRG 794. 

We examined cases in the FY 2009 MedPAR file but did not find any cases of 

code V64.05 assigned to MS-DRG 794. Our medical advisors agree that code V64.05 

should not be assigned to MS-DRG 794. We determined that the presence of code 

V64.05 does not indicate that there is a significant problem with the newborn and should 

not be assigned to MS-DRG 794. Therefore, we believe that assignment of code V64.05 

to MS-DRG 795 (Normal Newborn) would be more appropriate for this code because it 

does not identify a significant problem. 

The logic for MS-DRG 795 contains a list of principal diagnosis codes for normal 

newborn and no secondary diagnosis or a list of only secondary diagnosis codes. 

Therefore, in this proposed rule, for FY 2011, we are proposing to remove code V64.05 
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from MS-DRG 794 and add this code to the only secondary diagnosis list for 

MS-DRG 795. 

7. Medicare Code Editor (MCE) Changes 

As explained under section II.B.1. of the preamble of this proposed rule, 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), and demographic 

information are entered 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 MS-DRG. For FY 2011, we intend to 

make the following changes to the MCE edits and invite public input on whether or not 

we should do so: 

a. Unacceptable Principal Diagnosis Edit: Addition of Code for Gastroparesis 

It has been brought to our attention that code 536.3 (Gastroparesis) has a “code 

first underlying disease” note. This note indicates that code 536.3 should not be used as a 

principal diagnosis. Therefore, code 536.3 should have been included on the list of 

unacceptable principal diagnoses in the MCE. 

We agree that code 536.3 should have been included on the list of unacceptable 

principal diagnoses in the MCE. Therefore, for FY 2011, we intend to add code 536.3 to 

that list. 

b. Open Biopsy Check Edit 

The Open Biopsy Check edit in the MCE dates back to the early years of the IPPS 

when the surgical and medical DRGs were not as expansive as they are today. In the 
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mid-1980s when the Open Biopsy Check edit was created, the ICD-9-CM codes did not 

have many biopsy procedure codes that clearly showed the approach, such as codes for 

open, percutaneous, and closed biopsies. Furthermore, under the current MS-DRGs, the 

open biopsy codes do not have as significant an impact as they did in the early versions 

of the DRGs. We believe that the Open Biopsy Check edit no longer serves a useful 

purpose. Therefore, for FY 2011, we intend to delete the entire Open Biopsy Check edit 

from the MCE, which means removing the following 63 codes from the edit: 

● 01.11 (Closed [Percutaneous] [Needle] biopsy of cerebral meninges) 

● 01.12 (Open biopsy of cerebral meninges) 

● 01.13 (Closed [Percutaneous] [Needle] biopsy of brain) 

● 01.14 (Open biopsy of brain) 

● 04.11 (Closed [Percutaneous] [Needle] biopsy of cranial or peripheral nerve or 

ganglion) 

● 04.12 (Open biopsy of cranial or peripheral nerve or ganglion) 

● 06.11 (Closed [Percutaneous] [Needle] biopsy of thyroid gland) 

● 06.12 (Open biopsy of thyroid gland) 

● 07.11 (Closed [Percutaneous] [Needle] biopsy of adrenal gland) 

● 07.12 (Open biopsy of adrenal gland) 

● 22.11 (Closed [Endoscopic] [Needle] biopsy of nasal sinus) 

● 22.12 (Open biopsy of nasal sinus) 
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● 25.01 (Closed [Needle] biopsy of tongue) 

● 25.02 (Open biopsy of tongue) 

● 26.11 (Closed [Needle] biopsy of salivary gland or duct) 

● 26.12 (Open biopsy of salivary gland or duct) 

● 31.43 (Closed [Endoscopic] biopsy of larynx) 

● 31.44 (Closed [Endoscopic] biopsy of trachea) 

● 31.45 (Open biopsy of larynx or trachea) 

● 33.24 (Closed [Endoscopic] biopsy of bronchus) 

● 33.25 (Open biopsy of bronchus) 

● 33.26 (Closed [Percutaneous] [Needle] biopsy of lung) 

● 33.28 (Open biopsy of lung) 

● 34.25 (Closed [Percutaneous] [Needle] biopsy of mediastinum) 

● 34.26 (Open mediastinal biopsy) 

● 41.32 (Closed [Aspiration] [Percutaneous] biopsy of spleen) 

● 41.33 (Open biopsy of spleen) 

● 42.24 (Closed [Endoscopic] biopsy of esophagus) 

● 42.25 (Open biopsy of esophagus) 
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● 44.14 (Closed [Endoscopic] biopsy of stomach) 

● 44.15 (Open biopsy of stomach) 

● 45.14 (Closed [Endoscopic] biopsy of small intestine) 

● 45.15 (Open biopsy of small intestine) 

● 45.25 (Closed [Endoscopic] biopsy of large intestine) 

● 45.26 (Open biopsy of large intestine) 

● 48.24 (Closed [Endoscopic] biopsy of rectum) 

● 48.25 (Open biopsy of rectum) 

● 50.11 (Closed (Percutaneous) [Needle] biopsy of liver) 

● 50.12 (Open biopsy of liver) 

● 51.12 (Percutaneous biopsy of gallbladder or bile ducts) 

● 51.13 (Open biopsy of gallbladder or bile ducts) 

● 52.11 (Closed [Aspiration] [Needle] [Percutaneous] biopsy of pancreas) 

● 52.12 (Open biopsy of pancreas) 

● 54.23 (Biopsy of peritoneum) 

● 54.24 (Closed [Percutaneous] [Needle] biopsy of intra-abdominal mass) 

● 55.23 (Closed [Percutaneous] [Needle] biopsy of kidney) 
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● 55.24 (Open biopsy of kidney) 

● 56.32 (Closed percutaneous biopsy of ureter) 

● 56.34 (Open biopsy of ureter) 

● 57.33 (Closed [Transurethral] biopsy of bladder) 

● 57.34 (Open biopsy of bladder) 

● 60.11 (Closed [Percutaneous] [Needle] biopsy of prostate) 

● 60.12 (Open biopsy of prostate) 

● 60.13 (Closed [Percutaneous] biopsy of seminal vesicles) 

● 60.14 (Open biopsy of seminal vesicles) 

● 62.11 (Closed [Percutaneous] [Needle] biopsy of testis) 

● 62.12 (Open biopsy of testis) 

● 68.13 (Open biopsy of uterus) 

● 68.14 (Open biopsy of uterine ligaments) 

● 68.15 (Closed biopsy of uterine ligaments) 

● 68.16 (Closed biopsy of uterus) 

● 85.11 (Closed [Percutaneous] [Needle] biopsy of breast) 

● 85.12 (Open biopsy of breast) 
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c. Noncovered Procedure Edit 

 The ICD-9-CM procedure codes 52.80 (Pancreatic transplant, not otherwise 

specified) and 52.82 (Homotransplant of pancreas) alone (that is, without procedure code 

55.69 (Other kidney transplantation)) are considered noncovered procedures, except 

when either one is combined with at least one specific principal or secondary diagnosis 

code. These specific diagnosis codes identify Type I diabetes mellitus, not stated as 

uncontrolled, or else identified as uncontrolled. 

 To conform to the proposed change to Pre-MDC MS-DRGs 008 and 010 as 

discussed in section II.G.1. of this preamble, in which we are proposing to add code 

251.3 (Postsurgical hypoinsulinemia) to those MS-DRGs, we intend to add procedure 

code 251.3 to the list of acceptable principal or secondary diagnosis codes in the MCE. 

8. Surgical Hierarchies 

 Some inpatient stays entail multiple surgical procedures, each one of which, 

occurring by itself, could result in assignment of the case to a different MS-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 

MS-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 

MS-DRG associated with the most resource-intensive surgical class. 

 Because the relative resource intensity of surgical classes can shift as a function 

of MS-DRG reclassification and recalibrations, we reviewed the surgical hierarchy of 
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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 MS-DRGs. For example, in 

MDC 11, the surgical class "kidney transplant" consists of a single MS-DRG (MS-DRG 

652) and the class "major bladder procedures" consists of three MS-DRGs (MS-DRGs 

653, 654, and 655). Consequently, in many cases, the surgical hierarchy has an impact 

on more than one MS-DRG. The methodology for determining the most 

resource-intensive surgical class involves weighting the average resources for each 

MS-DRG by frequency to determine the weighted average resources for each surgical 

class. For example, assume surgical class A includes MS-DRGs 1 and 2 and surgical 

class B includes MS-DRGs 3, 4, and 5. Assume also that the average costs of MS-DRG 

1 is higher than that of MS-DRG 3, but the average costs of MS-DRGs 4 and 5 are higher 

than the average costs of MS-DRG 2. To determine whether surgical class A should be 

higher or lower than surgical class B in the surgical hierarchy, we would weigh the 

average costs of each MS-DRG in the class by frequency (that is, by the number of cases 

in the MS-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 MS-DRG (in the highest, most 

resource-intensive surgical class) of the available alternatives. However, given that the 
CMS-1498-P 203 

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 cost is ordered above a surgical class with a 

higher average cost. 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 costs for the MS-DRG or MS-DRGs in that surgical class may be 

higher than those 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 costs 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 costs are likely to shift such that the higher-ordered 

surgical class has a lower average costs than the class ordered below it. 

Based on the changes that we are proposing for FY 2011, as discussed in section 

II.C.2 of this preamble, we are proposing to revise the surgical hierarchy for Pre-MDCs 

and MDC 10 (Endocrine, Nutritional and Metabolic Diseases and Disorders) to reflect 

the resource intensiveness of the MS-DRGs, as follows: 
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In Pre-MDCs, we are proposing to reorder proposed new MS-DRG 014 

(Allogeneic Bone Marrow Transplant) above MS-DRG 007 (Lung Transplant); and 

proposed new MS-DRG 015 (Autologous Bone Marrow Transplant) above MS-DRG 010 

(Pancreas Transplant). 

In MDC 10, we are proposing to reorder MS-DRG 614 (Adrenal and Pituitary 

Procedures With CC/MCC) and MS-DRG 615 (Adrenal and Pituitary Procedures 

Without CC/MCC) above MS-DRG 625 (Thyroid, Parathyroid and Thyroglossal 

Procedures With MCC). 

9. Complications or Comorbidity (CC) Exclusions List 

a. Background 

 As indicated earlier in the preamble of this proposed rule, under the IPPS 

MS-DRG classification system, we have developed a standard list of diagnoses that are 

considered 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 the FY 2008 IPPS final rule with comment period for a 

discussion of the refinement of CCs in relation to the MS-DRGs we adopted for FY 2008 

(72 FR 47121 through 47152). 

b. Proposed CC Exclusions List for FY 2011 
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 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. 
CMS-1498-P 206 

● 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.2

(1) Proposed Limited Revisions Based on Changes to the ICD-9-CM Diagnosis Codes 

 For FY 2011, we are proposing to make limited revisions to the CC Exclusions 

List for FY 2011 to take into account the changes made in the ICD-9-CM diagnosis 

coding system effective October 1, 2009. (We refer readers to section II.G.11. of the 

preamble of this proposed rule 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, we are indicating on the CC 

Exclusions List some changes as a result of updates to the ICD-9-CM codes to reflect the 

 

2 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; the FY 2007 final rule (71 FR 47870) for the FY 2007 revisions; the FY 2008 final rule 

(72 FR 47130) for the FY 2008 revisions, the FY 2009 final rule (73 FR 48510), and the FY 2010 final rule (74 FR 43799). 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.
CMS-1498-P 207 

exclusion of codes from being MCCs under the MS-DRG system that we adopted in 

FY 2008. 

(2) Suggested Changes to Severity Levels for Obesity-Related and Major Osseous 

Defect Diagnosis Codes 

In the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43793 through 

43794), we indicated that several commenters on the FY 2010 IPPS proposed rule 

recommended that CMS consider making further adjustments to the MS-DRG 

assignments based on obesity and major osseous defects. The commenters stated that 

obesity, high Body Mass Index (BMI) ratings, and major osseous defects add to the 

complexity of care for patients such as those patients undergoing orthopedic procedures. 

The commenters recommended the following changes to the list of MCCs and CCs: 

Several commenters recommended that CMS add the following diagnosis codes, 

which are classified as non-CCs, to the CC or MCC list: 

● 731.3 (Major osseous defects) 

● V85.35 (Body mass index 35.0 – 35.9, adult) 

● V85.36 (Body mass index 36.0 – 36.9, adult) 

● V85.37 (Body mass index 37.0 – 37.9, adult) 

● V85.38 (Body mass index 38.0 – 38.9, adult) 

● V85.39 (Body mass index 39.0 – 39.9, adult) 

Several commenters recommended that CMS add the following diagnosis code, 

which is on the CC list, to the MCC list: 

● V85.40 (Body mass index 40 and over, adult) 
CMS-1498-P 208 

 We stated that we believed these comments were outside the scope of the 

proposal in the proposed rule. We did not propose significant revisions to the MS-DRGs 

in the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule (74 FR 24091) for these codes. 

We stated that we were encouraging individuals with comments about MS-DRG 

classifications to submit these comments no later than early December of each year 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, we did not add 

these codes to the MCC list or the CC list for FY 2010. We stated that we would 

consider their appropriateness for inclusion in next year's annual proposed rule. 

 In addition to the diagnosis codes mentioned above, we also have received 

requests that we consider changing the following diagnosis codes from a non-CC to a 

CC: 

● 278.00 (Obesity NOS) 

● 278.01 (Morbid obesity) 

● 278.02 (Overweight) 

We analyzed claims data for the diagnosis codes mentioned above related to 

obesity and major osseous defects. We used the same approach we used in initially 

creating the MS-DRGs and classifying secondary diagnosis codes as non-CCs, CCs, or 

MCC. A detailed discussion of the process and criteria we used in this process is 

described in the FY 2008 IPPS final rule (72 FR 47158 through 47161). We refer the 

readers to this discussion for complete information on our approach to developing the 

non-CC, CC, and MCC lists. Each diagnosis for which Medicare data were available was 
CMS-1498-P 209 

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 cost for each subset of cases was compared to the expected cost 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. 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 costs for patients with these conditions to 

the expected average cost 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 MCC. The C3 value reflects a patient with at least one other secondary diagnosis 

that is a MCC. A value close to 1.0 in the C1 field would suggest that the diagnosis code 

produces the same expected value as a non-CC. 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 additional details on this analysis, we refer 

readers to the FY 2008 IPPS final rule at 72 FR 47158 through 47161. 

The following chart shows the analysis for each of the obesity related and major 

osseous defect diagnosis codes that are currently classified as non-CCs. 

Code Diagnosis Cnt1 C1 Cnt2 C2 Cnt3 C3 

278.00 Obesity NOS 130,310 1.0755 116,304 1.7234 45,565 2.3843
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Code Diagnosis Cnt1 C1 Cnt2 C2 Cnt3 C3 

278.01 Morbid obesity 51,832 1.2619 106,169 1.9630 52,398 2.6787

278.02 Overweight 5,242 0.9948 3,594 1.7042 1,033 2.3471

731.3 Major osseous 

defects 215 1.3833 575 2.3390 186 2.7627

V85.35 

 BMI 35.0-

35.9,adult 2,621 0.9759 1,480 1.6932 499 2.3664

V85.36 

 BMI 36.0-

36.9,adult 2,359 0.9729 1,298 1.6536 466 2.3107

V85.37 

 BMI 37.0-

37.9,adult 2,305 0.9849 1,271 1.7225 473 2.4032

V85.38 

 BMI 38.0-

38.9,adult 2,152 0.9713 1,231 1.5964 432 2.2743

V85.39 

 BMI 39.0-

39.9,adult 2,253 0.9857 1,141 1.7741 445 2.4919

 

 The C1 findings do not support a reclassification of any of these diagnosis codes 

from a non-CC to a CC. As can be seen by the C1 findings, the codes range from a low 

of 0.9729 for code V85.35 to a high of 1.3833 for diagnosis code 731.3. These findings 

are consistent with a classification as a non-CC. Therefore, for FY 2011, we are not 

proposing to change the CC classification of any of the diagnosis codes mentioned in the 

chart above from a non-CC to a CC. Our clinical advisors agree with this 

recommendation. 

We also examined claims data for diagnosis code V85.4 (Body mass index 40 and 

over, adult), which is classified as a CC. We received a request to reclassify this code as 

a MCC. The following chart summaries our findings for this diagnosis code: 

Code Diagnosis Cnt1 C1 Cnt2 C2 Cnt3 C3 

V85.4 

 BMI 40 and over, 

adult 51,871 1.2323 59,941 2.1711 57,220 3.0465
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 We note that the C1 finding of 1.2323 does not support a reclassification of this 

diagnosis code from a CC to a MCC. This finding is much more consistent with 

classifying the code as a non-CC. Our clinical advisors recommended that CMS not 

reclassify this diagnosis code from a CC to a non-CC at this time. They recommended 

that CMS analyze data associated with this diagnosis code again in the future to 

determine if it continues to act like a non-CC. We are not recommending any change in 

the severity classification of diagnosis code V85.4. We are proposing to retain it as a CC 

for FY 2011. 

We welcome public comments on our proposal not to change the severity levels 

of the diagnosis codes mentioned above. 

(3) Suggested Change to the Severity Level for Alzheimer’s Disease Diagnosis Code 

 We received a request to change the severity classification for diagnosis code 

331.0 (Alzheimer’s disease). Currently, this diagnosis code is classified as a non-CC. 

We analyzed claims data for this diagnosis code. The following chart shows our 

findings: 

Code Diagnosis Cnt1 C1 Cnt2 C2 Cnt3 C3 

331.0 

Alzheimer's 

disease 83,743 1.1381 114,445 1.8890 77,841 2.4185

 The C1 finding of 1.1381 for Alzheimer’s disease supports the current 

classification of this diagnosis code as a non-CC. Our clinical advisors agree with this 

classification. Therefore, we are not proposing to change the severity classification of 
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diagnosis code 331.0 from a non-CC to a CC for FY 2011. We believe the code is 

appropriately classified as a non-CC. 

(4) Proposed Change to the Severity Level for Acute Renal Failure, Unspecified 

Diagnosis Code 

 We received a request to reclassify diagnosis code 584.9 (Acute renal failure, 

unspecified) from a MCC to a CC. The commenter stated that this code is being widely 

used to capture degrees of renal failure that range from that which is caused by mild 

dehydration with only minor laboratory abnormalities all the way through severe renal 

failure that requires dialysis. The commenter pointed out that there are no clinical criteria 

for assigning diagnosis code 584.9 (Acute renal failure, unspecified). The attending 

physician must simply document the presence of acute renal failure for the diagnosis 

code to be assigned. The concern is that the diagnosis code for Acute renal failure, 

unspecified (diagnosis code 584.9) is being assigned to patients with a low clinical 

severity level. 

 We also point out that the Editorial Advisory Board of Coding Clinic for 

ICD-9-CM has received a number of requests to clarify the use of diagnosis code 584.9. 

Coders are observing the terminology of “acute renal failure” being applied to patients 

who are simply dehydrated. These patients do not require renal dialysis, and they do not 

appear to be severely ill. Coders have stated that there appears to be an increase in the 

use of the terminology of acute renal failure for patients who were previously referred to 

as acute renal insufficiency. When acute renal insufficiency is documented, the 

ICD-9-CM index directs the use of code 593.9 (Unspecified disorder of kidney and 
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ureter). Diagnosis code 593.9 includes acute renal insufficiency and is classified as a 

non-CC. The problem is further compounded by the fact that there is no consistent 

convention among clinicians for documenting acute renal insufficiency versus acute renal 

failure. 

 We examined claims data on diagnosis code 584.9, and our findings are shown in 

the table below: 

Code Diagnosis Cnt1 C1 Cnt2 C2 Cnt3 C3 

584.9 

Acute kidney 

failure, unspecified 124,428 1.8364 411,667 2.6151 417,359 3.2429

 The C1 finding of 1.8364 is more consistent with a classification of a CC. Our 

clinical advisors agreed that cases captured by diagnosis code 584.9 are more 

appropriately classified as a CC. This unspecified type of kidney failure is clearly not 

capturing patients with a MCC severity level. Therefore, we are proposing to change the 

severity level for diagnosis code 584.9 from a MCC to a CC for FY 2011. 

 Tables 6G and 6H, Additions to and Deletions from the CC Exclusion List, 

respectively, which are effective for discharges occurring on or after October 1, 2010, are 

not being published in the Addendum to this proposed rule because of the length of the 

two tables. Instead, we are making them available through the Internet on the CMS Web 

site at: http://www.cms.hhs.gov/AcuteInpatientPPS. Each of these principal diagnoses 

for which there is a CC exclusion is shown in Tables 6G and 6H in the Addendum to this 

proposed rule 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. 
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A complete updated MCC, CC, and Non-CC Exclusions List is 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, 2010, the indented diagnoses will not be recognized by the GROUPER as 

valid CCs for the asterisked principal diagnosis. 

To assist readers in identifying the changes to the MCC and CC lists that occurred 

as a result of updates to the ICD-9-CM codes, as described in Tables 6A, 6C, and 6E of 

the Addendum to this proposed rule, we are providing the following summaries of those 

MCC and CC changes. 

There were no additions to the MS-DRG MCC List for FY 2011 (Table 6I.1). 

SUMMARY OF DELETIONS FROM THE MS-DRG MCC LIST--TABLE 6I.2 

Code Description 

584.9 Acute renal failure, unspecified 

SUMMARY OF ADDITIONS TO THE MS-DRG CC LIST--TABLE 6J.1 

Code Description 

584.9 Acute renal failure, unspecified 

786.30 Hemoptysis, unspecified 

786.31 Acute idiopathic pulmonary hemorrhage in infants [AIPHI] 

786.39 Other hemoptysis 

999.60 ABO incompatibility reaction, unspecified 

999.61 ABO incompatibility with hemolytic transfusion reaction not specified as 

acute or delayed 

999.62 ABO incompatibility with acute hemolytic transfusion reaction 

999.63 ABO incompatibility with delayed hemolytic transfusion reaction 

999.69 Other ABO incompatibility reaction 

999.70 Rh incompatibility reaction, unspecified 

999.71 Rh incompatibility with hemolytic transfusion reaction not specified as 

acute or delayed 

999.72 Rh incompatibility with acute hemolytic transfusion reaction 
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Code Description 

999.73 Rh incompatibility with delayed hemolytic transfusion reaction 

999.74 Other Rh incompatibility reaction 

999.75 Non-ABO incompatibility reaction, unspecified 

999.76 Non-ABO incompatibility with hemolytic transfusion reaction not 

specified as acute or delayed 

999.77 Non-ABO incompatibility with acute hemolytic transfusion reaction 

999.78 Non-ABO incompatibility with delayed hemolytic transfusion reaction 

999.79 Other non-ABO incompatibility reaction 

999.83 Hemolytic transfusion reaction, incompatibility unspecified 

999.84 Acute hemolytic transfusion reaction, incompatibility unspecified 

999.85 Delayed hemolytic transfusion reaction, incompatibility unspecified 

V85.41 Body Mass Index 40.0-44.9, adult 

V85.42 Body Mass Index 45.0-49.9, adult 

V85.43 Body Mass Index 50.0-59.9, adult 

V85.44 Body Mass Index 60.0-69.9, adult 

V85.45 Body Mass Index 70 and over, adult 

SUMMARY OF DELETIONS FROM THE MS-DRG CC LIST--TABLE 6J.2 

Code Description 

786.3 Hemoptysis 

999.6 ABO incompatibility reaction 

999.7 Rh incompatibility reaction 

V85.4 Body Mass Index 40 and over, adult 

 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 MS-DRG Definitions Manual, Version 27.0, is 

available for $250.00, which includes shipping and handling. Version 27.0 of the manual 

is also available on a CD for $200.00; a combination hard copy and CD is available for 

$400.00. Version 28.0 of this manual, which will include the final FY 2011 MS-DRG 

changes, will be available in CD only for $225.00. These manuals may be obtained by 
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writing 3M/HIS at the following address: 100 Barnes Road, Wallingford, CT 06492; or 

by calling (203) 949-0303, or by obtaining an order form at the Web site: 

http://www.3MHIS.com. Please specify the revision or revisions requested. 

10. Review of Procedure Codes in MS DRGs 981 through 983; 984 through 986; and 

987 through 989 

 Each year, we review cases assigned to former 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 adopted 

for FY 2008, CMS DRG 468 was split three ways and became MS-DRGs 981, 982, and 

983 (Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, 

and without CC/MCC, respectively). CMS DRG 476 became MS-DRGs 984, 985, and 

986 (Prostatic O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and 

without CC/MCC, respectively). CMS DRG 477 became MS-DRGs 987, 988, and 989 

(Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and 

without CC/MCC, respectively). 

 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 MS-DRGs 

are intended to capture atypical cases, that is, those cases not occurring with sufficient 

frequency to represent a distinct, recognizable clinical group. MS-DRGs 984 through 
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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 MS-DRGs 981 through 983 and 

987 through 989, with MS-DRGs 987 through 989 assigned to those discharges in which 
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the only procedures performed are nonextensive procedures that are unrelated to the 

principal diagnosis.3

 Our review of MedPAR claims data showed that there were 59 cases in which 

procedures related to the prostate were arrayed across 10 different MDCs. None of the 

59 cases were cases that should logically be assigned to any of the other MDCs. For 

example, there were a total of 16 cases of other transurethral prostate surgery that 

occurred in MDC 5 (Diseases and Disorders of the Circulatory System). In addition, 

none of the cases had lengths of stay or average charges that would indicate that these 

cases were anything other than some of the expected irregularities of medical care. 

Therefore, for FY 2011, we are not proposing to change the procedures assigned among 

these MS-DRGs. 

a. Moving Procedure Codes from MS-DRGs 981 through 983 or MS-DRGs 987 through 

989 into MDCs 

 We annually conduct a review of procedures producing assignment to MS-DRGs 

981 through 983 (Extensive O.R. procedure unrelated to principal diagnosis with MCC, 

with CC, and without CC.MCC, respectively) or MS-DRGs 987 through 989 

(Nonextensive O.R. procedure unrelated to principal diagnosis with MCC, with CC, and 

without CC/MCC, respectively) on the basis of volume, by procedure, to see if it would 

 

3The original list of the ICD-9-CM procedure codes for the procedures we consider nonextensive procedures, if performed with an unrelated principal 

diagnosis, was published in Table 6C in section IV. of the Addendum to the FY 1989 final rule (53 FR 38591). As part of the FY 1991 final rule 

(55 FR 36135), the FY 1992 final rule (56 FR 43212), the FY 1993 final rule (57 FR 23625), the FY 1994 final rule (58 FR 46279), the FY 1995 final 

rule (59 FR 45336), the FY 1996 final rule (60 FR 45783), the FY 1997 final rule (61 FR 46173), and the FY 1998 final rule (62 FR 45981), we moved 

several other procedures from DRG 468 to DRG 477, and some procedures from DRG 477 to DRG 468. No procedures were moved in FY 1999, as 

noted in the final rule (63 FR 40962); in FY 2000 (64 FR 41496); in FY 2001 (65 FR 47064); or in FY 2002 (66 FR 39852). In the FY 2003 final rule 

(67 FR 49999) we did not move any procedures from DRG 477. However, we did move procedure codes from DRG 468 and placed them in more 

clinically coherent DRGs. In the FY 2004 final rule (68 FR 45365), we moved several procedures from DRG 468 to DRGs 476 and 477 because the 

procedures are nonextensive. In the FY 2005 final rule (69 FR 48950), we moved one procedure from DRG 468 to 477. In addition, we added several 

existing procedures to DRGs 476 and 477. In the FY 2006 (70 FR 47317), we moved one procedure from DRG 468 and assigned it to DRG 477. In 

FY 2007, we moved one procedure from DRG 468 and assigned it to DRGs 479, 553, and 554. In FYs 2008, 2009, and FY 2010, no procedures were 

moved, as noted in the FY 2008 final rule with comment period (72 FR 46241), the FY 2009 final rule (73 FR 48513), and the FY 2010 final rule 

(74 FR 43796).
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be appropriate to move procedure codes out of these MS-DRGs into one of the surgical 

MS-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 

MS-DRGs for the MDC in which the diagnosis falls. Our review of claims data showed 

that there were 4,443 cases in MS-DRGs 981 through 983. These 4,443 cases were 

arrayed across 18 MDCs. The single most common procedure was code 00.66 

(Percutaneous transluminal coronary angioplasty [PTCA] of coronary atherectomy), 

21 cases, located in MDC 1 (Diseases and Disorders of the Nervous System). These 

cases represent a very small volume of cases that are unlikely to indicate medical practice 

trends. In addition, from a clinical coherence standpoint, we do not believe it benefits the 

GROUPER system to add cardiac procedures to the nervous system MDC. The same 

situation was evident in MS-DRGs 987 through 989. There were a total of 1,601 cases 

across 17 MDCs and, again, the cases did not represent clinically coherent examples of 

medical care that warranted movement of procedure codes into additional MS-DRGs. 

Examples of cases that we reviewed included six cases of bone biopsies in MDC 21 

(Injuries, Poisonings and Toxic Effects of Drugs) and one case of a destruction of a lesion 

of the knee in MDC 13 (Diseases and Disorders of the Female Reproductive System). 

Again, the volume of these cases is negligible, and clinical coherence is not demonstrated 
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to the degree that a change in the MS-DRGs is warranted. Therefore, for FY 2011, we 

are not proposing to remove any procedures from MS-DRGs 981 through 983 or 

MS-DRGs 987 through 989 into one of the surgical MS-DRGs for the MDC into which 

the principal diagnosis is assigned. 

b. Reassignment of Procedures among 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 MS-DRGs 981 

through 983, 984 through 986 (Prostatic O.R. procedure unrelated to principal diagnosis 

with MCC, with CC, or without CC/MCC, respectively), and 987 through 989, to 

ascertain whether any of those procedures should be reassigned from one of these three 

MS-DRGs to another of the three MS-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 MS-DRG assignment illogical. If we find these 

shifts, we would propose to move cases to keep the MS-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. 

 To reiterate, our review of claims data showed that 18 MDCs were represented in 

MS-DRGs 981 through 983, for a total of 4,443 cases. There were 10 MDCs represented 

in MS-DRGs 984 through 986, which contained 59 cases. In addition, our review of 

claims data for MS-DRGs 987 through 989 showed 1,601 cases across 17 MDCs. 

However, these cases represent such disparate situations as one case of a large bowel 
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incision assigned to MDC 1 (Diseases and Disorders of the Nervous System) and one 

case of a revision of the femoral component of a hip replacement assigned to MDC 3 

(Diseases and Disorders of the Ear, Nose, Mouth, and Throat). We do not believe that 

any of these cases represent shifts in either treatment practice or reporting practice. As 

these types of cases do not represent clinical coherence, we do not believe that the 

addition of these procedure codes identified in our review would positively benefit the 

overall MS-DRG logic. Therefore, for FY 2011, we are not proposing to move any 

procedure codes among these MS-DRGs. 

c. Adding Diagnosis or Procedure Codes to MDCs 

 Based on the review of cases in the MDCs as described above in sections G.10.a. 

and b., we are not proposing to add any diagnosis or procedure codes to MDCs for 

FY 2011. 

11. Changes to the ICD-9-CM Coding System, Including Discussion of the Replacement 

of the ICD-9-CM Coding System with the ICD-10-CM and ICD-10-PCS Systems in 

FY 2014 

a. ICD-9-CM Coding System 

 As described in section II.B.1. of the preamble of this proposed rule, the 

ICD-9-CM is a coding system currently 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 
CMS-1498-P 222 

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 $19.00 by calling (202) 512-1800.) 

Complete information on ordering the CD-ROM is also available at: 

http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/05_CDROM.asp#TopOfPage. 

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 
CMS-1498-P 223 

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 2011 at a public meeting held on September 16-17, 2009 and finalized the coding 

changes after consideration of comments received at the meetings and in writing by 

November 20, 2009. Those coding changes are announced in Tables 6A through 6F in 

the Addendum to this proposed rule. The Committee held its 2010 meeting on 

March 9-10, 2010. New codes for which there was a consensus of public support and for 

which complete tabular and indexing changes are made by May 2010 will be included in 

the October 1, 2010 update to ICD-9-CM. Code revisions that were discussed at the 

March 9-10, 2010 Committee meeting but that could not be finalized in time to include 

them in the Addendum to this proposed rule will be included in Tables 6A through 6F of 

the final rule and will be marked with an asterisk (*). 

Copies of the minutes of the procedure codes discussions at the Committee’s 

September 16-17, 2009 meeting and March 9-10, 2010 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 16-17, 2009 meeting 

and March 9-10, 2010 meeting are found at: http://www.cdc.gov/nchs/icd.htm. These 
CMS-1498-P 224 

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, 2010. The new ICD-9-CM codes are listed, along with their MS-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 soliciting comments on the proposed classification of 

these new codes, which are shown in Tables 6A and 6B of the Addendum to this 

proposed rule. 
CMS-1498-P 225 

 For codes that have been replaced by new or expanded codes, the corresponding 

new or expanded diagnosis codes are included in Table 6A in the Addendum to this 

proposed rule. New procedure codes are shown in Table 6B in the Addendum to this 

proposed rule. Diagnosis codes that have been replaced by expanded codes or other 

codes or have been deleted are in Table 6C (Invalid Diagnosis Codes) in the Addendum 

to this proposed rule. These invalid diagnosis codes will not be recognized by the 

GROUPER beginning with discharges occurring on or after October 1, 2010. Table 6D 

in the Addendum to this proposed rule contains invalid procedure codes. These invalid 

procedure codes will not be recognized by the GROUPER beginning with discharges 

occurring on or after October 1, 2010. Revisions to diagnosis code titles are in Table 6E 

(Revised Diagnosis Code Titles) in the Addendum to this proposed rule, which also 

includes the MS-DRG assignments for these revised codes. Table 6F in the Addendum 

to this proposed rule includes revised procedure code titles for FY 2011. 

 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 9-10, 2010 Committee meeting that 

receive consensus and that are finalized by May 2010 will be included in Tables 6A 

through 6F in 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 
CMS-1498-P 226 

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 
CMS-1498-P 227 

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 published on the 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 
CMS-1498-P 228 

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 approved for an expedited April l, 2010 implementation of an ICD-9-CM code at 

the September 16-17, 2009 Committee meeting. Therefore, there were no new 

ICD-9-CM codes implemented on April 1, 2010. 

 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 Medicare 

contractors for use in updating their systems and providing education to providers. 

These same means of disseminating information on new, revised, and deleted 

ICD-9-CM codes will be used to notify providers, publishers, software vendors, 
CMS-1498-P 229 

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 MS-DRG in which its predecessor code was assigned so there 

will be no MS-DRG impact as far as MS-DRG assignment. 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. 

b. Code Freeze 

The International Classification of Diseases, 10th Revision (ICD-10) coding 

system applicable to hospital inpatient services will be implemented on October 1, 2013, 

as described in the Health Insurance Portability and Accountability Act (HIPAA) 

Administrative Simplification: Modifications to Medical Data code Set Standards to 

Adopt ICD-10-CM and ICD-10-PCS final rule (74 FR 3328 through 3362, 

January 16, 2009). The ICD-10 coding system includes the International Classification 

of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) for diagnosis coding and 
CMS-1498-P 230 

the International Classification of Diseases, 10th Revision, Procedure Coding System 

(ICD-10-PCS) for inpatient hospital procedure coding, as well as the Official 

ICD-10-CM and ICM-10-PCS Guidelines for Coding and Reporting. In the 

January 16, 2009 ICD-10-CM and ICD-10-PCS final rule (74 FR 3328 through 3362), 

there was a discussion of the need for a partial or total freeze in the annual updates to 

both ICD-9-CM and ICD-10-CM and ICD-10-PCS codes. The public comment 

addressed in this final rule stated that the annual code set updates should cease l year 

prior to the implementation of ICD-10. The commenters stated that this freeze of code 

updates would allow for instructional and/or coding software programs to be designed 

and purchased early, without concern that an upgrade would take place immediately 

before the compliance date, necessitating additional updates and purchases. 

We responded to comments in the ICD-10 final rule that the ICD-9-CM 

Coordination and Maintenance Committee has jurisdiction over any action impacting the 

ICD-9-CM and ICD-10 code sets. Therefore, the issue of consideration of a moratorium 

on updates to the ICD-9-CM, ICD-10-CM, and ICD-10-PCS code sets in anticipation of 

the adoption of ICD-10-CM and ICD-10-PCS would be addressed through the 

Committee at a future public meeting. 

At the March 11-12, 2009 ICD-9-CM Coordination and Maintenance Committee 

meeting, the public was notified that there would be a discussion of whether there was a 

need to freeze updates to ICD-9-CM and/or ICD-10-CM and ICD-10-PCS prior to the 

implementation of ICD-10. The audience was asked to consider this issue and be 

prepared to discuss the topic at the September 16-17, 2009 ICD-9-CM Coordination and 
CMS-1498-P 231 

Maintenance Committee meeting. Advance written comments on this topic were 

welcomed. The first part of the meeting was devoted to this topic. 

CMS received comments in advance of the meeting. CMS staff summarized 

these advanced comments at the meeting as follows: 

No ICD-9-CM or ICD-10-CM/PCS updates beginning October 1, 2010 

(36 months for implementation activities without annual code updates). This 

approach involves updating ICD-9-CM and ICD-10 codes on October 1, 2010, and not 

updating them again until after ICD-10 implementation on October 1, 2013. The 

commenters mentioned the extensive work needed to prepare for the transition to ICD-10 

which will affect vendors, payers, providers, trainers, clearinghouses, and all claims 

handling organizations. The commenters stated that the 36 months between the last 

ICD-9-CM and ICD-10 updates on October 1, 2010 and the implementation of ICD-10 

on October 1, 2013, were necessary to prepare and train for the transition. 

No ICD-9-CM or ICD-10-CM/PCS updates beginning October 1, 2011 

(24 months for implementation activities without annual code updates). This 

approach involves updating ICD-9-CM and ICD-10 codes on October 1, 2011, and not 

updating them again until after ICD-10 implementation on October 1, 2013. The 

commenters raised similar concerns to those mentioned above. The commenters stated 

that, if codes continue to change, the changes would make it difficult for vendors, payers, 

and providers to be ready and for coder training to be successful. One commenter 

suggested that a provision be developed to perform limited annual updates to capture new 

technologies or new diagnoses. 
CMS-1498-P 232 

No ICD-10-CM/PCS updates beginning October 1, 2012 but continue annual 

updates to ICD-9-CM. This commenter supported annual updates to ICD-9-CM to 

capture advances in medical science. However, the commenter supported a freeze of 

ICD-10 beginning October 1, 2012, to give the industry time to update systems and 

prepare for ICD-10 implementation. 

No ICD-10 updates on October 1, 2012, but update ICD-9-CM without 

interruption. (No period for implementation activities without annual code 

updates.) The commenter recommended no ICD-10 updates on October 1, 2012, but 

then updating ICD-10 again on October 1, 2013. The commenter recommended updating 

ICD-9-CM continuously through a final update on October 1, 2012. The commenter 

stated that having a two or three year gap between updating the code books would lead to 

a loss of data. The commenter stated that there is a need to retain the ability to update the 

code books to capture conditions such as Swine flu. 

Update both ICD-9-CM and ICD-10-CM/PCS annually through 

October 1, 2013 (no period for implementation activities without annual code 

updates). The commenter stated that codes should not be frozen prior to the 

implementation of ICD-10. The commenter stated that freezing the updates would inhibit 

the recognition of new technologies. 

Many of the commenters suggested a resumption of updates to ICD-10-CM and 

ICD-10-PCS beginning on October 1, 2014. However, one commenter suggested annual 

updates of ICD-10-CM and ICD-10-PCS without interruptions, including on 

October 1, 2013. 
CMS-1498-P 233 

The topic was then opened for public discussion at the Committee meeting. CMS 

received a variety of comments from the participants that mirrored the advance written 

comments. These comments ranged from those supporting a complete freeze for both 

coding systems to those who recommended that both coding systems continue to be 

updated annually prior to ICD-10 implementation. There were also many comments that 

supported a more limited update process beginning on October 1, 2011, or 

October 1, 2012, which would allow only a small number of new codes to capture new 

technologies or new diseases. A number of commenters pointed out that section 503(a) 

of Pub. L. 108-173 included a requirement for updating ICD-9-CM codes twice a year to 

capture new technologies. The commenters stated that CMS must make a provision to 

capture new technologies despite any requests to freeze code updates. 

Commenters voiced concerns about the impact on vendors creating new ICD-10 

products when both ICD-9-CM and ICD-10-CM and ICD-10-PCS codes were 

extensively updated on an annual basis. Commenters stated that vendors and educators 

were reluctant to begin ICD-10 products and training materials until there was a period of 

stability without extensive annual updates. Some commenters stated that it was 

important for physician offices to have time to prepare for the implementation of ICD-10. 

Reducing the annual ICD-9-CM and ICD-10 annual updates would be helpful to 

physician offices. 

Other commenters stated that it was important to update codes annually so that 

information on new diseases and technologies can be captured. These commenters stated 
CMS-1498-P 234 

that vendors, providers, system maintainers, and coders were used to annual code 

updates, and that they should continue. 

One commenter requested that ICD-10-CM codes be frozen on October 1, 2011 

so that ICD-10-CM codes could be coordinated with the Diagnostic and Statistical 

Manual of Mental Disorders (DSM), Fifth Edition. The commenter stated that the 

American Psychiatric Association plans to publish the fifth edition in 2012. Updates to 

ICD-10-CM on or after October 1, 2011, would disrupt those plans. 

One commenter suggested an approach that would greatly reduce the number of 

updates and provide more stability in the coding systems during the implementation 

period. This commenter suggested that the large, regular code updates on ICD-9-CM be 

discontinued beginning on October 1, 2011, or October 1, 2012. The commenter 

suggested that CMS and CDC raise the bar for new code requests at that time and only 

consider requests for new codes that clearly describe a new technology or a new disease. 

The commenter stated that this may lead to the creation of some new procedure codes 

which do not ultimately receive FDA approval, as is the case now. 

CMS and CDC have carefully reviewed the comments received at the ICD-9-CM 

Coordination and Maintenance Committee meeting as well as the written comments 

submitted. Most commenters proposed a limited freeze on code updates to both 

ICD-9-CM and ICD-10-CM and ICD-10-PCS code sets, with an exception made for 

adding codes for new technologies and diseases. Providing this exception would comply 

with section 503(a) of Pub. L. 108-173, which, as previously stated, includes a 

requirement for updating ICD-9-CM codes twice a year to capture new technologies. 
CMS-1498-P 235 

There was support for making the last regular update on October 1, 2011. The 

commenters recommended that the ICD-9-CM Coordination and Maintenance 

Committee continue to discuss any new code updates for both coding systems. However, 

new codes would only be added to ICD-9-CM or ICD-10 to capture new technologies, as 

required by section 503(a) of Pub. L. 108-173. Other coding issues raised would be held 

for consideration after ICD-10 is implemented. 

In this proposed rule, we are soliciting additional input on this subject, especially 

in light of the requirements on hospitals for meaningful use of electronic health records. 

We welcome public comments that explore whether a freeze is needed to help with 

adoption of health IT, given other priorities such as achievement of meaningful use and 

implementation of ICD-10 by FY 2013. We welcome input on having the last regular, 

annual update to both ICD-9-CM and ICD-10 be made on October 1, 2011. On 

October 1, 2012, there would be only limited code updates to both the ICD-9-CM and 

ICD-10 coding systems to capture new technologies and diseases. On October 1, 2013, 

there would be only limited code updates to ICD-10 to capture new technologies and 

diagnoses. Any other issues raised would be considered for implementation in ICD 10 on 

October 1, 2014, a year after ICD-10 is implemented. We agree with commenters that 

there is a need to provide the provider, payer, and vendor community time to prepare for 

the implementation of ICD-10 and the accompanying system and product updates. The 

vendor community is especially interested in providing a more stable code set for ICD-10 

while they are developing new products. 
CMS-1498-P 236 

We believe that this advance notice of a partial code freeze would provide the 

health care industry ample time to request last major code updates to ICD-9-CM and 

ICD-10, which could be discussed at the September 15-16, 2010 and the March 2011 

ICD-9-CM Coordination and Maintenance Committee meeting. Codes discussed at these 

two meetings would be considered for the final major code updates on October 1, 2011. 

Any code issues raised after that time would be addressed at the ICD-9-CM Coordination 

and Maintenance Committee meetings in September 2011 through March 2013 to 

determine if they represented new technologies or new diseases. Any new technologies 

and diseases would be added during the regular annual updates. Other code requests 

would be held for implementation on October 1, 2014. 

We welcome additional input on having the last regular code updates to 

ICD-9-CM and ICD-10 on October 1, 2011, and to only add codes for new technologies 

and diseases on October 1, 2012 and 2013. We also welcome additional input on having 

the next regular update to ICD-10 occur again on October 1, 2014. 

Information on ICD-10 can be found on the CMS Web site at: 

http://www.cms.hhs.gov/ICD10. The final ICD-10 version of MS-DRGs would be 

adopted under the formal rulemaking process as part of our annual IPPS updates. 

c. Processing of 25 Diagnosis Codes and 25 Procedure Codes on Hospital Inpatient 

Claims 

 We have received repeated requests from the hospital community to process all 

25 diagnosis codes and 25 procedure codes submitted on electronic hospital inpatient 

claims. Hospitals can submit up to 25 diagnoses and 25 procedures; however, CMS’ 
CMS-1498-P 237 

current system limitations allow for the processing of only the first 9 diagnoses and 6 

procedures. While CMS accepts all 25 diagnoses and 25 procedures submitted on the 

claims, we do not process all of the codes because of these system limitations. We 

recognize that much valuable information is lost by not processing the additional 

diagnosis and procedure codes that are reported by hospitals. 

 We responded to hospitals’ requests that we process up to 25 diagnosis codes and 

25 procedure codes in the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43798). 

In that final rule, we referred readers to the ICD-10 final rule (74 FR 3328 through 3362) 

where we discuss the updating of Medicare systems prior to the implementation of 

ICD-10 on October 1, 2013. We mentioned that part of the system updates in preparation 

for ICD-10 is the “expansion of our ability to process more diagnosis and procedure 

codes.” In the FY 2009 IPPS final rule (73 FR 48433 through 48444), we also responded 

to multiple requests to increase the number of codes processed from 9 diagnosis and 

6 procedure codes to 25 diagnosis and 25 procedure codes. 

 CMS is currently undergoing extensive system updates as part of the move to 

5010, which includes the ability to accept ICD-10 codes. This complicated transition 

involves converting many internal systems prior to October 1, 2013, when ICD-10 will 

be implemented. One important step in this planned conversion process is the expansion 

of our ability to process additional diagnosis and procedure codes. We are currently 

planning to complete the expansion of this internal system capability so that we are able 

to process up to 25 diagnoses and 25 procedures on hospital inpatient claims as part of 

the HIPPA ASC X12 Technical Reports Type 3, Version 005010 (Version 5010) 
CMS-1498-P 238 

standards system update. CMS will be able to process up to 25 diagnosis codes and 25 

procedure codes when received on the 5010 format starting on January 1, 2011. We 

recognize the value of the additional information provided by this coded data for multiple 

uses such as for payment, quality measures, outcome analysis, and other important uses. 

We will continue to pursue this additional processing capacity as aggressively as possible 

in response to the multiple requests from the hospital industry. We appreciate the support 

of the health care community for this extensive system update process that will allow us 

to process more of this important data. Therefore, for claims submitted on the 5010 

format beginning January 1, 2011, we will increase the capacity to process diagnosis and 

procedure codes on hospital inpatient claims from the current 9 diagnoses and 6 

procedures up to 25 diagnoses and 25 procedures. 

H. Recalibration of MS-DRG Weights

In developing the proposed FY 2011 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 2009 MedPAR data used in this proposed rule 

include discharges occurring on October 1, 2008, through September 30, 2009, based on 

bills received by CMS through December 31, 2009, 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 2009 MedPAR file used in calculating the 

proposed relative weights includes data for approximately 11,004,046 Medicare 

discharges from IPPS providers. Discharges for Medicare beneficiaries enrolled in a 
CMS-1498-P 239 

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-based relative 

weighting methodology is the FY 2008 Medicare cost report data files from HCRIS (that 

is, cost reports beginning on or after October 1, 2007, and before October 1, 2008), which 

represents the most recent full set of cost report data available. We used the 

December 31, 2009 update of the HCRIS cost report files for FY 2008 in setting the 

relative cost-based weights. 

 The methodology we used to calculate the DRG cost-based relative weights from 

the FY 2009 MedPAR claims data and FY 2008 Medicare cost report data is as follows: 

● To the extent possible, all the claims were regrouped using the proposed 

FY 2011 MS-DRG classifications discussed in sections II.B. and G. of the preamble of 

this proposed rule. 

● The transplant cases that were used to establish the relative weights for heart 

and heart-lung, liver and/or intestinal, and lung transplants (MS-DRGs 001, 002, 005, 

006, and 007, respectively) were limited to those Medicare-approved transplant centers 

that have cases in the FY 2009 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 
CMS-1498-P 240 

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 MS-DRG and before eliminating statistical outliers. 

● Claims with total charges or total lengths 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 room charges, 

cardiology charges, laboratory charges, radiology charges, other service charges, labor 

and delivery charges, inhalation therapy charges, emergency room charges, blood 

charges, and anesthesia charges were also deleted. 

● At least 96.1 percent of the providers in the MedPAR file had charges for 10 

of the 15 cost centers. Claims for providers that did not have charges greater than zero 

for at least 10 of the 15 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 MS-DRG. 

● Effective October 1, 2008, because hospital inpatient claims include a POA 

indicator field for each diagnosis present on the claim, only for purposes of relative 

weight-setting, the POA indicator field was reset to "Y" for “Yes” for all claims that 

otherwise have an "N" (No) or a "U" (documentation insufficient to determine if the 

condition was present at the time of inpatient admission) in the POA field.
CMS-1498-P 241 

Under current payment policy, the presence of specific HAC codes, as indicated 

by the POA field values, can generate a lower payment for the claim. Specifically, if the 

particular condition is present on admission (that is, a "Y" indicator is associated with the 

diagnosis on the claim), then it is not a HAC, and the hospital is paid for the higher 

severity (and, therefore, the higher weighted MS-DRG). If the particular condition is not

present on admission (that is, an "N" indicator is associated with the diagnosis on the 

claim) and there are no other complicating conditions, the DRG GROUPER assigns the 

claim to a lower severity (and, therefore, the lower weighted MS-DRG) as a penalty for 

allowing a Medicare inpatient to contract a HAC. While the POA reporting meets policy 

goals of encouraging quality care and generates program savings, it presents an issue for 

the relative weight-setting process. Because cases identified as HACs are likely to be 

more complex than similar cases that are not identified as HACs, the charges associated 

with HACs are likely to be higher as well. Thus, if the higher charges of these HAC 

claims are grouped into lower severity MS-DRGs prior to the relative weight-setting 

process, the relative weights of these particular MS-DRGs would become artificially 

inflated, potentially skewing the relative weights. In addition, we want to protect the 

integrity of the budget neutrality process by ensuring that, in estimating payments, no 

increase to the standardized amount occurs as a result of lower overall payments in a 

previous year that stem from using weights and case-mix that are based on lower severity 

MS-DRG assignments. If this would occur, the anticipated cost savings from the HAC 

policy would be lost. 
CMS-1498-P 242 

 To avoid these problems, we reset the POA indicator field to "Y" only for 

relative weight-setting purposes for all claims that otherwise have a "N" or an "U" in the 

POA field. This resetting “forced” the more costly HAC claims into the higher severity 

MS-DRGs as appropriate, and the relative weights calculated for each MS-DRG more 

closely reflect the true costs of those cases. 

 Once the MedPAR data were trimmed and the statistical outliers were removed, 

the charges for each of the 15 cost groups for each claim were standardized to remove the 

effects of differences in area wage levels, IME and DSH payments, and for hospitals in 

Alaska and Hawaii, the applicable cost-of-living adjustment. Because hospital charges 

include charges for both operating and capital costs, we standardized total charges to 

remove the effects of differences in geographic adjustment factors, cost-of-living 

adjustments, and DSH payments under the capital IPPS as well. Charges were then 

summed by MS-DRG for each of the 15 cost groups so that each MS-DRG had 15 

standardized charge totals. These charges were then adjusted to cost by applying the 

national average CCRs developed from the FY 2008 cost report data. 

 The 15 cost centers that we used in the relative weight calculation are shown in 

the following table. The table shows the lines on the cost report and the corresponding 

revenue codes that we used to create the 15 national cost center CCRs. 

Cost 

Center 

Group 

Name 

(15 total) 

MedPAR 

Charge Field 

Revenue Codes 

contained in 

MedPAR Charge 

Field 

Cost Report 

Line 

Description 

(Worksheet C 

Part 1 & 

Wksheet D-4) 

Cost from 

HCRIS 

(Worksheet 

C, Part 1, 

Column 5 

and line 

number) 

Charges from 

HCRIS 

(Worksheet C, 

Part 1, Column 

6 & 7 and line 

number) 

Medicare 

Charges from 

HCRIS 

(Worksheet D-4, 

Column & line 

number) 

 
CMS-1498-P 243 

Cost 

Center 

Group 

Name 

(15 total) 

MedPAR 

Charge Field 

Revenue Codes 

contained in 

MedPAR Charge 

Field 

Cost Report 

Line 

Description 

(Worksheet C 

Part 1 & 

Wksheet D-4) 

Cost from 

HCRIS 

(Worksheet 

C, Part 1, 

Column 5 

and line 

number) 

Charges from 

HCRIS 

(Worksheet C, 

Part 1, Column 

6 & 7 and line 

number) 

Medicare 

Charges from 

HCRIS 

(Worksheet D-4, 

Column & line 

number) 

Routine 

Days 

Private Room 

Charges 011X and 014X 

Adults & 

Pediatrics 

(General 

Routine Care) C_1_C5_25 C_1_C6_25 D4_HOS_C2_25 

 

Semi-Private 

Room 

Charges 

010X, 012X, 013X 

and 016X-019X C_1_C7_25 D4_HOS_C2_26 

 Ward Charges 015X 

 

Intensive 

Days 

Intensive Care 

Charges 020X 

Intensive Care 

Unit C_1_C5_26 C_1_C6_26 D4_HOS_C2_26 

 C_1_C7_26 

 

Coronary Care 

Charges 021X 

Coronary 

Care Unit C_1_C5_27 C_1_C6_27 D4_HOS_C2_27 

 C_1_C7_27 

 

Burn Intensive 

Care Unit C_1_C5_28 C_1_C6_28 D4_HOS_C2_28 

 C_1_C7_28 

 

Surgical 

Intensive Care 

Unit C_1_C5_29 C_1_C6_29 D4_HOS_C2_29 

 C_1_C7_29 

 

Other Special 

Care Unit C_1_C5_30 C_1_C6_30 D4_HOS_C2_30 

 C_1_C7_30 

 

Drugs 

Pharmacy 

Charges 

025X, 026X and 

063X 

Intravenous 

Therapy C_1_C5_48 C_1_C6_48 D4_HOS_C2_48 

 C_1_C7_48 
CMS-1498-P 244 

Cost 

Center 

Group 

Name 

(15 total) 

MedPAR 

Charge Field 

Revenue Codes 

contained in 

MedPAR Charge 

Field 

Cost Report 

Line 

Description 

(Worksheet C 

Part 1 & 

Wksheet D-4) 

Cost from 

HCRIS 

(Worksheet 

C, Part 1, 

Column 5 

and line 

number) 

Charges from 

HCRIS 

(Worksheet C, 

Part 1, Column 

6 & 7 and line 

number) 

Medicare 

Charges from 

HCRIS 

(Worksheet D-4, 

Column & line 

number) 

 

Drugs 

Charged To 

Patient C_1_C5_56 C_1_C6_56 D4_HOS_C2_56 

 C_1_C7_56 

 

Supplies 

and 

Equipment 

Medical/Surgic

al Supply 

Charges 027X and 062X 

Medical 

Supplies 

Charged to 

Patients C_1_C5_55 C_1_C6_55 D4_HOS_C2_55 

 C_1_C7_55 

 

Durable 

Medical 

Equipment 

Charges 

0290, 0291, 0292 

and 0294-0299 DME-Rented C_1_C5_66 C_1_C6_66 D4_HOS_C2_66 

 C_1_C7_66 

 

Used Durable 

Medical 

Charges 0293 DME-Sold C_1_C5_67 C_1_C6_67 D4_HOS_C2_67 

 C_1_C7_67 

 

Therapy 

Services 

Physical 

Therapy 

Charges 042X 

Physical 

Therapy C_1_C5_50 C_1_C6_50 D4_HOS_C2_50 

 C_1_C7_50 

 

Occupational 

Therapy 

Charges 043X 

Occupational 

Therapy C_1_C5_51 C_1_C6_51 D4_HOS_C2_51 

 C_1_C7_51 

 

Speech 

Pathology 

Charges 044X and 047X 

Speech 

Pathology C_1_C5_52 C_1_C6_52 D4_HOS_C2_52 

 C_1_C7_52 
CMS-1498-P 245 

Cost 

Center 

Group 

Name 

(15 total) 

MedPAR 

Charge Field 

Revenue Codes 

contained in 

MedPAR Charge 

Field 

Cost Report 

Line 

Description 

(Worksheet C 

Part 1 & 

Wksheet D-4) 

Cost from 

HCRIS 

(Worksheet 

C, Part 1, 

Column 5 

and line 

number) 

Charges from 

HCRIS 

(Worksheet C, 

Part 1, Column 

6 & 7 and line 

number) 

Medicare 

Charges from 

HCRIS 

(Worksheet D-4, 

Column & line 

number) 

 

Inhalation 

Therapy 

 Inhalation 

Therapy 

Charges 041X and 046X 

Respiratory 

Therapy C_1_C5_49 C_1_C6_49 D4_HOS_C2_49 

 C_1_C7_49 

 

Operating 

Room 

Operating 

Room 

Charges 

036X, 071X and 

072X 

Operating 

Room C_1_C5_37 C_1_C6_37 D4_HOS_C2_37 

For all 

DRGs but 

Labor & 

Delivery C_1_C7_37 

 

Recovery 

Room C_1_C5_38 C_1_C6_38 D4_HOS_C2_38 

 C_1_C7_38 

 

Labor & 

Delivery 

Operating 

Room 

Charges 

036X, 071X and 

072X 

Delivery 

Room and 

Labor Room C_1_C5_39 C_1_C6_39 D4_HOS_C2_39 

ONLY FOR 

THE 6 

Labor & 

Delivery 

DRGs C_1_C7_39 

370, 371, 

372, 373, 

374, 375 Clinic Charges 051X 

Obstetrics 

Clinic C_1_C5_63 C_1_C6_63 D4_HOS_C2_63 

 C_1_C7_63 

 

Anesthesia 

Anesthesia 

Charges 037X 

Anesthesiology C_1_C5_40 C_1_C6_40 D4_HOS_C2_40 

 C_1_C7_40 
CMS-1498-P 246 

Cost 

Center 

Group 

Name 

(15 total) 

MedPAR 

Charge Field 

Revenue Codes 

contained in 

MedPAR Charge 

Field 

Cost Report 

Line 

Description 

(Worksheet C 

Part 1 & 

Wksheet D-4) 

Cost from 

HCRIS 

(Worksheet 

C, Part 1, 

Column 5 

and line 

number) 

Charges from 

HCRIS 

(Worksheet C, 

Part 1, Column 

6 & 7 and line 

number) 

Medicare 

Charges from 

HCRIS 

(Worksheet D-4, 

Column & line 

number) 

 

Cardiology 

Cardiology 

Charges 048X and 073X 

Electrocardiology C_1_C5_53 C_1_C6_53 D4_HOS_C2_53 

 C_1_C7_53 

 

Laboratory 

Laboratory 

Charges 

030X, 031X, 074X 

and 075X Laboratory C_1_C5_44 C_1_C6_44 D4_HOS_C2_44 

 C_1_C7_44 

 

PBP Clinic 

Laboratory 

Services C_1_C5_45 C_1_C6_45 D4_HOS_C2_45 

 C_1_C7_45 

 

Electro-encep

halography C_1_C5_54 C_1_C6_54 D4_HOS_C2_54 

 C_1_C7_54 

 

Radiology 

Radiology 

Charges 

028X, 032X, 033X, 

034X, 035X and 

040X 

Radiology - 

Diagnostic C_1_C5_41 C_1_C6_41 D4_HOS_C2_41 

 C_1_C7_41 

 

 MRI Charges 061X 

Radiology - 

Therapeutic C_1_C5_42 C_1_C6_42 D4_HOS_C2_42 

 Radioisotope C_1_C5_43 C_1_C6_43 D4_HOS_C2_43 

 C_1_C7_43 
CMS-1498-P 247 

Cost 

Center 

Group 

Name 

(15 total) 

MedPAR 

Charge Field 

Revenue Codes 

contained in 

MedPAR Charge 

Field 

Cost Report 

Line 

Description 

(Worksheet C 

Part 1 & 

Wksheet D-4) 

Cost from 

HCRIS 

(Worksheet 

C, Part 1, 

Column 5 

and line 

number) 

Charges from 

HCRIS 

(Worksheet C, 

Part 1, Column 

6 & 7 and line 

number) 

Medicare 

Charges from 

HCRIS 

(Worksheet D-4, 

Column & line 

number) 

 

Emergency 

Room 

Emergency 

Room 

Charges 045x Emergency C_1_C5_61 C_1_C6_61 D4_HOS_C2_61 

 C_1_C7_61 

Blood and 

Blood 

Products 

Blood 

Charges 038x 

Whole Blood 

& Packed Red 

Blood Cells C_1_C5_46 C_1_C6_46 D4_HOS_C2_46 

 C_1_C7_46 

Blood Storage 

/ Processing 039x 

Blood Storing, 

Processing, & 

Transfusing C_1_C5_47 C_1_C6_47 D4_HOS_C2_47 

 C_1_C7_47 

Other 

Services 

Lithotripsy 

Charge 079X 

 

 

Other Service 

Charge 

0002-0099, 022X, 

023X, 

024X,052X,053X 

 

055X-060X, 

064X-070X, 

076X-078X, 

090X-095X and 

099X 

 

ASC (Non 

Distinct Part) C_1_C5_58 C_1_C6_58 D4_HOS_C2_58 

 C_1_C7_58 

 

Outpatient 

Service 

Charges 049X and 050X 

Other 

Ancillary C_1_C5_59 C_1_C6_59 D4_HOS_C2_59 

 C_1_C7_59 

 Clinic C_1_C5_60 C_1_C6_60 D4_HOS_C2_60 
CMS-1498-P 248 

Cost 

Center 

Group 

Name 

(15 total) 

MedPAR 

Charge Field 

Revenue Codes 

contained in 

MedPAR Charge 

Field 

Cost Report 

Line 

Description 

(Worksheet C 

Part 1 & 

Wksheet D-4) 

Cost from 

HCRIS 

(Worksheet 

C, Part 1, 

Column 5 

and line 

number) 

Charges from 

HCRIS 

(Worksheet C, 

Part 1, Column 

6 & 7 and line 

number) 

Medicare 

Charges from 

HCRIS 

(Worksheet D-4, 

Column & line 

number) 

 C_1_C7_60 

 

Ambulance 

Charges 054X 

 

 

ESRD 

Revenue 

Setting 

Charges 

080X and 

082X-088X 

Observation 

beds C_1_C5_62 C_1_C6_62 D4_HOS_C2_62 

 C_1_C7_62 

 

Clinic Visit 

Charges 051X 

Observation 

beds C_1_C5_6201 C_1_C6_6201 

D4_HOS_C2_62

01 

 

(excluding 

Labor & 

Delivery 

DRGs) C_1_C7_6201 

 

Rural Health 

Clinic C_1_C5_6350 C_1_C6_6350 

D4_HOS_C2_63

50 

 

Professional 

Fees Charges 

096X, 097X, and 

098X C_1_C7_6350 

 FQHC C_1_C5_6360 C_1_C6_6360 

D4_HOS_C2_63

60 

 C_1_C7_6360 

 

Home 

Program 

Dialysis C_1_C5_64 C_1_C6_64 D4_HOS_C2_64 

 C_1_C7_64 

 Ambulance C_1_C5_65 C_1_C6_65 D4_HOS_C2_65 

 C_1_C7_65 

 

Other 

Reimbursable C_1_C5_68 C_1_C6_68 D4_HOS_C2_68 
CMS-1498-P 249 

Cost 

Center 

Group 

Name 

(15 total) 

MedPAR 

Charge Field 

Revenue Codes 

contained in 

MedPAR Charge 

Field 

Cost Report 

Line 

Description 

(Worksheet C 

Part 1 & 

Wksheet D-4) 

Cost from 

HCRIS 

(Worksheet 

C, Part 1, 

Column 5 

and line 

number) 

Charges from 

HCRIS 

(Worksheet C, 

Part 1, Column 

6 & 7 and line 

number) 

Medicare 

Charges from 

HCRIS 

(Worksheet D-4, 

Column & line 

number) 

 C_1_C7_68 

 

 We developed the national average CCRs as follows: 

 Taking the FY 2008 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 the Medicare charges for 

each line item from Worksheet D-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-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. 
CMS-1498-P 250 

After we multiplied the total charges for each MS-DRG in each of the 15 cost 

centers by the corresponding national average CCR, we summed the 15 "costs" across 

each MS-DRG to produce a total standardized cost for the MS-DRG. The average 

standardized cost for each MS-DRG was then computed as the total standardized cost for 

the MS-DRG divided by the transfer-adjusted case count for the MS-DRG. The average 

cost for each MS-DRG was then divided by the national average standardized cost per 

case to determine the relative weight. 

 The new cost-based relative weights were then normalized by an adjustment 

factor of 1.57461 so that the average case weight after recalibration was equal to the 

average case weight before recalibration. 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 15 proposed national average CCRs for FY 2011 are as follows: 

Group CCR 

Routine Days 0.553

Intensive Days 0.480

Drugs 0.200

Supplies & Equipment 0.348

Therapy Services 0.415

Laboratory 0.163

Operating Room 0.282

Cardiology 0.181

Radiology 0.161

Emergency Room 0.278

Blood and Blood Products 0.424

Other Services 0.426

Labor & Delivery 0.462

Inhalation Therapy 0.201

Anesthesia 0.136

 
CMS-1498-P 251 

 Since FY 2009, the relative weights have been based on 100 percent cost weights 

based on our MS-DRG grouping system. 

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. In 

this FY 2011 proposed rule, we are proposing to use that same case threshold in 

recalibrating the MS-DRG weights for FY 2011. Using the FY 2009 MedPAR data set, 

there are 8 MS-DRGs that contain fewer than 10 cases. Under the 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 to 17 years or age 17 years 

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 MS-DRGs will provide more stable 

payment for pediatric cases by determining their payment using adult cases that are much 

higher in total volume. Newborns are unique and require separate MS-DRGs that are not 

mirrored in the adult population. Therefore, it remains necessary to retain separate MSDRGs for newborns. All of the low-volume MS-DRGs listed below are for newborns. In 
CMS-1498-P 252 

FY 2011, because we do not have sufficient MedPAR data to set accurate and stable cost 

weights for these low-volume MS-DRGs, we are proposing to compute weights for the 

low-volume MS-DRGs by adjusting their FY 2010 weights by the percentage change in 

the average weight of the cases in other MS-DRGs. The crosswalk table is shown below: 

Low-Volume 

MS-DRG MS-DRG Title Crosswalk to MS-DRG 

768 Vaginal Delivery with O.R. 

Procedure Except Sterilization 

and/or D&C 

FY 2010 FR weight 

(adjusted by percent change 

in average weight of the 

cases in other MS-DRGs) 

789 Neonates, Died or Transferred to 

Another Acute Care Facility 

FY 2010 FR weight 

(adjusted by percent change 

in average weight of the 

cases in other MS-DRGs) 

790 Extreme Immaturity or Respiratory 

Distress Syndrome, Neonate 

FY 2010 FR weight 

(adjusted by percent change 

in average weight of the 

cases in other MS-DRGs) 

791 Prematurity with Major Problems FY 2010 FR weight 

(adjusted by percent change 

in average weight of the 

cases in other MS-DRGs) 

792 Prematurity without Major 

Problems 

FY 2010 FR weight 

(adjusted by percent change 

in average weight of the 

cases in other MS-DRGs) 

793 Full-Term Neonate with Major 

Problems 

FY 2010 FR weight 

(adjusted by percent change 

in average weight of the 

cases in other MS-DRGs) 

794 Neonate with Other Significant 

Problems 

FY 2010 FR weight 

(adjusted by percent change 

in average weight of the 

cases in other MS-DRGs) 

795 Normal Newborn FY 2010 FR weight 

(adjusted by percent change 

in average weight of the 

cases in other MS-DRGs) 
CMS-1498-P 253 

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

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 a 

new medical service or technology may be considered for new technology add-on 

payment 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." We note that beginning with FY 

2008, CMS transitioned from CMS-DRGs to MS-DRGs. 

 The regulations implementing these provisions specify three criteria for a new 

medical service or technology to receive the additional payment: (1) the medical service 

or technology must be new; (2) the medical service or technology must be costly such 

that the DRG rate otherwise applicable to discharges involving the medical service or 

technology is determined to be inadequate; and (3) the service or technology must 

demonstrate a substantial clinical improvement over existing services or technologies. 

These three criteria are explained below in the ensuing paragraphs in further detail. 

Under the first criterion, as reflected in 42 CFR 412.87(b)(2), a specific medical 

service or technology will be considered “new” for purposes of new medical service or 
CMS-1498-P 254 

technology add-on payments until such time as Medicare data are available to fully 

reflect the cost of the technology in the MS-DRG weights through recalibration. 

Typically, there is a lag of 2 to 3 years from the point a new medical service or 

technology is first introduced on the market (generally on the date that the technology 

receives FDA approval/clearance) and when data reflecting the use of the medical service 

or technology are used to calculate the MS-DRG weights. For example, data from 

discharges occurring during FY 2009 are used to calculate the proposed FY 2011 

MS-DRG weights in this proposed rule. Section 412.87(b)(2) of the regulations therefore 

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 MS-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 on the date on which the medical service or 

technology received FDA approval or clearance. (We note that, for purposes of this 

section of this proposed rule, we generally refer to both FDA approval and FDA 

clearance as FDA “approval.”) However, in some cases, there may be few to no 

Medicare data available for the new service or technology following FDA approval. For 

example, the newness period could extend beyond the 2-year to 3-year period after FDA 
CMS-1498-P 255 

approval is received in cases where the product initially was generally unavailable to 

Medicare patients following FDA approval, such as in cases of a national noncoverage 

determination or a documented delay in bringing the product onto the market after that 

approval (for instance, component production or drug production has been postponed 

following FDA approval due to shelf life concerns or manufacturing issues). After the 

MS-DRGs have been recalibrated to reflect the costs of an otherwise new medical service 

or technology, the medical service or technology is no longer eligible for special add-on 

payment for new medical services or technologies (as specified under §412.87(b)(2)). 

For example, an approved new technology that received FDA approval in October 2008 

and entered the market at that time may be eligible to receive add-on payments as a new 

technology for discharges occurring before October 1, 2011 (the start of FY 2012). 

Because the FY 2012 MS-DRG weights would be calculated using FY 2010 MedPAR 

data, the costs of such a new technology would be fully reflected in the FY 2012 

MS-DRG weights. Therefore, the new technology would no longer be eligible to receive 

add-on payments as a new technology for discharges occurring in FY 2012 and 

thereafter. 

We do not consider a service or technology to be new if it is substantially similar 

to one or more existing technologies. That is, even if a technology receives a new FDA 

approval, it may not necessarily be considered “new” for purposes of new technology 

add-on payments if it is “substantially similar” to a technology that was approved by 

FDA and has been on the market for more than 2 to 3 years. In the FY 2006 IPPS final 

rule (70 FR 47351), we explained our policy regarding substantial similarity in detail and 
CMS-1498-P 256 

its relevance for assessing if the hospital charge data used in the development of the 

relative weights for the relevant DRGs reflect the costs of the technology. In that final 

rule, we stated that, for determining substantial similarity, we consider (1) whether a 

product uses the same or a similar mechanism of action to achieve a therapeutic outcome, 

and (2) whether a product is assigned to the same or a different DRG. We indicated that 

both of the above criteria should be met in order for a technology to be considered 

“substantially similar” to an existing technology. However, in that same final rule, we 

also noted that, due to the complexity of issues regarding the substantial similarity 

component of the newness criterion, it may be necessary to exercise flexibility when 

considering whether technologies are substantially similar to one another. Specifically, 

we stated that we may consider additional factors, depending on the circumstances 

specific to each application. 

In the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43813 and 43814), 

we noted that the discussion of substantial similarity in the FY 2006 IPPS final rule 

related to comparing two separate technologies made by different manufacturers. 

Nevertheless, we stated that the criteria discussed in the FY 2006 IPPS final rule also are 

relevant when comparing the similarity between a new use and existing uses of the same 

technology (or a very similar technology manufactured by the same manufacturer). In 

other words, we stated that it is necessary to establish that the new indication for which 

the technology has received FDA approval is not substantially similar to that of the prior 

indication. We explained that such a distinction is necessary to determine the appropriate 

start date of the newness period in evaluating whether the technology would qualify for 
CMS-1498-P 257 

add-on payments (that is, the date of the “new” FDA approval or that of the prior 

approval), or whether the technology could qualify for separate new technology add-on 

payments under each indication. 

In the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43814), we added a 

third factor of consideration to our analysis of whether a new technology is substantially 

similar to one or more existing technologies. Specifically, in making a determination of 

whether a technology is substantially similar to an existing technology, we will consider 

whether the new use of the technology involves the treatment of the same or similar type 

of disease and the same or similar patient population (74 FR 24130), in addition to 

considering the already established factors described in the FY 2006 IPPS final rule (that 

is, (1) whether a product uses the same or a similar mechanism of action to achieve a 

therapeutic outcome; and (2) whether a product is assigned to the same or a different 

DRG). As we noted in the FY 2010 IPPS/RY 2010 LTCH PPS final rule, if all three 

components are present and the new use is deemed substantially similar to one or more of 

the existing uses of the technology (that is beyond the newness period), we would 

conclude that the technology is not new and, therefore, is not eligible for the new 

technology add-on payment. 

 Under the second criterion, §412.87(b)(3) further provides that, to be eligible for 

the add-on payment for new medical services or technologies, the MS-DRG prospective 

payment rate otherwise applicable to the discharge involving the new medical services or 

technologies must be assessed for adequacy. Under the cost criterion, to assess the 

adequacy of payment for a new technology paid under the applicable MS-DRG 
CMS-1498-P 258 

prospective payment rate, we evaluate whether the charges for cases involving the new 

technology exceed certain threshold amounts. 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 MS-DRG plus 75 percent of 1 standard deviation above the geometric 

mean standardized charge (based on the logarithmic values of the charges and converted 

back to charges) for all cases in the MS-DRG to which the new medical service or 

technology is assigned (or the case-weighted average of all relevant MS-DRGs, if the 

new medical service or technology occurs in more than one MS-DRG). 

 However, section 503(b)(1) of Pub. L. 108-173 amended section 

1886(d)(5)(K)(ii)(I) of the Act to provide that, beginning in FY 2005, CMS will apply "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 one standard deviation for the 

diagnosis-related group involved." (We refer readers 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 that was included in the final rule published in the Federal Register on 

August 27, 2009, contains the final thresholds that are being used to evaluate applications 

for new technology add-on payments for FY 2011 (74 FR 44173). We note that we plan 

to issue separate documents in the Federal Register addressing the provisions of Pub. L. 

111-148, as amended, that affect our proposed policies and payment rates for FY 2011 

under the IPPS and the LTCH PPS. In addition, we plan to issue further instructions 

addressing the provisions of Pub. L. 111-148, as amended, that affect the policies and 
CMS-1498-P 259 

paymet rates for FY 2010 under the IPPS and the LTCH PPS. At the time we issue those 

documents, we plan to update Table 10 that was published in the Federal Register on 

August 27, 2009 and Table 10 in the Addendum to this proposed rule. 

 In the September 7, 2001 final rule that established the new technology add-on 

payment regulations (66 FR 46917), we discussed 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. Specifically, 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 requirements by 

discussing how the HIPAA Privacy Rule permitted providers to share with health plans 

information needed to ensure correct payment, if they had 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 for 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 protected 

health information for treatment, payment, or health care operations, and expressly 

permits such entities to use or to disclose protected health information for any of these 

purposes. (We refer readers to 45 CFR 164.502(a)(1)(ii), and 164.506(c)(1) and (c)(3), 
CMS-1498-P 260 

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.) 

 Under the third criterion, §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. (We refer readers to the September 7, 2001 final rule 

for a complete discussion of this criterion (66 FR 46902).) 

The new medical service or technology add-on payment policy under the IPPS 

provides additional payments for cases with relatively high costs involving eligible new 

medical services or technologies while preserving some of the incentives inherent under 

an average-based prospective payment system. The payment mechanism is based on the 

cost to hospitals for the new medical service or technology. Under §412.88, if the costs 

of the discharge (determined by applying cost to charge ratios (“CCRs”) as described in 

§412.84(h)) exceed the full DRG payment (including payments for IME and DSH, but 

excluding outlier payments), Medicare will make an add-on payment equal to the lesser 

of: (1) 50 percent of the estimated costs of the new technology (if the estimated costs for 

the case including the new technology exceed Medicare’s payment); or (2) 50 percent of 

the difference between the full DRG payment and the hospital’s estimated cost for the 
CMS-1498-P 261 

case. Unless the discharge qualifies for an outlier payment, Medicare payment is limited 

to the full MS-DRG payment plus 50 percent of the estimated costs of the new 

technology. 

 Section 1886(d)(4)(C)(iii) of the Act requires that the adjustments to annual 

MS-DRG classifications and relative weights must be made in a manner that ensures that 

aggregate payments to hospitals are not more or less than they were in the prior fiscal 

year (i.e., they are “budget neutral”). Therefore, in the past, we accounted for projected 

payments under the new medical service and technology provision during the upcoming 

fiscal year, while at the same time estimating the payment effect of changes to the MSDRG 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. However, 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, in accordance with section 503(d)(2) of Pub. L. 108-173, addon payments for new medical services or technologies for FY 2005 and later years have 

not been subjected to budget neutrality. 

 In the FY 2009 IPPS final rule (73 FR 48561 through 48563), we modified our 

regulations at §412.87 to codify our current practice of how CMS evaluates the eligibility 

criteria for new medical service or technology add-on payment applications. We also 

amended §412.87(c) to specify that all applicants for new technology add-on payments 
CMS-1498-P 262 

must have FDA approval for their new medical service or technology by July 1 of each 

year prior to the beginning of the fiscal year that the application is being considered. 

 The Council on Technology and Innovation (CTI) at CMS oversees the agency's 

cross-cutting priority on coordinating coverage, coding and payment processes for 

Medicare with respect to new technologies and procedures, including new drug therapies, 

as well as promoting the exchange of information on new technologies between CMS and 

other entities. The CTI, composed of senior CMS staff and clinicians, was established 

under section 942(a) of Pub. L. 108-173. The Council is co-chaired by the Director of 

the Office of Clinical Standards and Quality (OCSQ) and the Director of the Center for 

Medicare Management (CMM), who is also designated as the CTI's Executive 

Coordinator. 

 The specific processes for coverage, coding, and payment are implemented by 

CMM, OCSQ, and the local claims-payment contractors (in the case of local coverage 

and payment decisions). The CTI supplements, rather than replaces, these processes by 

working to assure that all of these activities reflect the agency-wide priority to promote 

high-quality, innovative care. At the same time, the CTI also works to streamline, 

accelerate, and improve coordination of these processes to ensure that they remain up to 

date as new issues arise. To achieve its goals, the CTI works to streamline and create a 

more transparent coding and payment process, improve the quality of medical decisions, 

and speed patient access to effective new treatments. It is also dedicated to supporting 

better decisions by patients and doctors in using Medicare-covered services through the 
CMS-1498-P 263 

promotion of better evidence development, which is critical for improving the quality of 

care for Medicare beneficiaries. 

 CMS plans to continue its Open Door forums with stakeholders who are 

interested in CTI's initiatives. In addition, to improve the understanding of CMS’ 

processes for coverage, coding, and payment and how to access them, the CTI has 

developed an "innovator's guide" to these processes. The intent is to consolidate this 

information, much of which is already available in a variety of CMS documents and in 

various places on the CMS Web site, in a user-friendly format. This guide was published 

in August 2008 and is available on the CMS Web site at: 

http://www.cms.hhs.gov/CouncilonTechInnov/Downloads/InnovatorsGuide8_25_08.pdf. 

 As we indicated in the FY 2009 IPPS final rule (73 FR 48554), we invite any 

product developers or manufacturers of new medical technologies to contact the agency 

early in the process of product development if they have questions or concerns about the 

evidence that would be needed later in the development process for the agency's coverage 

decisions for Medicare. 

 The CTI aims to provide useful information on its activities and initiatives to 

stakeholders, including Medicare beneficiaries, advocates, medical product 

manufacturers, providers, and health policy experts. Stakeholders with further questions 

about Medicare's coverage, coding, and payment processes, or who want further guidance 

about how they can navigate these processes, can contact the CTI at CTI@cms.hhs.gov 

or from the "Contact Us" section of the CTI home page 

(http://www.cms.hhs.gov/CouncilonTechInnov/). 
CMS-1498-P 264 

 We note that applicants for add-on payments for new medical services or 

technologies for FY 2012 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 

that the medical service or technology meets the high-cost threshold. Complete 

application information, along with final deadlines for submitting a full application, will 

be posted as it becomes available on our Web site 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 2012, the Web site also will 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; 
CMS-1498-P 265 

● 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; and 

● 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 2011 prior to publication of this FY 2011 

IPPS/RY 2011 LTCH PPS proposed rule, we published a notice in the Federal Register 

on November 27, 2009 (74 FR 62339 through 62342), and held a town hall meeting at the 

CMS Headquarters Office in Baltimore, MD, on February 19, 2010. 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 2011 new medical service and technology add-on payment applications before the 

publication of this FY 2011 proposed rule. 

Approximately 80 individuals registered to attend the town hall meeting in 

person, while additional individuals listened over an open telephone line. Each of the 

three FY 2011 applicants presented information on its technology, including a discussion 
CMS-1498-P 266 

of data reflecting the substantial clinical improvement aspect of the technology. We 

considered each applicant’s presentation made at the town hall meeting, as well as written 

comments submitted on the applications, in our evaluation of the new technology add-on 

applications for FY 2011 in this proposed rule. 

In response to the published notice and the new technology town hall meeting, we 

received 11 written comments regarding applications for FY 2011 new technology 

add-on payments. We summarized these comments or, if applicable, indicated that there 

were no comments received, at the end of each discussion of the individual applications 

in this proposed rule. 

Comment: One commenter, a medical technology association, recommended that 

CMS, in its consideration as to whether a new technology meets the substantial clinical 

improvement criterion, judge a diagnostic device on the basis of a diagnostic outcome 

(improved diagnosis) rather than a therapeutic outcome, recognizing that earlier and 

improved detection of disease often leads to improved patient outcomes. 

Response: We thank the commenter for its comments on the substantial clinical 

improvement criterion. Similar to our statements in the FY 2010 IPPS/RY 2010 LTCH 

PPS final rule (74 FR 43817 through 43819), section 1886(d)(5)(K)(vi) of the Act 

authorizes the Secretary to establish through notice and comment rulemaking the criteria 

that a new medical service or technology must meet in order to be eligible for the new 

technology add-on payment. Under this authority, in the September 7, 2001 final rule, 

we established three criteria through notice and comment rulemaking--the newness 

criterion, the cost criterion, and the substantial clinical improvement criterion (66 FR 
CMS-1498-P 267 

46924). Specifically, §412.87(b)(1) of the regulations provides that a new medical 

service or technology must “represent an advance that substantially improves, relating to 

technologies previously available, the diagnosis or treatment of Medicare beneficiaries.” 

As we explained in the September 7, 2001 final rule, we consider a diagnostic 

technology to meet the substantial clinical improvement criterion if the technology not 

only “offers the ability to diagnose a medical condition in a patient population where that 

medical condition is currently undetectable or offers the ability to diagnose a medical 

condition earlier in a patient population than allowed by currently available methods,” 

but also if “use of the device to make a diagnosis affects the management of the patient” 

(66 FR 46914). We believe that this evidence is necessary to determine whether the new 

technology affords a “clear improvement over the use of previously available 

technologies.” We do not consider any particular type of evidence to be dispositive; 

instead, we consider all information presented for each application to determine whether 

there is evidence to support a conclusion that “use of the device to make a diagnosis 

affects the management of the patient” (in the case of a diagnostic technology). 

Specifically, we consider whether the peer-reviewed medical literature supports or 

clinical studies indicate that the diagnostic device should generally be used by providers 

in guiding the management of their patients. In addition, we consider evidence 

demonstrating clinically accepted use of the device in a manner that actually affects the 

management of patients. 

Under the commenter’s recommendation, a diagnostic technology effectively 

would only need to receive FDA approval and be the only technology approved for a 
CMS-1498-P 268 

particular diagnostic capability in order to be deemed a “substantial improvement” for 

purposes of new technology add-on payments, regardless of its ability to positively affect 

patient management. This approach would deem a device that led to the identification of 

new information as a substantial improvement in diagnosis even if such detection has not 

been “demonstrated to represent a substantial improvement in caring for Medicare 

beneficiaries” and was not linked to evidence-based, significant, and positive changes in 

the management of patients or, ultimately, to changes in clinical outcomes. We do not 

believe this rationale is consistent with our prior statements regarding the substantial 

clinical improvement criterion of the new technology add-on payment provision. 

Comment: One commenter, a medical device association, recommended that 

CMS “deem a device to satisfy the substantial clinical improvement criteria if it was 

granted a humanitarian device exemption or priority review based on the fact that it 

represents breakthrough technologies, which offer significant advantages over existing 

approved alternatives, for which no alternatives exist, or the availability of which is in the 

best interests of the patients.” In addition, the commenter remarked that this process 

would simplify CMS’ evaluation of applications for new technology add-on payments 

and would promote access to innovative treatments, as intended by Congress. Although 

the commenter also made remarks that were unrelated to substantial clinical 

improvement, because the purpose of the town hall meeting was specifically to discuss 

substantial clinical improvement of pending new technology applications, those 

comments are not summarized in this proposed rule. 
CMS-1498-P 269 

Response: We thank the commenter for its comments. We note that we have 

previously addressed the comment concerning automatically approving technologies that 

have a humanitarian device exemption (HDE) in the FY 2008 IPPS final rule 

(72 FR 47302). We refer readers to that rule for our response. A further discussion of 

our evaluation of the applications and the documentation for new technology add-on 

payments submitted for FY 2011 approval is provided under the specified areas under 

this section. 

3. FY 2011 Status of Technologies Approved for FY 2010 Add-On Payments 

a. Spiration® IBV® Valve System 

 Spiration, Inc. submitted an application for new technology add-on payments for 

the Spiration® IBV® Valve System (Spiration® IBV®). The Spiration® IBV® is a 

device that is used to place, via bronchoscopy, small, one-way valves into selected small 

airways in the lung in order to limit airflow into selected portions of lung tissue that have 

prolonged air leaks following surgery while still allowing mucus, fluids, and air to exit, 

thereby reducing the amount of air that enters the pleural space. The device is intended 

to control prolonged air leaks following three specific surgical procedures: lobectomy; 

segmentectomy; or lung volume reduction surgery (LVRS). According to the applicant, 

an air leak that is present on postoperative day 7 is considered “prolonged” unless present 

only during forced exhalation or cough. In order to help prevent valve migration, there 

are five anchors with tips that secure the valve to the airway. The implanted valves are 

intended to be removed no later than 6 weeks after implantation. 
CMS-1498-P 270 

 With regard to the newness criterion, the Spiration® IBV® received a HDE 

approval from the FDA on October 24, 2008. We were unaware of any previously FDAapproved predicate devices, or otherwise similar devices, that could be considered 

substantially similar to the Spiration® IBV®. However, the applicant asserted that the 

FDA had precluded the device from being used in the treatment of any patients until 

Institutional Review Board (IRB) approvals regarding its study sites. Therefore, the 

Spiration® IBV® met the newness criterion once it obtained at least one IRB approval 

because the device would then be available on the market to treat Medicare beneficiaries. 

After evaluation of the newness, costs, and substantial clinical improvement 

criteria for new technology payments for the Spiration® IBV® and consideration of the 

public comments we received on the FY 2010 IPPS proposed rule, including the 

additional analysis of clinical data and supporting information submitted by the applicant, 

we approved the Spiration® IBV® for new technology add-on payments for FY 2010. 

The Spiration® IBV® is the only device currently approved for the purpose of treating 

prolonged air leaks following lobectomy, segmentectomy, and LVRS patients in the 

United States. We stated that without the availability of this device, patients with 

prolonged air leaks (following lobectomy, segmentectomy, and LVRS) might otherwise 

remain inpatients in the hospital (and have a longer length of stay than they might 

otherwise have without the Spiration® IBV®) or might even require additional invasive 

surgeries to resolve the air leak. We also noted that use of the Spiration® IBV® may 

lead to more rapid beneficial resolution of prolonged air leaks and reduce recovery time 

following the three lung surgeries mentioned above. 
CMS-1498-P 271 

However, in the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43823), we 

indicated that we remained interested in seeing whether the clinical evidence continues to 

find it to be effective. This approval was on the basis of using the Spiration® IBV® 

consistent with the FDA approval (HDE), and we emphasized the need for appropriate 

patient selection accordingly. Therefore, we limited the add-on payment to cases 

involving prolonged air leaks following lobectomy, segmentectomy and LVRS in 

MS-DRGs 163, 164, and 165. Cases involving the Spiration® IBV® that are eligible for 

the new technology add-on payment are identified by assignment to MS-DRGs 163, 164, 

and 165 with procedure code 33.71 or 33.73 in combination with one of the following 

procedure codes: 32.22, 32.30, 32.39, 32.41, or 32.49. 

In the FY 2010 IPPS/RY 2010 LTCH PPS final rule, we stated that the average 

cost of the Spiration® IBV® is reported as $2,750. Based on data from the FY 2010 

application, the average amount of valves per case is 2.5. Therefore, the total maximum 

cost for the Spiration® IBV® was expected to be $6,875 per case ($2,750 x 2.5). Under 

§412.88(a)(2) of our regulations, new technology add-on payments are limited to the 

lesser of 50 percent of the average cost of the device or 50 percent of the costs in excess 

of the MS-DRG payment for the case. As a result, we finalized a maximum add-on 

payment for a case involving the Spiration® IBV® as $3,437.50. 

b. CardioWestTM Temporary Total Artificial Heart System (CardioWestTM TAH-t) 

 SynCardia Systems, Inc. submitted an application for approval of the 

CardioWestTM temporary Total Artificial Heart system (TAH-t) in FY 2009. The TAH-t 

is a technology that is used as a bridge to heart transplant device for heart transplant-
CMS-1498-P 272 

eligible patients with end-stage biventricular failure. The TAH-t pumps up to 9.5 liters of 

blood per minute. This high level of perfusion helps improve hemodynamic function in 

patients, thus making them better heart transplant candidates. 

 The TAH-t was approved by the FDA on October 15, 2004, for use as a bridge to 

transplant device in cardiac transplant-eligible candidates at risk of imminent death from 

biventricular failure. The TAH-t is intended to be used in hospital inpatients. One of the 

FDA’s post-approval requirements is that the manufacturer agrees to provide a 

post-approval study demonstrating success of the device at one center can be reproduced 

at other centers. The study was to include at least 50 patients who would be followed up 

to 1 year, including (but not limited to) the following endpoints: survival to transplant; 

adverse events; and device malfunction. 

 In the past, Medicare did not cover artificial heart devices, including the TAH-t. 

However, on May 1, 2008, CMS issued a final national coverage determination (NCD) 

expanding Medicare coverage of artificial hearts when they are implanted as part of a 

study that is approved by the FDA and is determined by CMS to meet CMS' Coverage 

with Evidence Development (CED) clinical research criteria. (The final NCD is 

available on the CMS Web site at: 

http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=211.) 

We indicated in the FY 2009 IPPS/RY 2009 LTCH PPS final rule (73 FR 48555) 

that, because Medicare’s previous coverage policy with respect to this device had 

precluded payment from Medicare, we did not expect the costs associated with this 

technology to be currently reflected in the data used to determine the relative weights of 
CMS-1498-P 273 

MS-DRGs. As we have indicated in the past, and as we discussed in the FY 2009 

IPPS/RY 2009 LTCH PPS final rule, although we generally believe that the newness 

period would begin on the date that FDA approval was granted, in cases where the 

applicant can demonstrate a documented delay in market availability subsequent to FDA 

approval, we would consider delaying the start of the newness period. This technology’s 

situation represented such a case. We also noted that section 1886(d)(5)(K)(ii)(II) of the 

Act requires that we provide for the collection of cost data for a new medical service or 

technology for a period of at least 2 years and no more than 3 years “beginning on the 

date on which an inpatient hospital code is issued with respect to the service or 

technology.” Furthermore, the statute specifies that the term “inpatient hospital code” 

means any code that is used with respect to inpatient hospital services for which payment 

may be made under the IPPS and includes ICD-9-CM codes and any subsequent 

revisions. Although the TAH-t has been described by the ICD-9-CM code(s) since the 

time of its FDA approval, because the TAH-t had not been covered under the Medicare 

program (and, therefore, no Medicare payment had been made for this technology), this 

code could not be "used with respect to inpatient hospital services for which payment" is 

made under the IPPS, and thus we assumed that none of the costs associated with this 

technology would be reflected in the Medicare claims data used to recalibrate the 

MS-DRG relative weights for FY 2009. For this reason, as discussed in the FY 2009 

IPPS/RY 2009 LTCH PPS final rule, despite the FDA approval date of the technology, 

we determined that TAH-t would still be eligible to be considered “new” for purposes of 

the new technology add-on payment because the TAH-t met the newness criterion on the 
CMS-1498-P 274 

date that Medicare coverage began, consistent with issuance of the final NCD, effective 

on May 1, 2008. 

After evaluation of the newness, costs, and substantial clinical improvement 

criteria for new technology add-on payments for the TAH-t and consideration of the 

public comments we received in response to the FY 2009 IPPS/RY 2009 LTCH PPS 

proposed rule, we approved the TAH-t for new technology add-on payments for FY 2009 

(73 FR 48557). We indicated that we believed the TAH-t offered a new treatment option 

that previously did not exist for patients with end-stage biventricular failure. However, 

we indicated that we recognized that Medicare coverage of the TAH-t is limited to 

approved clinical trial settings. The new technology add-on payment status does not 

negate the restrictions under the NCD nor does it obviate the need for continued 

monitoring of clinical evidence for the TAH-t. We remain interested in seeing whether 

the clinical evidence demonstrates that the TAH-t continues to be effective. If evidence 

is found that the TAH-t may no longer offer a substantial clinical improvement, we 

reserve the right to discontinue new technology add-on payments, even within the 2- to 

3-year period that the device may still be considered to be new. We also continued to 

make new technology add-on payments for the TAH-t in FY 2010. We welcome public 

comment regarding whether there is new evidence that demonstrates that the TAH-T 

continues to be effective and whether it should still be considered to be a substantial 

clinical improvement for FY 2011. 

The new technology add-on payment for the TAH-t for FY 2010 is triggered by 

the presence of ICD-9-CM procedure code 37.52 (Implantation of total heart replacement 
CMS-1498-P 275 

system), condition code 30, and the diagnosis code reflecting clinical trial--V70.7 

(Examination of participant in clinical trial). For FY 2010, we finalized a maximum 

add-on payment of $53,000 (that is, 50 percent of the estimated operating costs of the 

device of $106,000) for cases that involve this technology. 

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). The TAH-t is still eligible to be considered “new” for 

purposes of the new technology add-on payment because the 3-year anniversary date of 

the TAH-t entry on the market was in the second half of the fiscal year and the TAH-t 

met the newness criterion on the date that Medicare coverage began, consistent with 

issuance of the final NCD, effective on May 1, 2008. Therefore, for FY 2011, we are 

proposing to continue new technology add-on payments for cases involving the TAH-t in 

FY 2011 with a maximum add-on payment of $53,000. 

4. FY 2011 Applications for New Technology Add-On Payments 

We received five applications to be considered for new technology add-on 

payment for FY 2011. However, two applicants withdrew their applications: Nycomed 

Austria GmbH, which submitted an application for new technology add-on payments for 

FY 2011 for TachoSil®; and Zimmer, which submitted an application for new 

technology add-on payments for FY 2011 for the Dynesys Dynamic Stabilization System. 

Nycomed Austria GmbH withdrew its application from further review in January 2010, 

and Zimmer withdrew its application in February 2010. Because both applications were 
CMS-1498-P 276 

withdrawn prior to the town hall meeting and publication of this proposed rule, we are 

not discussing these two applications in this proposed rule. 

 A discussion of the remaining three applications is presented below. At the time 

this proposed rule was developed, one of the technologies had not yet received FDA 

approval. Consequently, our discussion below of this application may be limited. 

a. Auto Laser Interstitial Thermal Therapy (AutoLITTTM) System 

Monteris Medical submitted an application for new technology add-on payments 

for FY 2011 for the AutoLITTTM. We note that the applicant submitted an application for 

new technology add-on payments for FY 2010 but withdrew its application prior to the 

FY 2010 IPPS/RY 2010 LTCH PPS final rule. AutoLITTTM is a minimally invasive, 

MRI-guided catheter tipped laser designed to destroy malignant brain tumors with 

interstitial thermal energy causing immediate coagulation and necrosis of diseased tissue. 

The applicant asserts that the AutoLITTTM delivers laser energy to the lesion with a 

proprietary 3mm diameter probe that directs the energy radially (that is, at right angle to 

the axis of the probe, or side-firing) toward the targeted tumor tissue in a narrow beam 

profile and at the same time, a proprietary probe cooling system removes heat from tissue 

not directly in the path of the laser beam, ostensibly protecting it from thermal damage 

and enabling the physician to selectively ablate only targeted tissue. The AutoLITTTM 

received a 510K FDA clearance in May 2009. The AutoLITTTM is indicated for use to 

necrotize or coagulate soft tissue through interstitial irradiation or thermal therapy in 

medicine and surgery in the discipline of neurosurgery with 1064 nm lasers. The 

AutoLITTTM may be used in patients with glioblastoma multiforme brain tumors. The 
CMS-1498-P 277 

applicant stated in its application and through supplemental information that, due to 

required updates, the technology was actually introduced to the market in December 

2009. The applicant explained that it was necessary to reduce the thermal damage lines 

from three to one and complete International Electrotechnical Commission/Underwriter 

Laboratory testing, which led to the introduction of the technology to the market in 

December 2009, although the technology was approved by FDA in May 2009. The 

applicant also stated through supplementary information to its application that the first 

sale of the product took place on March 19, 2010. However, because the product was 

already available for use in December 2009, it appears that the newness date would begin 

in December 2009. We welcome public comments on this issue. 

With regard to the newness criterion, we are concerned that the AutoLITTTM may 

be substantially similar to the device that it listed as its predicate device in its application 

to the FDA for approval. Specifically, in making a determination of substantial 

similarity, we consider the following: (1) whether a product uses the same or similar 

mechanism of action to achieve a therapeutic action; and (2) whether a product is 

assigned to the same of different MS-DRG; and (3) whether the new use of a technology 

involves the treatment of the same or similar type of disease and the same or similar 

patient population. The applicant identified Visual-ase as its predicate device (which was 

approved by the FDA in 2006), which is also used to treat tumors of the brain. The 

applicant maintains that AutoLITTTM can be distinguished from the Visual-ase by its 

mechanism of action (that is, side-firing laser versus elliptical firing). Additionally, as 

mentioned above, the technology contains a proprietary probe cooling system that 
CMS-1498-P 278 

removes heat from tissue not directly in the path of the laser beam. We welcome 

comments from the public regarding whether or not the AutoLITTTM is substantially 

similar to the Visual-ase and if it meets the newness criteria. 

The technology can be identified by ICD-9-CM procedure codes 17.61 (Laser 

interstitial thermal therapy [LITT] of lesion or tissue of brain under guidance), and 17.62 

(Laser interstitial thermal therapy [LITT] of lesion or tissue of head and neck under 

guidance), which were effective on October 1, 2009. 

In an effort to demonstrate that AutoLITTTM meets the cost criterion, the applicant 

used 2007 Medicare data from the Healthcare Cost and Utilization Project (HCUP). We 

first note that the applicant believes that cases eligible for the AutoLITTTM will map to 

MS-DRG 25 (Craniotomy and Endovascular Intracranial Procedures with MCC), 

MS-DRG 26 (Craniotomy and Endovascular Intracranial Procedures with CC), and 

MS-DRG 27 (Craniotomy and Endovascular Intracranial Procedures without CC or 

MCC). The applicant explained through supplemental information to its application that 

most cases of the AutoLITTTM would map to MS-DRG 25 in the near-term. As the 

technology becomes more widely available, clinicians will use the technology instead of 

performing a craniotomy for brain cancer and on other different types of brain cancers 

including metastases, which would map to other MS-DRGs aside from MS-DRG 25. 

The applicant further stated that life expectancy with brain cancer is predicated on the 

removal of as much of the cancer as possible and asserted that over time the AutoLITTTM 

will do a better job of removing the majority of the cancer that is present within the brain 

tissue compared to other procedures. The applicant believes that physicians with the 
CMS-1498-P 279 

AutoLITTTM have a better tool at removing more cancer and killing it more precisely and 

accessing parts of the brain that surgical resection cannot access. Lastly, the applicant 

believes that the minimally invasive nature of the procedure will also result in broader 

usage to other less complicated procedures (as clinical and patient awareness expands). 

The applicant searched HCUP hospital data for cases potentially eligible for the 

AutoLITTTM that was assigned one of the following ICD-9-CM diagnosis codes: a 

diagnosis code that begins with a prefix of 191 (Malignant neoplasm of brain); diagnosis 

code 225.0 (Benign neoplasm of brain and other parts of nervous system); or diagnosis 

code 239.6 (Neoplasm of the brain of unspecified nature). The applicant found 41,021 

cases and weighted the standardized charge per case based on the number of cases found 

within each of the diagnosis codes listed above rather than the percentage of cases that 

would group to different MS-DRGs. Based on this analysis, the applicant calculated an 

average standardized charge per case was $57,511. While the applicant's analysis 

established a case-weighted average charge per case in the aggregate, it did not provide a 

case-weighted average standardized charge per case by MS-DRG (as required by the 

application). 

The applicant also noted that their estimate of the case-weighted average 

standardized charge per case of $57,511 did not include charges related to the 

AutoLITTTM. Therefore, it is necessary to add the charges related to the device to the 

case-weighted average standardized charge per case in evaluating the cost threshold 

criterion. Although the applicant submitted data related to the estimated cost of the 

AutoLITTTM per case, the applicant stated that the cost of the device was proprietary 
CMS-1498-P 280 

information. Based on a study of charge compression data by RTI4

 and charge master 

data from Stanford University and University of California, San Francisco, the applicant 

estimates $38,886 in charges related to the AutoLITTTM (we note that some of the data 

used a markup of 294 percent of the costs). Adding the estimated charges related to the 

device to the average standardized charge per case resulted in a total average 

standardized charge per case of $96,397 ($57,511 plus $38,886). We note, in the 

applicant’s discussion of substantial clinical improvement below, the applicant maintains 

that improved clinical outcomes using nonfocused LITT included reduced recovery time 

and a reduced rate of complications. Therefore, we are seeking comment on how reduced 

recovery time and a reduced rate of complications would affect the total case-weighted 

average standardized charge per case and the average length of stay (for cases eligible for 

the AutoLITTTM). 

As noted above, the applicant's analysis established a case-weighted average 

charge per case in the aggregate, but it did not provide a case-weighted average 

standardized charge per case by MS-DRG. However, the applicant explained through 

supplemental information to its application that the total average standardized charge per 

case significantly exceeds the cost threshold established by CMS for FY 2011 in Table 10 

(74 FR 44173) of $84,185 for MS-DRG 25. Additionally, the applicant further explained 

that the total average standardized charge per case would also exceed the cost thresholds 

established by CMS of $58,612 for MS-DRGs 26 and $47,053 for MS-DRG 27. Because 

the total average standardized charge per case exceeds the threshold amount for each 

 

4

 RTI International, A Study of Charge Compression in Calculating DRG Relative Weights, RTI Project 

No. 0207964.012.008; January 2007.
CMS-1498-P 281 

individual MS-DRG to which the technology would map (MS-DRGs 25, 26, and 27), the 

applicant maintains that the AutoLITTTM would meet the cost criterion. We invite public 

comment on whether or not the AutoLITTTM meets the cost criterion for a new 

technology add-on payment for FY 2011. 

With respect to the substantial clinical improvement criterion, the applicant 

maintains that it meets this criterion in its application. Specifically, the applicant stated 

that several non-AutoLITTTM clinical trials have demonstrated that nonfocused LITT 

(and more recently, the use of LITT plus MRI) improved survival, quality of life, and 

recovery in patients with advanced glioblastoma multiforme tumors and advanced 

metastatic brain tumors that cannot be effectively treated with surgery, radiosurgery, 

radiation, chemotherapy, or any currently available clinical procedure. In a number of 

these patients, nonfocused LITT was the treatment of last resort, due to either the 

unresponsiveness or inability of these therapies to treat the brain tumor (due to tumor 

location, type, or size, among others). The applicant also maintains that when compared 

to craniotomy, it offers improved clinical outcomes using nonfocused LITT, including 

reduced recovery time and a reduced rate of complications (that is, infection, brain 

edema). The applicant stated that these factors, as discussed in the FY 2001 final rule 

(66 FR 46914 through 46915) demonstrate that the AutoLITTTM meets the new 

technology criterion for substantial clinical improvement. 

 The applicant further asserts that AutoLITTTM would represent a substantial 

clinical improvement over existing standards of care for a number of reasons and should 

build upon less sophisticated, nonfocused LITT therapies. These clinical improvements 
CMS-1498-P 282 

cited by the applicant include: a less invasive method of tumor ablation, potentially 

leading to lower complication rates post procedure (infection, edema); an ability to 

employ multiple interventions over shorter periods of time and an ability to be used as a 

treatment of last resort (radiosurgery is limited due to radiation dosing and craniotomy is 

limited to 1 to 2 procedures); an ability to be used in hard-to-reach brain tumors (the 

AutoLITTTM may be used as a treatment of last resort); and a shorter recovery time (the 

possibility for same day surgery, which has been demonstrated above with nonfocused 

LITT). 

 We appreciate the applicant’s summary of why this technology represents a 

substantial clinical improvement. While we recognize the future potential of this 

interesting therapy, we have concerns that to date the AutoLITTTM has been used for the 

treatment of only a few patients as part of a safety evaluation with no comparative 

efficacy data and, therefore, there may not be sufficient objective clinical evidence to 

determine if the AutoLITTTM meets the substantial clinical improvement criteria. The 

applicant did note in its presentation at the new technology town hall meeting that it is 

currently conducting a clinical trial with a summary report expected in the near future. 

We welcome additional clinical data to demonstrate whether the AutoLITTTM meets the 

substantial clinical improvement criterion and invite public comment on whether or not 

the AutoLITTTM meets the substantial clinical improvement criterion. 

 We did not receive any written public comments regarding this application for 

new technology add-on payments concerning the new technology town hall meeting. 
CMS-1498-P 283 

b. LipiScanTM Coronary Imaging System 

InfraReDx, Inc. submitted an application for new technology add-on payments for 

FY 2011 for the LipiScanTM Coronary Imaging System (LipiScanTM). We note that an 

application was also submitted for FY 2010, but the application was denied on the 

grounds that it did not meet the substantial clinical improvement criterion at that time. 

The application for FY 2011 contains some additional clinical and charge data that were 

not available at the time that the FY 2010 new technology add-on payment decisions 

were made. 

The LipiScanTM device is a diagnostic tool that uses Intravascular Near Infrared 

Spectroscopy (INIRS) during an invasive coronary catheterization to scan the artery wall 

in order to determine coronary plaque composition. The purpose of the device is to 

identify lipid-rich areas in the artery because such areas have been shown to be more 

prone to rupture. The procedure does not require flushing or occlusion of the artery. 

INIRS identifies the chemical content of plaque by focusing near infrared light at the 

vessel wall and measuring reflected light at different wavelengths (that is, spectroscopy). 

The LipiScanTM system collects approximately 1,000 measurements per 12.5 mm of 

pullback, with each measurement interrogating an area of 1 to 2 mm2

 of lumen surface 

perpendicular to the longitudinal axis of the catheter. When the catheter is in position, 

the physician activates the pullback and rotation device and the scan is initiated providing 

360 degree images of the length of the artery. The rapid acquisition speed for the image 

freezes the motion of the heart and permits scanning of the inside of the arterial wall in 

less than 2 minutes. When the catheter pullback is completed, the console displays the 
CMS-1498-P 284 

scan results, which are referred to as a “chemogram” image. The chemogram image 

requires reading by a trained user, but, according to the applicant was designed to be 

simple to interpret. 

With regard to the newness criterion, the LipiScanTM received a 510K FDA 

clearance for a new indication on April 25, 2008, and was available on the market 

immediately thereafter. On June 23, 2006, InfraReDx, Inc. was granted a 510K FDA 

clearance for the “InfraReDx Near Infrared (NIR) Imaging System.” Both devices are 

under the common name of “Near Infrared Imaging System” according to the 510K 

summary document from the FDA. However, the InfraReDx NIR Imaging System 

device that was approved by the FDA in 2006 was approved “for the near infrared 

imaging of the coronary arteries,” whereas the LipiscanTM device cleared by the FDA in 

2008 is for a modified indication. The modified indication specified that LipiscanTM is 

“intended for the near-infrared examination of coronary arteries..., the detection of 

lipid-core-containing plaques of interest...[and] for the assessment of coronary artery 

lipid core burden.” In the FY 2010 IPPS/RY 201 LTCH PPS proposed rule 

(74 FR 24132 through 24134), we noted that we had concerns with whether LipiscanTM 

was substantially similar to its predicate device that was approved by the FDA in 2006. 

However, those concerns were addressed by the manufacturer during the comment 

period. Specifically, the manufacturer stated that there were technical problems with the 

original device and that LipiScanTM had to be modified in the following ways: 

2006 NIRS Device Marketed 2008 LipiScan 

Console No display of results of scan Results displayed immediately 
CMS-1498-P 285 

2006 NIRS Device Marketed 2008 LipiScan 

Catheter Saline-filled with microbubble 

problem obscuring many 

scans 

Air-filled with no microbubble problem 

Algorithm No algorithmic processing of 

NIR signals – no means of 

certifying that lipid core 

plaque is present 

Algorithm validated in over 1,000 autopsy 

measurements proving that NIRS can detect 

lipid core plaque, and providing diagnosis of 

lipid core plaque to the MD during the case 

The problems with the LipiScanTM device that was approved in 2006 were 

addressed in the second device that was granted FDA approval in April 2008. The 

LipiScanTM device was not marketed until after its second FDA clearance. Therefore, we 

no longer needed to make a determination as to whether the newer device was 

substantially similar to the predicate device and we determined in the FY 2010 

IPPS/RY 2010 LTCH PPS final rule (74 FR 43815) that LipiscanTM would be considered 

to be “new” to the market as of the date of its FDA approval in April 2008. Because a 

technology may be considered new for a period of up to 3 years if, during the third year, 

the technology is new for more than 6 months of the fiscal year, it appears that the 

technology would still be in the newness period for FY 2011. We welcome public 

comment on whether LipiscanTM meets the newness criterion. 

 We note that the LipiscanTM technology is identified by ICD-9-CM procedure 

code 38.23 (Intravascular spectroscopy), which became effective October 1, 2008, and 

cases involving the use of this device generally map to MS-DRG 246 (Percutaneous 

Cardiovascular Procedures with Drug-Eluting Stent(s) with MCC or 4+ Vessels/Stents); 

MS-DRG 247 (Percutaneous Cardiovascular Procedures with Drug-Eluting Stent(s) 

without MCC); MS-DRG 248 (Percutaneous Cardiovascular Procedures with Non-DrugEluting Stent(s) with MCC or 4+ Vessels/Stents); MS-DRG 249 (Percutaneous 
CMS-1498-P 286 

Cardiovascular Procedures with Non-Drug-Eluting Stent(s) without MCC); MS-DRG 

250 (Percutaneous Cardiovascular Procedures without Coronary Artery Stent with 

MCC); and MS-DRG 251 (Percutaneous Cardiovascular Procedures without Coronary 

Artery Stent without MCC). 

 In an effort to demonstrate that the technology meets the cost criterion, the 

applicant used the FY 2010 final rule After Outliers Removed (AOR) file (posted on the 

CMS Web site) to identify cases potentially eligible for LipiscanTM. The applicant 

believes that every case within MS-DRGs 246, 247, 248, 249, 250, and 251 is eligible for 

LipiscanTM. In addition, the applicant believes that LipiscanTM will be evenly distributed 

across patients in each of those six MS-DRGs (16.7 percent within each MS-DRG). 

Using data from the AOR file, the applicant found the average standardized charge per 

case for MS-DRGs 246, 247, 248, 249, 250, and 251 was $67,531, $44,485, $62,936, 

$40,149, $59,416, and $38,864, respectively, equating to a case-weighted average 

standardized charge per case of $52,230 (calculation performed using unrounded 

numbers). The applicant indicated that the case-weighted average standardized charge 

per case does not include charges related to LipiscanTM; therefore, it is necessary to add 

the charges related to the device to the average case-weighted standardized charge per 

case to evaluate the cost threshold criterion. Although the applicant submitted data 

related to the estimated cost per case of LipiscanTM, the applicant stated that the cost of 

the device is proprietary information. Based on a sampling of all 10 non-VA hospitals 

that are actively using the device, the applicant determined that the average charge for the 

device was $7,497. Adding the estimated average charge related for the device to the 
CMS-1498-P 287 

case-weighted standardized charge per case (based on the case distribution from the 

applicant’s FY 2010 AOR analysis) results in a total case-weighted average standardized 

charge per case of $59,727 ($52,230 plus $7,497). Using the FY 2011 thresholds 

published in Table 10 of the FY 2010 IPPS/RY 2010 LTCH PPS final rule 

(74 FR 44173), the case-weighted threshold for MS-DRGs 246, 247, 248, 249, 250, and 

251 is $56,487 (all calculations above were performed using unrounded numbers). 

Because the applicant’s calculation of the total case-weighted average standardized 

charge per case for the applicable MS-DRGs exceeds the case-weighted threshold 

amount, the applicant maintains that LipiscanTM meets the cost criterion. 

We note that in the applicant’s analysis of the cost criterion, instead of 

determining the case-weighted average standardized charge per case and the 

case-weighted threshold amount based on the actual number of cases from the FY 2010 

AOR file in the applicable MS-DRGs that are eligible for the LipiscanTM, the applicant’s 

analysis assumed an even distribution of patients in the applicable MS-DRGs. However, 

the data from the FY 2010 AOR file shows a varied distribution of cases in each of the 

applicable MS-DRGs. We believe the more appropriate way to determine the 

case-weighted average standardized charge per case and the case-weighted threshold 

amount for evaluating the cost criterion is to use the actual distribution of cases in the 

applicable MS-DRGs based on the number of cases from the AOR file because this 

would more accurately reflect the number and type of Medicare cases typically treated in 

the applicable MS-DRGs. Moreover, this would better conform with the applicant’s 

assertion that that the probability of use of LipiscanTM is the same in each of those six 
CMS-1498-P 288 

MS-DRGs. Using data from the FY 2010 AOR file, for MS-DRGs 246, 247, 248, 249, 

250, and 251, there were 30,411, 147,952, 19,736, 67,964, 8,184, and 38,091 cases, 

respectively. Using this case distribution and the average standardized charge per case 

for MS-DRGs 246, 247, 248, 249, 250, and 251 from the application (that is, $67,531, 

$44,485, $62,936, $40,149, $59,416, and $38,864, respectively, as stated above), the 

case-weighted average standardized charge per case is $46,657. As the applicant 

indicated above, the case-weighted average standardized charge per case does not include 

charges related to LipiscanTM. Therefore, it is necessary to add the average charge of 

$7,497 related to the device to the case-weighted standardized charge per case to evaluate 

the cost threshold criterion. Adding the estimated charges related to the device to the 

case-weighted average standardized charge per case (based on the case distribution from 

the FY 2010 AOR final rule file) results in a total case-weighted average standardized 

charge per case of $54,154 ($46,657 plus $7,497). Using the FY 2011 thresholds 

published in Table 10 of the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 44173) 

and the actual case distribution from the AOR file, the case-weighted threshold for MSDRGs 246, 247, 248, 249, 250, and 251 is $52,700 (all calculations above were 

performed using unrounded numbers). Because this alternative calculation of total caseweighted average standardized charge per case for the applicable MS-DRGs also exceeds 

the case-weighted threshold amount, it appears that LipiscanTM would meet the cost 

criterion. We invite public comment on whether or not LipiscanTM meets the cost 

criterion. 
CMS-1498-P 289 

 With regard to substantial clinical improvement, CMS determined that the 

FY 2010 new technology add-on payment application for LipiscanTM did not meet the 

substantial clinical improvement criterion because the evidence and information available 

at the time the new technology decisions were made did not allow CMS to determine that 

the application represented a substantial clinical improvement over existing technologies. 

Specifically, CMS found that there was a lack of evidence that demonstrated that 

LipiscanTM affected the medical management of patients in which the device was used. 

The applicant maintains that the device meets this criterion for the following 

reasons. The applicant noted that from November 2008 to 2009, the number of patients 

in whom LipiscanTM has been used for clinical purposes has increased from 100 to 500 

and during the same period, the number of hospitals using the product has increased from 

6 to 16. In addition, the applicant asserts that “during the past year, two LipiscanTM 

publications demonstrate that dilation of a lipid core plaque is responsible for slow or no 

reflow and myocardial infarction during the procedure.” The applicant noted that this is 

important because “several treatments are available that could prevent this stenting 

complication.” The applicant referenced the “700 patient PROSPECT Study” which was 

presented at Transcatheter Cardiovascular Therapeutics Conference in September 2009 

and found that 20.4 percent of patients experience a new event in the 3.4 years following 

stenting. The applicant pointed to that finding as evidence that there is a need for 

improved safety and efficacy of stenting and maintained that LipiscanTM offers clinicians 

the ability to make decisions that result in such improvements. 
CMS-1498-P 290 

The PROSPECT (Providing Regional Observations to Study Predictors of Events 

in the Coronary Tree) study is a cohort study of patients with acute coronary syndrome 

who underwent percutaneous coronary angioplasty and stenting (percutaneous coronary 

intervention). Following the procedure, angiography and intravascular ultrasound 

(IVUS) were performed. If a patient had a subsequent event, a new angiogram and IVUS 

image were obtained and compared to the original results. The investigators reported that 

“angiographically mild lesions with certain morphologic features on grayscale and IVUS 

present with a 3 year cardiac event rate of 17%, versus other morphologies 

(indistinguishable by conventional angiograms) with three year event risks of less than 

1%.” We are concerned that with this type of study design, it is not possible to determine 

whether the information for the IVUS image would have altered the angioplasty and 

stenting procedures since the images were collected after the procedure. The results are 

suggestive, but a prospective study is needed to determine the clinical utility of IVUS and 

whether use of IVUS leads to changes in clinical practice or improvements in health 

outcomes. The PROSPECT study generated a hypothesis that use of IVUS may help 

determine which plaques are vulnerable to future events but further clinical research is 

needed to confirm this hypothesis. We note that the PROSPECT study was presented at 

the Transcatheter Cardiovascular Therapeutics Conference in 2009, but that the study 

results have yet to be published in a peer-reviewed journal. We also note that methods 

and conclusions from a study may change from what was verbally presented during the 

peer review process that is required to publish the study results. 
CMS-1498-P 291 

As it did in its prior application, the applicant noted that the September 1, 2001 

final rule states that one facet of the criterion for substantial clinical improvement is “the 

device offers the ability to diagnose a medical condition in a patient population where the 

medical condition is currently undetectable or offers the ability to diagnose a medical 

condition earlier in a patient population than allowed by currently available methods. 

There must also be evidence that use of the device to make a diagnosis affects the 

management of the patient” (66 FR 46914). The applicant believes that LipiscanTM meets 

all facets of this criterion. The applicant asserted that the device is able to detect a 

condition that is not currently detectable. The applicant explained that LipiScanTM is the 

first device of its kind to be able to detect lipid-core-containing plaques of interest and to 

assess of coronary artery lipid core burden. The applicant further noted that FDA, in its 

approval documentation, has indicated that “This is the first device that can help assess 

the chemical makeup of coronary artery plaques and help doctors identify those of 

particular concern.” 

 In addition, the applicant stated that the LipiScanTM chemogram permits a 

clinician to detect lipid-core-containing plaques in the coronary arteries compared to 

other currently available devices that do not have this ability. The applicant explained 

that the angiogram, the conventional test for coronary atherosclerosis, shows only 

minimal coronary narrowing. However, the applicant indicated that the LipiScanTM 

chemogram has the ability to reveal when an artery contains extensive 

lipid-core-containing plaque at an earlier stage. 
CMS-1498-P 292 

 The applicant also noted that the device has the ability to make a diagnosis that 

better affects the management of the patient. Specifically, the applicant asserted that 

LipiScanTM “is currently used in the management of patients undergoing coronary 

stenting to improve the safety and efficacy of the procedure” and that while stenting has 

steadily improved, its results are not optimal in approximately 30 percent of cases due to 

3 problems: (1) peri-stenting MI due to embolization of lipid core contents and side 

branch occlusion; (2) major adverse coronary events (MACE) post stenting from 

difficulties at the stented site; and (3) MACE post stenting for non-stented vulnerable 

sites. We note that in order to demonstrate that the technology represents a substantial 

clinical improvement, there must be evidence that use of the device to make a diagnosis 

affects the medical management of the patient and leads to improved clinical outcomes. 

The applicant described three case studies where each of the above problems was 

addressed by use of the LipiScanTM. In addition, the applicant asserts that the 

chemogram results are available to the interventional cardiologist during the PCI 

procedure, and have been found to be useful in decision-making. According to the 

applicant, physicians have reported changes in therapy based on LipiScanTM findings in 

20 to 50 percent of patients in which the device has been used. According to the 

applicant, the most common use of LipiScanTM results has been by physicians for 

selection of the length of artery to be stented. In some cases a longer stent has been used 

when there is a lipid-core-containing plaque adjacent to the area that is being stented 

because a flow-limiting stenosis is present. The applicant also noted that, in some cases, 

physicians have chosen to use down-stream protective devices during stenting procedures 
CMS-1498-P 293 

on the basis of information gathered by use of LipiscanTM in several patients, and that this 

has directly impacted their outcome by capturing emboli and preventing further cardiac 

damage. Therefore, the applicant contends that the use of LipiScanTM by clinicians to 

select the length of artery to be stented and as an aid in selection of intensity of lipidaltering therapy, demonstrates that LipiScanTM affects the management of patients. 

 While we recognize that the identification of lipid-rich plaques in the coronary 

vasculature holds promise in the management of coronary artery disease, we are 

concerned that statements in the FDA approval documents, as well as statements made by 

investigators in the literature, suggest that the clinical implications of identifying these 

lipid-rich plaques are not yet certain and that further studies need to be done to 

understand the clinical implications of obtaining this information. 

 The applicant also submitted commentary from Interventional Cardiologists (a 

group of clinicians who currently utilize the LipiScanTM device) explaining the clinical 

benefits of the device. The applicant further noted that the device may have other 

potential uses that would be of clinical benefit, and studies are currently being conducted 

to investigate these other potential uses. The applicant explained that LipiScanTM offers 

promise as a means to enhance progress against the two leading problems in coronary 

disease management: (1) the high rate of second events that occur even after 

catheterization, revascularization, and the institution of optimal medical therapy; and 

(2) the failure to diagnose coronary disease early, which results in sudden death or MI 

being the first sign of the disease in most patients. The applicant further stated that the 

identification of coronary lipid-core-containing plaques, which can most readily be done 
CMS-1498-P 294 

in those already undergoing catheterization, is likely to be of benefit in the prevention of 

second events. In the longer term, the applicant stated that the identification of 

lipid-core-containing plaques by LipiScanTM may contribute to the important goal of 

primary prevention of coronary events, which, in the absence of adequate diagnostic 

methods, continue to cause extensive morbidity, mortality and health care expenditures in 

Medicare beneficiaries and the general population. 

 We welcome public comment regarding whether or not the LipiScanTM 

technology represents a substantial clinical improvement in the Medicare population. 

We received approximately nine public comments during the town hall meeting 

public comment period on the LipiScanTM and LipiScanTM IVUS. The comments relating 

to LipiScanTM IVUS are summarized at the end of the LipiScanTM IVUS application. 

Comment: Several commenters supported approving the LipiScanTM device for 

new technology add-on payments. They stated (using nearly identical language) that 

LipiScanTM provided accurate information about the presence of lipid core plaques that 

was previously unavailable. They also stated that the device “permits the detection of an 

earlier stage of coronary artery disease.” The commenters also stated that, “over the past 

year evidence has been obtained documenting that the presence of a lipid-core plaque at a 

stenotic site (as detected by LipiScanTM) is an excellent predictor or peri-stenting 

myocardial infarction due to distal embolization of the lipid core following balloon 

dilation. This valuable diagnostic information can be combined with well-established 

treatments (prophylactic administration of vasodilators and/or direct stenting) as a means 

to reduce the stenting complication of peri-stenting MI.” 
CMS-1498-P 295 

One commenter stated that “the knowledge that a patient possesses lipid laden 

atheroma will markedly alter medical therapy in order to prevent thrombotic events. 

These heretofore unrecognized (asymptomatic) patients identified to be at high risk by 

the Lipiscan chemogram will be treated with intensive antihyperlipdemic therapy and 

other medical strategies that otherwise would not have been implemented to modify 

risk.” Some commenters indicated that other potential uses of LipiScanTM include 

“determination of the length of the artery to be stented and selection of the intensity of 

lipid-altering therapy.” 

Several commenters stated that the “lack of specific reimbursement” for the 

technology was an impediment to the use and development of it. 

Response: We thank the commenters for their comments. We have considered 

the comments concerning the town hall meeting in this proposed rule. As stated above, 

we invite additional public comment on objective data regarding the assertions made by 

the commenters. Specifically, we welcome additional information (including specific 

case-descriptions) regarding how the use of the technology has affected the medical 

management of patients and how the changes in management have led to improved 

clinical outcomes for those patients (again, specific examples are welcomed). 

In response to the comments concerning Medicare reimbursement for LipiScanTM, 

we note that LipiScanTM is currently covered by Medicare and would thus be included in 

the MS-DRG payment made to the hospital. In general, the MS-DRG payment is 

considered to cover all costs associated with the case including those of new 

technologies. As noted above, typically, there is a lag of 2 to 3 years from the point a 
CMS-1498-P 296 

new medical service or technology is first introduced on the market (generally on the date 

that the technology receives FDA approval/clearance) and when data reflecting the use of 

the medical service or technology are used to calculate the MS-DRG weights. In addition, 

Congress specified that a new medical service or technology may be considered for new 

technology add-on payment 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." While we 

agree with the commenter that at this time there is no specific reimbursement for 

LipiscanTM within the MS-DRGs in the form of a new technology add-on payment, 

because LipiscanTM has applied for new technology add-on payments, we will evaluate it 

to determine whether it meets the criteria to receive new technology add-on payments in 

FY 2011. If the technology does not meet the new technology add-on payment criteria, it 

will continue to be paid as part of the regular MS-DRG payment and once the lag of 2 to 

3 years is over, the costs associated of LipiscanTM will be fully reflected in the relative 

weights that are used to recalibrate the MS-DRGs. 

c. LipiScanTM Coronary Imaging System with Intravascular Ultrasound (IVUS) 

InfraReDx, Inc. submitted an application for new technology add-on payments for 

FY 2011 for the LipiScanTM Coronary Imaging System with Intravascular Ultrasound 

(LipiScanTM IVUS). The LipiScanTM IVUS device is a diagnostic device that uses 

Intravascular near infrared spectroscopy (INIRS) combined with intravascular ultrasound 

(IVUS) during an invasive coronary angiography to determine the chemical composition 

of coronary plaques, which is accomplished using near infrared spectroscopy (INIRS) 
CMS-1498-P 297 

and to visualize stents and the structural features of coronary lesions, which is 

accomplished using IVUS. This new technology combines both capabilities in a single 

catheter. The IVUS part of the device utilizes sound to interrogate the artery and, 

according to the applicant, provides an image of the size of the plaque, the degree of 

stenosis produced by the plaque, the size of the artery and the degree of expansion of the 

stent. The device consists of a single-use catheter, a console and a “single pullback with 

the artery.” The device is intended to be used in patients already undergoing coronary 

stenting. 

With respect to the newness criterion, we note that this device is not currently 

approved by the FDA, but the manufacturer anticipates that FDA approval will be 

granted in the second quarter of 2010. We also note that IVUS has existed for over 

20 years. Therefore, IVUS, on its own, would not meet the newness criterion. The 

applicant asserts that one difference from the LipiscanTM product, for which it has also 

submitted an application for new technology add-on payments, is that the catheter for the 

combined product is filled with saline (which is required for transmission of sound). The 

manufacturer has also stated that the combined device only requires the use of one 

catheter, as opposed to two separate ones. The manufacturer asserts that the single-use 

catheter for the combined technologies is only supplied by InfraRedX (the manufacturer 

of LipiScanTM). However, we note that a physician could use LipiScanTM and IVUS as 

two separate products in the same patient (through the use of two catheters) and still be 

able to obtain the INIRS image and the ultrasound that are achieved through the 

combined product albeit separately. 
CMS-1498-P 298 

We welcome public comments regarding whether the combined LipiScanTM IVUS 

device should be considered to be “new” as of the date of the existing LipiScanTM device 

received FDA approval or whether it should be considered new from the FDA approval 

date for LipiScanTM IVUS (should such an approval be granted). We also welcome 

public comments regarding whether LipiScanTM IVUS, as a combined technology, should 

be considered to be substantially similar to each individual technology separately as of 

the date that each separate technology received FDA approval (or the date that each 

technology became available on the market, if either technology was not available on the 

market until a date after FDA approval). 

As stated above, in making a determination of substantial similarity, we consider 

the following: (1) whether a product uses the same or similar mechanism of action to 

achieve a therapeutic action; (2) whether a product is assigned to the same or a different 

DRG; and (3) whether new use of a technology involves treatment of the same or similar 

type of disease and the same or similar patient population. In the FY 2010 IPPS/RY 

2010 LTCH PPS final rule, we stated that “due to the complexity of issues regarding the 

substantial similarity component of the newness criterion, it may be necessary to exercise 

flexibility when considering whether technologies are substantially similar to one another 

(74 FR 43813). 

We note that the LipiScanTM IVUS device is identified by ICD-9-CM procedure 

codes 38.23 (Intravascular spectroscopy) and 00.24 (Intravascular imaging of coronary 

vessels). Cases involving the use of this device generally map to MS-DRG 246 

(Percutaneous Cardiovascular Procedures with Drug-Eluting Stent(s) with MCC or 4+ 
CMS-1498-P 299 

Vessels/Stents); MS-DRG 247 (Percutaneous Cardiovascular Procedures with DrugEluting Stent(s) without MCC); MS-DRG 248 (Percutaneous Cardiovascular Procedures 

with Non-Drug-Eluting Stent(s) with MCC or 4+ Vessels/Stents); MS-DRG 249 

(Percutaneous Cardiovascular Procedures with Non-Drug-Eluting Stent(s) without 

MCC); MS-DRG 250 (Percutaneous Cardiovascular Procedures without Coronary Artery 

Stent with MCC); and MS-DRG 251 (Percutaneous Cardiovascular Procedures without 

Coronary Artery Stent without MCC). 

In an effort to demonstrate that the technology meets the cost criterion, the 

applicant used the FY 2010 final rule After Outliers Removed (AOR) file (posted on the 

CMS Web site) to identify cases potentially eligible for LipiscanTM IVUS. The applicant 

believes that every case within MS-DRGs 246, 247, 248, 249, 250, and 251 is eligible for 

LipiscanTM IVUS. In addition, the applicant believes that LipiscanTM IVUS will be 

evenly distributed across patients in each of those six MS-DRGs (16.7 percent within 

each MS-DRG). Using data from the AOR file, the applicant found the average 

standardized charge per case for MS-DRGs 246, 247, 248, 249, 250, and 251 was 

$67,531, $44,485, $62,936, $40,149, $59,416, and $38,864 respectively, equating to a 

case-weighted average standardized charge per case of $52,230 (calculation performed 

using unrounded numbers). The applicant indicated that the case-weighted average 

standardized charge per case does not include charges related to LipiscanTM IVUS. 

Therefore, it is necessary to add the charges related to the device to the average 

case-weighted standardized charge per case to evaluate the cost threshold criterion. 

Although the applicant submitted data related to the estimated cost per case of LipiscanTM 
CMS-1498-P 300 

IVUS, the applicant stated that the cost of the device is proprietary information. The 

applicant analyzed Hospital Cost Report Information System (“HCRIS”) data from 2008 

to determine the charges related to the device. Specifically, the applicant searched for the 

100 cardiac catheterization labs that had the highest volume of cases in the United States. 

Based on the HCRIS data from these 100 labs, the applicant determined the mean 

cost-to-charge ratio was 0.188 with a mark-up of 532 percent yielding a charge of 

$15,957 for LipiscanTM IVUS. (We note that this estimate of charges related to the 

LipiscanTM IVUS is significantly higher than the estimate of charges related to the 

LipiscanTM device.) Adding the estimated average charge related for the device to the 

case-weighted standardized charge per case (based on the case distribution from the 

applicant’s FY 2010 AOR analysis) results in a total case-weighted average standardized 

charge per case of $68,190 ($52,230 plus $15,960). Using the FY 2011 thresholds 

published in Table 10 of the FY 2011 IPPS/RY 2010 LTCH PPS final rule 

(74 FR 44173), the case-weighted threshold for MS-DRGs 246, 247, 248, 249, 250, and 

251 is $56,487 (all calculations above were performed using unrounded numbers). 

Because the applicant’s calculation of the total case-weighted average standardized 

charge per case for the applicable MS-DRGs exceeds the case-weighted threshold 

amount, the applicant maintains that LipiscanTM IVUS meets the cost criterion. 

We note that in the applicant’s analysis of the cost criterion, instead of 

determining the case-weighted average standardized charge per case and the 

case-weighted threshold amount based on the actual number of cases from the FY 2010 

AOR file in the applicable MS-DRGs that are eligible for the LipiscanTM IVUS, the 
CMS-1498-P 301 

applicant’s analysis assumed an even distribution of patients in the applicable MS-DRGs. 

However, the data from the FY 2010 AOR file shows a varied distribution of cases in 

each of the applicable MS-DRGs. We believe the more appropriate way to determine the 

case-weighted average standardized charge per case and the case-weighted threshold 

amount for evaluating the cost criterion is to use the actual distribution of cases in the 

applicable MS-DRGs based on the number of cases from the AOR file because this 

would more accurately reflect the number and type of Medicare cases typically treated in 

the applicable MS-DRGs. Moreover, this would better conform with the applicant’s 

assertion that that the probability of use of LipiscanTM is the same in each of those six 

MS-DRGs. Using data from the FY 2010 AOR file, for MS-DRGs 246, 247, 248, 249, 

250, and 251, there were 30,411, 147,952, 19,736, 67,964, 8,184, and 38,091 cases, 

respectively. Using this case distribution and the average standardized charge per case 

for MS-DRGs 246, 247, 248, 249, 250, and 251 from the application (that is, $67,531, 

$44,485, $62,936, $40,149, $59,416, and $38,864, respectively, as stated above), the 

case-weighted average standardized charge per case is $46,657. As the applicant 

indicated above, the case-weighted average standardized charge per case does not include 

charges related to LipiscanTM IVUS. Therefore, it is necessary to add the average charge 

of $15,960 related to the device to the case-weighted standardized charge per case to 

evaluate the cost threshold criterion. Adding the estimated charges related to the device 

to the case-weighted average standardized charge per case (based on the case distribution 

from the FY 2010 AOR final rule file) results in a total case-weighted average 

standardized charge per case of $62,617 ($46,657 plus $15,960). Using the FY 2011 
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thresholds published in Table 10 of the FY 2010 IPPS/RY 2010 LTCH PPS final rule 

(74 FR 44173) and the actual case distribution from the AOR file, the case-weighted 

threshold for MS-DRGs 246, 247, 248, 249, 250, and 251 is $52,700 (all calculations 

above were performed using unrounded numbers). Because this alternative calculation of 

total case-weighted average standardized charge per case for the applicable MS-DRGs 

exceeds the case-weighted threshold amount, it appears that LipiscanTM IVUS would 

meet the cost criterion. 

In addition to the analysis above, the applicant searched the FY 2008 MedPAR 

file for cases potentially eligible for use of the LipiscanTM IVUS. Because the technology 

can potentially be used for all cases within MS-DRGs 246 through 251, the applicant 

searched the FY 2008 MedPAR file for all cases within these MS-DRGs. The applicant 

found 30,265 cases (or 9.7 percent of all cases) in MS-DRG 246; 147,695 cases (or 47.4 

percent of all cases) in MS-DRG 247; 19,642 cases (or 6.3 percent of all cases) in 

MS-DRG 248; 67,840 cases (or 21.8 percent of all cases) in MS-DRG 249; 8,120 cases 

(or 2.6 percent of all cases) in MS-DRG 250; and 38,022 cases (or 12.2 percent of all 

cases) in MS-DRG 251. The average standardized charge per case was $66,958 for 

MS-DRG 246, $50,192 for MS-DRG 247, $72,099 for MS-DRG 248, $45,086 for 

MS-DRG 249, $71,355 for MS-DRG 250, and $46,141 for MS-DRG 251, equating to a 

case-weighted average standardized charge per case of $45,964. 

 Similar to above, the average standardized charge per case does not include 

charges related to the LipiscanTM IVUS; therefore, it is necessary to add the charges 

related to the device to the average standardized charge per case in evaluating the cost 
CMS-1498-P 303 

threshold criterion. Although the applicant submitted data related to the estimated cost of 

LipiscanTM IVUS per case, the applicant noted that the cost of the device was proprietary 

information. Based on 2008 HCRIS data from the cardiac catheterization laboratories for 

all IPPS hospitals, the applicant determined a mean cost-to-charge ratio of 0.246 with a 

markup of 351 percent, yielding a charge of $10,543 for LipiscanTM IVUS. Assuming 

that the LipiscanTM IVUS device was marked up 351 percent, the total case-weighted 

average standardized charge per case for cases involving the use of LipiscanTM IVUS 

would be $56,507 ($45,964 plus $10,543) across MS-DRGs 246 through 251. 

 Using the FY 2011 thresholds published in Table 10 of the FY 2010 IPPS/RY 

2010 LTCH PPS final rule (74 FR 44173), the case-weighted threshold for MS-DRGs 

246, 247, 248, 249, 250, and 251 is $52,692 (all calculations above were performed using 

unrounded numbers). Because the applicant’s calculation of the total case-weighted 

average standardized charge per case for the applicable MS-DRGs exceeds the 

case-weighted threshold amount, the applicant maintains that LipiscanTM IVUS meets the 

cost criterion. We invite public comment on whether or not LipiscanTM IVUS meets the 

cost criterion. 

 With regard to substantial clinical improvement, the applicant asserts that 

LipiScanTM IVUS lends all the same benefits of LipiScanTM by itself (see discussion of 

LipiScanTM with respect to clinical improvement in the above application analysis) and 

also gives added benefits of IVUS. Specifically, the applicant maintains that LipiScanTM 

IVUS is superior to perfusion imaging and coronary angiography because those 

procedures only provide information about the lumen, but not the wall of the vessel. The 
CMS-1498-P 304 

applicant asserts that it is superior to IVUS (by itself) because IVUS alone cannot 

identify plaque composition. The applicant further maintains that LipiScanTM IVUS 

provides a substantial clinical benefit over Optical Coherence Tomography (OCT) 

because OCT cannot be used if blood is present in the field of view and identification of 

lipid by OCT is “time-consuming with a requirement for expert interpretation.” In 

contrast, “the LipiScanTM signal is available immediately after the coronary pullback and 

does not require expert interpretation.” 

 The applicant also states that LipiScanTM IVUS makes it possible to find the lipid 

core plaques that are strongly associated with peri-stenting MI and adverse events post 

MI that current methods of diagnosis fail to find. 

Finally, the applicant asserts that LipiScanTM IVUS affects the management of the 

patient by improving the safety and efficacy of stenting. Further, the applicant states that 

while stenting has steadily improved, its results are not optimal in approximately 30% of 

cases due to 3 problems: (1) peri-stenting MI due to embolization of lipid core contents 

and side branch occlusion; (2) major adverse coronary events (MACE) post stenting from 

difficulties at the stented site; and (3) MACE post stenting for non-stented vulnerable 

sites.” 

The applicant described three case studies where each of the above problems were 

addressed by use of the LipiScanTM IVUS. LipiScanTM IVUS achieves its utility to 

differentiate lipid core plaque from fibrotic plaque, a differentiation that cannot be made 

by angiography or grayscale IVUS. 
CMS-1498-P 305 

The applicant referenced the “700 patient PROSPECT Study” which was 

presented at Transcatheter Cardiovascular Therapeutic Conference in September 2009 

and found that 20.4 percent of patients experience a new event in the 3.4 years following 

stenting. The applicant pointed to that finding as evidence that there is a need for 

improved safety and efficacy of stenting and maintained that LipiscanTM offers clinicians 

the ability to make decisions that result in such improvements. 

The PROSPECT (Providing Regional Observations to Study Predictors of Events 

in the Coronary Tree) study is a cohort study of patients with acute coronary syndrome 

who underwent percutaneous coronary angioplasty and stenting (percutaneous coronary 

intervention). Following the procedure, angiography and IVUS were performed. If a 

patient had a subsequent event, a new angiogram and IVUS image were obtained and 

compared to the original results. The investigators reported that “angiographically mild 

lesions with certain morphologic features on grayscale and IVUS present with a 3 year 

cardiac event rate of 17%, versus other morphologies (indistinguishable by conventional 

angiograms) with three year event risks of less than 1%.” We are concerned that with 

this type of study design, it is not possible to determine whether the information for the 

IVUS image would have altered the angioplasty and stenting procedures since the images 

were collected after the procedure. The results are suggestive, but a prospective study is 

needed to determine the clinical utility of IVUS and whether use of IVUS leads to 

changes in clinical practice or improvements in health outcomes. The PROSPECT study 

generated a hypothesis that use of IVUS may help determine which plaques are 

vulnerable to future events but further clinical research is needed to confirm this 
CMS-1498-P 306 

hypothesis. We note that the PROSPECT study was presented at the Transcatheter 

Cardiovascular Therapeutics Conference in 2009, but that the study results have yet to be 

published in a peer reviewed journal. We also note that methods and conclusions from a 

study may change from what was verbally presented during the peer review process that 

is required to publish the study results. 

We are concerned that, in the LipiScanTM IVUS application, the applicant has 

generally repeated the statements made regarding use of LipiScanTM alone and has not 

provided information that indicates that combined use of LipiScanTM plus IVUS offers 

additional clinical benefit. Indeed, we note that most of the studies that were presented in 

an effort to support that LipiScanTM by itself was a substantial clinical improvement, 

were also included to support the LipiScanTM IVUS application. The applicant did not 

present any published peer-reviewed journal articles that were specifically related to the 

clinical merits of the combined LipiScanTM IVUS device. 

We welcome public comments on whether the LipiScanTM IVUS represents a 

substantial clinical improvement over existing technologies as well as public comments 

on what is the appropriate comparison for LipiScanTM IVUS. 

 As we noted at the end of the discussion of the LipiScanTM application, we 

received approximately nine public comments on both the LipiScanTM and the 

LipiScanTM IVUS applications. 

 Comment: Several commenters acknowledged that LipiScanTM IVUS is not yet 

approved by the FDA, but stated that they would support the LipiScanTM IVUS being 

approved for new technology add-on payments should FDA approval be granted. With 
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regard to the clinical merits of LipiScanTM IVUS, the commenters stated that the 

LipiScanTM IVUS afforded all the same diagnostic abilities of the LipiScanTM, but also 

provided the added benefit of IVUS, which has “been used in patients for over 20 years 

[and] is already supported by the [American College of Cardiologists and the American 

Hospital Association] for usage in stenting.” 

One commenter stated that once the LipiScanTM IVUS becomes approved by the 

FDA, he plans to use it in all of his patients who need IVUS imaging “because of the 

wealth of added information regarding the presence of lipid laden plaque, a harbinger of 

myocardial infarction and sudden death.” 

Response: We thank the commenters for their comments. However, we note that 

unless the technology is approved by the FDA by July 1, 2010, it cannot be approved for 

add-on payments in FY 2011 since it would not be considered “new.” Should the 

technology receive FDA approval by July 1, 2010, we will take these comments into 

consideration in our review of the application for new technology add-on payments for 

FY 2011. 

III. Proposed Changes to the Hospital Wage Index for Acute Care Hospitals 

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 
CMS-1498-P 308 

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 2011 hospital wage index based on the 

statistical areas, including OMB’s revised definitions of Metropolitan Areas, appears 

under section III.C. 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 of the Act 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 2011 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 
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proposed budget neutrality adjustment for FY 2011 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, 2010 (the proposed FY 2011 wage index) 

appears under section III.D. of this preamble. 

B. Wage Index Reform

1. Wage Index Study Required under the MIEA-TRHCA 

a. Legislative Requirement 

 Section 106(b)(1) of the MIEA-TRHCA (Pub. L. 109-432) required MedPAC to 

submit to Congress, not later than June 30, 2007, a report on the Medicare wage index 

classification system applied under the Medicare IPPS. Section 106(b) of 

MIEA-TRHCA required 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 the MIEA-TRHCA instructed 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 Secretary was also to consider 

each of the following: 
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● 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 (BLS) 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. 

● 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. 

 In the FY 2009 IPPS final rule (73 FR 48563 through 48567), we discussed the 

MedPAC’s study and recommendations, the CMS contract with Acumen, L.L.C. for 

assistance with impact analysis and study of wage index reform, and public comments we 

received on the MedPAC recommendations and the CMS/Acumen study and analysis. 
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b. Interim and Final Reports on Results of Acumen's Study 

(1) Interim Report on Impact Analysis of Using MedPAC's Recommended Wage Index 

 In the FY 2009 IPPS final rule (73 FR 48566 through 48567), we discussed the 

analysis conducted by Acumen comparing use of the MedPAC recommended wage 

indices to the current CMS wage index. We refer readers to section III.B.1.e. of that final 

rule for a full discussion of the impact analysis as well as to Acumen's interim report 

available on the Web site: http://www.acumenllc.com/reports/cms. 

(2) Acumen’s Final Report on Analysis of the Wage Index Data and Methodology 

Acumen’s final report addressing the issues in section 106(b)(2) of the 

MIEA-TRHCA is divided into two parts. In the FY 2010 IPPS/RY 2010 LTCH PPS 

final rule (74 FR 43824), we provided a description of Acumen’s analyses for both parts. 

The first part of Acumen’s final report analyzed the strengths and weaknesses of the data 

sources used to construct the MedPAC and CMS indexes. The first part of the report was 

published on Acumen’s Web site after the publication of the FY 2010 IPPS/RY 2010 

LTCH PPS proposed rule. In its conclusion, Acumen suggested that MedPAC’s 

recommended methods for revising the wage index represented an improvement over the 

existing methods, and that the BLS data should be used so that the MedPAC approach 

can be implemented. 

The second part of Acumen’s final report focuses on the methodology of wage 

index construction and covers issues related to the definition of wage areas and methods 

of adjusting for differences among neighboring wage areas, as well as reasons for 

differential impacts of shifting to a new index. Acumen published the second part of its 
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final report in March 2010 on its Web site at: http:/www./acumenllc.com/reports/cms. In 

particular, the report analyzes MedPAC’s recommended method of improving upon the 

definition of the wage areas used in the current wage index. MedPAC’s method first 

blends MSA and county-level wages and then implements a “smoothing” step that limits 

differences in wage index values between adjacent counties to no more than 10 percent. 

Acumen found MedPAC’s method to be an improvement over the current wage index 

construct. However, although MedPAC’s method diminishes the size of differences 

between adjacent areas, Acumen suggested that MedPAC’s method does not guarantee an 

accurate representation of a hospital labor market and would not necessarily eliminate or 

reduce hospitals’ desire to reclassify for a higher wage index. Acumen recommended 

further exploration of labor market area definitions using a wage area framework based 

on hospital-specific characteristics, such as commuting times from hospitals to 

population centers, to construct a more accurate hospital wage index. Acumen suggested 

that such an approach offers the greatest potential for replacing or greatly reducing the 

need for hospital reclassifications and exceptions. 

 We indicated in the FY 2009 IPPS final rule (73 FR 48566) that, in developing 

any proposal(s) for additional wage index reform that may be included in the FY 2010 

IPPS proposed rule, we would consider all of the public comments on the MedPAC 

recommendations that we had received in that proposed rulemaking cycle, along with the 

interim and final reports to be submitted to us by Acumen. As Acumen’s study was not 

complete at the time of issuance of the FY 2010 IPPS/RY 2010 LTCH PPS proposed 

rule, we did not propose any additional changes to the hospital wage index for the 
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FY 2010 IPPS. We also are not proposing any additional changes regarding reforming 

the wage index for the FY 2011 IPPS. We welcome comments regarding the second part 

of Acumen’s final report. 

2. FY 2009 Policy Changes in Response to Requirements under Section 106(b) of the 

MIEA-TRHCA 

 To implement the requirements of section 106(b) of the MIEA-TRHCA and 

respond to MedPAC’s recommendations in its June 2007 report to Congress, in the 

FY 2009 IPPS final rule (73 FR 48567 through 48574), we made the following policy 

changes relating to the hospital wage index. (We refer readers to the FY 2009 IPPS final 

rule for a full discussion of the basis for the proposals, the public comments received, and 

the FY 2009 final policy.) In the FY 2010 IPPS final rule (74 FR 43825), we reiterated 

these policy changes, especially as they related to the FY 2010 IPPS. 

a. Reclassification Average Hourly Wage Comparison Criteria 

In the FY 2009 IPPS final rule, we adopted the policy to adjust the reclassification 

average hourly wage standard, comparing a reclassifying hospital’s (or county hospital 

group’s) average hourly wage relative to the average hourly wage of the area to which it 

seeks reclassification. We provided for a phase-in of the adjustment over 2 years. For 

applications for reclassification for the first transitional year, FY 2010, the average hourly 

wage standards were set at 86 percent for urban hospitals and group reclassifications and 

84 percent for rural hospitals. For applications for reclassification for FY 2011 (for which 

the application deadline was September 1, 2009) and for subsequent fiscal years, the average 

hourly wage standards are 88 percent for urban and group reclassifications and 86 percent for 
CMS-1498-P 314 

rural hospitals (§§412.230, 412.232, and 412.234 of the regulations). As stated above, these 

policies were adopted in the FY 2009 IPPS final rule and are reflected in the wage index in 

the Addendum to this proposed rule. We note that these criteria were recently changed by 

provisions of section 3137(c) of the PPACA (Pub. L. 111-148). We will address the changes 

made by Pub. L. 111-148 in a separate rulemaking document in the Federal Register. 

b. Budget Neutrality Adjustment for the Rural and Imputed Floors 

In the FY 2009 IPPS final rule (73 FR 48574 through 48575), we adopted State level 

budget neutrality (rather than the national budget neutrality adjustment) for the rural and 

imputed floors, effective beginning with the FY 2009 wage index. The transition from the 

national budget neutrality adjustment to the State level budget neutrality adjustment was 

phased in over a 3-year period. In FY 2009, hospitals received a blended wage index that 

was 20 percent of a wage index with the State level rural and imputed floor budget neutrality 

adjustment and 80 percent of a wage index with the national budget neutrality adjustment. In 

FY 2010, the blended wage index reflects 50 percent of the State level adjustment and 

50 percent of the national adjustment. In FY 2011, as reflected in the IPPS wage index in 

this proposed rule, the adjustment will be completely transitioned to the State level 

methodology. 

In the FY 2009 IPPS final rule, we incorporated this policy in our regulation at 

§412.64(e)(4). Specifically, the regulations specify that CMS makes an adjustment to the 

wage index to ensure that aggregate payments after implementation of the rural floor under 

section 4410 of the Balanced Budget Act of 1997 (Pub. L. 105-33) and the imputed floor 

under §412.64(h)(4) are made in a manner that ensures that aggregate payments to hospitals 
CMS-1498-P 315 

are not affected and that, beginning October 1, 2008, CMS would transition from a 

nationwide adjustment to a statewide adjustment, with a statewide adjustment fully in place 

by October 1, 2010. 

 As stated above, these policies for the rural and imputed floors were adopted in the 

FY 2009 IPPS final rule and are reflected in the wage index in the Addendum to this 

proposed rule. However, these policies were recently changed by the provisions of section 

3141 of the PPACA (Pub. L. 111-148). We will address the provisions of section 3141 of 

Pub. L. 111-148 in a separate rulemaking document in the Federal Register. 

C. Core-Based Statistical Areas for the Hospital Wage Index

 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). 

 As with the FY 2010 final rule, in this FY 2011 proposed rule, we are proposing 

to provide that hospitals receive 100 percent of their wage index based upon the CBSA 

configurations. Specifically, for each hospital, we are proposing to determine a wage 

index for FY 2011 employing wage index data from hospital cost reports for cost 

reporting periods beginning during FY 2007 and using the CBSA labor market 

definitions. We consider CBSAs that are MSAs to be urban, and CBSAs that are 
CMS-1498-P 316 

Micropolitan Statistical Areas as well as areas outside of CBSAs to be rural. In addition, 

it has been our longstanding policy that where an MSA has been divided into 

Metropolitan Divisions, we consider the Metropolitan Division to comprise the labor 

market areas for purposes of calculating the wage index (69 FR 49029) (regulations at 

§412.64(b)(1)(ii)(A)). 

 On December 1, 2009, OMB announced changes to the principal cities and, if 

applicable, titles of a number of CBSAs and Metropolitan Divisions (OMB Bulletin No. 

10-2). The changes to the principal cities and titles are as follows: 

● San Marcos, TX qualifies as a new principal city of the Austin-Round Rock, 

TX CBSA. The new title is Austin-Round Rock-San Marcos, TX CBSA. 

● Delano, CA qualifies as a new principal city of the Bakersfield, CA CBSA. 

The new title: Bakersfield-Delano, CA CBSA. 

● Conroe, TX qualifies as a new principal city of the Houston-Sugar 

Land-Baytown, TX CBSA. The CBSA title is unchanged. 

● North Port, FL qualifies as a new principal city of the Bradenton-SarasotaVenice, FL CBSA. The new title is North Port-Bradenton-Sarasota, FL CBSA. The new 

code is CBSA 35840. 

● Sanford, FL qualifies as a new principal city of the Orlando-Kissimmee, FL 

CBSA. The new title is Orlando-Kissimmee-Sanford, FL CBSA. 

● Glendale, AZ qualifies as a new principal city of the Phoenix-Mesa-Scottsdale, 

AZ CBSA. The new title is Phoenix-Mesa-Glendale, AZ CBSA. 
CMS-1498-P 317 

● Palm Desert, CA qualifies as a new principal city of the Riverside-San 

Bernardino-Ontario, CA CBSA. The CBSA title is unchanged. 

● New Braunfels, TX qualifies as a new principal city of the San Antonio, TX 

CBSA. The new title is San Antonio-New Braunfels, TX CBSA. 

● Auburn, WA qualifies as a new principal city of the Seattle-Tacoma-Bellevue, 

WA CBSA. The CBSA title is unchanged. 

The changes to titles resulting from changes to the order of principal cities based 

on population are as follows: 

● Rockville, MD replaces Frederick, MD as the second most populous principal 

city in the Bethesda-Frederick-Rockville, MD Metropolitan Division. The new title is 

Bethesda-Rockville-Frederick, MD Metropolitan Division. 

● Rock Hill, SC replaces Concord, NC as the third most populous principal city 

in the Charlotte-Gastonia-Concord, NC-SC CBSA. The new title is Charlotte-GastoniaRock Hill, NC-SC CBSA. 

● Joliet, IL replaces Naperville, IL as the second most populous principal city in 

the Chicago-Naperville-Joliet, IL Metropolitan Division. The new title is Chicago-JolietNaperville, IL Metropolitan Division. 

● Crestview, FL replaces Fort Walton Beach, FL as the most populous principal 

city in the Fort Walton Beach-Crestview-Destin, FL CBSA. The new title is 

Crestview-Fort Walton Beach-Destin, FL CBSA. The new code is 18880. 
CMS-1498-P 318 

● Hillsboro, OR replaces Beaverton, OR as the third most populous principal city 

in the Portland-Vancouver-Beaverton, OR-WA CBSA. The new title is 

Portland-Vancouver-Hillsboro, OR-WA CBSA. 

● Steubenville, OH replaces Weirton, WV as the most populous principal city in 

the Weirton-Steubenville, WV-OH CBSA. The new title is Steubenville-Weirton, 

OH-WV CBSA. The new CBSA code is 44600. 

 The OMB bulletin is available on the OMB Web site at 

http://www.whitehouse.gov/OMB - go to “Agency Information” and click on “Bulletins”. 

CMS will apply these changes to the IPPS beginning October 1, 2010. 

D. Proposed Occupational Mix Adjustment to the Proposed FY 2011 Wage Index

 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. 
CMS-1498-P 319 

1. Development of Data for the Proposed FY 2011 Occupational Mix Adjustment Based 

on the 2007-2008 Occupational Mix Survey 

 As provided for under section 1886(d)(3)(E) of the Act, we collect data every 

3 years on the occupational mix of employees for each short-term, acute care hospital 

participating in the Medicare program. 

 For the FY 2010 hospital wage index, we used occupational mix data collected on 

a revised 2007-2008 Medicare Wage Index Occupational Mix Survey (the 2007-2008 

survey) to compute the occupational mix adjustment for FY 2010. (We refer readers to 

the FY 2010 IPPS final rule (74 FR 43827) for a detailed discussion of the 2007-2008 

survey.) Again, for the proposed FY 2011 hospital wage index, we used data from the 

2007-2008 survey (including revised data for 45 hospitals) to compute the proposed 

FY 2011 adjustment. 

2. New 2010 Occupational Mix Survey for the FY 2013 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 used occupational mix data collected on the 2007-2008 survey to compute 

the occupational mix adjustment for FY 2010 and the proposed FY 2011 wage index in 

this proposed rule. We also plan to use the 2007-2008 survey data for the FY 2012 wage 

index. Therefore, a new measurement of occupational mix will be required for FY 2013. 

Since we implemented the 2007-2008 survey, we received several public 

comments suggesting further improvements to the occupational mix survey. Specifically, 
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commenters recommended that CMS use the calendar year (that is, January 1 through 

December 31) as the 1-year reporting period instead of July 1 through June 30. 

Commenters also requested that CMS allow for a 6-month period after the end of the 

survey reporting period for hospitals to complete and submit their data to their Medicare 

fiscal intermediaries and MACs. The commenters suggested that these changes will 

allow hospitals more time to develop their occupational mix data before submitting the 

data to the Medicare contractors and CMS for use in development of the wage index. 

Based on these comments, we revised the occupational mix survey. The new 2010 

survey (Form CMS-10079 (2010)) will provide for the collection of hospital-specific 

wages and hours data for calendar year 2010 (that is, payroll periods ending between 

January 1, 2010 and December 31, 2010) and will be applied beginning with the FY 2013 

wage index. 

On September 4, 2009, we published in the Federal Register a notice soliciting 

comments on the proposed 2010 survey (74 FR 45860). The comment period for the 

notice ended on November 3, 2009. After considering the comments we received, we 

made a few minor editorial changes and published the final 2010 survey in the Federal 

Register on January 15, 2010 (75 FR 2548). The survey was approved by OMB on 

February 26, 2010 (OMB control number 0938-0907) and is available on the CMS Web 

site at: http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage, and 

through the fiscal intermediaries/MACs. Hospitals are required to submit their completed 

2010 surveys to their fiscal intermediaries/MACs by July 1, 2011. The preliminary, 

unaudited 2010 survey data will be released in early October 2011, along with the 
CMS-1498-P 321 

FY 2009 Worksheet S-3 wage data, for the FY 2013 wage index review and correction 

process. 

3. Calculation of the Proposed Occupational Mix Adjustment for FY 2011 

 For FY 2011 (as we did for FY 2010), 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. Repeat this computation for each of the four nursing 

subcategories: registered nurses; 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 four 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. 
CMS-1498-P 322 

 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 is 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 is 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.G. 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). 
CMS-1498-P 323 

 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.G. 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 
CMS-1498-P 324 

national hours. The proposed FY 2011 occupational mix adjusted national average 

hourly wage is $34.9124. 

 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 proposed FY 2011 occupational mix 

adjusted Puerto Rico-specific average hourly wage is $14.7567. 

 The table below is an illustrative example of the occupational mix adjustment.
CMS-1498-P 325 

Example of Occupational Mix Adjustment 

Hospital A 

 Step 1 Step 2 Step 3 Step 5 

Provider 

Occupational 

Mix Hours 

Provider 

Occupational Mix 

Salaries 

Provider % 

by 

Subcategor

y 

National AHWs 

by Subcategory 

Provider 

Adjusted 

AHW 

National 

Adjusted 

Nurse AHW 

Registered Nurses 1,642,129 18,125,763 79.84% $40.00 $31.94 Licensed Practical Nurses and Surgical Technologists 67,860 404,822 3.30% $20.00 $0.66 Nursing Aides, Orderlies, & Attendants 259,177 1,762,579 12.60% $13.00 $1.64 Medical Assistants 87,622 577,045 4.26% $12.00 $0.51 

Total Nurse Hours and Salaries 2,056,788 20,870,209 $34.75 $27.0

ALL OTHER 5,000,000 $18,957,010 Step 4 TOTAL 7,056,788 $39,827,219 Wage Data from Cost Report Wages (From S-3, Parts II and III) 

$83,312,942.5

5 

Hours (From S-3, Parts II and III) 3,836,299.60 Hospital A Unadjusted AHW $21.72 Nurse Occupational Mix Wages $33,925,838 Step 7 All Other Unadjusted Occupational Mix Wages $39,655,400 Step 7 Total Occupational Mix Wages $73,581,237 Step 8 Hospital A Final Occupational Mix Adjusted AHW $19.18 Step 8 
CMS-1498-P 326 

Hospital B 

 Step 1 Step 2 Step 3 Step 5 

Provider Occupational Mix Hours 

Provider Occupational Mix Salaries 

Provider % 

by 

Subcategor

y 

National AHWs 

by Subcategory 

Provider 

Adjusted 

AHW 

National 

Adjusted 

Nurse AHW 

Registered Nurses 1,142,129 18,125,763 72.43% $30.00 $21.73 Licensed Practical Nurses and Surgical Technologists 67,860 404,822 4.30% $20.00 $0.86 Nursing Aides, Orderlies, & Attendants 279,177 1,762,579 17.71% $13.00 $2.30 Medical Assistants 87,622 577,045 5.56% $12.00 $0.67 

Total Nurse Hours and Salaries 1,576,788 20,870,209 $25.56 $27.0

ALL OTHER 5,000,000 18,957,010 Step 4 TOTAL 6,576,788 $39,827,219 Wage Data from Cost Report Wages (From S-3, Parts II and III) $25,979,714 Hours (From S-3, Parts II and III) 1,097,585 Hospital B Unadjusted AHW $23.67 Nurse Occupational Mix Wages $14,381,144 Step 7 All Other Unadjusted Occupational Mix Wages $12,365,857 Step 7 Total Occupational Mix Wages $26,747,001 Step 8 Hospital B Final Occupational Mix Adjusted AHW $24.37 Step 8 Note: The numbers in this example are hypothetical, including all National AHW amounts. 
CMS-1498-P 327 

 Because the occupational mix adjustment is required by statute, all hospitals that 

are subject to payments under the IPPS, or any hospital that 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 2011 wage 

index. For the FY 2007-2008 survey, the response rate was 90.4 percent. 

In computing the proposed FY 2011 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. We believe 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 proposed occupational mix 

adjustment, we applied the national occupational mix factor of 1.0000 in calculating the 

area’s proposed FY 2011 occupational mix adjusted wage index. In addition, if a hospital 

submitted a survey, but that survey data could not be used because we determine 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 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 
CMS-1498-P 328 

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 0.9252 (CBSA 17780, College 

Station-Bryan, TX), to a high of 1.1199 (CBSA 40980, Saginaw-Saginaw Township 

North, MI). 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 2011, there are 5 CBSAs (that include 5 hospitals) for which we did 

not have occupational mix data for any of its hospitals. The CBSAs are: 

● CBSA 21940 Fajardo, PR (one hospital) 

● CBSA 22140 (Farmington, NM (one hospital) 

● CBSA 36140 Ocean City, NJ (one hospital) 

● CBSA 41900 San German-Cabo Rojo, PR (two hospitals) 

● CBSA 49500 Yauco, PR (one hospital) 

 Since the FY 2007 IPPS final rule, we have periodically discussed applying a 

hospital-specific penalty to hospitals that fail to submit occupational mix survey data. 

(71 FR 48013 through 48014; 72 FR 47314 through 47315; 73 FR 48580; and 

74 FR 43832). During the FY 2008 rulemaking cycle, some commenters suggested a 

penalty equal to a 1- to 2-percent reduction in the hospital’s wage index value or a set 

percentage of the standardized amount. During the FY 2009 and FY 2010 rulemaking 
CMS-1498-P 329 

cycles, several commenters reiterated their view that full participation in the occupational 

mix survey is critical, and that CMS should develop a methodology that encourages 

hospitals to report occupational mix survey data but does not unfairly penalize 

neighboring hospitals. We indicated in the FY 2010 IPPS/RY 2010 LTCH PPS proposed 

rule that, while we were not proposing a penalty at that time, we would consider the 

public comments we previously received, as well as any public comments on the 

proposed rule, as we develop the proposed FY 2011 wage index. 

To gain a better understanding of why some hospitals are not submitting the 

occupational mix data, beginning with the new 2010 occupational mix survey (discussed 

in section III.D.2. of this preamble), we will require hospitals that do not submit 

occupational mix data to provide an explanation for not complying with the submission 

requirements. We will instruct fiscal intermediaries/MACs to gather this information as 

part of the FY 2013 wage index desk review process. We note that we reserve the right 

to apply a different approach in future years, including potentially penalizing 

nonresponsive hospitals. 

E. Worksheet S-3 Wage Data for the Proposed FY 2011 Wage Index

 The proposed FY 2011 wage index values are based on the data collected from 

the Medicare cost reports submitted by hospitals for cost reporting periods beginning in 

FY 2007 (the FY 2010 wage index was based on data from cost reporting periods 

beginning during FY 2006). 
CMS-1498-P 330 

1. Included Categories of Costs 

 The proposed FY 2011 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, and certain contract indirect patient care services (as discussed in the FY 2008 

final rule with comment period (72 FR 47315)) 

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

We note that, for developing pension and deferred compensation costs for purposes of the 

wage index, CMS requires hospitals to comply with the requirements in 42 CFR 413.100, 

the Provider Reimbursement Manual (PRM), Part I, Sections 2140, 2141, and 2142, and 

related Medicare program instructions, as discussed in the cost reporting instructions for 

Worksheet S-3, Part II, Lines 13 through 20, and in the FY 2006 IPPS final rule 

(70 FR 47369). On March 28, 2008, CMS published Revision 436, a technical 

clarification to the PRM, Part I policies for pension and deferred compensation costs. In 

addition, in November 2009, CMS released, through a Joint Signature Memorandum, 

instructions and a spreadsheet to assist hospitals and Medicare contractors in determining 

the annual allowable defined benefit pension cost for the FY 2011 wage index 

(JSM/TDL-10061, 11-20-09, December 3, 2009). These instructions and spreadsheet 
CMS-1498-P 331 

crosswalk the current interest, liability, and normal cost terminology found in the 

Medicare reimbursement policies under Section 2142 of the PRM, Part I to the new 

terminology applicable under the Pension Protection Act of 2006. The spreadsheet and 

instructions can be downloaded from the CMS Web site at 

http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/itemdetail.asp?filterType=none&filte

rByDID=0&sortByDID=3&sortOrder=descending&itemID=CMS1231035&intNumPerP

age=10. 

2. Excluded Categories of Costs 

 Consistent with the wage index methodology for FY 2009, the wage index for 

FY 2010 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 2011 wage index also excludes the salaries, hours, and wage-related costs of 

hospital-based rural health clinics (RHCs), and Federally qualified health centers 

(FQHCs) because Medicare pays for these costs outside of the IPPS (68 FR 45395). In 

addition, salaries, hours, and wage-related costs of CAHs are excluded from the wage 

index, for the reasons explained in the FY 2004 IPPS final rule (68 FR 45397). 

3. 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 (HHAs), and 
CMS-1498-P 332 

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, other than for LTCHs. 

Such comments should be made in response to separate proposed rules for those 

providers. 

F. Verification of Worksheet S-3 Wage Data

 The wage data for the proposed FY 2011 wage index were obtained from 

Worksheet S-3, Parts II and III of the Medicare cost report for cost reporting periods 

beginning on or after October 1, 2006, and before October 1, 2007. For wage index 

purposes, we refer to cost reports during this period as the “FY 2007 cost report,” the 

“FY 2007 wage data,” or the “FY 2007 data.” Instructions for completing Worksheet S3, Parts II and III are in the Provider Reimbursement Manual (PRM), Part II, sections 

3605.2 and 3605.3. The data file used to construct the wage index includes FY 2007 data 

submitted to us as of March 3, 2010. As in past years, we performed an intensive review 

of the wage data, mostly through the use of edits designed to identify aberrant data. 

 We asked our fiscal intermediaries/MACs to revise or verify data elements that 

resulted in specific edit failures. For the proposed FY 2011 wage index, we identified 

and excluded 14 providers with data that was too aberrant to include in the proposed 

wage index, although if data elements for some of these providers are corrected, we 

intend to include some of these providers in the FY 2011 final 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 14, 2010. 
CMS-1498-P 333 

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 FY 2011 IPPS final rule. 

In constructing the proposed FY 2011 wage index, we included the wage data for 

facilities that were IPPS hospitals in FY 2007, inclusive of those facilities that have since 

terminated their participation in the program as hospitals, as long as those data did 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 and to ensure that the current wage 

index represents the labor market area's current wages as compared to the national 

average of wages. However, we excluded the wage data for CAHs as discussed in the 

FY 2004 IPPS final rule (68 FR 45397). For this proposed rule, we removed 8 hospitals 

that converted to CAH status between February 16, 2009, the cut-off date for CAH 

exclusion from the FY 2010 wage index, and February 15, 2010, the cut-off date for 

CAH exclusion from the FY 2011 wage index. After removing hospitals with aberrant 

data and hospitals that converted to CAH status, the proposed FY 2011 wage index is 

calculated based on 3,513 hospitals. 

In the FY 2008 final rule with comment period (72 FR 47317) and the FY 2009 

IPPS final rule (73 FR 48582), we discussed our policy for allocating a multicampus 

hospital’s wages and hours data, by full-time equivalent (FTE) staff, among the different 

labor market areas where its campuses are located. During the FY 2011 wage index desk 

review process, we requested fiscal intermediaries/MACs to contact multicampus 

hospitals that had campuses in different labor market areas to collect the data for the 
CMS-1498-P 334 

allocation. The proposed FY 2011 wage index in this proposed rule includes separate 

wage data for campuses of three multicampus hospitals. 

 For FY 2011, we are again allowing hospitals to use FTE or discharge data for the 

allocation of a multicampus hospital's wage data among the different labor market areas 

where its campuses are located. The Medicare cost report was updated in May 2008 to 

provide for the reporting of FTE data by campus for multicampus hospitals. Because the 

data from cost reporting periods that begin in FY 2008 will not be used in calculating the 

wage index until FY 2012, a multicampus hospital will still have the option, through the 

FY 2011 wage index, to use either FTE or discharge data for allocating wage data among 

its campuses by providing the information from the applicable cost reporting period to 

CMS through its fiscal intermediary/MAC. Two of the three multicampus hospitals 

chose to have their wage data allocated by their Medicare discharge data for the FY 2011 

wage index. One of the hospitals provided FTE staff data for the allocation. The average 

hourly wage associated with each geographical location of a multicampus hospital is 

reflected in Table 2 of the Addendum to this proposed rule. 

G. Method for Computing the Proposed FY 2011 Unadjusted Wage Index

 The method used to compute the proposed FY 2011 wage index without an 

occupational mix adjustment follows: 

 Step 1--As noted above, we are basing the proposed FY 2011 wage index on 

wage data reported on the FY 2007 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 
CMS-1498-P 335 

reporting period beginning on or after October 1, 2006, and before October 1, 2007. In 

addition, we included data from some hospitals that had cost reporting periods beginning 

before October 2006 and reported a cost reporting period covering all of FY 2007. 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 2007 data. We note that, if a hospital had more than one cost reporting 

period beginning during FY 2007 (for example, a hospital had two short cost reporting 

periods beginning on or after October 1, 2006, and before October 1, 2007), we included 

wage data from only one of the cost reporting periods, the longer, in the wage index 

calculation. If there was more than one cost reporting period and the periods were equal 

in length, we included the wage data from the later period in the wage index calculation. 

 Step 2--Salaries--The method used to compute a hospital’s average hourly wage 

excludes certain costs that are not paid under the IPPS. (We note that, beginning with 

FY 2008 (72 FR 47315), we include Lines 22.01, 26.01, and 27.01 of Worksheet S-3, 

Part II for overhead services in the wage index. However, we note that the wages and 

hours on these lines are not incorporated into Line 101, Column 1 of Worksheet A, 

which, through the electronic cost reporting software, flows directly to Line 1 of 

Worksheet S-3, Part II. Therefore, the first step in the wage index calculation for 

FY 2011 is to compute a “revised” Line 1, by adding to the Line 1 on Worksheet S-3, 

Part II (for wages and hours respectively) the amounts on Lines 22.01, 26.01, and 27.01.) 

In calculating a hospital’s average salaries plus wage-related costs, we subtract from 
CMS-1498-P 336 

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 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 
CMS-1498-P 337 

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 minus the sum of lines 22.01, 

26.01, and 27.01) to revised hours excluding the sum of lines 22.01, 26.01, and 27.01 

(Line 1 minus the sum of Lines 2, 3, 4.01, 5, 5.01, 6, 6.01, 7, 8, 8.01, 22.01, 26.01, and 

27.01). (We note that for the FY 2008 and subsequent wage index calculations, we are 

excluding the sum of lines 22.01, 26.01, and 27.01 from the determination of the ratio of 

overhead hours to revised hours because hospitals typically do not provide fringe benefits 

(wage-related costs) to contract personnel. Therefore, it is not necessary for the wage 

index calculation to exclude overhead wage-related costs for contract personnel. Further, 

if a hospital does contribute to wage-related costs for contracted personnel, the 

instructions for Lines 22.01, 26.01, and 27.01 require that associated wage-related costs 

be combined with wages on the respective contract labor lines.); (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 
CMS-1498-P 338 

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 we are not proposing to make any changes to the 

usage for FY 2011. 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 Factor

10/14/2006 11/15/2006 1.04377 

11/14/2006 12/15/2006 1.04077 

12/14/2006 01/15/2007 1.03786 

01/14/2007 02/15/2007 1.03508 

02/14/2007 03/15/2007 1.03243 

03/14/2007 04/15/2007 1.02981 

04/14/2007 05/15/2007 1.02709 

05/14/2007 06/15/2007 1.02430 

06/14/2007 07/15/2007 1.02153 

07/14/2007 08/15/2007 1.01891 

08/14/2007 09/15/2007 1.01643 
CMS-1498-P 339 

After Before Adjustment Factor

09/14/2007 10/15/2007 1.01394 

10/14/2007 11/15/2007 1.01127 

11/14/2007 12/15/2007 1.00844 

12/14/2007 01/15/2008 1.00556 

01/14/2008 02/15/2008 1.00275 

02/14/2008 03/15/2008 1.00000 

03/14/2008 04/15/2008 0.99732 

 For example, the midpoint of a cost reporting period beginning January 1, 2007, 

and ending December 31, 2007, is June 30, 2007. An adjustment factor of 1.02153 

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 2007 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. 
CMS-1498-P 340 

 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 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 (unadjusted for occupational 

mix) is $34.9330. 

 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 (unadjusted for occupational mix) of $14.7351 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 
CMS-1498-P 341 

rural areas in that State. The areas affected by this provision are identified in Table 4D-2 

of the Addendum to this proposed rule. 

 In the FY 2005 IPPS final rule (69 FR 49109), we adopted the “imputed” floor as 

a temporary 3-year measure to address a concern by some individuals that hospitals in 

all-urban States were disadvantaged by the absence of rural hospitals to set a wage index 

floor in those States. The imputed floor was originally set to expire in FY 2007, but we 

extended it an additional year in the FY 2008 IPPS final rule with comment period 

(72 FR 47321). In the FY 2009 IPPS final rule (73 FR 48570 through 48574 and 48584), 

we extended the imputed floor for an additional 3 years, through FY 2011. 

H. Analysis and Implementation of the Proposed Occupational Mix Adjustment and the 

Proposed FY 2011 Occupational Mix Adjusted Wage Index

 As discussed in section III.D. of this preamble, for FY 2011, we are proposing to 

apply the occupational mix adjustment to 100 percent of the proposed FY 2011 wage 

index. We calculated the proposed occupational mix adjustment using data from the 

2007-2008 occupational mix survey data, using the methodology described in section 

III.D.3. of this preamble. 

Using the occupational mix survey data and applying the occupational mix 

adjustment to 100 percent of the proposed FY 2011 wage index results in a proposed 

national average hourly wage of $34.9124 and a proposed Puerto-Rico specific average 

hourly wage of $14.7567. After excluding data of hospitals that either submitted aberrant 

data that failed critical edits, or that do not have FY 2007 Worksheet S-3 cost report data 

for use in calculating the proposed FY 2011 wage index, we calculated the proposed 
CMS-1498-P 342 

FY 2011 wage index using the occupational mix survey data from 3,178 hospitals. Using 

the Worksheet S-3 cost report data of 3,513 hospitals and occupational mix survey data 

from 3,178 hospitals represents a 90.4 percent survey response rate. The proposed 

FY 2011 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 Wage 

National RN 36.100857731

National LPN and Surgical Technician 20.877391755

National Nurse Aide, Orderly, and Attendant 14.632232352

National Medical Assistant 16.482939594

National Nurse Category 30.504184147

 The proposed national average hourly wage for the entire nurse category as 

computed in Step 5 of the occupational mix calculation is $30.504184147. 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 2007-2008 occupational mix survey data, we determined (in Step 7 

of the occupational mix calculation) that the national percentage of hospital employees in 

the nurse category is 44.32 percent, and the national percentage of hospital employees in 

the all other occupations category is 55.68 percent. At the CBSA level, the percentage of 
CMS-1498-P 343 

hospital employees in the nurse category ranged from a low of 29.08 percent in one 

CBSA, to a high of 70.76 percent in another CBSA. 

 We compared the proposed FY 2011 occupational mix adjusted wage indices for 

each CBSA to the proposed unadjusted wage indices for each CBSA. As a result of 

applying the occupational mix adjustment to the wage data, the proposed wage index 

values for 203(51.9 percent) urban areas and 32 (68.1 percent) rural areas would increase. 

One hundred five (26.9 percent) urban areas would increase by 1 percent or more, and 6 

(1.5 percent) urban areas would increase by 5 percent or more. Eighteen (38.3 percent) 

rural areas would increase by 1 percent or more, and no rural areas would increase by 5 

percent or more. However, the wage index values for 188 (48.1 percent) urban areas and 

15 (31.9 percent) rural areas would decrease. Ninety (23.0 percent) urban areas would 

decrease by 1 percent or more, and no urban area would decrease by 5 percent or more. 

Seven (14.9 percent) rural areas would decrease by 1 percent or more, and no rural areas 

will decrease by 5 percent or more. The largest positive impacts are 7.83 percent for an 

urban area and 2.87 percent for a rural area. The largest negative impacts are 3.98 

percent for an urban area and 2.41 percent for a rural area. No urban or rural areas are 

unaffected. These results indicate that a larger percentage of rural areas (68.1 percent) 

benefit from the occupational mix adjustment than do urban areas (51.9 percent). While 

these results are more positive overall for rural areas than under the previous 

occupational mix adjustment that used survey data from 2006, approximately one-third 

(31.9 percent) of rural CBSAs will still experience a decrease in their wage indices as a 

result of the occupational mix adjustment. 
CMS-1498-P 344 

 The proposed wage index values for FY 2011 (except those for hospitals 

receiving wage index adjustments under section 1886(d)(13) of the Act) included in 

Tables 4A, 4B, 4C, and 4F of the Addendum to this proposed rule include the proposed 

occupational mix adjustment. 

 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 or reclassification of 

hospitals based on FYs 2009, 2010, and 2011 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 2005 and FY 2006 cost reporting periods, as well as the FY 2007 

period used to calculate the proposed FY 2011 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 

average hourly wages in Tables 2, 3A, and 3B in the Addendum to this proposed rule 

include the proposed occupational mix adjustment. The proposed wage index values in 

Tables 4A, 4B, 4C, and 4D-1 also include the proposed State-specific rural floor and 

imputed floor budget neutrality adjustments. 
CMS-1498-P 345 

I. Revisions to the Wage Index Based on Hospital Redesignations and Reclassifications

1. General 

 Under section 1886(d)(10) of the Act, the MGCRB considers applications by 

hospitals for geographic reclassification for purposes of payment under the IPPS. 

Hospitals must apply to the MGCRB to reclassify 13 months prior to the start of the fiscal 

year for which reclassification is sought (generally by September 1). 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 42 CFR 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 average hourly 

wage data from the 3 most recently published hospital wage surveys 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 42 CFR 412.235. 
CMS-1498-P 346 

 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 labor market 

area 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 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. Eligible counties are discussed and identified under section III.I.5. 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 are applicable both to the hospitals 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 
CMS-1498-P 347 

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 also has adopted the following policies:

 • The wage data for a reclassified urban hospital is included in both the wage 

index calculation of the urban 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. 
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 • In cases where hospitals have reclassified to rural areas, such as urban hospitals 

reclassifying to rural areas under 42 CFR 412.103, the hospital's 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. 

The effect of this policy, in combination with the statutory requirement at section 

1886(d)(8)(C)(ii) of the Act, is that rural areas may receive a wage index based upon the 

highest of: (1) wage data from hospitals geographically located in the rural area; 

(2) wage data from hospitals geographically located in the rural area, but excluding all 

data associated with hospitals reclassifying out of the rural area under section 

1886(d)(8)(B) or section 1886(d)(10) of the Act; or (3) wage data associated with 

hospitals geographically located in the area plus all hospitals reclassified into the rural 

area. 

 In addition, in accordance with the statutory language referring to "hospitals" in 

the plural under sections 1886(d)(8)(C)(i) and 1886(d)(8)(C)(ii) of the Act, our 

longstanding policy is to consider reclassified hospitals as a group when deciding 

whether to include or exclude them from both urban and rural wage index calculations. 

3. FY 2011 MGCRB Reclassifications 

a. FY 2011 Reclassifications Requirements and Approvals 

 Under section 1886(d)(10) of the Act, the MGCRB considers applications by 

hospitals for geographic reclassification for purposes of payment under the IPPS. The 

specific procedures and rules that apply to the geographic reclassification process are 

outlined in 42 CFR 412.230 through 412.280. 
CMS-1498-P 349 

 At the time this proposed rule was constructed, the MGCRB had completed its 

review of FY 2011 reclassification requests. Based on such reviews, there were 311 

hospitals approved for wage index reclassifications by the MGCRB for FY 2011. 

Because MGCRB wage index reclassifications are effective for 3 years, for FY 2011, 

hospitals reclassified during FY 2009 or FY 2010 are eligible to continue to be 

reclassified to a particular labor market area based on such prior reclassifications. There 

were 258 hospitals approved for wage index reclassifications in FY 2009 and 254 

hospitals approved for wage index reclassifications in FY 2010. Of all of the hospitals 

approved for reclassification for FY 2009, FY 2010, and FY 2011, based upon the review 

at the time of this proposed rule, 832 hospitals are in a reclassification status for FY 2011. 

 Under 42 CFR 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. Generally stated, the request for withdrawal of an application for reclassification or 

termination of an existing 3-year reclassification that would be effective in FY 2011 has 

to be received by the MGCRB within 45 days of the publication of the proposed rule. 

Hospitals may also cancel prior reclassification withdrawals or terminations in certain 

circumstances. 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 42 CFR 412.273, as well as the FY 2002 IPPS final rule 

(66 FR 39887) and the FY 2003 IPPS final rule (67 FR 50065). Additional discussion on 

withdrawals and terminations, and clarifications regarding reinstating reclassifications 
CMS-1498-P 350 

and “fallback” reclassifications, were included in the FY 2008 IPPS final rule 

(72 FR 47333). 

 Changes to the wage index that result from withdrawals of requests for 

reclassification, terminations, wage index corrections, appeals, and the Administrator's 

review process for FY 2011 will be incorporated into the wage index values published in 

the FY 2011 IPPS/LTCH PPS final rule. These changes affect not only the wage index 

value for specific geographic areas, but also the wage index value 

redesignated/reclassified 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/reclassified hospitals. Further, the wage index value for the area from 

which the hospitals are redesignated/reclassified may be affected. 

b. Applications for Reclassifications for FY 2012 

Applications for FY 2012 reclassifications are due to the MGCRB by 

September 1, 2010. We note that this is also the deadline for canceling a previous wage 

index reclassification withdrawal or termination under 42 CFR 412.273(d). Applications 

and other information about MGCRB reclassifications may be obtained, beginning in 

mid-July 2010, via the CMS Internet Web site at: 

http://cms.hhs.gov/MGCRB/02_instructions_and_applications.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. 
CMS-1498-P 351 

c. Appeals of MGCRB Denials of Withdrawals and Terminations 

Section 412.278 of the regulations permits a hospital or a group of hospitals 

dissatisfied with the MGCRB’s decision regarding its geographic designation to request 

the Administrator’s review of the decision. Section 412.273(e) permits a hospital to file 

an appeal to the Administrator regarding the MGCRB’s denial of the hospital’s request 

for withdrawal of an application. However, currently, this section of the regulations does 

not address Administrator review of the MGCRB’s denial of a hospital’s request for 

termination; that is, “terminations” are not specified in the regulations at §412.273(e). 

We are proposing to revise the regulations to specify the availability of 

Administrator review of MGCRB decisions regarding withdrawals and terminations, as 

well as cancellations of withdrawals or terminations. Because reclassifications are 

considered budget neutral actions, we believe these proposed revisions would have no 

impact on total IPPS payments. 

In addition, during our review of §412.273, we determined that some of the 

existing language in the section could be clarified to make it more easily understood. For 

example, we believe it would be helpful to clarify the distinction between terminations 

and withdrawals by defining these terms in a new paragraph (a), which would also 

include the timing provisions now under existing paragraph (b)(1)(ii). To account for this 

new paragraph, we are proposing to redesignate the existing contents of paragraph (e) as 

paragraph (f) and also to revise the language to specify the ability of a hospital to appeal 

an MGCRB denial of a request for “termination” of an approved reclassification, as well 

as cancellation of a withdrawal or termination. We also believe it would be helpful (1) to 
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establish the introductory language of existing paragraph (a) as a general rule under new 

paragraph (b); (2) to establish a new paragraph (c) that addresses the timing provisions 

currently in paragraphs (a)(1), (a)(2), and (b)(1)(i); (3) to clarify the existing language of 

paragraphs (b)(2)(i) (b)(2)(ii), (b)(2)(iii), and (d) and incorporate it under new paragraph 

(d); and (4) to redesignate the existing contents of paragraph (c) as new paragraph (e). 

4. Redesignations of Hospitals under Section 1886(d)(8)(B) of the Act 

 Section 1886(d)(8)(B) of the Act requires 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 

are met. Effective beginning FY 2005, we use OMB’s 2000 CBSA standards and the 

Census 2000 data to identify counties in which hospitals qualify under 

section 1886(d)(8)(B) of the Act to receive the wage index of 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 FY 2011 chart 

below with the listing of the rural counties containing the hospitals designated as urban 

under section 1886(d)(8)(B) of the Act. For discharges occurring on or after 

October 1, 2010, hospitals located in the rural county 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 Containing Hospitals Redesignated as Urban 

under Section 1886(d)(8)(B) of the Act 

(Based on CBSAs and Census 2000 Data) 

Rural County CBSA 

Cherokee, AL Rome, GA 

Macon, AL Auburn-Opelika, AL 

Talladega, AL Anniston-Oxford, AL 
CMS-1498-P 353 

Rural County CBSA 

Hot Springs, AR Hot Springs, AR 

Windham, CT Hartford-West Hartford-East Hartford, CT 

Bradford, FL Gainesville, FL 

Hendry, FL West Palm Beach-Boca Raton-Boynton, FL 

Levy, FL Gainesville, FL 

Walton, FL Fort Walton Beach-Crestview-Destin, FL 

Banks, GA Gainesville, GA 

Chattooga, GA Chattanooga, TN-GA 

Jackson, GA Atlanta-Sandy Springs-Marietta, GA 

Lumpkin, GA Atlanta-Sandy Springs-Marietta, GA 

Morgan, GA Atlanta-Sandy Springs-Marietta, GA 

Peach, GA Macon, GA 

Polk, GA Atlanta-Sandy Springs-Marietta, GA 

Talbot, GA Columbus, GA-AL 

Bingham, ID Idaho Falls, ID 

Christian, IL Springfield, IL 

DeWitt, IL Bloomington-Normal, IL 

Iroquois, IL Kankakee-Bradley, IL 

Logan, IL Springfield, IL 

Mason, IL Peoria, IL 

Ogle, IL Rockford, IL 

Clinton, IN Lafayette, IN 

Henry, IN Indianapolis-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 
CMS-1498-P 354 

Rural County CBSA 

Davidson, NC Greensboro-High Point, NC 

Granville, NC Durham, NC 

Harnett, NC Raleigh-Cary, NC 

Lincoln, NC Charlotte-Gastonia-Concord, NC-SC 

Polk, NC Spartanburg, SC 

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 
CMS-1498-P 355 

Rural County CBSA 

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 may 

compare the reclassified wage index for the labor market area in Table 4C in the 

Addendum to the proposed rule into which they would be reclassified by the MGCRB to 

the wage index for the area to which they are redesignated under section 1886(d)(8)(B) of 

the Act. Hospitals may withdraw from an MGCRB reclassification within 45 days of the 

publication of this proposed rule. 

5. Reclassifications under Section 1886(d)(8)(B) of the Act 

 As discussed in the FY 2009 IPPS final rule (73 FR 48588), Lugar hospitals are 

treated like reclassified hospitals for purposes of determining their applicable wage index 

and receive the reclassified wage index 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 MGCRB, they are subject to the rural reclassification 

rules set forth at 42 CFR 412.230. The procedural rules set forth at §412.230 list the 

criteria that a hospital must meet in order to reclassify as a rural hospital. Lugar hospitals 
CMS-1498-P 356 

are subject to the proximity criteria and payment thresholds that apply to rural hospitals. 

Specifically, the hospital must be no more than 35 miles from the area to which it seeks 

reclassification (§412.230(b)(1)); and the hospital must 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)). In accordance with policy adopted 

in the FY 2009 IPPS final rule (73 FR 48568 and 48569), beginning with reclassifications 

for the FY 2010 wage index, a Lugar hospital must also demonstrate that its average 

hourly wage is equal to at least 84 percent (for FY 2010 reclassifications) and 86 percent 

(for reclassifications for FY 2011 and subsequent fiscal years) 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. We treat New England deemed counties in a manner consistent with 

how we treat Lugar counties. (We refer readers to FY 2008 IPPS final rule with 

comment period (72 FR 47337) for a discussion of this policy.) 

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

 Section 508 of Pub. L. 108-173 allowed certain qualifying hospitals to receive 

wage index reclassifications and assignments that they otherwise would not have been 
CMS-1498-P 357 

eligible to receive under the law. Although section 508 originally was scheduled to 

expire after a 3-year period, Congress extended the provision several times, as well as 

certain special exceptions that would have otherwise expired. For a discussion of the 

original section 508 provision and its various extensions, we refer readers to the FY 2009 

IPPS final rule (73 FR 48588). The most recent extension of the provision was included 

in section 124 of Pub. L. 110-275 (MIPPA). Section 124 extended, through FY 2009, 

section 508 reclassifications as well as certain special exceptions. Because the section 

124 extension of these provisions expired on September 30, 2009 (and, therefore, will not 

be applicable in FY 2011 unless there is intervening legislation to extend the provisions), 

we are not proposing to make any changes related to these provisions in this proposed 

rule for FY 2011. 

 We note that section 508 and special exceptions reclassifications were recently 

extended again, through September 30, 2010, under section 10317 of the PPACA 

(Pub. L. 111-148). We intend to imminently issue instructions regarding implementation 

of section 10317 of Pub. L. 111-148. 

J. Proposed FY 2011 Wage Index Adjustment Based on Commuting Patterns of Hospital 

Employees

 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 "out-migration" adjustment). The process, outlined in the 

FY 2005 IPPS final rule (69 FR 49061), provides for an increase in the wage index for 
CMS-1498-P 358 

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. Beginning with the FY 2008 wage index, we use post-reclassified 

wage indices when determining the out-migration adjustment (72 FR 47339). 

For the proposed FY 2011 wage index, we are proposing to calculate the outmigration adjustment using the same formula described in the FY 2005 IPPS final rule 

(69 FR 49064), with the addition of using the post-reclassified wage indices, to calculate 

the out-migration adjustment. This adjustment is calculated as follows: 
CMS-1498-P 359 

 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 index areas, multiply this result by the result obtained 

in Step 1. 

 Step 3--Sum the products resulting from Step 2 (if the qualifying county has 

workers commuting to more than one higher wage index 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. 

For example, hospitals that received the adjustment for the first time in FY 2010 will be 

eligible to retain the adjustment for FY 2011. 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, 2010. 

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 FYs 2005 through 

2010 IPPS final rules, we are specifying that hospitals redesignated under section 

1886(d)(8) of the Act or reclassified under section 1886(d)(10) of the Act will be deemed 
CMS-1498-P 360 

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 adjustment, 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 within 45 days from the 

publication of this proposed rule that they elect to receive the out-migration adjustment 

instead. 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 2011. 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 within the necessary 

timeframe. In addition, hospitals eligible to receive the out-migration wage index 

adjustment and that withdraw their application for reclassification will automatically 

receive the wage index adjustment listed in Table 4J in the Addendum to this proposed 

rule. The wage index is updated annually and, as such, hospitals wishing to waive their 
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Lugar redesignation in order to receive their home area wage index plus the 

out-migration adjustment must request the waiver annually. 

K. Process for Requests for Wage Index Data Corrections

 The preliminary, unaudited Worksheet S-3 wage data and occupational mix 

survey data files for the proposed FY 2011 wage index were made available on 

October 5, 2009, through the Internet on the CMS Web site at: 

http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage. 

 In the interest of meeting the data needs of the public, beginning with the 

proposed FY 2009 wage index, we post an additional public use file on our Web site that 

reflects the actual data that are used in computing the proposed wage index. The release 

of this new file does not alter the current wage index process or schedule. We notified 

the hospital community of the availability of these data as we do with the current public 

use wage data files through our Hospital Open Door forum. We encouraged hospitals to 

sign up for automatic notifications of information about hospital issues and the 

scheduling of the Hospital Open Door forums at: 

http://www.cms.hhs.gov/OpenDoorForums/. 

 In a memorandum dated October 21, 2009, we instructed all fiscal 

intermediaries/MACs 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/MACs 

to advise hospitals that these data were also made available directly through their 

representative hospital organizations. 
CMS-1498-P 362 

 If a hospital wished to request a change to its data as shown in the 

October 5, 2009 wage and occupational mix data files, the hospital was to submit 

corrections along with complete, detailed supporting documentation to its fiscal 

intermediary/MAC by December 7, 2009. 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 files on the Internet, 

through the October 21, 2009 memorandum referenced above. 

In the October 21, 2009 memorandum, we also specified that a hospital requesting 

revisions to its occupational mix survey data was to copy its record(s) from the 

CY 2007-2008 occupational mix preliminary files posted to our Web site in October, 

highlight the revised cells on its spreadsheet, and submit its spreadsheet(s) and complete 

documentation to its fiscal intermediary/MAC no later than December 7, 2009. 

The fiscal intermediaries/MACs notified the hospitals by mid-February 2010 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/MACs also 

submitted the revised data to CMS by mid-February 2010. CMS published the proposed 

wage index public use files that included hospitals’ revised wage index data on 

February 22, 2010. Hospitals had until March 8, 2010, to submit requests to the fiscal 

intermediaries/MACs for reconsideration of adjustments made by the fiscal 

intermediaries/MACs 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 
CMS-1498-P 363 

data. Hospitals also were required to submit sufficient documentation to support their 

requests. 

 After reviewing requested changes submitted by hospitals, fiscal 

intermediaries/MACs are to transmit any additional revisions resulting from the 

hospitals’ reconsideration requests by April 14, 2010. The deadline for a hospital to 

request CMS intervention in cases where the hospital disagrees with the fiscal 

intermediary's (or, if applicable, the MAC’s) policy interpretations is April 21, 2010. 

 Hospitals should examine Table 2 in the Addendum to this proposed rule. 

Table 2 in the Addendum to this proposed rule contains each hospital’s adjusted average 

hourly wage used to construct the wage index values for the past 3 years, including the 

FY 2007 data used to construct the proposed FY 2011 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 in March 2010. 

We will release the final wage index data public use files by May 7, 2010 on the 

Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage. The 

May 2010 public use files are made available solely for the limited purpose of identifying 

any potential errors made by CMS or the fiscal intermediary/MAC in the entry of the 

final wage index data that resulted from the correction process described above (revisions 

submitted to CMS by the fiscal intermediaries/MACs by April 14, 2010). If, after 

reviewing the May 2010 final files, a hospital believes that its wage or occupational mix 

data are incorrect due to a fiscal intermediary/MAC or CMS error in the entry or 

tabulation of the final data, the hospital should send a letter to both its fiscal 
CMS-1498-P 364 

intermediary/MAC and CMS that outlines why the hospital believes an error exists and 

provide all supporting information, including relevant dates (for example, when it first 

became aware of the error). CMS and the fiscal intermediaries (or, if applicable, the 

MACs) must receive these requests no later than June 7, 2010. 

Each request also must be sent to the fiscal intermediary/MAC. The fiscal 

intermediary/MAC will review requests upon receipt and contact CMS immediately to 

discuss any findings. 

 At this point in the process, that is, after the release of the May 2010 wage index 

data files, changes to the wage and occupational mix data will only be made in those very 

limited situations involving an error by the fiscal intermediary/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/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 MACs on or 

before April 21, 2010. 

● Requests for correction of errors that were not, but could have been, identified 

during the hospital's review of the February 22, 2010 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 MACs (that is, by June 7, 2010) will be incorporated into the final 
CMS-1498-P 365 

wage index in the FY 2011 IPPS/LTCH PPS final rule, which will be effective 

October 1, 2010. 

 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 2011 payment rates. Accordingly, hospitals that did 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 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 readers also to the FY 2000 IPPS 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 have access to the final wage index data by early May 2010, 

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 2011 wage index by August 2010, and the implementation of the FY 2011 wage 
CMS-1498-P 366 

index on October 1, 2010. If hospitals availed 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 7, 2010, we retain the right 

to make midyear changes to the wage index under very limited circumstances. 

Specifically, in accordance with 42 CFR 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 7 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, because 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 MACs 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. 
CMS-1498-P 367 

In the FY 2006 IPPS final rule (70 FR 47385), we revised 42 CFR 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 7, 2010 deadline for the 

FY 2011 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 requested a correction to its wage index 

data before CMS calculates the final wage index (that is, by the June 7, 2010 deadline), 

and CMS acknowledges that the error in the hospital’s wage index data was caused by 

CMS’ 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 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; and it can only be used 

for the current Federal fiscal year. In other situations where our policies would allow 
CMS-1498-P 368 

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 FY 2011 Wage Index

 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 
CMS-1498-P 369 

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. 

 In the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43850 through 

43856), we rebased and revised the hospital market basket for operating costs. We 

established a FY-2006-based IPPS hospital market basket to replace the FY 2002-based 

IPPS hospital market basket, effective October 1, 2009. In that final rule, we presented 

our analysis and conclusions regarding the frequency and methodology for updating the 

labor-related share for FY 2010. We also recalculated a labor-related share of 

68.8 percent, using the FY 2006-based IPPS market basket, for discharges occurring on 

or after October 1, 2009. In addition, we implemented this revised and rebased laborrelated share in a budget neutral manner, but consistent with section 1886(d)(3)(E) of the 

Act, we did not take into account the additional payments that would be made as a result 

of hospitals with a wage index less than or equal to 1.0 being paid using a labor-related 

share lower than the labor-related share of hospitals with a wage index greater than 1.0. 

The labor-related share is used to determine the proportion of the national IPPS 

base payment rate to which the area wage index is applied. In this proposed rule, we are 

not proposing to make any further changes to the national average proportion of 

operating costs that are attributable to wages and salaries, fringe benefits, contract labor, 

the labor-related portion of professional fees, administrative and business support 
CMS-1498-P 370 

services, and all other labor-related services (previously referred to in the FY 2002-based 

IPPS market basket as labor-intensive). Therefore, we are proposing to continue to use a 

labor-related share of 68.8 percent for discharges occurring on or after October 1, 2010. 

Tables 1A and 1B in the Addendum to this proposed rule reflects 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." Therefore, for all IPPS 

hospitals whose wage indices are less than 1.0000, we are applying the wage index to a 

labor-related share of 62 percent of the national standardized amount. For all IPPS 

hospitals whose wage indices are greater than 1.0000, we are applying the wage index to 

a labor-related share of 68.8 percent of the national standardized amount. 

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. We are 

proposing to continue to use a labor-related share for the Puerto Rico-specific 

standardized amounts of 62.1 percent for discharges occurring on or after 

October 1, 2010. This Puerto Rico labor-related share of 62.1 percent was also adopted 

in the FY 2010 IPPS/LTCH PPS final rule (74 FR 43857) at the time the FY 2006-based 

hospital market basket was established, effective October 1, 2009. 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, the 

labor-related portion of professional fees, administrative and business support services, 
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and all other labor-related services (previously referred to in the FY 2002-based IPPS 

market basket as labor-intensive) 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. The labor-related share of a 

hospital's Puerto Rico-specific rate will be either the Puerto Rico-specific labor-related 

share of 62.1 percent or 62 perecent, 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 62.1 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 62 percent of the Puerto Rico-specific rates because the lower 

labor-related share will result in higher payments. The proposed Puerto Rico 

labor-related share of 62.1 percent for FY 2011 is reflected in the Table 1C of the 

Addendum to this proposed rule. 

V. 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 

a. Overview 

 CMS is seeking to promote higher quality and more efficient health care for 

Medicare beneficiaries. This effort is supported by the adoption of an increasing number 
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of widely-agreed upon quality measures. CMS has worked with relevant stakeholders to 

define measures of quality in almost every setting and currently measures some aspect of 

care for almost all Medicare beneficiaries. These measures assess structural aspects of 

care, clinical processes, patient experiences with care, and, increasingly, outcomes. 

CMS has implemented quality measure reporting programs for multiple settings 

of care. To measure the quality of hospital inpatient services, CMS implemented the 

Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program. In 

addition, CMS has implemented quality reporting programs for hospital outpatient 

services, the Hospital Outpatient Quality Data Reporting Program (HOP QDRP), and for 

physicians and other eligible professionals, the Physician Quality Reporting Initiative 

(PQRI). CMS has also implemented quality reporting programs for home health agencies 

and skilled nursing facilities that are based on conditions of participation, and an 

end-stage renal disease quality reporting program that is based on conditions for 

coverage. 

b. Hospital Quality Data Reporting under Section 501(b) of Pub. L. 108-173 

 Section 501(b) of the Medicare Prescription Drug, Improvement, and 

Modernization Act of 2003 (MMA), Pub. L. 108-173, added section 1886(b)(3)(B)(vii) to 

the Act. This section established the authority for the RHQDAPU program and revised 

the mechanism used to update the standardized payment amount for inpatient hospital 

operating costs. Specifically, section 1886(b)(3)(B)(vii)(I) of the Act, before it was 

amended by section 5001(a) of Pub. L. 109-171, provided for a reduction of 

0.4 percentage points to the update percentage increase (also known as the market basket 
CMS-1498-P 373 

update) for FY 2005 through FY 2007 for any subsection (d) hospital that did not submit 

data on a set of 10 quality indicators established by the Secretary as of 

November 1, 2003. It also provides that any reduction would apply only to the fiscal year 

involved, and would not be taken into account in computing the applicable percentage 

increase for a subsequent fiscal year. The statute thereby established an incentive for 

IPPS hospitals to submit data on the quality measures established by the Secretary, and 

also built upon the previously established Voluntary Hospital Quality Data Reporting 

Program that we described in the FY 2009 IPPS final rule (73 FR 48598). 

 We implemented section 1886(b)(3)(B)(vii) of the Act in the FY 2005 IPPS final 

rule (69 FR 49078) and codified the applicable percentage change in §412.64(d) of our 

regulations. We adopted additional requirements under the RHQDAPU program in the 

FY 2006 IPPS final rule (70 FR 47420). 

c. Hospital Quality Data Reporting under Section 5001(a) of Pub. L. 109-171 

 Section 5001(a) of the Deficit Reduction Act of 2005 (DRA), Pub. L. 109-171, 

further amended section 1886(b)(3)(B) of the Act to revise the mechanism used to update 

the standardized payment amount for hospital inpatient operating costs, in particular, by 

adding new section 1886(b)(3)(B)(viii) to the Act. 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 be reduced by 2.0 percentage points for any 

subsection (d) hospital that does not submit quality data in a form and manner, and at a 

time, specified by the Secretary. 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 
CMS-1498-P 374 

fiscal year involved, and will not be taken into account for computing the applicable 

percentage increase for a subsequent fiscal year. In the FY 2007 IPPS final rule 

(71 FR 48045), 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 

subsection (d) hospitals that do not comply with requirements for reporting quality data, 

as provided for under section 1886(b)(3)(B)(viii) of the Act. 

(1) Quality Measures 

 Section 1886(b)(3)(B)(viii)(III) of the Act requires that the Secretary expand the 

"starter set" of 10 quality measures that was established by the Secretary as of 

November 1, 2003, as the Secretary determines to be appropriate for the measurement of 

the quality of care furnished by a hospital in inpatient settings. In expanding this set of 

measures, section 1886(b)(3)(B)(viii)(IV) of the Act requires that, effective for payments 

beginning with FY 2007, the Secretary begin to adopt the baseline set of performance 

measures as set forth in a report issued by the Institute of Medicine (IOM) of the National 

Academy of Sciences under section 238(b) of Pub. L. 108-173.5

 Section 1886(b)(3)(B)(viii)(V) of the Act requires that, effective for payments 

beginning with FY 2008, the Secretary add other quality measures that reflect consensus 

among affected parties, and to the extent feasible and practicable, have been set forth by 

one or more national consensus building entities. The NQF is a voluntary consensus 

 

5

 Institute of Medicine, "Performance Measurement: Accelerating Improvement," 

December 1, 2005, available at: http://www.iom.edu/CMS/3809/19805/31310.aspx. 

IOM set forth these baseline measures in a November 2005 report. However, the IOM 

report was not released until December 1, 2005 on the IOM Web site. 
CMS-1498-P 375 

standard-setting organization with a diverse representation of consumer, purchaser, 

provider, academic, clinical, and other health care stakeholder organizations. The NQF 

was established to standardize health care quality measurement and reporting through its 

consensus development process. We have generally adopted NQF-endorsed measures. 

However, we believe that consensus among affected parties also can be reflected by other 

means, including consensus achieved during the measure development process, 

consensus shown through broad acceptance and use of measures, and consensus through 

public comment. 

 Section 1886(b)(3)(B)(viii)(VI) of the Act authorizes the Secretary 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 is 

granted broad discretion to replace measures that are no longer appropriate for the 

RHQDAPU program. 

 In the FY 2007 IPPS final rule, we began to expand the RHQDAPU program 

measures by adding 11 quality measures to the 10-measure starter set to establish an 

expanded set of 21 quality measures for the FY 2007 payment determination 

(71 FR 48033 through 48037, 48045). 

 In the CY 2007 OPPS/ASC final rule (71 FR 68201), we adopted six additional 

quality measures for the FY 2008 payment determination, for a total of 27 measures. 

Two of these measures (30-Day Risk Standardized Mortality Rates for Heart Failure and 

30-Day Risk Standardized Mortality Rates for AMI) were calculated using existing 
CMS-1498-P 376 

administrative Medicare claims data; thus, no additional data submission by hospitals was 

required for these two measures. The measures used for the FY 2008 payment 

determination included, for the first time, the HCAHPS patient experience of care survey. 

 In the FY 2008 IPPS final rule (72 FR 47348 through 47358) and the CY 2008 

OPPS/ASC final rule with comment period (72 FR 66875 through 66877), we added 

three additional process measures to the RHQDAPU program measure set. (These three 

measures are SCIP-Infection-4: Cardiac Surgery Patients with Controlled 6AM 

Postoperative Serum Glucose, SCIP-Infection-6: Surgery Patients with Appropriate Hair 

Removal, and Pneumonia 30-day mortality (Medicare patients).) The addition of these 

3 measures brought the total number of RHQDAPU program measures to be used for the 

FY 2009 payment determination to 30 (72 FR 66876). The 30 measures used for the 

FY 2009 annual payment determination are listed in the FY 2009 IPPS final rule 

(73 FR 48600 through 48601). 

For the FY 2010 payment determination, we added 15 new measures to the 

RHQDAPU program measure set and retired one measure from the program (PN-1: 

Oxygenation Assessment). Of the new measures, 13 were adopted in the FY 2009 IPPS 

final rule (73 FR 48602 through 48611) and two additional measures were finalized in the 

CY 2009 OPPS/ASC final rule with comment period (73 FR 68780 through 68781). This 

resulted in an expansion of the RHQDAPU program measures from 30 measures for the 

FY 2009 payment determination to 44 measures for the FY 2010 payment determination. 

The RHQDAPU program measures for the FY 2010 payment determination consist of: 

26 chart-abstracted process measures, which measure quality of care provided for Acute 
CMS-1498-P 377 

Myocardial Infarction (AMI), Heart Failure (HF), Pneumonia (PN), and Surgical Care 

Improvement (SCIP); 6 claims-based measures, which evaluate 30-day mortality and 

30-day readmission rates for AMI, HF, or PN; 9 claims-based AHRQ patient safety 

indicators and inpatient quality indicators; 1 claims-based nursing sensitive measure; 

1 structural measure that assesses participation in a systematic database for cardiac 

surgery; and the HCAHPS patient experience of care survey. The measures are listed in 

the IPPS FY 2009 final rule at 73 FR 46809 and in the CY 2009 OPPS/ASC final rule 

with comment period at 73 FR 68781. 

On December 31, 2008, CMS advised hospitals that they would no longer be 

required to submit data for the RHQDAPU program measure AMI-6-Beta blocker at 

arrival, beginning with discharges occurring on April 1, 2009. This change was based on 

the evolving evidence regarding AMI patient care, as well as changes in the American 

College of Cardiology/American Heart Association (ACC/AHA) practice guidelines for 

ST-segment elevation myocardial infarction and non-ST segment elevation myocardial 

infarction, upon which AMI-6 is based. CMS took action to remove the measure from 

reporting initiatives based on the lack of support by the measure developer and the 

clinical and scientific considerations described in the FY 2010 IPPS/RY 2010 LTCH PPS 

final rule at 74 FR 43863. 

We had previously discussed considerations relating to retiring or replacing 

measures in the FY 2008 IPPS final rule with comment period and the FY 2009 IPPS 

final rule, including the “topping out” of hospitals’ performance under a measure 

(72 FR 47358 through 47359 and 73 FR 48603 through 48604, respectively). However, 
CMS-1498-P 378 

in this instance, the measure no longer “represent[s] the best clinical practice,” an 

additional basis under section 1886(b)(3)(B)(viii)(VI) of the Act for retiring a measure. 

In the FY 2010 IPPS/RY 2010 LTCH PPS final rule, we formally retired the AMI-6 

measure from the RHQDAPU program for the FY 2011 payment determination and 

subsequent payment determinations. 

For the FY 2011 payment determination, we retained 41 of the FY 2010 quality 

measures; harmonized two FY 2010 RHQDAPU program quality measures (combining 

PSI 04-Death among surgical patients with treatable serious complications; and Nursing 

Sensitive – Failure to rescue into a single measure (Death among surgical inpatients with 

serious, treatable complications); added two chart-abstracted measures 

(SCIP-Infection-9: Postoperative Urinary Catheter Removal on Post Operative Day 1 or 2 

and SCIP-Infection-10: Perioperative Temperature Management); and added two 

structural measures (1) Participation in a Systematic Clinical Database Registry for 

Stroke Care; and (2) Participation in a Systematic Clinical Database Registry for Nursing 

Sensitive Care) (74 FR 43868 through 43873). The 46 measures we adopted for the 

FY 2011 payment determination are: 

Topic RHQDAPU Program Quality Measures for the FY 2011 Payment 

Determination as Finalized in FY 2010 IPPS/RY 2010 LTCH PPS 

Final Rule

Acute Myocardial Infarction (AMI) 

● AMI-1 Aspirin at arrival 

● AMI-2 Aspirin prescribed at discharge 

● AMI-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or 

Angiotensin II Receptor Blocker (ARB) for left ventricular systolic 

dysfunction 

● AMI-4 Adult smoking cessation advice/counseling 

● AMI-5 Beta blocker prescribed at discharge 
CMS-1498-P 379 

Topic RHQDAPU Program Quality Measures for the FY 2011 Payment 

Determination as Finalized in FY 2010 IPPS/RY 2010 LTCH PPS 

Final Rule

● AMI-7a Fibrinolytic (thrombolytic) agent received within 30 minutes 

of hospital arrival 

● AMI-8a Timing of Receipt of Primary Percutaneous Coronary 

Intervention (PCI) 

Heart Failure (HF) 

● HF-1 Discharge instructions 

● HF-2 Left ventricular function assessment 

● HF-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or 

Angiotensin II Receptor Blocker (ARB) for left ventricular systolic 

dysfunction 

● HF-4 Adult smoking cessation advice/counseling 

Pneumonia (PN) 

● PN-2 Pneumococcal vaccination status 

● PN-3b Blood culture performed before first antibiotic received in 

hospital 

● PN-4 Adult smoking cessation advice/counseling 

● PN-5c Timing of receipt of initial antibiotic following hospital arrival 

● PN-6 Appropriate initial antibiotic selection 

● PN-7 Influenza vaccination status 

Surgical Care Improvement Project (SCIP) 

● SCIP-1 Prophylactic antibiotic received within 1 hour prior to surgical 

incision 

● SCIP-3 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 

● SCIP-Infection-4: Cardiac Surgery Patients with Controlled 6AM 

Postoperative Serum Glucose 

● SCIP-Infection-6: Surgery Patients with Appropriate Hair Removal 

● SCIP–Infection-9: Postoperative Urinary Catheter Removal on Post 

Operative Day 1 or 2* 

● SCIP-Infection-10: Perioperative Temperature Management* 

● SCIP-Cardiovascular-2: Surgery Patients on a Beta Blocker Prior to 

Arrival Who Received a Beta Blocker During the Perioperative Period 

Mortality Measures (Medicare Patients) 

● MORT-30-AMI: Acute Myocardial Infarction 30-day mortality –

Medicare patients 
CMS-1498-P 380 

Topic RHQDAPU Program Quality Measures for the FY 2011 Payment 

Determination as Finalized in FY 2010 IPPS/RY 2010 LTCH PPS 

Final Rule

● MORT-30-HF: Heart Failure 30-day mortality Medicare patients 

● MORT-30-PN: Pneumonia 30-day mortality -Medicare patients 

Patients' Experience of Care 

● HCAHPS survey 

Readmission Measure (Medicare Patients) 

● READ-30-HF: Heart Failure 30-Day Risk Standardized Readmission 

Measure (Medicare patients) 

● READ-30-AMI: Acute Myocardial Infarction 30-Day Risk 

Standardized Readmission Measure (Medicare patients) 

● READ-30-PN: Pneumonia 30-Day Risk Standardized Readmission 

Measure (Medicare patients) 

AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs) and 

Composite Measures 

● PSI 06: Iatrogenic pneumothorax, adult 

● PSI 14: Postoperative wound dehiscence 

● PSI 15: Accidental puncture or laceration 

● IQI 11: Abdominal aortic aneurysm (AAA) mortality rate (with or 

without volume) 

● IQI 19: Hip fracture mortality rate 

● Mortality for selected surgical procedures (composite) 

● Complication/patient safety for selected indicators (composite) 

● Mortality for selected medical conditions (composite) 

AHRQ PSI and Nursing Sensitive Care** 

● Death among surgical inpatients with serious, treatable complications 

Cardiac Surgery 

● Participation in a Systematic Database for Cardiac Surgery 

Stroke Care 

● Participation in a Systematic Clinical Database Registry for Stroke Care* 

Nursing Sensitive Care 

● Participation in a Systematic Clinical Database Registry for Nursing Sensitive Care* 

(2) Maintenance of Technical Specifications for Quality Measures 

The technical specifications for the RHQDAPU program measures, or links to 

Web sites hosting technical specifications, are contained in the CMS/The Joint 

Commission Specifications Manual for National Hospital Inpatient Quality Measures 

(Specifications Manual). This Specifications Manual is posted on the CMS QualityNet 
CMS-1498-P 381 

Web site at https://www.QualityNet.org/. We maintain the technical specifications by 

updating this Specifications Manual semiannually, or more frequently in unusual cases, 

and include detailed instructions and calculation algorithms for hospitals to use when 

collecting and submitting data on required measures. These semiannual updates are 

accompanied by notifications to users, providing sufficient time between the change and 

the effective date in order to allow users to incorporate changes and updates to the 

specifications into data collection systems. 

(3) Public Display of Quality Measures 

Section 1886(b)(3)(B)(viii)(VII) of the Act requires that the Secretary establish 

procedures for making quality data available to the public after ensuring that a hospital 

has the opportunity to review its data before they are made public. To meet this 

requirement, data from the RHQDAPU program are typically displayed on CMS Web 

sites such as the Hospital Compare Web site, http://www.hospitalcompare.hhs.gov after a 

30-day preview period. An interactive Web tool, this Web site assists beneficiaries by 

providing information on hospital quality of care to those who need to select a hospital. 

It further serves to encourage beneficiaries to work with their doctors and hospitals to 

discuss the quality of care hospitals provide to patients, thereby providing an additional 

incentive to hospitals to improve the quality of care that they furnish. The RHQDAPU 

program currently includes process of care measures, risk adjusted outcome measures, 

the HCAHPS patient experience of care survey, and structural measures, all of which are 

featured on the Hospital Compare Web site. However, information that may not be 

salient to or understood by beneficiaries and information for which there are unresolved 
CMS-1498-P 382 

display issues or design considerations for inclusion on Hospital Compare may be made 

available on other CMS Web sites that are not intended to be used as an interactive Web 

tool, such as http://www.cms.hhs.gov/HospitalQualityInits/. Publicly reporting the 

information in this manner, though not on the Hospital Compare Web site, allows CMS 

to meet the requirement under section 1886(b)(3)(B)(viii)(VII) of the Act for establishing 

procedures to make quality data used for RHQDAPU payment determinations available 

to the public following a preview period. In such circumstances, affected parties are 

notified via CMS listservs, CMS e-mail blasts, national provider calls, and QualityNet 

announcements regarding the release of preview reports followed by the posting of data 

on a Web site other than Hospital Compare. 

2. Retirement of RHQDAPU Program Measures 

a. Considerations in Retiring Quality Measures from the RHQDAPU Program 

Unless stated otherwise, we generally retain measures from the current year’s 

RHQDAPU program measure set for subsequent years’ measure set. We have previously 

retired one measure, PN-1: Oxygenation Assessment for Pneumonia, from the 

RHQDAPU program on the basis of high unvarying performance among hospitals, as 

measures with very high performance among hospitals present little opportunity for 

improvement, and do not provide meaningful distinctions in performance for consumers. 

We also have retired one measure from the program because it no longer “represent[ed] 

the best clinical practice,” as stated under section 1886(b)(3)(B)(viii)(VI) of the Act. In 

this latter situation, we stated that when there is reason to believe that the continued 

collection of a measure as it is currently specified raises potential patient safety concerns 
CMS-1498-P 383 

that it is appropriate for CMS to take immediate action to remove a measure from the 

RHQDAPU program and not wait for the annual rulemaking cycle. Therefore, in the 

FY 2010 IPPS/RY 2010 LTCH PPS final rule, we stated that we would promptly retire 

such measures followed by subsequent confirmation of the retirement in the next IPPS 

rulemaking. When we do so, we will notify hospitals and the public through the usual 

hospital and QIO communication channels used for the RHQDAPU program, which 

include memo and email notification and QualityNet Web site articles and postings. 

In the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule, we invited public 

comment regarding additional RHQDAPU program measures that should be considered 

for retirement along with criteria that should be used for retiring measures. In the 

FY 2010 IPPS/RY 2010 LTCH PPS final rule, commenters recommended 11 RHQDAPU 

program measures for retirement for various reasons (74 FR 43865). Among the criteria 

suggested by commenters that CMS should consider when determining whether to retire 

RHQDAPU program measures were: (1) measure performance among hospitals is so 

high and unvarying that meaningful distinctions and improvements in performance can 

no longer be made; (2) performance or improvement on a measure does not result in 

better patient outcomes; (3) a measure does not align with current clinical guidelines or 

practice; (4) the availability of a more broadly applicable (across settings, populations, or 

conditions) quality measure for the topic; (5) the availability of a measure that is more 

proximal in time to desired patient outcomes for the particular topic; (6) the availability 

of a measure that is more strongly associated with desired patient outcomes for the 

particular topic; (7) collection and/or public reporting of a measure leads to negative 
CMS-1498-P 384 

unintended consequences other than patient harm. We agreed with commenters that 

these criteria should be among those considered in evaluating current RHQDAPU 

program measures for retirement. We again invite commenters to submit suggestions for 

additional measure retirement criteria for CMS to consider. 

b. Proposed Retirement of Quality Measures under the RHQDAPU Program for the 

FY 2011 Payment Determination and Subsequent Years 

In the FY 2009 IPPS final rule, for the FY 2010 payment determination we 

adopted nine measures that were developed by the Agency for Healthcare Research and 

Quality (AHRQ), and in the FY 2010 IPPS/RY 2010 LTCH PPS we subsequently 

retained these measures for the FY 2011 payment determination. One of these measures 

was the AHRQ Mortality for Selected Surgical Procedures Composite, which is 

comprised of measures from the AHRQ Inpatient Quality Indicator (IQI) measure set. In 

late June of 2009, following an NQF steering committee evaluation of the AHRQ 

Mortality for Selected Surgical Procedures composite, the AHRQ issued guidance6

 that 

this composite is “not recommended for comparative reporting” as specified due to 

significant evidence gaps, and that these significant evidence gaps are unlikely to be 

addressed with further development or validation work. This guidance is available at: 

http://www.qualityindicators.ahrq.gov/downloads/publications/AHRQ%20QI%20Guide

%20to%20Comparative%20Reporting%20v10.pdf. 

 

6

 AHRQ. Guidance on Using the AHRQ QI for Hospital-Level Comparative Reporting. 

June 2009. 

http://www.qualityindicators.ahrq.gov/downloads/publications/AHRQ%20QI%20Guide

%20to%20Comparative%20Reporting%20v10.pdf
CMS-1498-P 385 

For this reason, we are proposing to retire the Mortality for Selected Procedures 

Composite from the RHQDAPU program measure set from the RHQDAPU program 

measure set for the FY 2011 payment determination and for subsequent payment 

determinations because the measure is not considered suitable for purposes of 

comparative reporting by the measure developer. We will neither calculate this measure 

for the FY 2011 payment determination, nor display results for this measure on Hospital 

Compare. We invite comment on our proposal to retire this measure from the 

RHQDAPU program for the FY 2011 payment determination and for subsequent 

payment determinations. We also invite commenters to submit suggestions and 

rationales for retirement of other RHQDAPU program measures. 

Set out below are the RHQDAPU program quality measures for the FY 2011 

payment determination reflecting our proposed retirement of one measure: 

Topic RHQDAPU Program Quality Measures for the FY 2011 Payment 

Determination Reflecting Proposed Retirement of One Measure 

Acute Myocardial Infarction (AMI) 

● AMI-1 Aspirin at arrival 

● AMI-2 Aspirin prescribed at discharge 

● AMI-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or 

Angiotensin II Receptor Blocker (ARB) for left ventricular systolic 

dysfunction 

● AMI-4 Adult smoking cessation advice/counseling 

● AMI-5 Beta blocker prescribed at discharge 

● AMI-7a Fibrinolytic (thrombolytic) agent received within 30 minutes 

of hospital arrival 

● AMI-8a Timing of Receipt of Primary Percutaneous Coronary 

Intervention (PCI) 

Heart Failure (HF) 

● HF-1 Discharge instructions 

● HF-2 Left ventricular function assessment 

● HF-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or 

Angiotensin II Receptor Blocker (ARB) for left ventricular systolic 
CMS-1498-P 386 

Topic RHQDAPU Program Quality Measures for the FY 2011 Payment 

Determination Reflecting Proposed Retirement of One Measure 

dysfunction 

● HF-4 Adult smoking cessation advice/counseling 

Pneumonia (PN) 

● PN-2 Pneumococcal vaccination status 

● PN-3b Blood culture performed before first antibiotic received in 

hospital 

● PN-4 Adult smoking cessation advice/counseling 

● PN-5c Timing of receipt of initial antibiotic following hospital arrival 

● PN-6 Appropriate initial antibiotic selection 

● PN-7 Influenza vaccination status 

Surgical Care Improvement Project (SCIP) 

● SCIP-1 Prophylactic antibiotic received within 1 hour prior to surgical 

incision 

● SCIP-3 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 

● SCIP-Infection-4: Cardiac Surgery Patients with Controlled 6AM 

Postoperative Serum Glucose 

● SCIP-Infection-6: Surgery Patients with Appropriate Hair Removal 

● SCIP–Infection-9: Postoperative Urinary Catheter Removal on Post 

Operative Day 1 or 2* 

● SCIP-Infection-10: Perioperative Temperature Management* 

● SCIP-Cardiovascular-2: Surgery Patients on a Beta Blocker Prior to 

Arrival Who Received a Beta Blocker During the Perioperative Period 

Mortality Measures (Medicare Patients) 

● MORT-30-AMI: Acute Myocardial Infarction 30-day mortality –

Medicare patients 

● MORT-30-HF: Heart Failure 30-day mortality Medicare patients 

● MORT-30-PN: Pneumonia 30-day mortality -Medicare patients 

Patients' Experience of Care 

● HCAHPS survey 

Readmission Measure (Medicare Patients) 

● READ-30-HF: Heart Failure 30-Day Risk Standardized Readmission 

Measure (Medicare patients) 

● READ-30-AMI: Acute Myocardial Infarction 30-Day Risk 

Standardized Readmission Measure (Medicare patients) 

● READ-30-PN: Pneumonia 30-Day Risk Standardized Readmission 
CMS-1498-P 387 

Topic RHQDAPU Program Quality Measures for the FY 2011 Payment 

Determination Reflecting Proposed Retirement of One Measure 

Measure (Medicare patients) 

AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs) and 

Composite Measures 

● PSI 06: Iatrogenic pneumothorax, adult 

● PSI 14: Postoperative wound dehiscence 

● PSI 15: Accidental puncture or laceration 

● IQI 11: Abdominal aortic aneurysm (AAA) mortality rate (with or 

without volume) 

● IQI 19: Hip fracture mortality rate 

● Complication/patient safety for selected indicators (composite) 

● Mortality for selected medical conditions (composite) 

AHRQ PSI and Nursing Sensitive Care** 

● Death among surgical inpatients with serious, treatable complications 

Cardiac Surgery 

● Participation in a Systematic Database for Cardiac Surgery 

Stroke Care 

● Participation in a Systematic Clinical Database Registry for Stroke Care* 

Nursing Sensitive Care 

● Participation in a Systematic Clinical Database Registry for Nursing Sensitive Care* 

3. Proposed Expansion Plan for Quality Measures for the FY 2012, FY 2013, and 

FY 2014 Payment Determinations 

a. Considerations in Expanding and Updating Quality Measures under the RHQDAPU 

Program 

In the FY 2009 IPPS final rule (73 FR 48613) and the FY 2010 IPPS/RY 2010 

LTCH PPS final rule (74 FR 43866 through 43869), we acknowledged the data collection 

burden for hospitals participating in the RHQDAPU program, and reiterated our desire to 

expand the RHQDAPU program measure set while minimizing burden and seeking to 

provide alternative mechanisms for data submission for the RHQDAPU program. In the 

FY 2010 IPPS/RY 2010 LTCH PPS final rule, we also stated that in future expansions 

and updates to the RHQDAPU program measure set, we would be taking into 
CMS-1498-P 388 

consideration several important goals. These goals include: (a) expanding the types of 

measures beyond process of care measures to include an increased number of outcome 

measures, efficiency measures, and patients' experience-of-care measures; (b) expanding 

the scope of hospital services to which the measures apply; (c) considering the burden on 

hospitals in collecting chart-abstracted data; (d) harmonizing the measures used in the 

RHQDAPU program with other CMS quality programs to align incentives and promote 

coordinated efforts to improve quality; (e) seeking to use measures based on alternative 

sources of data that do not require chart abstraction or that utilize data already being 

reported by many hospitals, such as data that hospitals report to clinical data registries, or 

all-payer claims data bases; and (f) weighing the relevance and utility of the measures 

compared to the burden on hospitals in submitting data under the RHQDAPU program. 

Specifically, we give priority to quality measures that assess performance on: 

(a) conditions that result in the greatest mortality and morbidity in the Medicare 

population; (b) conditions that are high volume and high cost for the Medicare program; 

and (c) conditions for which wide cost and treatment variations have been reported, 

despite established clinical guidelines. We have used and continue to use these criteria to 

guide our decisions regarding what measures to add to the RHQDAPU program measure 

set. 

 RHQDAPU program measures were initially based solely on a hospital’s 

submission of chart-abstracted quality measure data. However, in recent years we have 

adopted measures that do not require chart abstraction, including structural and 

claims-based quality measures which we can calculate using other data sources. This 
CMS-1498-P 389 

supports our goal of expanding the measures for the RHQDAPU program while 

minimizing the burden on hospitals and, in particular, without significantly increasing the 

chart abstraction burden. 

 In addition to structural and claims-based measures, we previously noted that 

registries7 and electronic health records (EHRs) are potential alternative sources of 

hospital data for the RHQDAPU program. We observed that many hospitals already 

submit data to and participate in existing registries, and that registries often capture 

outcome information and provide ongoing quality improvement feedback to registry 

participants. We envisioned that instead of requiring hospitals to submit the same data to 

CMS that many hospitals are already submitting to registries, that we would collect the 

data directly from the registries. This could enable the expansion of the RHQDAPU 

program measure set without increasing the burden of data collection for those hospitals 

participating in the registries. We cited as examples of registries actively used by 

hospitals the Society of Thoracic Surgeons (STS) Cardiac Surgery Registry (with 

approximately 90 percent participation by cardiac surgery programs), the AHA Stroke 

Registry (with approximately 1200 hospitals participating), and the American Nursing 

Association (ANA) Nursing Sensitive Measures Registry (with approximately 1400 

hospitals participating). In the FY 2009 IPPS final rule (73 FR 48608 through 48609), 

we adopted the first RHQDAPU program measure related to registries: Participation in a 

Systematic Database for Cardiac Surgery. Subsequently, in the FY 2010 IPPS/RY 2010 

 

7

 A registry is a collection of clinical data for purposes of assessing clinical performance, 

quality of care, and opportunities for quality improvement. 
CMS-1498-P 390 

LTCH PPS final rule (74 FR 43870 through 43872), we adopted two additional structural 

measures of registry participation for the topics of Stroke and Nursing Sensitive Care. 

We continue to evaluate the feasibility of leveraging registry-based data collection 

mechanisms for the RHQDAPU program and we are proposing to collect such data for 

the FY 2013 payment determination. 

 We also stated our intention to explore mechanisms for data submission using 

EHRs (73 FR 48614; 74 FR 43866, 43892). Establishing such a system will require 

interoperability between EHRs and CMS data collection systems, additional 

infrastructure development on the part of hospitals and CMS, and the adoption of 

standards for the capturing, formatting, and transmission of data elements that make up 

the measures. However, once these activities are accomplished, the adoption of measures 

that rely on data obtained directly from EHRs will enable us to expand the RHQDAPU 

program measure set with less cost and burden to hospitals. 

In the FY 2009 IPPS final rule, we adopted nine AHRQ measures for the 

RHQDAPU program, one of which is now proposed for retirement for the FY 2011 

payment determination and subsequent payment determinations in this proposed rule. 

We stated that we would initially calculate the measures using Medicare claims data 

(73 FR 48608). However, we also stated that we remained interested in using all-payer 

claims data to calculate them and that we might propose to collect such data in the future. 

In the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule (74 FR 24169), we invited input 

and suggestions on how all-payer claims data can be collected and used by CMS to 
CMS-1498-P 391 

calculate these measures, as well as on additional AHRQ measures that we should 

consider adopting for future RHQDAPU program payment determinations. 

In summary, we will continue to pursue goals regarding the expansion and 

updating of quality measures under the RHQDAPU program while minimizing burden. 

We will take into account the public comments we receive on the possible uses of EHRs, 

registries, and all-payer claims data in the RHQDAPU program. We also will consider 

the measure selection criteria suggested by various commenters in prioritizing and 

selecting quality measures for the future.” In particular, we are concerned about the lack 

of progress in reducing the rates of healthcare associated infections that was recently 

reported in the 2009 National Healthcare Quality Report 

(http://www.ahrq.gov/qual/nhqr09/nhqr09.pdf). For example, the report found that rates 

of postoperative sepsis increased by 8 percent. It is evident that more attention needs to 

be paid to ensure health care does not result in avoidable harm and that patients are 

informed about hospitals’ performance. We are soliciting comment on the option to 

include among our prioritization criteria quality measures that assess performance on 

healthcare associated infections. Also, while the current and proposed measures cover 

many aspects of healthcare associated infections, we are soliciting public comment on 

additional measures that could be added to those hospitals would report and that CMS 

would make available to the public in order promote improvement in healthcare 

associated infection rates. 

In the past, we have proposed to add new RHQDAPU program measures for one 

year’s payment determination in a given rulemaking cycle. Although in prior years we 
CMS-1498-P 392 

have identified various measures for future consideration, we have not proposed or 

finalized measures for the RHQDAPU program beyond those to be collected for the 

purpose of the next sequential payment determination. In this FY 2011 rulemaking cycle, 

we are proposing an expansion to the RHQDAPU program that will take place over three 

payment years, and are proposing to add measures not only for the FY 2012 payment 

determination, but also for the FY 2013 and FY 2014 payment determinations. To the 

extent we finalize some or all of these proposed measures this year, we believe that we 

will be providing greater certainty for hospitals to plan to meet future reporting 

requirements and implement related quality improvement efforts. We will also have 

more time to prepare, organize and implement the necessary infrastructure necessary to 

collect data on the measures and make payment determinations. 

Finally, in section V.A.5.(2) of this proposed rule, we discuss a proposal to make 

RHQDAPU payment determinations beginning with FY 2013 using, in part, a 

consecutive calendar year of quality measure data. This proposed approach, of 

synchronizing the quarters for which data on these measures must be submitted during 

each year with the quarters we will use to make payment determinations, would apply 

beginning with January 1, 2011 discharges although it would not affect our payment 

determinations until FY 2013. We invite public comment on the measures and timeframe 

for their addition to the RHQDAPU program measure set. 
CMS-1498-P 393 

b. Proposed RHQDAPU Program Quality Measures for the FY 2012 Payment 

Determination 

(1) Proposed Retention of 45 Existing RHQDAPU Program Quality Measures for the 

FY 2012 Payment Determination 

 As noted above, we are proposing to retire the AHRQ Mortality for Selected 

Surgical Procedures Composite for the FY 2011 payment determination. We are 

proposing that the remaining 45 of the 46 quality measures for the FY 2011 RHQDAPU 

program payment determination will be used for the FY 2012 RHQDAPU program 

payment determination. Details regarding data submission requirements are discussed in 

section V.A.5. of this proposed rule. We invite comment on the proposal to include all 

FY 2011 measures except for the AHRQ Mortality for Selected Surgical Procedures 

Composite in the FY 2012 RHQDAPU measure set. 

 In proposing to retain 45 of the 46 FY 2011 measures, we recognize that we are 

not significantly reducing the burden for hospitals, since the one measure that we are 

proposing to remove is a measure that currently is calculated based on Medicare claims. 

At the same time, we are proposing to expand the measures for the FY 2012 and 

subsequent years’ payment determinations, which may add additional reporting burdens 

and new focus areas for hospital quality improvement efforts. In view of our concern 

about the burden of reporting for hospitals, especially when it comes to reporting chartabstracted measures, another option that we have considered to accommodate the 

expansion of the measure set is the retirement of additional measures. Specifically, we 

have considered retiring one or more of those measures suggested by various commenters 
CMS-1498-P 394 

that were listed in the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43865). We 

noted in that final rule that 11 RHQDAPU program chart-abstracted measures were 

recommended for retirement by commenters. Seven of these 11 measures were 

recommended for retirement based on their performance being uniformly high 

nationwide, with little variability among hospitals. Information on the performance rates 

for hospitals reporting is available at: 

http://www.cms.hhs.gov/HospitalQualityInits/downloads/HospitalNationalLevelPerforma

nce.pdf. These measures are: 

● AMI-1 Aspirin at arrival 

● AMI-3 ACEI/ARB for left ventricular systolic dysfunction 

● AMI-4 Adult smoking cessation advice/counseling 

● AMI-5 Beta-blocker prescribed at discharge 

● HF-4 Adult smoking cessation advice/counseling 

● PN-4 Adult smoking cessation advice/counseling 

● SCIP-Infection-6: Surgery patients with appropriate hair removal 

 In addition to these “topped out” measures, commenters recommended we retire 

four additional measures listed below for reasons unrelated to high unvarying 

performance. These measures are: 

● HF-1 Discharge instructions 

● PN- 3b Blood culture performed before first antibiotic received in hospital 

● SCIP-Infection-2: Prophylactic antibiotic selection for surgical patients 
CMS-1498-P 395 

● SCIP-Infection-4: Cardiac Surgery Patients with Controlled 6AM 

Postoperative Serum Glucose 

Reasons given by commenters included the following: (1) Care process measured 

has weak or no relationship to better outcomes; (2) Collection burden of measure negates 

or outweighs the benefit of reporting the measure; and (3) Measure perceived to be 

discordant with current guidelines. 

 We invite comments on the option to retire one or more of these 11 measures that 

were suggested for retirement by commenters to the FY 2010 IPPS proposed rule. We 

note that some of these measures were proposed for electronic reporting under the 

program for payment incentives for meaningful use of electronic health records 

(75 FR 1896). 

 In addition, we are considering an option under which if we propose and finalize 

measures that are specified to more broadly address a clinical topic, and thus would 

require hospitals to submit the same data that they are already submitting on more 

narrowly specified measures that we previously adopted for the RHQDAPU program, we 

would propose to retire the more narrowly specified measures from the RHQDAPU 

measure set. An example of this that we are considering would be to retire the current 

Influenza and Pneumoccocal vaccination measures that apply only to the Pneumonia 

admission inpatient population (PN-2 Pneumococcal vaccination status; and PN-7 

Influenza vaccination status) if we proposed and finalized measures of Influenza and 

Pneumoccocal vaccination that apply to all inpatients. We invite comments on this 
CMS-1498-P 396 

option to retire narrowly specified measures in order to accommodate more broadly 

specified measures on a given topic. 

(2) Proposed New Claims-Based Measures 

 We are proposing to add 10 claims-based measures to the RHQDAPU program 

measure set for the FY 2012 payment determination: 2 AHRQ Patient Safety Indicators 

and 8 Hospital Acquired Condition measures. These proposed measures would be 

calculated using up to three years’ of Medicare claims for discharges prior to 

January 1, 2011. These measures are discussed below. 

(A) Proposed AHRQ Patient Safety Indicators 

 In the FY 2009 IPPS final rule we adopted a number of AHRQ Patient Safety 

Indicators and Inpatient Quality Indicators for the RHQDAPU program to be calculated 

using Medicare claims. The addition of these measures to the RHQDAPU program 

allowed us to expand the RHQDAPU program measure set to include measures of patient 

safety, in-hospital mortality, adverse events and complications without increasing the 

data submission burden on hospitals. In the FY 2010 IPPS/RY 2010 LTCH PPS final 

rule, we retained these measures for the FY 2011 payment determination. In this 

proposed rule, we are proposing to retire one of those measures (Mortality for Selected 

Surgical Procedures Composite) from the RHQDAPU program measure set for the 

FY 2011 payment determination. For the FY 2012 payment determination, we are 

proposing to adopt 2 additional Patient Safety Indicators developed by the AHRQ. These 

are: PSI-11: Post-Operative Respiratory Failure and PSI-12: Post-Operative Pulmonary 

Embolism (PE) or Deep Vein Thrombosis (DVT). Both measures address post-operative 
CMS-1498-P 397 

complications, a topic that is currently not well represented in the RHQDAPU program 

measure set. Both measures are NQF-endorsed, and have a Tier 1 evidence rating by 

AHRQ, the measure developer. Indicators given this level of evidentiary rating by AHRQ 

have the strongest evidence base, with established evidence in several or most evidentiary 

areas established by AHRQ, no substantial evidence suggesting that the indicators may not be 

useful for comparative reporting purposes, and in most cases the indicators have been 

NQF-endorsed.8

 The specific measures that we are proposing to add are NQF-endorsed, 

thus reflecting consensus among affected parties, and are deemed appropriate for 

comparative public reporting by the measure developer. Like the current AHRQ 

measures in the RHQDAPU program, these indicators are risk-adjusted outcome 

measures that can be calculated based on existing Medicare claims, placing no additional 

reporting burden on hospitals while allowing us to expand outcomes measurement in the 

RHQDAPU program. The specifications for these measures can be found at 

http://www.qualityindicators.ahrq.gov/TechnicalSpecs41.htm#PSI41. We invite 

comment on our proposal to adopt these two AHRQ Patient Safety Indicators for the 

FY 2012 payment determination. 

(B) Proposed Hospital Acquired Condition (HAC) Measures 

Section 1886(d)(4)(D) of the Act required the Secretary to select, in consultation 

with the Centers for Disease Control and Prevention (CDC), at least two conditions that: 

(a) are high cost, high volume, or both; (b) are assigned to a higher paying MS–DRG 

when present as a secondary diagnosis (that is, conditions under the MS–DRG system 

 

8

http://www.qualityindicators.ahrq.gov/downloads/publications/AHRQ%20QI%20Guide%20to%20Compar

ative%20Reporting%20v10.pdf
CMS-1498-P 398 

that are CCs or MCCs); and (c) could reasonably have been prevented through the 

application of evidence based guidelines. We currently have 10 categories of Hospital 

Acquired Conditions (HACs). We refer readers to: section II.F. of the FY 2008 IPPS 

final rule with comment period (72 FR 47202 through 47218); section II.F. of the 

FY 2009 IPPS final rule with comment period (73 FR 48474 through 48486); and 

section II.F. of the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43782 through 

43785) for detailed discussions regarding the selection of the current 10 HAC categories. 

We refer readers to section II.F. of this proposed rule for additional discussion and our 

proposals for HAC policy for FY 2011. 

We have worked collaboratively with public health and infectious disease 

professionals from across HHS, including CDC, AHRQ, and the Office of Public Health 

and Science, to identify and select preventable HACs with input and comment from 

affected parties. CMS and CDC have also collaborated on the process for hospitals to 

submit a present on admission (POA) indicator for each diagnosis listed on IPPS hospital 

Medicare claims and on the payment implications for POA reporting (74 FR 43783).

CMS, CDC and AHRQ held jointly sponsored HAC and POA Listening Sessions 

(December 17, 2007 and December 18, 2008) to receive input from affected parties, 

individuals, and organizations regarding the selection and definition of HACs. The 

adoption of HACs were informed and continue to be informed by feedback received 

during the listening sessions, as well as through public comment received during the IPPS 

rulemaking process. In addition to receiving comments regarding the selection of 

conditions and POA indicator reporting, in the FY 2010 IPPS/LTCH PPS final rule 
CMS-1498-P 399 

(74 FR 43785), commenters suggested that CMS consider making aggregate POA 

information publicly available, and providing comparative information as a means of 

facilitating improvements in preventing the incidence of HACs. 

We are proposing to adopt as RHQDAPU measures for the FY 2012 payment 

determination eight (of 10) current HACs defined in section II.F. of this proposed rule, 

six of which have been identified by NQF as serious reportable events, and to publicly 

report these measures as we do other RHQDAPU program measures. These measures 

are: 

● Foreign Object Retained After Surgery 

● Air Embolism 

● Blood Incompatibility 

● Pressure Ulcer Stages III & IV 

● Falls and Trauma: (Includes: Fracture, Dislocation, Intracranial Injury, 

Crushing, Injury, Burn, Electric Shock) 

● Vascular Catheter-Associated Infection 

● Catheter-Associated Urinary Tract Infection (UTI) 

● Manifestations of Poor Glycemic Control 

We do not believe that it is necessary to propose to adopt the other two current 

HAC categories as RHQDAPU measures because the topics that they deal with would 

substantially overlap with other RHQDAPU program measures discussed below that we 

are proposing to adopt for future payment determinations as chart-abstracted measures 

(which allows us to collect data on all patients). By contrast, the eight proposed HAC 
CMS-1498-P 400 

measures are claims-based measures for which we can only (at this time) collect data 

only on Medicare beneficiaries. 

We are proposing to utilize Medicare claims data to calculate measure rates for 

these eight HACs using the ICD-9-CM codes in conjunction with POA coding of “N” or 

“U,” as defined in IPPS rulemaking. We refer readers to section II.F.6. of the FY 2008 

IPPS final rule with comment period (72 FR 47202 through 47218), section II.F.7. of the 

FY 2009 IPPS final rule (73 FR 48474 through 48486), section II.F.6. (74 FR 43782 

through 43785) of the FY 2010 IPPS/RY 2010 LTCH PPS final rule, and section II.F. of 

this proposed rule for detailed discussions regarding the use of the POA indicator in 

conjunction with ICD-9-CM coding to determine the presence of HACs. We also refer 

readers to the current ICD-9-CM codes and proposed updates for these eight HAC 

categories in this proposed rule. We are proposing to use the ICD-9-CM codes in 

conjunction with the “N” and “U” POA indicators for the HAC categories that will be 

finalized in the FY 2011 IPPS/RY 2011 LTCH PPS final rule to calculate the eight HAC 

measures for the RHQDAPU program. 

We believe that these HAC measures reflect consensus among affected parties as 

required for RHQDAPU program measures by section 1886(b)(3)(B)(viii)(V) of the Act. 

In addition to meeting the consensus requirement through rulemaking and public 

comment, Vascular Catheter-Associated Infection and Catheter-Associated UTI are the 

subject of a quality measure which gained NQF endorsement in August 2009. The 

remaining six HAC categories have been identified as serious reportable events through 

the NQF consensus process and have also been selected as HACs through rulemaking 
CMS-1498-P 401 

and public comment. Data reporting requirements for these measures are provided in 

section V.A.5. of this proposed rule. We invite comment on our proposal to adopt these 

eight HAC measures for the FY 2012 payment determination. 

(3) Proposed All-Patient Volume Data for Selected MS-DRGs 

CMS currently displays volume data for 70 MS-DRGs, 55 of which relate to 

RHQDAPU program measures on the Hospital Compare Web site. However, the volume 

data currently shown on Hospital Compare is based on Medicare claims only. Although 

we do not consider volume alone to be a quality measure unless volume has been 

determined to be an indicator of quality, we believe that to the extent all-patient volume 

data are related to the measures, as they provide context for the quality measures in the 

inpatient hospital setting, and may assist Hospital Compare users in understanding the 

measure calculations. In general, in implementing RHQDAPU program measures, we 

have sought where currently possible to measure the care rendered to all patients within a 

hospital, and not just Medicare patients. For this reason, the chart-abstracted process of 

care measures we collect and display on Hospital Compare are based on the entire 

inpatient population for the hospital. 

We are proposing that hospitals begin submitting as data on measures selected for 

the RHQDAPU program the all-patient data elements discussed in section V.A.5. of this 

proposed rule for 55 MS-DRGs displayed on Hospital Compare that relate to adopted 

RHQDAPU program measures. The specific MS-DRGs are listed below. As stated 

above, we believe that the addition of this data will enable us and Medicare beneficiaries 

to better understand and evaluate the quality of care provided by hospitals with respect to 
CMS-1498-P 402 

both the chart-abstracted and claims-based measures. We intend to publicly display this 

volume data along with the corresponding measure results on Hospital Compare. 

Hospitals would begin reporting these data once annually beginning with January 1, 2011 

discharges by submitting the all-patient data elements needed to calculate MS-DRG 

volume to QualityNet so we can determine the volume of cases treated by a hospital for 

the 55 MS-DRGs currently displayed on Hospital Compare. Rather than require 

hospitals to group their all-patient claims data by MS-DRG category themselves, CMS 

would use the data to be submitted by hospitals to group the data.We invite comments on 

this proposal. 

We also invite comment on an alternative that hospitals submit all-patient volume 

data based upon specific ICD-9-CM codes related to the proposed MS-DRGs rather than 

all data necessary to calculate the MS-DRGs. 

 The proposed RHQDAPU measure set for the FY 2012 payment determination is 

listed below: 

Topic Proposed RHQDAPU Program Quality Measures for the FY 2012 

Payment Determination

Acute Myocardial Infarction (AMI) 

● AMI-1 Aspirin at arrival 

● AMI-2 Aspirin prescribed at discharge 

● AMI-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or 

Angiotensin II Receptor Blocker (ARB) for left ventricular systolic 

dysfunction 

● AMI-4 Adult smoking cessation advice/counseling 

● AMI-5 Beta blocker prescribed at discharge 

● AMI-7a Fibrinolytic (thrombolytic) agent received within 30 minutes 

of hospital arrival 

● AMI-8a Timing of Receipt of Primary Percutaneous Coronary 

Intervention (PCI) 
CMS-1498-P 403 

Topic Proposed RHQDAPU Program Quality Measures for the FY 2012 

Payment Determination

Heart Failure (HF) 

● HF-1 Discharge instructions 

● HF-2 Left ventricular function assessment 

● HF-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or 

Angiotensin II Receptor Blocker (ARB) for left ventricular systolic 

dysfunction 

● HF-4 Adult smoking cessation advice/counseling 

Pneumonia (PN) 

● PN-2 Pneumococcal vaccination status 

● PN-3b Blood culture performed before first antibiotic received in 

hospital 

● PN-4 Adult smoking cessation advice/counseling 

● PN-5c Timing of receipt of initial antibiotic following hospital arrival 

● PN-6 Appropriate initial antibiotic selection 

● PN-7 Influenza vaccination status 

Surgical Care Improvement Project (SCIP) 

● SCIP-1 Prophylactic antibiotic received within 1 hour prior to surgical 

incision 

● SCIP-3 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 

● SCIP-Infection-4: Cardiac Surgery Patients with Controlled 6AM 

Postoperative Serum Glucose 

● SCIP-Infection-6: Surgery Patients with Appropriate Hair Removal 

● SCIP–Infection-9: Postoperative Urinary Catheter Removal on Post 

Operative Day 1 or 2 

● SCIP-Infection-10: Perioperative Temperature Management 

● SCIP-Cardiovascular-2: Surgery Patients on a Beta Blocker Prior to 

Arrival Who Received a Beta Blocker During the Perioperative Period 

Mortality Measures (Medicare Patients) 

● MORT-30-AMI: Acute Myocardial Infarction 30-day mortality –

Medicare patients 

● MORT-30-HF: Heart Failure 30-day mortality Medicare patients 

● MORT-30-PN: Pneumonia 30-day mortality -Medicare patients 

Patients' Experience of Care 

● HCAHPS survey 
CMS-1498-P 404 

Topic Proposed RHQDAPU Program Quality Measures for the FY 2012 

Payment Determination

Readmission Measure (Medicare Patients) 

● READ-30-HF: Heart Failure 30-Day Risk Standardized Readmission 

Measure (Medicare patients) 

● READ-30-AMI: Acute Myocardial Infarction 30-Day Risk 

Standardized Readmission Measure (Medicare patients) 

● READ-30-PN: Pneumonia 30-Day Risk Standardized Readmission 

Measure (Medicare patients) 

AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs) and 

Composite Measures 

● PSI 06: Iatrogenic pneumothorax, adult 

● PSI 11: Post Operative Respiratory Failure * 

● PSI 12: Post Operative PE or DVT * 

● PSI 14: Postoperative wound dehiscence 

● PSI 15: Accidental puncture or laceration 

● IQI 11: Abdominal aortic aneurysm (AAA) mortality rate (with or 

without volume) 

● IQI 19: Hip fracture mortality rate 

● Complication/patient safety for selected indicators (composite) 

● Mortality for selected medical conditions (composite) 

AHRQ PSI and Nursing Sensitive Care 

● Death among surgical inpatients with serious, treatable complications 

Cardiac Surgery 

● Participation in a Systematic Database for Cardiac Surgery 

Stroke Care 

● Participation in a Systematic Clinical Database Registry for Stroke 

Care 

Nursing Sensitive Care 

● Participation in a Systematic Clinical Database Registry for Nursing 

Sensitive Care 

Hospital Acquired Condition Measures * 

• Foreign Object Retained After Surgery *

• Air Embolism *

• Blood Incompatibility *

• Pressure Ulcer Stages III & IV *

• Falls and Trauma: (Includes: Fracture Dislocation Intracranial Injury 

Crushing Injury Burn Electric Shock)*

• Vascular Catheter-Associated Infection* 

• Catheter-Associated Urinary Tract Infection (UTI)*

• Manifestations of Poor Glycemic Control*

All-Patient Volume Data for Selected MS-DRGs * 

MS-DRGs: 038; 039; 190; 191; 193; 219; 220; 221; 224; 226; 235; 236; 237; 
CMS-1498-P 405 

Topic Proposed RHQDAPU Program Quality Measures for the FY 2012 

Payment Determination

243; 247; 280; 281; 282; 291; 292; 293; 328; 329; 330; 331; 353; 354; 417; 

418; 459; 461; 462; 466; 467; 468; 469; 470; 471; 472; 477; 478; 490; 507; 

515; 656; 657; 658; 659; 668; 673; 674; 675; 713; 743; 748 * 

* Proposed for FY 2012 payment determination 

 We invite comment on these proposed measures for the FY 2012 payment 

determination.

c. Proposed RHQDAPU Program Quality Measures for the FY 2013 Payment 

Determination 

(1) Proposed Retention of FY 2012 Payment Determination Measures for the FY 2013 

Payment Determination 

 We generally propose to retain RHQDAPU program measures from one year to 

the next. Consistent with this approach, we are proposing to retain all of the proposed 

measures for the FY 2012 RHQDAPU payment determination, if finalized, for the 

FY 2013 payment determination. We invite public comment on this proposal. 

(2) Proposed New Chart-Abstracted Measure for the FY 2013 Payment Determination 

 We are proposing to add one new chart-abstracted measure for the FY 2013 

payment determination - AMI-statin at discharge. This measure is similar to the 

NQF-endorsed stroke measure “Ischemic stroke patients with LDL >/= 100 mg/dL, or 

LDL not measured, or, who were on cholesterol reducing therapy prior to hospitalization 

are discharged on a statin medication” (NQF #0439), only specified for the AMI 

population. Current scientific evidence supports the continuation of statins more strongly 

for AMI patients than for stroke patients. Several randomized clinical trials have proven 

the benefits of statin drugs (also known as HMG Co-A reductase inhibitors) in reducing 
CMS-1498-P 406 

the risk of death and recurrent cardiovascular events in a broad range of patients with 

established cardiovascular disease, including those with prior myocardial infarction. 

Current ACC/AHA guidelines place a strong emphasis on the initiation or maintenance of 

statin drugs for patients hospitalized with AMI, particularly those with LDL-cholesterol 

levels at or above 100 mg/dL. As a result of the strength of the evidence and guideline 

support, the ACC/AHA has developed a performance measure to assess this aspect of 

care for AMI patients. 

 Because statins are generally well-tolerated, most AMI patients are appropriate 

candidates for this therapy. As a result of this clinical evidence, the NQF has been asked 

to review whether it should broaden the current endorsed measure specification to include 

the AMI population. This ad hoc review is occurring now and is expected to be 

completed prior to publication of the FY 2011 IPPS/LTCH PPS final rule. Information 

on this project can be found at: http://www.qualityforum.org/Projects/ab/Ad_Hoc_Reviews/Statin_Medication/Ad_Hoc_Review__Discharged_on_Statin.aspx. 

We will decide whether to finalize this measure based on whether it achieves NQF 

endorsement and public comments. We believe that minimal additional burden would 

result from adoption of this measure into the RHQDAPU program because the AMI 

population that is the focus of this measure is already part of data collection efforts for 

RHQDAPU, and very few additional data elements would be needed to be abstracted for 

the proposed new measure on this existing measurement population. We proposed that 

hospitals would begin submission of data for the AMI-statin at discharge measure 
CMS-1498-P 407 

beginning with January 1, 2011 dischares for the RHQDAPU 2013 payment 

determination. 

(3) Proposed New Healthcare Associated Infection (HAI) Measures for the FY 2013 

Payment Determination 

 In the FY 2009 and FY 2010 IPPS rulemakings, we listed several Healthcare 

Associated Infection (HAI) measures as being under consideration for future adoption. 

Commenters to the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule supported the HAI 

measures that were listed as being under consideration for the future and encouraged 

CMS to consider others as well (74 FR 43876). For the measure set to be used for the 

FY 2013 payment determination, we are proposing to adopt two new measures of 

Healthcare Acquired Infections that are currently being collected by the CDC via the 

National Healthcare Safety Network (NHSN). These measures are: (1) Central Line 

Associated Blood Stream Infection (NQF #0139) and (2) Surgical Site Infection 

(NQF #0299). 

The NHSN is a secure, Internet-based surveillance system maintained and 

managed by the CDC, and can be utilized by all types of healthcare facilities in the 

United States, including acute care hospitals, long term acute care hospitals, psychiatric 

hospitals, rehabilitation hospitals, outpatient dialysis centers, ambulatory surgery centers, 

and long term care facilities. The NHSN enables healthcare facilities to collect and use 

data about HAIs, adherence to clinical practices known to prevent HAIs, the incidence or 

prevalence of multidrug-resistant organisms within their organizations, and other adverse 

events. Some States use NHSN as a means for healthcare facilities to submit data on 
CMS-1498-P 408 

HAIs mandated through their specific State legislation. Currently, 21 States require 

hospitals to report HAIs using NHSN, and CDC supports more than 2000 hospitals that 

are using NHSN.9

 Both the Central Line Associated Blood Stream Infection measure and the 

Surgical Site Infection measure are NQF-endorsed, and therefore meet the statutory 

requirement for measure selection of reflecting consensus among affected parties. The 

measures address HAIs, a topic area widely acknowledged by the HHS, IOM, the 

National Priorities Partnership and others as a high priority requiring measurement and 

improvement. HAIs are among the leading causes of death in the United States. CDC 

estimates that as many as 2 million infections are acquired each year in hospitals and 

result in approximately 90,000 deaths per year. 10 It is estimated that more Americans die 

each year from HAIs than from auto accidents and homicides combined. HAIs not only 

put the patient at risk, but also increase the days of hospitalization required for patients 

and add considerable health care costs. 

HAIs are largely preventable through interventions such as better hygiene and 

advanced scientifically tested techniques for surgical patients. Therefore, many health 

care consumers and organizations are calling for public disclosure of HAIs, arguing that 

public reporting of HAI rates provides the information health care consumers need to 

choose the safest hospitals, and gives hospitals an incentive to improve infection control 

efforts. Both of the measures we are proposing to add for the FY 2013 payment 

 

9

 http://www.cdc.gov/nhsn/

10 McKibben L, Horan T Guidance on public reporting of healthcare-associated infections: 

recommendations of the Healthcare Infection Control Practices Advisory Committee. AJIC 

2005;33:217-26
CMS-1498-P 409 

determination are NQF-endorsed, and are currently collected using the NHSN as part of 

State-mandated reporting and surveillance requirements for hospitals. NHSN data 

collection occurs via a Web-based tool hosted by CDC provided free of charge to 

hospitals. Additionally, data submission for these measures through EHRs may be 

possible in the near future. 

(A) Central Line Associated Blood Stream Infection 

This HAI measure assesses the rate of laboratory-confirmed cases of bloodstream 

infection or clinical sepsis among ICU patients. It was endorsed by the NQF in 2004 and 

was adopted by the HQA in 2007. The measure can be stratified by the type of ICU. 

(B) Surgical Site Infection 

 This HAI measure assesses the number of NHSN-defined operative procedures 

with a surgical site infection (deep incisional or organ space) within 30 days, or 1 year if 

an implant is in place. Infections are identified on original admission or upon 

readmission to the facility of original operative procedure within the relevant time frame 

(30 days for no implants; within 1 year for implants). The measure can be stratified by 

procedure type or risk factors. This measure was NQF-endorsed in 2007 and was 

adopted by the HQA in 2008. 

 We invite comment on our proposal to adopt these two HAI measures into the 

RHQDAPU program for the FY 2013 payment determination. Collection of these 

measures would begin with January 1, 2011 discharges for the FY 2013 payment 

determination. We are proposing that hospitals use the NHSN infrastructure to report the 
CMS-1498-P 410 

measures for RHQDAPU program purposes. The proposed reporting mechanism for 

these HAI measures is discussed in greater detail in section V.A.5. of this proposed rule. 

(4) Proposed New Registry-Based Measures 

 For the FY 2013 payment determination, we are proposing that hospitals choose 

one of the following four proposed measure topics: (1) Implantable Cardioverter 

Defibrillator (ICD) Complications; (2) Cardiac Surgery; (3) Stroke; or (4) 

Nursing-Sensitive Care. With respect to the proposed measure topic selected by a 

hospital, we are proposing that the hospital report data on the proposed measure(s) 

applicable to the measure topic (discussed below) to a qualified registry for the specific 

topic, and direct the registry to both calculate the measure results for the hospital and 

release those results (along with the numerator/denominator information and exclusion 

information) to CMS for the RHQDAPU program. We are proposing that hospitals begin 

submitting data to the qualified registry of its choosing for discharges on or after 

January 1, 2011, and we intend to release a list of qualified registries before that date. In 

section V.A.13. of this proposed rule, we specify the self-nomination process we are 

proposing to use to qualify registries for each proposed registry-based measure topic. 

Proposed procedural and submission requirements for the proposed registry-based 

measures are discussed in section V.A.5. of this proposed rule. Below is a discussion of 

the proposed registry-based measure topics and specific registry-based measures that fall 

within each topic that we are proposing to add to the RHQDAPU program for the 

FY 2013 payment determination. 
CMS-1498-P 411 

(A) Proposed Implantable Cardioverter Defibrillator (ICD) Complications 

Registry-Based Topic and Measure 

Implantable Cardioverter Defibrillators (ICDs) reduce the risk of sudden cardiac 

death for select high risk patients, and the number of patients undergoing ICD 

implantation increased from 5,600 in 1990 to 108,680 by 2005.11 ICD implantation is an 

expensive procedure performed on patients with advanced cardiovascular disease and, 

often, significant comorbidities. Despite improvements in technology and increasing 

experience with device implantation, the procedure carries a significant risk of 

complications,12 which in turn increases its cost, the patient’s length of stay, and the 

patient’s risk of mortality.13 In the FY 2010 IPPS/RY 2010 LTCH PPS final rule 

(74 FR 43873 through 43875), our list of potential future quality measures under 

consideration included a measure of ICD complications. This measure is a risk-adjusted 

complication and mortality rate following implantation of ICDs in Medicare Fee for 

Service (FFS) patients at least 65 years of age, with complication specific outcome time 

frames. The measure (NQF #OT1-007-09) is currently undergoing NQF review under 

Phase 1 of a call for Patient Outcome Measures initiated in Fall of 2009. We are 

 

11 Brown, D.W., Croft, J.B., et al. (2008). “Trends in Hospitalizations for the 

Implantation of Cardioverter-Defibrillators in the United States, 1990-2005.” American 

Journal of Cardiology 101 (12): 1753-1755. 

12 Hammill S and Curtis J. Publicly Reporting Implantable Cardioverter Defibrillator 

Outcomes – Grading the Report Card. Circ Arrhythmia Electrophysiol. 2008;1:235-237). 

13 Al-Khatib SM, Greiner MA, Peterson ED, Hernandez AF, Schulman KA, Curtis LH. 

Patient and Implanting Physician Factors Associated With Mortality and Complications 

After Implantable Cardioverter-Defibrillator Implantation, 2002-2005. Circ Arrhythmia 

Electrophysiol. 2008;1:240-249. 
CMS-1498-P 412 

proposing to add the ICD complications topic and measure to the RHQDAPU measure 

set for collection beginning with January 1, 2011 discharges for the FY 2013 RHQDAPU 

payment determination pending NQF endorsement. We anticipate that a final 

endorsement decision will occur in the fall of 2010, after publication of the FY 2011 

IPPS/LTCH PPS final rule. Therefore, the decision whether to finalize this measure for 

the FY 2013 payment determination will be made in the CY 2011OPPS/ASC final rule 

with comment period. 

The proposed ICD complications measure was developed based upon data 

submitted to the American College of Cardiology-National Cardiovascular Data 

Registry’s (ACC-NCDR) ICD registry, and data from that registry has been linked with 

CMS administrative claims data used to identify procedural complications. For this 

proposed measure, the measured outcome for each ICD index admission is one or more 

complications or mortality within 30 or 90 days (depending on the complication) 

following ICD implantation. Complications are counted in the measure only if they 

occur during a hospital admission. Complications measured for 30 days include: 

(1) Pneumothorax or hemothorax plus a chest tube; (2) Hematoma plus a blood 

transfusion or evacuation; (3) Cardiac tamponade or pericardiocentesis; and (4) Death. 

Complications measured for 90 days include: (5) Mechanical complications requiring a 

system revision; (6) Device related infection; and (7) Additional ICD implantation. 

To comply with a January 2005 National Coverage Determination for ICDs for 

primary prevention, all hospitals in which ICD procedures are performed are currently 

submitting to the ACC-NCDR ICD registry patient information needed for us to 
CMS-1498-P 413 

determine whether the procedure was reasonable and necessary. This requirement is 

documented in section 20.4 of the following Medicare National Coverage Determination 

Manual: http://www.cms.hhs.gov/manuals/downloads/ncd103c1_Part1.pdf . For 

purposes of the 2005 National Coverage Determination, we require that hospitals submit 

data to the ACC-NCDR ICD registry for primary prevention patients only but do not 

require hospitals to submit data on patients undergoing ICD implantation for secondary 

prevention. However, the ICD complication measure as submitted to the NQF for 

endorsement is specified such that it includes all ICD patients, regardless of whether they 

receive an ICD for the primary or secondary prevention of sudden cardiac death. 

Therefore, hospitals that choose this registry-based measure topic for the 

RHQDAPU program would submit data on the ICD complications measure for both 

primary and secondary prevention patients to the qualified registry. For risk adjustment, 

data matching, and secondary prevention population identification purposes, we are 

proposing that hospitals also submit to the qualified ICD complications registry an 

additional 11 data elements not currently required under the NCD in order for the 

measure to be calculated for RHQDAPU program purposes. 

 In sum, we are proposing to add the ICD complications measure topic as one of 

four proposed measure topics that hospitals can choose from to submit required data 

elements to a qualified registry for the FY 2013 RHQDAPU payment determination. The 

only measure that we are proposing to include in this proposed topic at this time would be 

the ICD complications measure. Because the ICD complications measure is a 

risk-adjusted outcome measure, it is necessary that all data for the measure be collected 
CMS-1498-P 414 

by a single qualified registry in order for that registry to be able to accurately calculate 

the risk adjustment model and subsequent measure results. Therefore, we are proposing 

to qualify one registry for this topic. Proposed registry qualification criteria are discussed 

in section V.A.13. of this proposed rule. We note that the ACC-NCDR ICD registry has 

already been qualified to receive and transmit data to CMS for a Medicare National 

Coverage Determination, and is currently the only registry to which hospitals submit data 

for this NCD. However, this would not preclude another registry from self-nominating to 

become a qualified registry for this proposed topic for the RHQDAPU program. Because 

the ICD complication measure is a risk adjusted measure, it requires that all data be 

collected at a single repository for calculation of the measure. Therefore, we anticipate 

qualifying a single registry to collect all of the data for the proposed ICD complications 

registry-based topic. 

(B) Proposed Stroke Registry-Based Topic and Measures 

 We proposed to add five stroke measures to the RHQDAPU measure set in the 

FY 2009 IPPS proposed rule (73 FR 23648). We indicated that we would again consider 

these measures once NQF reviewed and endorsed the measures. Since that time, eight 

stroke measures received NQF endorsement in July of 2008, and in the FY 2010 

IPPS/RY 2010 LTCH PPS final rule we included these measures in the list of potential 

future measures. We also included these measures in the preview section of the 

Specifications Manual, and have worked with the Office of the National Coordinator for 

Health Information Technology (ONC) and its partners to create a set of electronic 

specifications for these measures to facilitate collection through EHRs. 
CMS-1498-P 415 

 We are also aware that a number of hospitals are already submitting these 

measures to registries, and in the FY 2010 IPPS/RY 2010 LTCH PPS final rule, we 

finalized a structural measure of participation in a systematic clinical database registry for 

stroke care. Stroke is a topic of great relevance to the Medicare population due to its 

impact on morbidity and mortality, and is an area of great potential improvement for 

hospitals. Commenters on the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule 

expressed support for these measures, indicating that they accurately measure 

evidence-based care of the stroke patient to minimize secondary strokes and other 

complications, are widely recognized, and have great potential for quality improvement 

(74 FR 43875). 

 Therefore, we are proposing to include the following eight measures in the Stroke 

registry-based topic: 

Proposed Measures for Stroke Registry-Based Topic

STK-1: Venous 

Thromboembolism (VTE) 

Prophylaxis for patients with 

ischemic or hemorrhagic 

stroke (NQF #0434) 

Patients with an ischemic stroke or a hemorrhagic stroke 

and who are non-ambulatory should start receiving DVT 

prophylaxis by end of hospital day two. 

STK-2: Ischemic stroke 

patients discharged on 

antithrombotic therapy. (NQF 

#0435) 

Patients with an ischemic stroke prescribed 

antithrombotic therapy at discharge. 

STK-3: Anticoagulation 

therapy for atrial 

fibrillation/flutter. (NQF 

#0436) 

Patients with an ischemic stroke with atrial fibrillation 

discharged on anticoagulation therapy. 

STK-4: Thrombolytic 

Therapy for Acute ischemic 

stroke patients. (NQF #0437) 

Acute ischemic stroke patients who arrive at the hospital 

within 120 minutes (2 hours) of time last known well 

and for whom IV t-PA was initiated at this hospital 

within 180 minutes (3 hours) of time last known well. 
CMS-1498-P 416 

STK-5: Antithrombotic 

therapy by the end of hospital 

day two. (NQF #0438) 

Patients with ischemic stroke who receive 

antithrombotic therapy by the end of hospital day two. 

STK-6: Discharged on statin 

medication. (NQF #0439) 

Ischemic stroke patients with LDL >/= 100 mg/dL, or 

LDL not measured, or, who were on cholesterol 

reducing therapy prior to hospitalization are discharged 

on a statin medication. 

STK-8: Stroke education. 

(NQF #0440) 

Patients with ischemic or hemorrhagic stroke or their 

caregivers who were given education or educational 

materials during the hospital stay addressing all of the 

following: personal risk factors for stroke, warning signs 

for stroke, activation of emergency. 

STK-10: Assessed for 

rehabilitation services. (NQF 

#0441) 

Patients with an ischemic stroke or hemorrhagic stroke 

who were assessed for rehabilitation services. 

 We are proposing to add the stroke registry-based topic, which would include 

these eight registry-based stroke measures, to the RHQDAPU program measure set as 

one of the four proposed measure topics that hospitals can choose from to submit data to 

a qualified registry for the FY 2013 payment determination beginning with 

January 1, 2011 discharges. We invite comment on the measures as well as the timing of 

their addition to the RHQDAPU measure set. 

(C) Proposed Nursing Sensitive Care Registry-Based Topic and Measures 

 In the FY 2010 IPPS/RY 2010 LTCH PPS final rule, we indicated that we were 

considering adopting a number of nursing-sensitive care measures for future RHQDAPU 

program payment determinations. Also in that rule, we adopted a structural measure of 

participation in a registry for nursing-sensitive care, under which hospitals submit data 

directly to the QIO Clinical Warehouse. 

 For the FY 2013 payment determination, we are proposing to add a nursing 

sensitive care registry-based topic to the RHQDAPU measure set, which would include 
CMS-1498-P 417 

the eight nursing-sensitive care measures listed below. All of the proposed nursing 

sensitive measures are NQF-endorsed. Hospitals selecting this topic would begin 

reporting data on the eight proposed nursing-sensitive care registry-based measures to a 

qualified nursing-sensitive care registry beginning with January 1, 2011 discharges. 

Hospitals would continue reporting the nursing-sensitive care structural measure 

previously adopted for the RHQDAPU program directly to the QIO Clinical Warehouse.

 We invite comment on the proposed addition of a nursing sensitive care registrybased topic, which would include 8 proposed nursing sensitive care measures, as well as 

the timing of this addition to the RHQDAPU program for the FY 2013 payment 

determination. 

Proposed Measures for Nursing Sensitive Care Registry-Based Topic

Patient Falls: All documented falls with or without injury, experienced by patients on an eligible 

unit in a calendar month. (NQF #0141)

Falls with Injury: All documented patient falls with an injury level of minor or greater. (NQF 

#0202)

Pressure Ulcer Prevalence (NQF #0201)

Restraint Prevalence (vest and limb) (NQF #0203)

Skill Mix: Percentage of hours worked by: RN, LPN/LVN, UAP, Contract/Agency (NQF #0204)

Hours per patient day worked by RN, LPN, and UAP (NQF #0205)

Practice Environment Scale-Nursing Work Index (NQF #0206)

Voluntary turnover for RN, APN, LPN, UAP (NQF #0207)

(D) Proposed Cardiac Surgery Registry-Based Topic and Measures 

We have previously proposed to add several measures on the topic of cardiac 

surgery to the RHQDAPU measure set (73 FR 48608), and have also listed a set of 

NQF-endorsed cardiac surgery measures in prior rules as being under consideration for 

future adoption (74 FR 43874). We also adopted a structural measure of cardiac surgery 

participation in the FY 2010 IPPS/RY 2010 LTCH PPS final rule. Cardiac surgery 
CMS-1498-P 418 

procedures carry a significant risk of morbidity and mortality. We believe that the 

nationwide public reporting of the 15 proposed cardiac surgery registry-based measures 

would provide highly meaningful information for Medicare beneficiaries because they 

address procedures widely performed on Medicare beneficiaries. Analysis of the 

structural measure data we have received from hospitals indicates that nearly 90 percent 

of hospitals performing these procedures already report these data to clinical registries. 

Therefore, if we adopt this proposed registry-based topic, a hospital would not face any 

additional data submission burden if it chooses this registry-based topic for purposes of 

the FY 2013 payment determination and the registry to which it already submits data is 

qualified for this proposed topic. 

For the FY 2013 payment determination, we are proposing to include 15 cardiac 

surgery registry-based measures in the cardiac surgery registry-based measure topic. 

These proposed registry-based measures are listed below, and hospitals would submit 

data on these measures to a qualified registry for the cardiac surgery registry-based topic. 

Hospitals would continue submitting data for the cardiac surgery structural measure 

previously adopted for the RHQDAPU program directly to the QIO Clinical Warehouse. 

Proposed Measures for Proposed Cardiac Surgery Registry-Based Topic

Post-operative Renal Failure (NQF# 0114) 

Surgical Re-exploration (NQF# 0115) 

Anti-Platelet Medication at Discharge (NQF# 0116) 

Beta Blockade at Discharge (NQF# 0117) 

Anti-Lipid Treatment Discharge (NQF# 0118) 

Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft CABG 

(NQF# 0119)* 

Risk-Adjusted Operative Mortality for Aortic Valve Replacement (AVR) (NQF# 

0120)* 
CMS-1498-P 419 

Proposed Measures for Proposed Cardiac Surgery Registry-Based Topic

Risk-Adjusted Operative Mortality for Mitral Valve Replacement/Repair (MVR) 

(NQF# 0121)* 

Risk-Adjusted Operative Mortality MVR+CABG Surgery (NQF# 0122)* 

Risk-Adjusted Operative Mortality for AVR+CABG (NQF# 0123)* 

Pre-Operative Beta Blockade (NQF# 0127) 

Duration of Prophylaxis for Cardiac Surgery Patients (NQF# 0128) 

Prolonged Intubation (ventilation) (NQF# 0129) 

Deep Sternal Wound Infection Rate (NQF# 0130) 

Stroke/Cerebrovascular Accident (NQF# 0131) 

* Requires risk adjustment 

 Because these measures were endorsed by the NQF in May of 2007, they meet the 

statutory requirement of reflecting consensus among affected parties. Hospitals selecting 

this topic would begin submitting data on the proposed measures to a qualified cardiac 

surgery registry beginning with January 1, 2011 discharges. We note that five of these 

measures (indicated with an asterisk in the table above) must be risk-adjusted in order to 

be calculated properly. Therefore, the data needed to calculate these measures must be 

collected by a single registry. While the remaining measures do not require risk 

adjustment, we believe it may be overly burdensome for hospitals to submit data for this 

topic to more than one registry. For this reason, we anticipate qualifying a single registry 

to collect all of the data for the proposed cardiac surgery registry-based topic. We invite 

comment on this proposal. 

 Set out below are the RHQDAPU program topics and quality measures we are 

proposing to adopt for the FY 2013 payment determination:

Topic Proposed RHQDAPU Program Quality Measures for the FY 2013 

Payment Determination

Acute Myocardial Infarction (AMI)

• AMI-1 Aspirin at arrival 
CMS-1498-P 420 

Topic Proposed RHQDAPU Program Quality Measures for the FY 2013 

Payment Determination

• AMI-2 Aspirin prescribed at discharge 

• AMI-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or Angiotensin II 

Receptor Blocker (ARB) for left ventricular systolic dysfunction 

• AMI-4 Adult smoking cessation advice/counseling 

• AMI-5 Beta blocker prescribed at discharge 

• AMI-7a Fibrinolytic (thrombolytic) agent received within 30 minutes of 

hospital arrival 

• AMI-8a Timing of Receipt of Primary Percutaneous Coronary Intervention 

(PCI) 

• AMI-Statin at Discharge ** 

Heart Failure (HF)

• HF-1 Discharge instructions 

• HF-2 Left ventricular function assessment 

• HF-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or Angiotensin II 

Receptor Blocker (ARB) for left ventricular systolic dysfunction 

• HF-4 Adult smoking cessation advice/counseling 

Pneumonia (PN)

• PN-2 Pneumococcal vaccination status 

• PN-3b Blood culture performed before first antibiotic received in hospital 

• PN-4 Adult smoking cessation advice/counseling 

• PN-5c Timing of receipt of initial antibiotic following hospital arrival 

• PN-6 Appropriate initial antibiotic selection 

• PN-7 Influenza vaccination status 

Surgical Care Improvement Project (SCIP) 

• SCIP-1 Prophylactic antibiotic received within 1 hour prior to surgical 

incision 

• SCIP-3 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 

• SCIP-Infection-4: Cardiac Surgery Patients with Controlled 6AM 

Postoperative Serum Glucose 

• SCIP-Infection-6: Surgery Patients with Appropriate Hair Removal 

• SCIP–Infection-9: Postoperative Urinary Catheter Removal on Post 

Operative Day 1 or 2 

• SCIP-Infection-10: Perioperative Temperature Management 

• SCIP-Cardiovascular-2: Surgery Patients on a Beta Blocker Prior to Arrival 

Who Received a Beta Blocker During the Perioperative Period 

Mortality Measures (Medicare Patients)

• MORT-30-AMI: Acute Myocardial Infarction 30-day mortality –Medicare 

patients 
CMS-1498-P 421 

Topic Proposed RHQDAPU Program Quality Measures for the FY 2013 

Payment Determination

• MORT-30-HF: Heart Failure 30-day mortality Medicare patients 

• MORT-30-PN: Pneumonia 30-day mortality -Medicare patients 

Patients' Experience of Care

• HCAHPS survey 

Readmission Measure (Medicare Patients)

• READ-30-HF: Heart Failure 30-Day Risk Standardized Readmission 

Measure (Medicare patients) 

• READ-30-AMI: Acute Myocardial Infarction 30-Day Risk Standardized 

Readmission Measure (Medicare patients) 

• READ-30-PN: Pneumonia 30-Day Risk Standardized Readmission Measure 

(Medicare patients) 

AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs) and Composite Measures

• PSI 06: Iatrogenic pneumothorax, adult 

• PSI -11: Post Operative Respiratory Failure * 

• PSI – 12: Post Operative PE or DVT * 

• PSI 14: Postoperative wound dehiscence 

• PSI 15: Accidental puncture or laceration 

• IQI 11: Abdominal aortic aneurysm (AAA) mortality rate (with or without 

volume) 

• IQI 19: Hip fracture mortality rate 

• Complication/patient safety for selected indicators (composite) 

• Mortality for selected medical conditions (composite) 

AHRQ PSI and Nursing Sensitive Care

• Death among surgical inpatients with serious, treatable complications 

Cardiac Surgery

• Participation in a Systematic Database for Cardiac Surgery 

Stroke Care 

• Participation in a Systematic Clinical Database Registry for Stroke Care 

Nursing Sensitive Care

• Participation in a Systematic Clinical Database Registry for Nursing 

Sensitive Care 

Healthcare Associated Infections **

• Central Line Associated Bloodstream Infection ** 

• Surgical Site Infection ** 

ICD Complications -- Registry Based **

• ICD Complications and Mortality ** 

Stroke -- Registry Based **

• STK-1: Venous Thromboembolism (VTE) Prophylaxis for patients with 

ischemic or hemorrhagic stroke ** 

• STK-2: Ischemic stroke patients discharged on antithrombotic therapy.** 

• STK-3: Anticoagulation therapy for atrial fibrillation/flutter.** 

• STK-4: Thrombolytic Therapy for Acute ischemic stroke patients.** 

• STK-5: Antithrombotic therapy by the end of hospital day two.** 
CMS-1498-P 422 

Topic Proposed RHQDAPU Program Quality Measures for the FY 2013 

Payment Determination

• STK-6: Discharged on statin medication.** 

• STK-8: Stroke education. ** 

• STK-10: Assessed for rehabilitation services.** 

Nursing Sensitive Care – Registry Based **

• Patient Falls: All documented falls with or without injury, experienced by 

patients on an eligible unit in a calendar month.** 

• Falls with Injury: All documented patient falls with an injury level of minor 

or greater.** 

• Pressure Ulcer Prevalence** 

• Restraint Prevalence (vest and limb)** 

• Skill Mix: Percentage of hours worked by: RN, LPN/LVN, UAP, 

Contract/Agency** 

• Hours per patient day worked by RN, LPN, and UAP** 

• Practice Environment Scale-Nursing Work Index** 

• Voluntary turnover for RN, APN, LPN, UAP** 

 

Cardiac Surgery – Registry Based **

• Post-operative Renal Failure** 

• Surgical Re-exploration** 

• Anti-Platelet Medication at Discharge** 

• Beta Blockade at Discharge** 

• Anti-Lipid Treatment Discharge** 

• Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft 

CABG** 

• Risk-Adjusted Operative Mortality for Aortic Valve Replacement (AVR)** 

• Risk-Adjusted Operative Mortality for Mitral Valve Replacement/Repair 

(MVR)** 

• Risk-Adjusted Operative Mortality MVR+CABG Surgery** 

• Risk-Adjusted Operative Mortality for AVR+CABG** 

• Pre-Operative Beta Blockade** 

• Duration of Prophylaxis for Cardiac Surgery Patients** 

• Prolonged Intubation (ventilation)** 

• Deep Sternal Wound Infection Rate** 

• Stroke/Cerebrovascular Accident** 

HAC Prevalence Measures *

• Foreign Object Retained After Surgery * 

• Air Embolism * 

• Blood Incompatibility * 

• Pressure Ulcer Stages III & IV * 

• Falls and Trauma: (Includes: Fracture Dislocation Intracranial Injury 

Crushing Injury Burn Electric Shock) * 

• Vascular Catheter-Associated Infections * 
CMS-1498-P 423 

Topic Proposed RHQDAPU Program Quality Measures for the FY 2013 

Payment Determination

• Catheter-Associated Urinary Tract Infection (UTI) * 

• Manifestations of Poor Glycemic Control * 

All-Patient Volume Data for Selected MS-DRGs *

• MS-DRGs: 038; 039; 190; 191; 193; 219; 220; 221; 224; 226; 235; 236; 

237; 243; 247; 280; 281; 282; 291; 292; 293; 328; 329; 330; 331; 353; 354; 

417; 418; 459;461; 462; 466; 467; 468; 469; 470; 471; 472;477; 

478;490;507;515;656; 657; 658; 659; 668; 673; 674; 675; 713;; 743; 748 * 

* Proposed for FY 2012 payment determination. 

** Proposed for FY 2013 payment determination. 

d. Proposed RHQDAPU Program Quality Measures for the FY 2014 Payment 

Determination 

(1) Proposed Retention of FY 2013 Payment Determination Measures for the FY 2014 

Payment Determination 

 We are proposing to retain all of the measures adopted for the FY 2013 payment 

determination for the FY 2014 payment determination. Collection of data for these 

measures would begin with January 1, 2012 discharges. We invite comment on this 

proposal. 

(2) Proposed New Chart-Abstracted Measures for the FY 2014 Payment Determination 

 We also are proposing to add the following 4 new chart-abstracted measures to 

the RHQDAPU program measure set for the FY 2014 payment determination: (1) ED 

[Emergency Department]Throughput – Admit Decision Time to ED Departure Time for 

Admitted Patients (NQF #0497); (2) ED Throughput - Median time from emergency 

department arrival to ED departure for admitted patients (NQF #0495); (3) Global Flu 

Immunization; and (4) Global Pneumonia Immunization. In proposing to adopt these 

chart-abstracted measures, we recognize that we are proposing to increase the chart-
CMS-1498-P 424 

abstraction burden on hospitals with respect to the RHQDAPU program. However, the 

burden associated with the proposed immunization measures for all inpatients could be 

counterbalanced by future retirement of the two current immunization measures that 

apply only to pneumonia inpatients. This measure retirement option is discussed earlier 

in section V.A.2. of this proposed rule. Furthermore, we note that the ED-Throughput 

measures have been specified for EHR-based collection, which may also serve to reduce 

burden associated with these measures in the future. 

(A) Emergency Department (ED)-Throughput Measures 

 The two ED-Throughput measures we are proposing for the FY 2014 payment 

determination are: (1) Median time from admit decision time to time of departure from 

the emergency department for emergency department patients admitted to inpatient 

status; and(2) Median time from emergency department arrival to time of departure from 

the emergency room for patients admitted to the facility from the emergency department. 

 The ED–Throughput measures reflect not only the processes of care that occur 

while the patient is in the emergency department, but also reflect the coordination of care, 

communication, and efficiency of service provision beyond the walls of the emergency 

department. These measures have been NQF-endorsed (NQF #0497 and #0495) and 

adopted by HQA. Specifications for these measures are available in the preview section 

of the current Specifications Manual available on QualityNet. 

 These measures also address ED overcrowding, which the IOM identified as a 

major quality issue. Reducing the time patients remain in the ED can improve access to 

treatment and increase the quality of care, and capability of the hospital to provide 
CMS-1498-P 425 

adequate treatment to patients. ED overcrowding may result in delays in the 

administration of medication such as antibiotics for pneumonia and has been associated 

with perceptions of compromised emergency care. For patients with 

non-ST-segment-elevation myocardial infarction, long ED stays were associated with 

decreased use of guideline-recommended therapies and a higher risk of recurrent 

myocardial infarction. Overcrowding and heavy emergency resource demand have led to 

a number of problems, including ambulance refusals, prolonged patient waiting times, 

increased suffering for those who wait, rushed and unpleasant treatment environments, 

and potentially poor patient outcomes. Finally, when EDs are overwhelmed, their ability 

to respond to community emergencies and disasters may be compromised. 

(B) Global Immunization Measures 

 For the FY 2014 payment determination, we are proposing to adopt two global 

immunization measures: (1) Pneumoccocal Immunization; and (2) Influenza 

Immunization. Increasing influenza (flu) and pneumonia vaccination could reduce 

unnecessary hospitalizations and secondary complications particularly among high risk 

populations such as the elderly. About 36,000 adults die annually and over 200,000 are 

hospitalized for flu-related causes. Older adults are more vulnerable, and adults over 

65 comprise about 90 percent of flu-related deaths. Vaccinations can significantly reduce 

the number of flu related illnesses and deaths. The measures we are proposing were 

endorsed by the NQF as part of a consensus development project titled “National 

Voluntary Consensus Standards for Influenza and Pneumococcal Immunizations” which 

concluded in 2008. This project resulted in the endorsement of immunization measures 
CMS-1498-P 426 

that reflect current consensus among affected parties that standard measure specifications 

for influenza and pneumonia immunization should be broadly applicable across 

conditions, populations, and care settings. The technical specifications for these global 

measures will be available for preview in the Specifications Manual published in 

April 2010. The difference between these proposed immunization measures, and the two 

immunization measures that are currently part of the RHQDAPU program is that the 

current measures only apply to inpatients admitted for pneumonia, whereas the proposed 

measures apply to all inpatients regardless of admission diagnosis. 

 We are proposing to adopt these four chart-abstracted measures into the 

RHQDAPU program measure set for the FY 2014 payment determination. Data 

submission for these measures would begin with January 1, 2012 discharges. We invite 

comment on these proposed measures as well as the proposed timing of their addition to 

the RHQDAPU program for the FY 2014 payment determination. The complete list of 

proposed quality measures for the FY 2014 payment determination is set out below. 

Topic Proposed RHQDAPU Program Quality Measures for the FY 2014 

Payment Determination

Acute Myocardial Infarction (AMI)

• AMI-1 Aspirin at arrival 

• AMI-2 Aspirin prescribed at discharge 

• AMI-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or 

Angiotensin II Receptor Blocker (ARB) for left ventricular systolic 

dysfunction 

• AMI-4 Adult smoking cessation advice/counseling 

• AMI-5 Beta blocker prescribed at discharge 

• AMI-7a Fibrinolytic (thrombolytic) agent received within 30 minutes 

of hospital arrival 

• AMI-8a Timing of Receipt of Primary Percutaneous Coronary 

Intervention (PCI) 

• AMI Statin at Discharge ** 
CMS-1498-P 427 

Topic Proposed RHQDAPU Program Quality Measures for the FY 2014 

Payment Determination

Heart Failure (HF)

• HF-1 Discharge instructions 

• HF-2 Left ventricular function assessment 

• HF-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or 

Angiotensin II Receptor Blocker (ARB) for left ventricular systolic 

dysfunction 

• HF-4 Adult smoking cessation advice/counseling 

Pneumonia (PN)

• PN-2 Pneumococcal vaccination status 

• PN-3b Blood culture performed before first antibiotic received in 

hospital 

• PN-4 Adult smoking cessation advice/counseling 

• PN-5c Timing of receipt of initial antibiotic following hospital arrival 

• PN-6 Appropriate initial antibiotic selection 

• PN-7 Influenza vaccination status 

Surgical Care Improvement Project (SCIP) 

• SCIP-1 Prophylactic antibiotic received within 1 hour prior to 

surgical incision 

• SCIP-3 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 

• SCIP-Infection-4: Cardiac Surgery Patients with Controlled 6AM 

Postoperative Serum Glucose 

• SCIP-Infection-6: Surgery Patients with Appropriate Hair Removal 

• SCIP–Infection-9: Postoperative Urinary Catheter Removal on Post 

Operative Day 1 or 2 

• SCIP-Infection-10: Perioperative Temperature Management 

• SCIP-Cardiovascular-2: Surgery Patients on a Beta Blocker Prior to 

Arrival Who Received a Beta Blocker During the Perioperative 

Period 

Mortality Measures (Medicare Patients)

• MORT-30-AMI: Acute Myocardial Infarction 30-day mortality –

Medicare patients 

• MORT-30-HF: Heart Failure 30-day mortality Medicare patients 

• MORT-30-PN: Pneumonia 30-day mortality -Medicare patients 

Patients' Experience of Care

• HCAHPS survey 

Readmission Measure (Medicare Patients)

• READ-30-HF: Heart Failure 30-Day Risk Standardized Readmission 
CMS-1498-P 428 

Topic Proposed RHQDAPU Program Quality Measures for the FY 2014 

Payment Determination

Measure (Medicare patients) 

• READ-30-AMI: Acute Myocardial Infarction 30-Day Risk 

Standardized Readmission Measure (Medicare patients) 

• READ-30-PN: Pneumonia 30-Day Risk Standardized Readmission 

Measure (Medicare patients) 

AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs) and Composite 

Measures

• PSI -06: Iatrogenic pneumothorax, adult 

• PSI -11: Post Operative Respiratory Failure * 

• PSI –12: Post Operative PE or DVT * 

• PSI 14: Postoperative wound dehiscence 

• PSI 15: Accidental puncture or laceration 

• IQI 11: Abdominal aortic aneurysm (AAA) mortality rate (with or 

without volume) 

• IQI 19: Hip fracture mortality rate 

• Complication/patient safety for selected indicators (composite) 

• Mortality for selected medical conditions (composite) 

AHRQ PSI and Nursing Sensitive Care

• Death among surgical inpatients with serious, treatable complications 

Cardiac Surgery

• Participation in a Systematic Database for Cardiac Surgery 

Stroke Care 

• Participation in a Systematic Clinical Database Registry for Stroke 

Care 

Nursing Sensitive Care

• Participation in a Systematic Clinical Database Registry for Nursing 

Sensitive Care 

Healthcare Associated Infections **

• Central Line Associated Bloodstream Infection ** 

• Surgical Site Infection ** 

ICD Complications -- Registry–Based **

• ICD Complications and Mortality ** 

Stroke -- Registry-Based **

• STK-1: Venous Thromboembolism (VTE) Prophylaxis for patients 

with ischemic or hemorrhagic stroke. ** 

• STK-2: Ischemic stroke patients discharged on antithrombotic 

therapy. ** 

• STK-3: Anticoagulation therapy for atrial fibrillation/flutter. ** 

• STK-4: Thrombolytic Therapy for Acute ischemic stroke patients. ** 

• STK-5: Antithrombotic therapy by the end of hospital day two. ** 

• STK-6: Discharged on statin medication. ** 

• STK-8: Stroke education. ** 

• STK-10: Assessed for rehabilitation services. ** 
CMS-1498-P 429 

Topic Proposed RHQDAPU Program Quality Measures for the FY 2014 

Payment Determination

Nursing Sensitive Care – Registry-Based **

• Patient Falls: All documented falls with or without injury, 

experienced by patients on an eligible unit in a calendar month ** 

• Falls with Injury: All documented patient falls with an injury level of 

minor or greater ** 

• Pressure Ulcer Prevalence ** 

• Restraint Prevalence (vest and limb) ** 

• Skill Mix: Percentage of hours worked by: RN, LPN/LVN, UAP, 

Contract/Agency ** 

• Hours per patient day worked by RN, LPN, and UAP ** 

• Practice Environment Scale-Nursing Work Index ** 

• Voluntary turnover for RN, APN, LPN, UAP ** 

Cardiac Surgery – Registry–Based **

• Post-operative Renal Failure ** 

• Surgical Re-exploration ** 

• Anti-Platelet Medication at Discharge ** 

• Beta Blockade at Discharge ** 

• Anti-Lipid Treatment Discharge ** 

• Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft 

CABG ** 

• Risk-Adjusted Operative Mortality for Aortic Valve Replacement 

(AVR) ** 

• Risk-Adjusted Operative Mortality for Mitral Valve 

Replacement/Repair (MVR) ** 

• Risk-Adjusted Operative Mortality MVR+CABG Surgery ** 

• Risk-Adjusted Operative Mortality for AVR+CABG ** 

• Pre-Operative Beta Blockade ** 

• Duration of Prophylaxis for Cardiac Surgery Patients ** 

• Prolonged Intubation (ventilation) ** 

• Deep Sternal Wound Infection Rate ** 

• Stroke/Cerebrovascular Accident ** 

HAC Prevalence Measures *

• Foreign Object Retained After Surgery * 

• Air Embolism * 

• Blood Incompatibility * 

• Pressure Ulcer Stages III & IV * 

• Falls and Trauma: (Includes: Fracture Dislocation Intracranial Injury 

Crushing Injury Burn Electric Shock) * 

• Vascular Catheter-Associated Infection * 

• Catheter-Associated Urinary Tract Infection (UTI) * 

• Manifestations of Poor Glycemic Control * 

All-Patient Volume Data for Selected MS-DRGs *
CMS-1498-P 430 

Topic Proposed RHQDAPU Program Quality Measures for the FY 2014 

Payment Determination

• MS-DRGs: 038; 039; 190; 191; 193; 219; 220; 221; 224; 226; 235; 

236; 237; 243; 247; 280; 281; 282; 291; 292; 293; 328; 329; 330; 

331; 353; 354; 417; 418; 459;461; 462; 466; 467; 468; 469; 470; 471; 

472;477; 478;490;507;515;656; 657; 658; 659; 668; 673; 674; 675; 

713; 743; 748 * 

Emergency Department Throughput ***

• Median time from admit decision time to time of departure from the 

emergency department for emergency department patients admitted 

to inpatient status. ***

• Median time from emergency department arrival to time of departure 

from the emergency room for patients admitted to the facility from 

the emergency department. ***

Global Immunization Measures *** 

• Immunization for Influenza ***

• Immunization for Pneumonia ***

*Proposed for FY 2012 payment determination. 

**Proposed for FY 2013 payment determination. 

*** Proposed for FY 2014 payment determination. 

4. Possible New Quality Measures for Future Years 

 We are inviting public comment on the following quality measures and topics set 

out below that we are considering for the future. We also are seeking suggestions and 

rationales to support the adoption of measures and topics that are not included in this list 

for the RHQDAPU program. 

Possible RHQDAPU Program Future Measures and Topics 

Measurement Topic Measure Title/ Description/Concept

Surgical Safety Surgical checklist use for surgical procedures 

Complications Lower Extremity Bypass Complications 

PCI Readmission 

30-day risk-standardized readmission rate following 

Percutaneous Coronary Intervention (PCI) among patients aged 

18 years or older. 

PCI Mortality 

30-day risk-standardized mortality rate following PCI for 

STEMI/shock patients. 
CMS-1498-P 431 

Possible RHQDAPU Program Future Measures and Topics 

Measurement Topic Measure Title/ Description/Concept

PCI Mortality 30-day risk-standardized mortality rate following PCI for nonSTEMI/non-shock patients. 

VTE VTE-1: Venous Thromboembolism Prophylaxis 

VTE VTE-2: Intensive Care Unit Venous Thromboembolism 

Prophylaxis 

VTE VTE-3: Venous Thromboembolism Patients with Anticoagulation 

Overlap Therapy 

VTE 

VTE-4: Venous Thromboembolism Patients Receiving 

Unfractionated Heparin with Dosages/Platelet Count Monitoring 

by Protocol 

VTE VTE-5: Venous Thromboembolism Discharge Instructions 

VTE VTE-6: Incidence of Potentially-Preventable Venous 

Thromboembolism. 

SCIP Short Half-Life prophylactic administered preoperatively redosed 

within 4 hours after preoperative dose 

Care Transitions for 

AMI 30-Day Post-Hospital AMI Discharge ED Visit Measure 

Care Transitions for 

AMI 

30-Day Post-Hospital AMI Discharge Evaluation and 

Management Service Measure 

Care Transitions for 

AMI 

30-Day Post-Hospital AMI Discharge Care Transition Composite 

Measure 

Care Transitions for 

Heart Failure 30-Day Post-Hospital HF Discharge ED Visit Rate 

Care Transitions for 

Heart Failure 

30-Day Post-Hospital HF Discharge Evaluation and Management 

Service Measure 

Care Transitions for 

Heart Failure 

30-Day Post-Hospital HF Discharge Care Transition Composite 

Measure 

Care Transitions for 

Pneumonia 30-Day Post-Hospital Pneumonia Discharge ED Visit Rate 

Care Transitions for 

Pneumonia 

30-Day Post-Hospital Pneumonia Discharge Evaluation and 

Management Service Measure 

Care Transitions for 

Pneumonia 

30-Day Post-Hospital Pneumonia Discharge Care Transition 

Composite Measure 

Healthcare 

Associated Infections Ventilator Associated Pneumonia 

Healthcare 

Associated Infections Multidrug-resistant organism (MDRO) infection 

Healthcare 

Associated Infections Clostridium Difficile Associated Diseases (CDAD) 

Health Care 

Personnel 

Immunization 

Influenza Vaccination for Healthcare Personnel 
CMS-1498-P 432 

Possible RHQDAPU Program Future Measures and Topics 

Measurement Topic Measure Title/ Description/Concept

Cardiac 

Rehabilitation 

Referral 

Cardiac Rehabilitation Referral for AMI, HF, Cardiac Surgery 

End of Life Care Appropriate Pain Management 

Serious Reportable 

Events NQF approved Serious Reportable Events 

5. Form, Manner, and Timing of Quality Data Submission 

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 be reduced by 2.0 percentage points for any 

subsection (d) hospital that does not submit quality data in a form and manner, and at a 

time, specified by the Secretary. The data submission requirements, Specifications 

Manual, and submission deadlines are posted on the QualityNet Web site at: 

http://www.QualityNet.org/. CMS requires that hospitals submit data in accordance with 

the specifications for the appropriate discharge periods. 

Hospitals submit quality data through the secure portion of the QualityNet Web 

site (formerly known as QualityNet Exchange) (https://www.QualityNet.org). This Web 

site meets or exceeds all current Health Insurance Portability and Accountability Act 

(HIPAA) requirements for security of protected health information. 

a. Proposed RHQDAPU Program Requirements for FY 2012, FY 2013, and FY 2014 

(1) Procedural Requirements for the FY 2012, FY 2013, and FY 2014 Payment 

Determinations 

For the FY 2012, FY 2013, and FY 2014 payment determination, we are 

proposing that the following procedures would apply to hospitals participating in the 

RHQDAPU program. These procedures are, for the most part, the same as the 
CMS-1498-P 433 

procedures that apply to the FY 2011 payment determination. We identify below where 

we are proposing to modify a procedure. 

● Register with QualityNet, before participating hospitals initially begin 

reporting data, regardless of the method used for submitting data. 

● Identify a QualityNet Administrator who follows the registration process 

located on the QualityNet Web site (http://www.QualityNet.org). 

● Complete a Notice of Participation. New subsection (d) hospitals and existing 

hospitals that wish to participate in the RHQDAPU program for the first time must 

complete a revised “Reporting Hospital Quality Data for Annual Payment Update Notice 

of Participation'' form (Notice of Participation form) that includes the name and address 

of each hospital campus that shares the same CMS Certification Number (CCN). We 

will revise the Notice of Participation form as needed and will provide appropriate 

notification of any revisions to hospitals and QIOs through the routine RHQDAPU 

communication channels which include memo and email notification and QualityNet 

Web site articles and postings. 

We are proposing that, consistent with our policy for the FY 2011 payment 

determination, any hospital that receives a new CCN on or after October 15, 2009 

(including new subsection (d) hospitals and hospitals that have merged) that wishes to 

participate in the RHQDAPU program and has not otherwise submitted a Notice of 

Participation form using the new CCN must submit a completed Notice of Participation 

form no later than 180 days from the date identified as the open date (that is, the 

Medicare acceptance date) on the approved CMS Online System Certification and 
CMS-1498-P 434 

Reporting (OSCAR) system to participate in the RHQDAPU program for FY 2012 and 

future years. We believe that this deadline will give these hospitals a sufficient amount 

of time to get their operations up and running while simultaneously providing CMS with 

clarity regarding whether they intend to participate in the RHQDAPU program for 

FY 2012. 

(2) Synchronization of RHQDAPU Program Data Submission and Validation Quarters 

with Quarters Used to Make Payment Determinations 

Currently we determine, in part, whether a hospital has met the RHQDAPU 

program requirements for a given fiscal year by looking at whether the hospital properly 

submitted data with respect to a number of quarterly discharge periods. However, the 

quarters that we look at for HCAHPS data, chart-abstracted RHQDAPU program 

measures, and structural measures may not be the same for a single payment 

determination. For example, for the FY 2011 payment determination, we looked at 

discharge data submitted by hospitals from 4th quarter 2008 through 3rd quarter 2009 for 

AMI, HF, and PN chart-abstracted RHQDAPU program measures, 1st quarter 2010 for 

the newly added SCIP Infection 9 and 10 measures, April 2008 through March 2009 data 

for HCAHPS, and January 1, 2010 through June 30, 2010 data for structural measures. 

This lack of synchronization has developed because we have generally made 

payment decisions using the four earliest occurring discharge quarters for each measure 

topic that we did not include in a previous year’s payment determination, and we have 

not synchronized when hospitals must begin reporting data on new measures. 
CMS-1498-P 435 

Starting with the FY 2013 payment determination, we are proposing to determine 

whether the hospital meets the data submission requirement for quality measure data by 

looking at whether the hospital properly submitted data on the applicable measures 

during the same quarterly discharge periods. Specifically, the quarterly discharge periods 

that will apply to a particular payment determination will be the four quarters that occur 

within a calendar year. In other words, beginning with the FY 2013 payment 

determination, we will look at whether the hospital properly submitted data for quality 

measure data for the four calendar year quarters of CY 2011. 

With respect to our requirement that hospital data be successfully validated in 

order for the hospital to earn the full payment update for a given fiscal year, we are also 

proposing, beginning with the FY 2013 payment determination, to validate four discharge 

quarters, but the quarters will be the 4th calendar quarter of the calendar year that occurs 

two years before the payment determination and the first 3 calendar quarters of the 

following calendar year. Thus, for the FY 2013 payment determination, we will validate 

data from the 4th calendar quarter of 2010 through the 3rd calendar quarter of 2011. We 

believe this is appropriate given the time required for the validation abstraction and 

appeal process. 

This proposed synchronization will give us a more complete picture of the quality 

of care provided by a hospital during a given time period, thus enabling us to link that 

quality of care to the applicable RHQDAPU payment determination. In addition, this 

proposal will provide clarity to hospitals regarding what data we will look at to make 

payment determinations for a given fiscal year. We believe that this synchronization will 
CMS-1498-P 436 

also assist us to more effectively implement the RHQDAPU program because we will be 

able to achieve operational consistency regarding what data applies to what payment 

determination. Further, we believe that this proposal may assist the agency in 

implementing Hospital Value-Based Purchasing as authorized by the Patient Protection 

and Affordable Care Act, Pub. L. 111-148, because it will improve the link between 

quality, as measured during a single period of time, and the payment amounts provided to 

hospitals. For example, under our proposal, the HCAHPS patient experience of care 

measure and chart-abstracted measures for a single set of discharge quarters will be used 

together for a single payment determination. Finally, we believe that this proposal will 

improve hospitals’ ability to implement quality improvement strategies that affect 

RHQDAPU program measures and their quality of care. 

We will post a table outlining the discharge quarters that will be used to make 

each fiscal year payment determination no later than September 15th annually on the 

QualityNet Web site (http://www.QualityNet.org). We welcome comments on this 

proposal. 

(3) Proposed HCAHPS Requirements for the FY 2012, FY 2013 and FY 2014 Payment 

Determinations 

 We are proposing that, for the FY 2012, FY 2013 and FY 2014 payment 

determinations, except as noted below, the RHQDAPU program HCAHPS requirements 

we adopted for FY 2011 would continue to apply. Under these requirements, a hospital 

must continuously collect and submit HCAHPS data in accordance with the current 

HCAHPS Quality Assurance Guidelines and the quarterly data submission deadlines, 
CMS-1498-P 437 

both of which are posted at http://www.hcahpsonline.org. In order for a hospital to 

participate in the collection of HCAHPS data, a hospital must either: (1) contract with an 

approved HCAHPS survey vendor that will conduct the survey and submit data on the 

hospital’s behalf to the QIO Clinical Warehouse; or (2) self-administer the survey 

without using a survey vendor provided that the hospital attends HCAHPS training and 

meets Minimum Survey Requirements as specified on the Web site at: 

http://www.hcahpsonline.org. A current list of approved HCAHPS survey vendors can 

be found on the HCAHPS Web site at: http://www.hcahpsonline.org. 

 We are proposing that the FY 2012 payment determination for the RHQDAPU 

program for HCAHPS will be based on discharges from April 1, 2010 through 

December 31, 2010. 

 We are proposing that the FY 2013 payment determination for the RHQDAPU 

program for HCAHPS will be based on discharges from January 1, 2011 through 

December 31, 2011. 

 We are proposing that the FY 2014 payment determination for the RHQDAPU 

program for HCAHPS will be based on discharges from January 1, 2012 through 

December 31, 2012. 

Every hospital choosing to contract with a survey vendor should provide the 

sample frame of HCAHPS-eligible discharges to its survey vendor with sufficient time to 

allow the survey vendor to begin contacting each sampled patient within 6 weeks of 

discharge from the hospital. (We refer readers to the Quality Assurance Guidelines

located at http://www.hcahpsonline.org for details about HCAHPS eligibility and sample 
CMS-1498-P 438 

frame creation.) In addition, the hospital must authorize the survey vendor to submit data 

via My QualityNet, the secure part of the QualityNet Web site, on the hospital’s behalf. 

After the survey vendor submits the data to the QIO Clinical Warehouse, we 

strongly recommend that hospitals employing a survey vendor promptly review the two 

HCAHPS Feedback Reports (the Provider Survey Status Summary Report and the Data 

Submission Detail Report) that are available. These reports enable a hospital to ensure 

that its survey vendor has submitted the data on time and the data has been accepted into 

the QIO Clinical Warehouse. 

Any hospital that has five or fewer HCAHPS-eligible discharges in any month is 

no longer required to submit HCAHPS surveys for that month, although the hospital may 

voluntarily choose to submit these data. However, the hospital still must submit its total 

number of HCAHPS-eligible cases for that month to the QIO Clinical Warehouse as part 

of its quarterly HCAHPS data submission. 

In order to ensure compliance with HCAHPS survey and administration 

protocols, hospitals and survey vendors must participate in all oversight activities. As 

part of the oversight process, during the onsite visits or conference calls, the HCAHPS 

Project Team will review the hospital’s or survey vendor’s survey systems and assess 

protocols based upon the most recent HCAHPS Quality Assurance Guidelines. All 

materials relevant to survey administration will be subject to review. The systems and 

program review includes, but is not limited to: (a) survey management and data systems; 

(b) printing and mailing materials and facilities; (c) telephone and IVR materials and 

facilities; (d) data receipt, entry and storage facilities; and (e) written documentation of 
CMS-1498-P 439 

survey processes. Organizations will be given a defined time period in which to correct 

any problems and provide follow-up documentation of corrections for review. As 

needed, hospitals and survey vendors will be subject to follow-up site visits or conference 

calls. If CMS determines that a hospital is not compliant with HCAHPS program 

requirements, CMS may determine that the hospital is not submitting HCAHPS data that 

meet the requirements of the RHQDAPU program. 

We continue to strongly recommend that each new hospital participate in an 

HCAHPS dry run, if feasible, prior to beginning to collect HCAHPS data on an ongoing 

basis to meet RHQDAPU program requirements. New hospitals can conduct a dry run in 

the last month of a calendar quarter. The dry run will give newly participating hospitals 

the opportunity to gain first-hand experience collecting and transmitting HCAHPS data 

without the public reporting of results. Using the official survey instrument and the 

approved modes of administration and data collection protocols, hospitals/survey vendors 

will collect HCAHPS dry-run data and submit the data to My QualityNet, the secure 

portion of QualityNet. 

 We are again encouraging hospitals to regularly check the HCAHPS Web site at 

http://www.hcahpsonline.org for program updates and information. 
CMS-1498-P 440 

b. Additional Proposed RHQDAPU Program Procedural Requirements for the FY 2012, 

FY 2013 and FY 2014 Payment Determinations 

(1) Chart-Abstracted Measures For Which Data Is Submitted Directly to CMS (via 

QualityNet) 

Hospitals must begin submitting RHQDAPU program data starting with the first 

day of the quarter following the date when the hospital registers to participate in the 

program. For purposes of meeting this requirement, we interpret the registration date to 

be the date that the hospital submits a completed Notice of Participation form. As 

proposed previously in this section, hospitals must also register with QualityNet and 

identify a QualityNet Administrator who follows the QualityNet registration process 

before submitting RHQDAPU program data. 

 Hospitals must continuously collect and report data to CMS (via QualityNet) for 

each of the quality measures under the topic areas that require chart abstraction (and are 

not registry-based topic areas). For the FY 2012 and FY 2013 payment determinations, 

the proposed topic areas are AMI, HF, PN, and SCIP. For the FY 2014 payment 

determination, the proposed topic areas are AMI, HF, PN, SCIP, Emergency Department 

Throughput (EDT), and Global Immunization (GIM). 

 For FY 2012, we are proposing that hospitals must submit data for five calendar 

year discharge quarters as follows: 4Q CY 2009, 1Q CY 2010 (AMI, HF and PN only), 

2Q CY 2010, 3Q CY 2010 and 4Q CY 2010. For the FY 2013 payment determination, 

we are proposing that hospitals must submit data for four consecutive calendar year 

discharge quarters as follows: 1Q CY 2011, 2Q CY 2011, 3Q CY 2011 and 4Q CY 2011. 
CMS-1498-P 441 

For the FY 2014 payment determination, hospitals must submit data for four consecutive 

calendar year discharge quarters as follows: 1Q CY 2012, 2Q CY 2012, 3Q CY 2012 and 

4Q CY 2012. Hospitals must report these data by each quarterly deadline. 

 Hospitals must submit the data to the QIO Clinical Warehouse using the CMS 

Abstraction & Reporting Tool (CART), The Joint Commission ORYX® Core Measures 

Performance Measurement System, or another third-party vendor tool that meets the 

measurement specification requirements for data transmission to QualityNet. All 

submissions will be executed through My QualityNet, the secure part of the QualityNet 

Web site. Because the information in the QIO Clinical Warehouse is considered QIO 

information, it is subject to the stringent QIO confidentiality regulations in 

42 CFR Part 480. The QIO Clinical Warehouse will submit the data to CMS on behalf of 

the hospitals. 

 Hospitals must submit complete data for each quality measure that requires chart 

abstraction in accordance with the joint CMS/The Joint Commission sampling 

requirements located on the QualityNet Web site. These requirements specify that 

hospitals must submit a random sample or complete population of cases for each of the 

topics covered by the quality measures. Hospitals must meet the sampling requirements 

for these quality measures for discharges in each quarter. 

 For the FY 2012 payment determination, we are proposing that hospitals must 

submit population and sampling data for three consecutive calendar year discharge 

quarters as follows: 2Q CY 2010, 3Q CY 2010 and 4Q CY 2010. 
CMS-1498-P 442 

 For the FY 2013 payment determination, we are proposing that hospitals must 

submit population and sampling data for four consecutive calendar year discharge 

quarters as follows: 1Q CY 2011, 2Q CY 2011, 3Q CY 2011 and 4Q CY 2011 

 For the FY 2014 payment determination, we are proposing that hospitals must 

submit population and sampling data for four consecutive calendar year discharge 

quarters as follows: 1Q CY 2012, 2Q CY 2012, 3Q CY 2012 and 4Q CY 2012. 

 Hospitals must submit to CMS on a quarterly basis aggregate population and 

sample size counts for Medicare and non-Medicare discharges for the topic areas for 

which chart-abstracted data must be submitted (currently AMI, HF, PN, and SCIP). For 

clarification, we are proposing that hospitals are required to submit a numeric 

representation of their aggregate population and sample size count for each topic area 

even if the hospital has not treated patients in a specific topic area. For example, if a 

hospital has not treated AMI patients, the hospital is still required to submit a zero for its 

quarterly aggregate population and sample count for that topic in order to meet the 

requirement. 

In order to reduce the burden on hospitals that treat a low number of patients in a 

RHQDAPU program topic area, a hospital that has five or fewer discharges (Medicare 

and non-Medicare combined) in a topic area during a quarter in which data must be 

submitted is not required to submit patient-level data for that topic area for the quarter. 

The hospital must still submit its aggregate population and sample size counts for 

Medicare and non-Medicare discharges for the topic areas each quarter. We also note 
CMS-1498-P 443 

that hospitals meeting the five or fewer patient discharge exception may voluntarily 

submit these data. 

 The quarterly data submission deadline for hospitals to submit patient level data 

for the proposed measures that require chart abstraction is 41⁄2 months following the last 

discharge date in the calendar quarter. CMS will post the quarterly submission deadline 

schedule on the QualityNet Web site (http://www.QualityNet.org). Chart-abstracted 

measures have not been added for the FY 2012 payment determination. The collection of 

new chart-abstracted measures proposed for the FY 2013 payment determination would 

begin with the 1st calendar quarter 2011 discharges, for which the submission deadline 

would be August 15, 2011. The collection of new chart-abstracted measures proposed 

for the FY 2014 payment determination would begin with the 1st calendar quarter 2012 

discharges, for which the submission deadline would be August 15, 2012. Hospitals must 

comply with the discharge quarter submission deadlines in any fiscal year for each 

quarter for which data submission is required (Quarter 1- August 15th; Quarter 2- 

November 15th; Quarter 3- February 15th; Quarter 4- May 15th). 

The data submission deadline for hospitals to submit aggregate population and 

sample size count data for the measures requiring chart abstraction is four months 

following the last discharge date in the calendar quarter. This requirement allows CMS 

to advise hospitals regarding their submission status in enough time for them to make 

appropriate revisions before the data submission deadline. We will post the aggregate 

population and sample size count data submission deadlines on the QualityNet Web site 

(http://www.QualityNet.org). 
CMS-1498-P 444 

CMS strongly recommends that hospitals review the QIO Clinical Warehouse 

Feedback Reports and the RHQDAPU Program Provider Participation Reports that are 

available after patient level data are submitted to the QIO Clinical Warehouse. CMS 

generally updates these reports on a daily basis to provide accurate information to 

hospitals about their submissions. These reports enable hospitals to ensure that their data 

were submitted on time and accepted into the QIO Clinical Warehouse. 

(2) Data Submission Requirements for HCAHPS 

 Hospitals must continuously collect and submit HCAHPS data in accordance with 

the current HCAHPS Quality Assurance Guidelines, which can be found on the 

HCAHPS Web site, http://www.hcahpsonline.org. The QIO Clinical Warehouse is able 

to accept submissions indicating zero HCAHPS-eligible discharges in a month. A 

hospital with zero HCAHPS-eligible discharges in a month must submit a zero as its total 

number of HCAHPS-eligible cases to the QIO Clinical Warehouse for that month as part 

of its quarterly HCAHPS data submission. 

 In order to reduce the burden on hospitals that treat a low number of patients that 

would be otherwise covered by the HCAHPS submission requirements, a hospital that 

has five or fewer HCAHPS-eligible discharges during a month is not required to submit 

HCAHPS surveys for that month. However, hospitals that meet this exception may 

voluntarily submit this data. A hospital with five or fewer HCAHPS-eligible discharges 

must submit its number of HCAHPS-eligible cases to the QIO Clinical Warehouse for the 

month(s) in which it had five or fewer HCAHPS-eligible discharges as part of its 

quarterly HCAHPS data submission. 
CMS-1498-P 445 

 (3) Procedures for Claims-Based Measures 

Hospitals are encouraged to regularly check the QualityNet Web site, 

http://www.QualityNet.org, for program updates and information. 

● The following RHQDAPU program claims-based measures would be 

calculated using Medicare claims: 

Topic FY 2012 Payment Determination: Proposed Claims-Based Quality 

Measures (No Additional Hospital Data Submission Required)

Mortality Measures (Medicare Patients)

● MORT-30-AMI Acute Myocardial Infarction 30-day mortality –Medicare 

patients

● MORT-30-HF Heart Failure 30-day mortality Medicare patients

● MORT-30-PN Pneumonia 30-day mortality -Medicare patients

Readmission Measures (Medicare Patients)

● READ-30-HF Heart Failure (HF) 30-Day Risk Standardized Readmission 

Measure (Medicare patients)

● READ-30-AMI Acute Myocardial Infarction (AMI) 30-Day Risk 

Standardized Readmission Measure (Medicare patients)

● READ-30-PN Pneumonia (PN) 30-Day Risk Standardized Readmission 

Measure (Medicare patients)

AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs) and Composite 

Measures

● PSI 06: Iatrogenic pneumothorax, adult

● PSI -11: Post Operative Respiratory Failure *

● PSI – 12: Post Operative PE or DVT *

● PSI 14: Postoperative wound dehiscence

● PSI 15: Accidental puncture or laceration

● IQI 11: Abdominal aortic aneurysm (AAA) mortality rate (with or without 

volume)

● IQI 19: Hip fracture mortality rate

 

● Complication/patient safety for selected indicators (composite) 

● Mortality for selected medical conditions (composite)

AHRQ Patient Safety Indicator (PSI) and Nursing Sensitive Care

● Death among surgical inpatients with serious, treatable complications

Hospital Acquired Condition Measures

• Foreign Object Retained After Surgery * 

• Air Embolism * 

• Blood Incompatibility * 
CMS-1498-P 446 

Topic FY 2012 Payment Determination: Proposed Claims-Based Quality 

Measures (No Additional Hospital Data Submission Required)

• Pressure Ulcer Stages III & IV * 

• Falls and Trauma: (Includes: Fracture Dislocation Intracranial Injury 

Crushing Injury Burn Electric Shock)* 

• Vascular Catheter-Associated Infection* 

• Catheter-Associated Urinary Tract Infection (UTI) * 

• Manifestations of Poor Glycemic Control* 

*New proposed measure

 For the claims-based RHQDAPU program measures listed above, hospitals are 

not required to submit the data to the QIO Clinical Warehouse. CMS uses the existing 

Medicare fee-for-service claims to calculate the measures. For the FY 2012 payment 

determination, CMS would use up to 3 years of discharges prior to January 1, 2011 (as 

appropriate for the measure), to calculate the 30-day mortality and 30-day readmission 

measures AHRQ PSI, IQI and Composite measures (including the AHRQ PSI and 

Nursing Sensitive Care measure, Death among surgical inpatients with serious, treatable 

complications), and the proposed new HAC Measures. For the FY 2013 and FY 2014 

payment determinations, CMS would use up to 3 years of discharges (as appropriate for 

the measure) prior to January 1, 2012, and January 1, 2013 respectively. Hospitals are 

required to appropriately report the POA indicator in conjunction with ICD-9-CM coding 

to determine the presence of HACs so that the proposed HAC measures can be calculated 

for the RHQDAPU program using Medicare claims. 

(4) Data Submission Requirements for Structural Measures 

● We are proposing that for the FY 2012 payment determination, hospitals 

submit the required registry participation information once for the structural measures via 
CMS-1498-P 447 

a Web-based collection tool between July 1, 2011 – August 15, 2011 with respect to the 

time period of July 1, 2010 through December 31, 2010. 

Below is the list of structural measures we are proposing to adopt for the FY 2012 

payment determination: 

Topic FY 2012 Payment Determination: Proposed Structural Measures

Cardiac Surgery

• Participation in a Systematic Database for Cardiac Surgery

Stroke Care

• Participation in a Systematic Clinical Database Registry for Stroke Care

Nursing Sensitive Care

• Participation in a Systematic Clinical Database Registry for Nursing 

Sensitive Care

(5) Data Submission of All-Patient Volume Data for Selected MS-DRGs Related to 

RHQDAPU Program Measures 

 For submission of the all-patient volume data for selected MS-DRGs, we are 

proposing that hospitals submit patient level information needed for CMS to apply the 

MS-DRG GROUPER software to calculate the all-patient MS-DRG volumes, the data 

elements for which would be defined in the Specifications Manual. Hospitals would 

begin submitting this data quarterly via QualityNet beginning with January 1, 2011 

discharges. 

We invite comment on an alternative that hospitals submit hospital-level 

all-patient volume data based upon specific ICD-9-CM codes that are related to the 

selected MS-DRGs (rather than the patient-level data) necessary for CMS to calculate the 

MS-DRGs. Hospitals would begin submitting this data quarterly via QualityNet 

beginning with January 1, 2011 discharges. 
CMS-1498-P 448 

(6) Proposed Data Submission and Reporting Requirements for HAI Measures 

Reported via NHSN 

We are proposing that hospitals participating in RHQDAPU submit the data 

elements needed to calculate the Central Line Associated Blood Stream Infection and 

Surgical Site Infection measures to the NHSN using the standard procedures that have 

been set forth by CDC for NHSN participation in general and for submission of these two 

measures to NHSN in particular. This would include NHSN participation forms and 

indications to CDC allowing CMS to access data for these two measures for RHQDAPU 

program purposes, adherence to training requirements, use of standard CDC measure 

specifications, data element definitions, data collection requirements and instructions, and 

data reporting timeframes. Detailed requirements for NHSN participation, measure 

specifications, and data collection can be found at http://www.cdc.gov/nhsn/. Hospitals 

must use the current specifications and data collection tools available on the CDC Web 

site to submit data for the Central Line Associated Bloodstream Infection and Surgical 

Site Infection measures. We are proposing that hospitals would submit data for these two 

measures to CDC’s NHSN on a monthly basis for discharges occurring on or after 

January 1, 2011. 

For the FY 2013 payment determination, we are proposing that hospitals must 

submit HAI data via the NHSN for four consecutive calendar year discharge quarters as 

follows: 1Q CY 2011, 2Q CY 2011, 3Q CY 2011 and 4Q CY 2011. 
CMS-1498-P 449 

For the FY 2014 payment determination, hospitals must submit HAI data for four 

consecutive calendar year discharge quarters as follows: 1Q CY 2012, 2Q CY 2012, 3Q 

CY 2012 and 4Q CY 2012. 

We are proposing that once quarterly each hospital would utilize an automated 

report function that will be made available to submitters in the NHSN, to generate a 

quarterly report containing hospital-level numerator, denominator, and exclusion counts 

for these two CDC measures specifically for the RHQDAPU program. The CDC will 

create this automated RHQDAPU report function and add it to NHSN’s reporting 

functionalities in the next few months. While hospitals may be reporting other data 

elements to CDC for other reporting programs (that is: State mandated surveillance 

programs), the quarterly RHQDAPU report that would be generated within NHSN would 

only contain those data elements needed to calculate the two measures currently being 

proposed for the RHQDAPU program. CMS will access the reports in the NHSN and 

will compile the reports for RHQDAPU program and public reporting purposes. 

We invite comment on the proposed mechanism for submitting data for the 

Central Line Associated Blood Stream Infection measure and the Surgical Site Infection 

measure for the RHQDAPU program beginning with the FY 2012 payment 

determination. 

(7) Data Submission Requirements for Registry-Based Measures 

We are proposing that hospitals participating in RHQDAPU would be required 

to choose at least one of four registry based measure topics (ICD Complications, Stroke, 

Nursing Sensitive Care, or Cardiac Surgery), and would submit the data needed to 
CMS-1498-P 450 

calculate the measures included in the chosen registry-based topic to a qualified registry 

in order to meet the requirements to receive the full FY 2013 annual payment update. 

 We are proposing that hospitals then would arrange to have the qualified 

registry calculate the measures and submit to the QIO Clinical Warehouse the results, as 

well as the numerator, denominator, and exclusions. Any arrangement reached between 

the hospital and the qualified registry must comply with HIPAA. The qualified registry 

would also submit registry-derived hospital-level measure calculations to the QIO 

Clinical Warehouse using a CMS-specified record layout and file format that we will 

make available. 

 Our program and its data system must maintain compliance with HIPAA 

requirements for requesting, processing, storing, and transmitting data. For the FY 2013 

RHQDAPU payment determination, hospitals would need to submit data for the proposed 

registry-based measures to the qualified registry in the form and manner and by the 

deadline(s) specified by the registry. 

 CMS will begin qualifying registries for the four proposed registry-based topics 

so that hospitals may begin submitting data for discharges beginning January 1, 2011. 

Proposed registry qualification criteria are discussed in a section V.A.13. of this proposed 

rule. We are proposing to post on the RHQDAPU program section of the QualityNet 

Web site http://www.qualitynet.org a list of qualified registries for the FY 2013 

RHQDAPU payment determination, including the registry name, contact information, 

and the measure(s) that the registry has been qualified to collect and report for the 

RHQDAPU program. 
CMS-1498-P 451 

 We anticipate posting the list of qualified FY 2011 registries as soon as we have 

completed vetting the registries interested in participating in the FY 2013 RHQDAPU 

program payment determination and identified the qualified registries for the FY 2013 

RHQDAPU program payment determination, which we anticipate will be completed by 

December 31, 2010. Specific data submission requirements for the registry-based 

measures are discussed below: 

(A) Hospitals that Choose to Report the ICD Complications Measure 

 If the hospital chooses the ICD Complications measure, it would submit specified 

data elements for specified populations to the qualified ICD registry. We intend to 

establish criteria and begin qualifying registries for this topic so that hospitals can begin 

submitting data for discharges beginning January 1, 2011. The hospital would follow the 

standard participation and reporting procedures set by the registry regarding the 

submission of data elements for the particular measures we have specified for the topic. 

These data elements and population definitions will be listed in the Specifications 

Manual. 

Hospitals must allow the qualified registry it is using to report the patient-level 

data to CMS in order to calculate the ICD complications measure. 

(B) Hospitals that Choose to Report Either the Stroke, Nursing Sensitive Care, or 

Cardiac Surgery Measures 

 If a hospital chooses the Stroke, Nursing Sensitive Care, or Cardiac Surgery 

measure topics, it would submit data on the measures listed for these topics to a qualified 

registry for the topic. CMS intends to establish criteria and begin qualifying registries for 
CMS-1498-P 452 

these topics so that hospitals can begin submitting data for discharges beginning 

January 1, 2011. The hospital would follow the standard participation and reporting 

procedures set by the registry regarding the submission of data elements for the particular 

measures CMS has specified for the topic. Additionally, the hospital would agree to 

allow the registry to send calculations of the measures, numerator, denominator and 

exclusion counts to CMS for the RHQDAPU program. 

6. RHQDAPU Program Disaster Extensions and Waivers 

 In the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule (74 FR 24176), we 

solicited public comment about rules we could adopt that would enable hospitals to 

request either an extension or a waiver of various RHQDAPU program requirements in 

the event of a disaster (such as a hurricane that damages or destroys the hospital). 

 Specifically, we welcomed public comment on the following issues: 

● Recommendations for rules that we could follow when considering whether to 

grant an extension or waiver of RHQDAPU program requirements in the event of a 

disaster, including suggested criteria that we should take into account (for example, 

specific hospital infrastructure damage, hospital closure time period, degree of 

destruction of medical records, impact on data vendors, and long-term evacuation of 

discharged patients impacting HCAHPS survey participation). 

● The role that QIOs and QIO support contractors should play in the event of a 

disaster, including communicating with affected hospitals, communicating with State 

hospital associations, and collecting information directly from hospitals. 
CMS-1498-P 453 

● How CMS extension or waiver decisions should be communicated to affected 

hospitals. 

● Any other issues commenters deem relevant to a hospital’s request for an 

extension or waiver of RHQDAPU program requirements in the event of a disaster. 

 We responded to public comments in the FY 2010 IPPS/RY 2010 LTCH PPS 

final rule (74 FR 43881). We recognize that there are times when hospitals are unable to 

submit quality data due to extraordinary circumstances that are not within their control. 

It is our goal to not penalize hospitals for such circumstances and we do not want to 

unduly increase their burden during these times. 

 Therefore, we are proposing a process for hospitals to request and for CMS to 

grant extensions or waivers with respect to the reporting of required quality data when 

there are extraordinary circumstances beyond the control of the hospital. Under the 

proposed process, in the event of extraordinary circumstances not within the control of 

the hospital, for the hospital to receive consideration for an extension or waiver of the 

requirement to submit quality data for one or more quarters, a hospital must submit to the 

QIO in the hospital’s State a request form that will be made available on the QualityNet 

Web site. The following information should be noted on the form: 

● Hospital CCN; 

● Hospital Name; 

● CEO and any other designated personnel contact information, including name, 

e-mail address, telephone number, and mailing address (must include a physical address, 

a post office box address is not acceptable); 
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● Hospital’s reason for requesting an extension or waiver; 

● Evidence of the impact of the extraordinary circumstances, including but not 

limited to photographs, newspaper and other media articles; and 

● A date when the hospital will again be able to submit RHQDAPU data, and a 

justification for the proposed date. 

 The request form must be signed by the hospital’s CEO. A request form must be 

submitted within 45 days of the date that the extraordinary circumstance occurred. The 

QIO in the hospital’s state will forward the request form to CMS. Following receipt of 

the request form, CMS will: (1) provide a written acknowledgement using the contact 

information provided in the request, to the CEO and any additional designated hospital 

personnel, notifying them that the hospital’s request has been received; and (2) provide a 

formal response to the CEO and any additional designated hospital personnel using the 

contact information provided in the request notifying them of our decision. 

This proposal does not preclude CMS from granting waivers or extensions to 

hospitals that have not requested them when we determine that an extraordinary 

circumstance, such as an act of nature (for example, hurricane), affects an entire region or 

locale. If CMS makes the determination to grant a waiver or extension to hospitals in a 

region or locale, CMS will communicate this decision through routine communication 

channels to hospitals, vendors and QIOs, including but not limited to issuing memos, 

emails and notices on the QualityNet Web site. We invite comment on this proposal. 
CMS-1498-P 455 

7. Proposed Chart Validation Requirements for Chart-Abstracted Measures 

a. Chart Validation Requirements and Methods for the FY 2012 Payment Determination 

 For the FY 2012 payment determination, we will use the chart validation 

requirements and methods that we adopted for FY 2012 in the FY 2010 IPPS/RY 2010 

LTCH PPS final rule (74 FR 43884 through 43889). These requirements, as well as 

additional information on these requirements, will be posted on the QualityNet Web site 

after we issue the FY 2011 IPPS/RY 2011 LTCH PPS final rule. 

 Specifically, we will: 

● Randomly select on an annual basis 800 participating hospitals that submitted 

chart-abstracted data for at least 100 discharges combined in the measure topics to be 

validated. To determine whether a hospital meets this “100-case threshold,” we will look 

to the discharge data submitted by the hospital during the calendar year three years prior 

to the fiscal year of the relevant payment determination. For example, if the 100-case 

threshold applied for the FY 2011 payment determination (which it will not), the 

applicable measure topics would be AMI, HF, PN, and SCIP, and we would choose 

800 hospitals that submitted discharge data for at least 100 cases combined in these topics 

during calendar year 2008. If a hospital did not submit discharge data for at least 

100 cases in these topics during CY 2008, we would not select the hospital for validation. 

We will announce the topic areas that apply for the FY 2012 payment determination at a 

later date, and we plan to select the first 800 hospitals in July 2010. We will select 

hospitals for the FY 2012 validation if they meet the 100-case threshold during CY 2009. 

We adopted this 100-case threshold because we believe that it strikes the appropriate 
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balance between ensuring that the selected hospitals have a large enough patient 

population to be able to submit sufficient data to allow us to complete an accurate 

validation, while not requiring validation for hospitals with a low number of submitted 

quarterly cases and relatively unreliable measure estimates. Based on previously 

submitted data, we estimate that 98 percent of participating RHQDAPU program 

hospitals will meet this threshold and, thus, be eligible for validation. As noted below, 

we solicited comments and suggestions on how we might be able to target the remaining 

2 percent of hospitals for validation. 

● Validate for each of the 800 hospitals a randomly selected stratified sample for 

each quarter of the validation period. Each quarterly sample will include 12 cases, with 

at least one but no more than three cases per topic for which chart-abstracted data was 

submitted by the hospital. However, we recognize that some selected hospitals might not 

have enough cases in all of the applicable topics to submit data (for example, if they have 

5 or fewer discharges in a topic area in a quarter). For those hospitals, we will validate 

measures in only those topic areas for which they have submitted data. For the FY 2012 

payment determination, we will validate 1st calendar quarter 2010 through 3rd calendar 

quarter 2010 discharge data. We will validate 3 quarters of data for FY 2012 in order to 

provide hospitals with enough time to assess their medical record documentation and 

abstraction practices, and to take necessary corrective actions to improve these practices, 

before documenting their 1st calendar quarter 2010 discharges into medical records that 

may be sampled as part of this proposed validation process. 
CMS-1498-P 457 

The CDAC contractor will, each quarter that applies to the validation, ask each of 

the 800 selected hospitals to submit 12 randomly selected medical charts from which data 

was abstracted and submitted by the hospital to the QIO Clinical Warehouse. We note 

that, under our current requirements, hospitals must begin submitting RHQDAPU 

program data starting with the first day of the quarter following the date when the 

hospital registers to participate in the program. For purposes of meeting this requirement, 

we interpret the registration date to be the date that the hospital submits a completed 

Notice of Participation form. As proposed previously in this section, hospitals must also 

register with QualityNet and identify a QualityNet Administrator who follows the 

QualityNet registration process before submitting RHQDAPU program data. 

In addition, we will continue the following timeline with respect to CDAC 

contractor requests for paper medical records for the purpose of validating RHQDAPU 

program data. Beginning with CDAC contractor requests for second calendar quarter 

2009 paper medical records, the CDAC contractor will request paper copies of the 

randomly selected medical charts from each hospital via certified mail (or other trackable 

method that requires a hospital representative to sign for the letter), and the hospital will 

have 45 days from the date of the request (as documented on the request letter) to submit 

the requested records to the CDAC contractor. If the hospital does not comply within 30 

days, the CDAC contractor will send a second certified letter to the hospital, reminding 

the hospital that it must return paper copies of the requested medical records within 

45 calendar days following the date of the initial CDAC contractor medical record 

request. If the hospital still does not comply, then the CDAC contractor will assign a 
CMS-1498-P 458 

“zero” score to each measure in each missing record. The letter from the CDAC 

contractor is addressed to the hospital’s medical record staff identified by the hospital to 

their state Quality Improvement Organization (QIO). CMS recommends that hospitals 

routinely check with their State QIO to ensure the correct person is listed to receive the 

record request. If CMS has evidence from the CDAC contractor that the hospital 

received both letters requesting medical records (as determined by the tracking system 

used by CDAC contractor), the hospital is responsible for not returning their charts and 

will not be able to submit charts as part of their reconsideration request. 

Under the validation methodology, once the CDAC contractor receives the charts, 

it will re-abstract the same data submitted by the hospitals and calculate the percentage of 

matching RHQDAPU program measure numerators and denominators for each measure 

within each chart submitted by the hospital. Specifically, we will estimate the accuracy 

by calculating a match rate percent agreement for all of the variables submitted in all of 

the charts. For any selected record, a measure’s numerator and denominator can have 

two possible states, included or excluded, depending on whether the hospital accurately 

included the cases in the measure numerator(s) and denominator(s). We will count each 

measure in a selected record as a match if the hospital submitted measure numerator and 

denominator sets match the measure numerator and denominator states independently 

abstracted by our contractor. For example, one heart failure case from which data has 

been abstracted for four RHQDAPU program chart-abstracted measures (that is, HF-1, 

HF-2, HF-3, and HF-4) would receive a 75 percent match if three out of four of the 

hospital-reported heart failure measure numerator and denominator states matched the re-
CMS-1498-P 459 

abstracted numerator and denominator states. This proposed scoring approach is the 

same as recommended in the CMS Hospital Value-Based Purchasing Report to Congress, 

and is illustrated in further detail using an example in pages 83-84 of the report which can 

be found on our Web site at: 

http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/HospitalVBPPlanRTCFINALSU

BMITTED2007.pdf. We believe that this approach is appropriate, and it was supported 

by many commenters when we requested comment in the FY 2009 and FY 2010 IPPS 

final rules for input about the RHQDAPU program validation process (73 FR 48622 and 

48623, 74 FR 43886 and 43887). 

Under the validation methodology, we will: 

● Use, as we currently do, each selected case as a cluster comprising one or 

multiple measures utilized in a validation score estimate. Each selected case will have 

multiple measures included in the validation score (for example, for the FY 2011 

payment determination, a heart failure record will include 4 heart failure measures). 

Specifically, we will continue 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 and clinical topic is treated as a stratum for variance estimation purposes. 

We believe that the clustering approach is a statistically appropriate technique for 

calculating the annual validation confidence interval. Because we will not be validating 
CMS-1498-P 460 

all hospital records, we need to calculate a confidence interval that incorporates a 

potential sampling error. Our clustering approach incorporates the degree of correlation 

at the individual data record level, because our previous validation experience indicates 

that hospital data mismatch errors tend to be clustered in individual data records. We 

have used this clustering since the inception of the RHQDAPU program validation 

requirement to calculate variability estimates needed for calculating confidence intervals 

(70 FR 47423). 

● Use the upper bound of a one-tailed 95 percent confidence interval to estimate 

the validation score; and 

● Require all RHQDAPU program participating hospitals selected for validation 

to attain at least a 75 percent validation score per quarter to pass the validation 

requirement. 

We believe that this modified validation methodology incorporates many of the 

principles supported by the vast majority of commenters in response to our solicitation 

for public comments in the FY 2009 and FY 2010 IPPS proposed rule (73 FR 23658 

through 23659, 74 FR 43886 and 43887). Specifically, we believe that the increased 

annual sample size per hospital will provide more reliable estimates of validation 

accuracy. The sample size of 12 records per quarter would provide a total of 36 records 

across the three sampled quarters for the FY 2012 payment determination, and 48 records 

in subsequent years. This estimate would improve the reliability of our validation 

estimate, as compared to the current RHQDAPU program annual validation sample of 20 

cases per year. We also believe that modifying the validation score to reflect measure 
CMS-1498-P 461 

numerator and denominator accuracy will ensure that accurate data are posted on the 

Hospital Compare Web site. 

In addition, we believe that stratified quarterly samples by topic will improve the 

feedback provided to hospitals. CMS will provide validation feedback to hospitals about 

all sampled topics submitted by the hospitals each quarter. Because all relevant data 

elements submitted by the hospital must match the independently re-abstracted data 

elements to count as a match, we reduced the passing threshold from 80 percent to 

75 percent. We will use a one-tail confidence interval to calculate the validation score 

because we strongly believe that a one-tail test most appropriately reflects the pass or fail 

dichotomous nature of the statistical test regarding whether the confidence interval 

includes or is completely above the 75 percent passing validation score. 

 We also will continue to allow hospitals that fail to meet the passing threshold for 

the quarterly validation an opportunity to appeal the validation results to their State QIO. 

QIOs are currently tasked by CMS to provide education and technical assistance about 

RHQDAPU program data abstraction and measures to hospitals, and the quarterly 

validation appeals process will provide hospitals with an opportunity to both appeal their 

quarterly results and receive education free of charge from their State QIO. This State 

QIO quarterly validation appeals process is independent of the proposed RHQDAPU 

program reconsideration procedures for hospital reconsideration requests involving 

validation for the FY 2010 payment update proposed in this proposed rule. 
CMS-1498-P 462 

b. Proposed Supplements to the Chart Validation Process for the FY 2013 Payment 

Determination and Subsequent Years 

For FY 2013 and future years, we are also proposing to adopt the same validation 

requirements that we adopted for the FY 2012 payment determination, except as set forth 

below. 

 For FY 2013 and future years, we are proposing to modify our FY 2012 criteria 

by adding a targeting criterion, refining our random sample approach, and changing our 

data discharge quarters validated as part of our proposed synchronization of RHQDAPU 

timelines. Specifically, we are proposing the following changes for FY 2013: 

We are proposing to validate the data submitted by a hospital if the hospital failed 

the previous year’s RHQDAPU program validation. We are proposing this targeting 

criterion to improve data accuracy for all hospitals failing our validation requirement in a 

previous year. We believe that this proposal is an appropriate method to ensure data 

accuracy, since it targets our resources on the hospitals with the least accurate data based 

on FY 2012 validation results. We also believe that these hospitals must correct the data 

inaccuracies identified in RHQDAPU validation for their internal quality improvement 

and RHQDAPU measures publicly reported on Hospital Compare. Our proposal allows 

CMS to assess the accuracy of these hospitals’ data and provide feedback to hospitals 

until they comply with our RHQDAPU validation requirement. 

 Specifically, we are proposing that all hospitals selected for validation for the 

FY 2012 payment determination and that fail the validation will be selected for validation 

for the FY 2013 payment determination. Based on data analysis of past validation 
CMS-1498-P 463 

results, we estimate that targeting these hospitals would add about 20 to 40 hospitals to 

our list of validated hospitals to be selected in the FY 2013 validation sample. 

 For FY 2013, we also are proposing the following changes to the FY 2012 

RHQDAPU validation random sample approach: 

Starting in FY 2013, we are proposing to discontinue the 100 case minimum 

threshold for selection in the RHQDAPU 800 hospital random sample. We believe that 

discontinuing this requirement would improve the robustness of the RHQDAPU program 

validation sample by including the smallest hospitals participating in the RHQDAPU 

program in the sample. All hospitals successfully submitting at least one RHQDAPU 

case for the third calendar quarter of the year two years prior to the year to which the 

validation applies would be eligible to be selected for validation. For example, for the 

FY 2013 payment determination, we would select the sample in early 2011, and all 

hospitals that submitted at least one RHQDAPU case for third quarter 2010 discharges 

would be eligible to be selected. Starting in FY 2013, we are proposing this change to 

the RHQDAPU random validation sample, rather than including these hospitals in a 

targeted sample, to ensure that all RHQDAPU participating hospitals are equally likely to 

be selected in the random validation sample. 

 For the FY 2013 payment determination, we are proposing to modify the 

quarterly stratified sample selection by reallocating sample cases when a hospital has 

submitted fewer than three cases in a topic within a quarter. In these rare cases, we are 

proposing to randomly reallocate the extra sample cases to other topics with more than 3 

submitted quarterly cases. This proposed modification is designed to ensure that CMS 
CMS-1498-P 464 

selects 12 cases for all hospitals in a quarter, including those hospitals specializing in 

only one topic. For example, an orthopedic specialty surgery hospital submitting only 

SCIP measure cases in a given quarter would have only SCIP measure cases randomly 

selected in the validation sample for that quarter. This would provide a more reliable 

estimate of abstraction and measure accuracy by maintaining the same 12 case total 

quarterly validation sample. 

For the FY 2013 payment determination, we also are proposing to validate data 

from the 4th calendar quarter of 2010 through the 3rd calendar quarter of 2011 in 

accordance with our proposed synchronization of RHQDAPU data as outlined in section 

V.A.5.a.(2) of this proposed rule. This lag between the time a hospital submits data and 

the time we can validate that data is necessary because data is not due to the QIO Clinical 

Warehouse until 41⁄2 months after the end of each quarter, and we need additional time to 

select hospitals and complete the validation process. 

 We are also considering additional changes to our validation approach for future 

years. Beginning with the FY 2014 payment determination, we are considering adding 

two strata to the current RHQDAPU program validation sample of SCIP, AMI, HF, and 

PN cases. We are considering selecting 2 additional validation samples of 3 cases per 

selected hospital per quarter. One additional quarterly sample would enable us to 

validate the Central Line Associated Bloodstream Infection (CLABSI) and Surgical Site 

Infection (SSI) measures that we are proposing to add to the RHQDAPU measure set for 

the FY 2013 payment determination, and the second additional quarterly sample would 

enable us to validate the ED-Throughput and the Immunization for Influenza and 
CMS-1498-P 465 

Immunization for Pneumonia global measures that we are proposing to add to the 

RHQDAPU measure set for the FY 2014 payment determination. Thus, we would be 

validating a total of 18 records per quarter per validated hospital in six strata (1) SCIP, 

(2) AMI, (3) HF, (4) PN, (5) CLABSI/SSI, and (6) ED-Throughput/Immunization 

measures). We are also considering requiring hospitals to sign a written form explicitly 

granting CMS access to their patient level data submitted to for the proposed Central 

Line Associated Blood Stream Infection measure and the Surgical Site Infection 

measure. We believe that the CLABSI/SSI stratum is necessary to validate the data in the 

reports that we will access from NHSN for the RHQDAPU program. We invite comment 

on our validation proposals and considerations. 

We note that we are considering proposing, beginning with the FY 2015 payment 

determination, to add hospitals to our validation sample if they were open under their 

current CCNs in FY 2012 but not selected for validation in the three previous annual 

RHQDAPU validation samples. We are considering this addition to supplement our 

validation approach to ensure that all eligible RHQDAPU program hospitals are selected 

for validation at least once every 4 years. We are considering this addition beginning 

with the FY 2015 payment determination because FY 2015 would be the fourth year that 

we will be using the random validation approach. 

8. Data Accuracy and Completeness Acknowledgement Requirements for the FY 2011 

Payment Determination and Subsequent Years 

For the FY 2011 payment determination and subsequent years, in the FY 2010 

IPPS/RY 2010 LTCH PPS proposed rule (74 FR 24180), we proposed to require 
CMS-1498-P 466 

hospitals to electronically acknowledge on an annual basis the completeness and 

accuracy of the data submitted for the RHQDAPU program payment determination. 

Hospitals will be able to submit this acknowledgement on the same Web page that they 

use to submit data necessary to calculate the structural measures, and we believe that this 

Web page will provide a secure vehicle for hospitals to directly acknowledge that their 

information is complete and accurate to the best of their knowledge. A single annual 

electronic acknowledgement will provide us with explicit documentation acknowledging 

that the hospital’s data is accurate and complete, but will not unduly burden hospitals. 

We noted that commenters generally supported the idea of electronic attestation in the 

FY 2009 IPPS final rule (73 FR 48625) at the point of data submission to the QIO 

Clinical Warehouse. 

In addition, the Government Accountability Office (GAO) recommended in a 

2006 report (GAO-06-54) that hospitals self-report that their data are complete and 

accurate. Therefore, in the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43890) 

for the FY 2010 payment determination, we required hospitals to electronically 

acknowledge their data accuracy and completeness once between July 1, 2009, and 

August 15, 2009. Hospitals will acknowledge that all information that is, or will be, 

submitted as required by the RHQDAPU program for the FY 2010 payment 

determination is complete and accurate to the best of their knowledge. 

We are proposing to require hospitals to electronically acknowledge their data 

accuracy and completeness once between July 1, 2010 and August 15, 2010 for data to be 

used for the –FY 2012 RHQDAPU program payment determination. 
CMS-1498-P 467 

9. Proposed Public Display Requirements for the FY 2012 Payment Determination and 

Subsequent Years 

 Section 1886(b)(3)(B)(viii)(VII) of the Act provides that the Secretary shall 

establish procedures for making data submitted under the RHQDAPU program available 

to the public. As we noted in section V.A.1.c.(3) of this proposed rule, the RHQDAPU 

program quality measures are typically reported on the Hospital Compare Web site 

(http://www.hospitalcompare.hhs.gov), but on occasion are reported on other CMS Web 

sites. We require that hospitals sign a Notice of Participation form when they first 

register to participate in the RHQDAPU program. Once a hospital has submitted a form, 

the hospital is considered to be an active RHQDAPU program participant until such time 

as the hospital submits a withdrawal form to CMS (72 FR 47360). Hospitals signing this 

form agree that they will allow CMS to publicly report the quality measures included in 

the RHQDAPU program. 

 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. 

10. Proposed Reconsideration and Appeal Procedures for the FY 2011 Payment 

Determination 

 The general deadline for submitting a request for reconsideration in connection 

with the FY 2011 payment determination is November 1, 2010. As discussed more fully 

below, we are proposing that all hospitals submit a request for reconsideration and 
CMS-1498-P 468 

receive a decision on that request before they can file an appeal with the Provider 

Reimbursement Review Board (PRRB). 

For the FY 2011 payment determination, we are proposing to continue utilizing 

most of the same procedures that we utilized for the FY 2010 requests for 

reconsideration. Under these proposed procedures, the hospital must -- 

 Submit to CMS, via QualityNet, a Reconsideration Request form (available on the 

QualityNet Web site) containing the following information: 

 -- Hospital CMS Certification number (CCN). 

 -- Hospital Name. 

 -- CMS-identified reason for failure (as provided in the CMS notification of 

failure letter to the hospital). 

 -- Hospital basis for requesting reconsideration. This must identify the hospital's 

specific reason(s) for believing it met the RHQDAPU program requirements and should 

receive the full FY 2011 IPPS annual payment update. 

-- CEO contact information, including name, e-mail address, telephone number, 

and mailing address (must include the physical address, not just the post office box). We 

no longer require that the hospital’s CEO sign the RHQDAPU program reconsideration 

request. We have found that this requirement increases the burden for hospitals because 

it prevents them from electronically submitting the RHQDAPU program reconsideration 

request forms. In addition, to the extent that a hospital can submit a request for 

reconsideration on-line, the burden on our staff is reduced and, as a result, we can more 

quickly review the request. 
CMS-1498-P 469 

 -- QualityNet System Administrator contact information, including name, e-mail 

address, telephone number, and mailing address (must include the physical address, not 

just the post office box). 

-- Paper medical record requirement for reconsideration requests involving 

validation. We are proposing that if a hospital asks us to reconsider an adverse 

RHQDAPU program payment decision made because the hospital failed the validation 

requirement, the hospital must submit paper copies of all the medical records that it 

submitted to the CDAC contractor each quarter for purposes of the validation. Hospitals 

must submit this documentation to a CMS contractor. The contractor will be a QIO 

support contractor, which has authority to review patient level information under 

42 CFR Part 480. We will post the address where hospitals can ship the paper charts on 

the QualityNet Web site after we issue the FY 2011 IPPS/LTCH PPS final rule. 

Hospitals submitting a RHQDAPU program validation reconsideration request will have 

all mismatched data reviewed by CMS, and not their State QIO. (As discussed in section 

V.A.6.b. of this proposed rule, the State QIO is available to conduct a quarterly validation 

appeal if so requested by a hospital.) 

For the FY 2011 payment determination, the RHQDAPU program data that will 

be validated is 4th calendar quarter 2008 through 3rd quarter calendar year 2009 discharge 

data. Hospitals must provide a written justification for each appealed data element 

classified during the validation process as a mismatch. We will review the data elements 

that were labeled as mismatched, as well as the written justifications provided by the 

hospitals, and make a decision on the reconsideration request. As we mentioned above, 
CMS-1498-P 470 

we are proposing that all hospitals submit a reconsideration request to CMS and receive a 

decision on that request prior to submitting a PRRB appeal. We believe that the 

reconsideration process is less costly for both CMS and hospitals, and that this 

requirement will decrease the number of PRRB appeals by resolving issues earlier in the 

appeals process. 

Following receipt of a request for reconsideration, we will-- 

● Provide an e-mail acknowledgement, using the contact information provided in 

the reconsideration request, to the CEO and the QualityNet Administrator that the request 

has been received. 

● Provide written notification to the hospital CEO, using the contact information 

provided in the reconsideration request, regarding our decision. We expect the process to 

take approximately 90 days from the reconsideration request due date of 

November 1, 2010. 

As we stated in the in the FY 2010 IPPS/RY 2010 LTCH PPS final rule 

(74 FR 43892), the scope of our review when a hospital requests reconsideration because 

it failed our validation requirements will be as follows:

 1. Hospital requests reconsideration for CDAC contractor-abstracted data 

elements classified as mismatches affecting validation scores. Hospitals must timely 

submit a copy of the entire requested medical record to the CDAC contractor during the 

quarterly validation process for the requested case to be eligible to be reconsidered on the 

basis of mismatched data elements. 
CMS-1498-P 471 

 2. Hospital requests reconsideration for medical record copies submitted during 

the quarterly validation process and classified as invalid record selections. Invalid record 

selections are defined as medical records submitted by hospitals during the quarterly 

validation process that do not match the patient’s episode of care information as 

determined by the CDAC contractor (in other words, the contractor determines that the 

hospital returned a medical record that is different from that which was requested). If the 

CDAC contractor determines that the hospital has submitted an invalid record selection 

case, it awards a zero validation score for the case because the hospital did not submit the 

entire copy of the medical record for that requested case. During the reconsideration 

process, our review of invalid record selections will initially be limited to determining 

whether the record submitted to the CDAC contractor was actually an entire copy of the 

requested medical record. If we determine during reconsideration that the hospital did 

submit the entire copy of the requested medical record, then we would abstract data 

elements from the medical record submitted by the hospital. 

 3. Hospital requests reconsideration for medical records not submitted to the 

CDAC contractor within the 45 calendar day deadline. Our review will initially be 

limited to determining whether the CDAC contractor received the requested record 

within 45 calendar days, and whether the hospital received the initial medical record 

request and reminder notice. If we determine during reconsideration that the CDAC 

contractor did receive a paper copy of the requested medical record within 45 calendar 

days, then we would abstract data elements from the medical record submitted by the 

hospital. If we determine that the hospital received two letters requesting medical records 
CMS-1498-P 472 

and still did not submit the requested records within the 45 day period, CMS will not 

accept these records as part of the reconsideration. CMS will not abstract data from 

charts not received timely by the CDAC contractor. 

 In sum, we are initially limiting the scope of our reconsideration reviews 

involving validation to information already submitted by the hospital during the quarterly 

validation process, and we will not abstract medical records that were not submitted to 

the CDAC contractor during the quarterly validation process. We will expand the scope 

of our review only if we find during the initial review that the hospital correctly and 

timely submitted the requested medical records. In that case, then we would abstract data 

elements from the medical record submitted by the hospital as part of our review of its 

reconsideration request.

If a hospital is dissatisfied with the result of a RHQDAPU program 

reconsideration decision, the hospital may file a claim under 42 CFR Part 405, Subpart R 

(a PRRB appeal). We are again soliciting public comments on the extent to which these 

proposed procedures will be less costly for hospitals, and whether they will lead to fewer 

PRRB appeals. 

11. Proposed RHQDAPU Program Withdrawal Deadlines 

 We are proposing to accept RHQDAPU program withdrawal forms for the 

FY 2012 payment determination from hospitals until August 15, 2011. We are proposing 

this deadline so that we would have sufficient time to update the FY 2012 payment to 

hospitals starting on October 1, 2011. If a hospital withdraws from the program for the 

FY 2012 payment determination, it will receive a 2.0 percentage point reduction in its 
CMS-1498-P 473 

FY 2012 annual payment update. We noted that once a hospital has submitted a Notice 

of Participation form, it is considered to be an active RHQDAPU program participant 

until such time as the hospital submits a withdrawal form to CMS. 

12. Electronic Health Records (EHRs) 

a. Background 

 Starting with the FY 2006 IPPS final rule, we have encouraged hospitals to take 

steps toward the adoption of EHRs (also referred to in previous rulemaking documents as 

electronic medical records) that will allow for reporting of clinical quality data from the 

EHRs directly to a CMS data repository (70 FR 47420 through 47421). We encouraged 

hospitals that are implementing, upgrading, or developing EHR systems to ensure that the 

technology obtained, upgraded, or developed conforms to standards adopted by HHS. 

We suggested that hospitals also take due care and diligence to ensure that the EHR 

systems accurately capture quality data and that, ideally, such systems provide 

point-of-care decision support that promotes optimal levels of clinical performance. 

 We also continue to work with standard setting organizations and other entities to 

explore processes through which EHRs could speed the collection of data and minimize 

the resources necessary for quality reporting as we have done in the past. 

 We note that we have initiated work directed toward enabling EHR submission of 

quality measures through EHR standards development and adoption. We have sponsored 

the creation of electronic specifications for quality measures that are currently proposed 

for the RHQDAPU program and measures under future consideration. We look to 

continue this activity in the future. 
CMS-1498-P 474 

b. EHR Testing of Quality Measures Submission 

 As we have previously stated, we are interested in the reporting of quality 

measures using EHRs, and we continue to encourage hospitals to adopt and use EHRs 

that conform to the certification criteria as will be defined by the Office of the National 

Coordinator for Health Information Technology, HHS at 45 CFR Part 170. We believe 

that the testing of EHR submission is an important and necessary step to establish the 

ability of EHRs to report clinical quality measures and the capacity of CMS to receive 

such data. 

 The electronic specifications and interoperability standards for EHR-based 

collection and transmission of the data elements for the ED Throughput, Stroke, and 

Venous Thromboembolism (VTE) measures have been finalized by the Health 

Information Technology Standards Panel (HITSP) and are available for review and 

testing at http//www.HITSP.org. We anticipate testing the components required for the 

submission of clinical quality data extracted from EHRs for these measures, and are 

exploring different mechanisms and formats that will aid the submission process, as well 

as ensure that the summary measure results extracted from the EHRs are reliable. 

 We anticipate moving forward with testing CMS’ technical ability to accept data 

from EHRs for the ED, Stroke, and VTE measures as early as summer of 2011. We 

anticipate building upon the work completed by the HITSP in both the Connectathon and 

Health Information Management Systems Society (HIMSS) Interoperability Showcase. 

This testing will encompass an “end to end” view of data transmission. Pursuant to the 

Paperwork Reduction Act, we have previously published a Federal Register notice and 
CMS-1498-P 475 

information collection request for CMS-10296 (74 FR 44366) seeking public comments 

on the process we intended to follow to select EHR vendors/hospitals for testing CMS 

ability to accept EHR-based data submissions. We will notify interested parties of 

changes in the process and timeline for testing via the Inpatient EHR testing Web site at: 

http://www.cms.hhs.gov/HospitalQualityInits/15_HospitalInpatientEHRTesting.asp. 

 The test measures described above are not currently required under the 

RHQDAPU program. In addition, the posting of the electronic specifications for any 

particular measure should not be interpreted as a signal that we intend to select the 

measure for inclusion in the RHQDAPU program measure set. 

c. HITECH Act EHR Provisions 

 The HITECH Act (Title IV of Division B of the ARRA, together with Title XIII 

of Division A of the ARRA) authorizes payment incentives under Medicare for the 

adoption and use of certified EHR technology beginning in FY 2011. Hospitals are 

eligible for these payment incentives if they meet requirements for meaningful use of 

certified EHR technology, which include reporting on quality measures using certified 

EHR technology. With respect to the selection of quality measures for this purpose, 

under section 1886(n)(3)(A)(ii) of the Act, as added by section 4102 of the HITECH Act, 

the Secretary shall select measures, including clinical quality measures, that hospitals 

must provide to CMS in order to be eligible for the EHR incentive payments. With 

respect to the clinical quality measures, section 1886(n)(3)(B)(i) of the Act requires the 

Secretary to give preference to those clinical quality measures that have been selected for 

the RHQDAPU program under section 1886(b)(3)(B)(viii) of the Act or that have been 
CMS-1498-P 476 

endorsed by the entity with a contract with the Secretary under section 1890(a) of the 

Act. Any measures must be proposed for public comment prior to their selection, except 

in the case of measures previously selected for the RHQDAPU program under 

section 1886(b)(3)(B)(viii) of the Act. 

 Thus, the RHQDAPU program and the HITECH Act have important areas of 

overlap and synergy with respect to the reporting of quality measures using EHRs. We 

believe the financial incentives under the HITECH Act for the adoption and meaningful 

use of certified EHR technology by hospitals will encourage the adoption and use of 

certified EHRs for the reporting of clinical quality measures under the RHQDAPU 

program. Further, these efforts to test the submission of quality data through EHRs may 

provide a foundation for establishing the capacity of hospitals to send, and for CMS to 

receive, quality measures via hospital EHRs for future RHQDAPU program measures. 

 We again note that the provisions in this proposed rule do not implicate or 

implement any HITECH statutory provisions. Those provisions are the subject of 

separate rulemaking and public comment. 

13. Qualification of Registries for RHQDAPU Data Submission 

 In section V.A.3. c.(3) of this proposed rule, we proposed that hospitals would 

select at least one of four registry-based measure topics for which they will report data on 

proposed measures to a qualified registry beginning with January 1, 2011 discharges, and 

allow the registry to calculate and report measure data for the specified measures to CMS 

(via QualityNet) for RHQDAPU program purposes. The process and requirements that 

we are proposing to use to determine whether a registry is qualified to collect and submit 
CMS-1498-P 477 

quality measure data are described below. We will post on the RHQDAPU program 

section of the QualityNet Web site http://www.qualitynet.org no later than 

December 31, 2010 a list of qualified registries for the FY 2013 RHQDAPU payment 

determination, including the registry name, contact information, and the measure(s) for 

which the registry is qualified and will report for the FY 2013 RHQDAPU payment 

determination. We have proposed measures for inclusion in each of the four registrybased topics, and a registry seeking to be qualified for a particular topic would have to 

agree to collect and report the measures included in the topic. The proposed measures 

support CMS and HHS priorities for improved quality and efficiency of care for 

Medicare beneficiaries (such as, prevention; chronic conditions; high cost and high 

volume conditions; elimination of health disparities; healthcare-associated infections and 

other conditions; and effective management of acute and chronic episodes of care). We 

note, however, that none of the registries that we qualify for this purpose will be acting as 

a CMS contractor or agent. In other words, hospitals will still be responsible for making 

sure that the data it submits to the qualified registry is successfully processed and 

transmitted by the registry to CMS. 

 We are proposing to implement a self-nomination process for registries seeking 

to submit FY 2013 RHQDAPU program quality measures (including measure 

calculations, numerators, denominators, and exclusions) on behalf of hospitals beginning 

with January 1, 2011 discharges. A registry would be able to self-nominate if it meets the 

following requirements: 
CMS-1498-P 478 

● The registry has been collecting data elements needed to calculate the 

particular measures that are being proposed for inclusion in the registry-based topic for 

which the registry is seeking qualification for at least 3 years prior to January 1, 2010. 

● As of January 1, 2010, the registry has been collecting such data from at least 

750 hospitals. 

● The registry must have the capability to collect from hospitals all of the data 

elements which are included in the measure specifications and calculate the results for the 

specified measures. The measures are NQF-endorsed and will be listed in the 

Specifications Manual. 

● The registry must agree to report the hospital level measure data to CMS (via 

QualityNet). During the registry qualification process, CMS will inform the registries of 

the specified reporting format which will include: 

o The volume of eligible cases (reporting denominator); 

o The volume of numerator events for the quality measure (reporting 

numerator); 

o The number of cases excluded from the measure; 

o The measure results 

● The registry must agree to transmit quality measure data in a CMS-approved 

format. We expect that this CMS-specified record layout will be made available in late 

2010; 

● The registry must be able to perform data quality validation checks on the data 

received from hospitals to determine if the data submitted by the hospitals are accurate 
CMS-1498-P 479 

and agree to submit an acceptable ``validation strategy'' to CMS by December 15, 2011. 

A validation strategy ascertains whether hospitals have submitted data accurately to the 

registry. An acceptable validation strategy may include such provisions as the registry 

being able to verify the accuracy of hospital data through random sampling or through the 

hospital’s adherence to a required sampling method; 

● The registry must agree to enter into and maintain with its participating 

hospitals an appropriate Business Associate agreement that complies with HIPAA.

● The registry must obtain and keep on file signed documentation showing that 

each of its participating hospitals has authorized the registry to calculate and submit the 

quality measure hospital-level data specified by CMS to CMS. This documentation must 

be obtained at the time the hospital arranges to submit RHQDAPU program quality 

measure data to the registry; 

● The registry must agree to provide CMS with access (if requested) to review 

the data that the hospital submitted to it for purposes of the RHQDAPU program; 

● The registry must agree to indicate to CMS upon request whether a particular 

hospital has satisfied the registry’s participation requirements; 

● The registry must agree to provide CMS with a signed, written attestation 

statement via mail or e-mail which states that the quality measure data that the registry 

has submitted to CMS on behalf of its participating hospitals is accurate and complete. 

● The registry must agree to provide at least 1 feedback report per year to 

participating hospitals; 
CMS-1498-P 480 

● The registry must agree to provide on-going technical assistance to its 

participating hospitals with respect to the hospitals’ submission of RHQDAPU data; and 

● The registry must agree to participate in periodic RHQDAPU program support 

calls hosted by CMS. 

 To apply to be a qualified registry for any of the four proposed registry-based 

topics, a registry must submit a self-nomination letter by October 15, 2010 to 

RHQDAPU_Registries@cms.hhs.gov containing the registry name, point of contact, the 

proposed registry-based measure topic for which qualification is being sought, and 

detailed information regarding how the registry satisfies the criteria listed above. 

B. Payment for Transfers of Cases from Medicare Participating Acute Care Hospitals to 

Nonparticipating Hospitals and CAHs (§412.4)

1. Background 

Existing regulations at §412.4(a) provide that an inpatient is considered 

discharged from a hospital paid under the IPPS when the patient is either formally 

released from the hospital or dies in the hospital. Under certain circumstances, a 

discharge is considered a transfer for purposes of payment under the IPPS. Section 

412.4(b) defines acute care transfers, and §412.4(c) identifies those discharges considered 

a postacute care transfer. In accordance with §412.4(f), when a patient is transferred and 

his or her length of stay is less than the geometric mean length of stay for the MS-DRG to 

which the case is assigned, the transferring hospital is generally paid based on a 

graduated per diem rate for each day of the stay, not to exceed the full MS–DRG 

payment that would have been made if the patient had been discharged without being 

transferred. In the case of acute care transfers, the receiving hospital that ultimately 
CMS-1498-P 481 

discharges the transferred patient receives the full MS-DRG payment, regardless of 

whether the length of the patient’s inpatient stay exceeds the geometric mean length of 

stay for the applicable MS-DRG. 

The per diem rate paid to a transferring hospital is calculated by dividing the full 

MS–DRG payment by the geometric mean length of stay for the MS–DRG. Based on an 

analysis that showed that the first day of hospitalization is the most expensive 

(60 FR 5804), our policy generally provides for payment that is double the per diem 

amount for the first day, with each subsequent day paid at the per diem amount up to the 

full DRG payment (§412.4(f)(1)). Transfer cases also are eligible for outlier payments. 

In general, the outlier threshold for transfer cases, as described in §412.80(b) of the 

regulations, is equal to the fixed-loss outlier threshold for nontransfer cases (adjusted for 

geographic variations in costs), divided by the geometric mean length of stay for the 

MS-DRG, and multiplied by the length of stay for the case plus one day. 

The transfer policy adjusts the payments of the transferring hospital to 

approximate the reduced costs of transfer cases. Medicare adopted its IPPS transfer 

policy because, if Medicare were to pay the full MS-DRG payment regardless of whether 

a patient is transferred or discharged, there would be a strong incentive for hospitals to 

transfer patients to another IPPS hospital early in their stay in order to minimize costs 

while still receiving the full MS-DRG payment. 

b. Proposed Policy Change 

The regulations at §412.4(b) state that a discharge of a hospital inpatient is 

considered to be an acute care transfer when the patient is readmitted on the same day to 
CMS-1498-P 482 

another hospital that is paid under the IPPS, or to a hospital that is excluded from the 

IPPS because of participation in a statewide cost control program, unless the readmission 

is unrelated to the initial discharge. These regulations were developed under the 

authority granted in section 1886(d)(5)(I)(ii) of the Act. Because a discharge is only 

considered an acute care transfer if the receiving hospital either is paid under IPPS or 

participates in a statewide cost control program, the current acute care transfer policy 

only applies to transfers between acute care hospitals that participate in the Medicare 

program (“participating acute care hospitals”); it does not currently apply to acute care 

hospitals that would otherwise be eligible to be paid under the IPPS, but do not have an 

agreement to participate in the Medicare program (“nonparticipating acute care 

hospitals”). The acute care transfer policy also does not currently apply to IPPS acute 

care hospital transfers to CAHs. 

The intent of the acute care transfer policy is to make payment to the transferring 

hospital commensurate with the resources it expends in treating Medicare beneficiaries. 

As stated above, a participating acute care hospital that admits a beneficiary from a 

transferring hospital receives a full MS-DRG payment, as long as the receiving hospital 

does not subsequently transfer the beneficiary prior to the geometric mean length of stay 

for that MS-DRG. The transferring hospital receives a reduced per diem payment 

amount. If the acute care transfer policy did not exist, Medicare would make separate 

full MS-DRG payments to each of the hospitals involved with the treatment of the 

beneficiary, even though the hospitals shared in one episode of care for the same 

beneficiary and neither provided the full spectrum of care for that beneficiary for that 
CMS-1498-P 483 

episode of care. Such a policy would inappropriately pay a “double” Medicare payment 

and would be inconsistent with the intent of the acute care transfer policy. 

Although a nonparticipating acute care hospital is generally ineligible to receive 

payments under Medicare, such a hospital may still treat Medicare patients. In addition, 

acute care hospitals that do participate in the Medicare program are not precluded from 

transferring a Medicare patient to a nonparticipating acute care hospital. We note that a 

hospital that transfers a patient early in the patient’s stay (that is, prior to the geometric 

mean length of stay of the patient’s MS-DRG) incurs reduced costs for that case, 

regardless of whether the patient is transferred to a Medicare participating acute care 

hospital or a nonparticipating acute care hospital. A hospital that sends such a transfer to 

a CAH incurs similarly reduced costs, despite the fact that transfers to CAHs are not 

currently included under the Medicare acute care transfer policy. 

These policy changes are also being proposed in order to avoid creating a 

financial incentive for an IPPS hospital to transfer cases to one type of provider versus 

another. A transfer decision should be made based on the clinical merits of the 

beneficiary’s situation and the transferring hospital’s capabilities. More pointedly, we 

want to avoid providing a Medicare participating acute care hospital with an incentive to 

transfer cases to a nonparticipating acute care hospital or a CAH. Without a policy 

change, these incentives still exists as payment issues relating to the IPPS transfer policy. 

With respect to nonparticipating acute care hospitals, it is frequently explained that the 

Medicare conditions of participation provide a certain minimum standard of care that 

beneficiaries can expect, and that Medicare does not make payments to nonparticipating 
CMS-1498-P 484 

acute care hospitals because these hospitals do not commit to adhering to these conditions 

of participation. As such, the lack of a policy with regard to transfers to nonparticipating 

acute care hospitals results in an inappropriate payment incentive. 

Accordingly, in order to further align the IPPS regulations relating to transfer of 

cases under §412.4(b) with its original intent (that is, that a hospital’s payment should be 

commensurate with the resources it expends for the case), in this proposed rule, we are 

proposing to add a new paragraph (b)(3) to §412.4 to specify that an acute care hospital 

“transfer case” includes a transfer to an acute care hospital that would otherwise be 

eligible to be paid under the IPPS, but does not have an agreement to participate in the 

Medicare program, and a new paragraph (b)(4) to state that an acute care hospital 

“transfer” also includes a transfer to a CAH. 

Hospitals must use patient discharge status code “66” (Discharged/Transferred to 

a Critical Access Hospital) on IPPS claims to identify transfers to CAHs. For transfers to 

nonparticipating acute care hospitals, hospitals must continue to use patient status code 

“02” (Discharged/Transferred to a Short-Term General Hospital for Inpatient Care) on 

IPPS claims. We note that the National Uniform Billing Committee (NUBC) 

periodically updates or changes patient status codes; therefore, hospitals should check 

NUBC guidance periodically to determine whether there have been any changes to these 

codes. 

C. Technical Change to Regulations

 In the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43939 through 

43940), in response to public comments we received on the FY 2010 proposed rule 
CMS-1498-P 485 

relating to the effects on CAH status arising from the redesignation by OMB of three 

Micropolitan Statistical Areas as MSAs, we amended our regulations at §485.610 by 

adding a paragraph (b)(4) to provide for a transition period for the CAHs that are located 

in counties that are reclassified from rural to urban to obtain a rural redesignation. 

However, when we added the new paragraph (b)(4) to §485.610, we inadvertently failed 

to make a conforming change to the introductory text of paragraph (b) to include a 

reference to paragraph (b)(4) as one of the requirements that the CAH must meet in order 

to satisfy the conditions of participation for CAHs. We are proposing to make this 

confirming change. 

D. Medicare-Dependent, Small Rural Hospitals (MDHs): Change to Criteria (§412.108)

1. Background 

 Under the IPPS, separate special payment protections are provided to a 

Medicare-dependent, small rural hospital (MDH). Section 1886(d)(5)(G)(iv) of the Act 

defines an MDH as a hospital that is located in a rural area, has not more than 100 beds, 

is not an SCH, and has a high percentage of Medicare discharges (that is, not less than 

60 percent of its inpatient days or discharges either in its 1987 cost reporting year or in 

two of its most recent three settled Medicare cost reporting years). The regulations that 

set forth the criteria that a hospital must meet to be classified as an MDH are at 

42 CFR 412.108. 

Although MDHs are paid under an adjusted payment methodology, they are still 

IPPS hospitals paid under section 1886(d) of the Act. Like all IPPS hospitals paid under 
CMS-1498-P 486 

section 1886(d) of the Act, MDHs are paid for their discharges based on the DRG 

weights calculated under section 1886(d)(4) of the Act. 

Through and including FY 2006, under section 1886(d)(5)(G) of the Act, MDHs 

are paid based on the Federal rate or, if higher, the Federal rate plus 50 percent of the 

amount by which the Federal rate is exceeded by the updated hospital-specific rate based 

on the hospital’s FY 1982 or FY 1987 costs per discharge, whichever of these 

hospital-specific rates is higher. Section 5003(b) of Pub. L. 109-171 (DRA 2005) 

amended section 1886(d)(5)(G) of the Act to provide that, for discharges occurring on or 

after October 1, 2006, MDHs are paid based on the Federal rate or, if higher, the Federal 

rate plus 75 percent of the amount by which the Federal rate is exceeded by the updated 

hospital-specific rate based on FY 1982, FY 1987, or FY 2002 costs per discharge, 

whichever of these hospital-specific rates is highest. 

For each cost reporting period, the fiscal intermediary or MAC determines which 

of the payment options will yield the highest aggregate payment. Interim payments are 

automatically made at the highest rate using the best data available at the time the fiscal 

intermediary or MAC makes the determination. However, it may not be possible for the 

fiscal intermediary or MAC to determine in advance precisely which of the rates will 

yield the highest aggregate payment by year’s end. In many instances, it is not possible 

to forecast the outlier payments, the amount of the DSH adjustment or the IME 

adjustment, all of which are applicable only to payments based on the Federal rate and 

not to payments based on the hospital-specific rate. The fiscal intermediary or MAC 
CMS-1498-P 487 

makes a final adjustment at the settlement of the cost report after it determines precisely 

which of the payment rates would yield the highest aggregate payment to the hospital. 

If a hospital disagrees with the fiscal intermediary’s or the MAC’s determination 

regarding the final amount of program payment to which it is entitled, it has the right to 

appeal the determination in accordance with the procedures set forth in 42 CFR Part 405, 

Subpart R, which govern provider payment determinations and appeals. 

2. Medicare-Dependency: Counting Medicare Inpatients 

Currently, in order for an IPPS hospital to qualify as an MDH, at least 60 percent 

of its inpatient days or discharges must be attributable to individuals receiving Medicare 

Part A benefits (§412.108(a)(1)(iii) of the regulations). 

The MDH policy, as explained in the FY 1991 final rule (55 FR 35994 through 

35998), does not include in the count of Medicare inpatients those Medicare beneficiaries 

who have exhausted their Medicare Part A inpatient benefits. Currently, for purposes of 

determining DSH payment adjustments under the IPPS, section 1886(d)(5)(F)(vi)(I) of 

the Act and our policy include, in the Medicare inpatient count, individuals entitled to 

Medicare Part A benefits, regardless of whether or not they have exhausted Medicare 

Part A coverage. This policy is discussed in the FY 2005 IPPS final rule (69 FR 49090 

through 49099). In addition, section 1886(d)(5)(G)(iv)(IV) of the Act specifies that a 

hospital is Medicare-dependent if “not less than 60 percent of its inpatient days or 

discharges during the cost reporting period beginning in fiscal year 1987, or two of the 

three most recently audited cost reporting periods for which the Secretary has a settled 

cost report, were attributable to inpatients entitled to benefits under part A.” The use of 
CMS-1498-P 488 

the word “entitled” in the statute would encompass individuals who are entitled to 

Medicare Part A even though they have exhausted their Part A hospital days. Individuals 

who have exhausted their Part A inpatient benefit coverage remain “entitled” to Medicare 

Part A because they retain the Medicare Part A insurance benefit coverage (for example, 

covered SNF days), and they continue to meet all statutory criteria for entitlement to 

Part A benefits under section 226 of the Act (Entitlement to Hospital Insurance Benefits). 

Accordingly, we are proposing to revise the Medicare-dependency criterion at 

§412.108(a)(1)(iii) of the regulations to replace the term “receiving” with the phrase 

“entitled to”. As a result, we would include in the count of Medicare inpatient days or 

discharges all days or discharges attributable to individuals entitled to the Medicare 

Part A insurance benefit, including individuals who have exhausted their Medicare Part A 

inpatient hospital coverage benefit, as well as individuals enrolled in Medicare 

Advantage plans and section 1876 cost contracts, that is, health maintenance 

organizations (HMOs) and competitive medical plans (CMPs). We note that, for 

inpatient care provided to Medicare Part A beneficiaries enrolled with an HMO or a 

CMP, we provided that the days and discharges for those stays are counted for purposes 

of determining Medicare-dependency for MDH purposes (55 FR 35995). This was the 

case when HMOs and CMPs were included under Medicare Part A, and continues to be 

the case since 1997 when HMOs and CMPs were placed under Medicare Part C. 

E. Rural Referral Centers (RRCs) (§412.96)

 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 
CMS-1498-P 489 

as an RRC. For discharges that occurred before October 1, 1994, RRCs received the 

benefit of payment based on the other urban standardized amount rather than the rural 

standardized amount (as discussed in the FY 1993 IPPS final rule (59 FR 45404 through 

45409)). 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 RRCs such that 

they are not subject to the 12-percent cap on DSH payments that is applicable to other 

rural hospitals. RRCs are also not subject to the proximity criteria when applying for 

geographic reclassification. In addition, they do not have to meet the requirement that a 

hospital's average hourly wage must exceed, by a certain percentage, 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 IPPS final rule with 

comment period (62 FR 45999), CMS reinstated RRC status for all hospitals that lost the 

status due to triennial review or MGCRB reclassification. However, CMS did not 

reinstate the status of hospitals that lost RRC status because they were now urban for all 

purposes because of the OMB designation of their geographic area as urban. 

Subsequently, in the August 1, 2000 IPPS final rule (65 FR 47089), we indicated that we 

were revisiting that decision. Specifically, we stated that we would permit hospitals that 
CMS-1498-P 490 

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 all of the other applicable criteria. 

We use the definitions of "urban" and "rural" specified in Subpart D of 42 CFR Part 412. 

One of the criteria under which a hospital may qualify as an 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). (We refer readers to §412.96(c)(1) through (c)(5) and 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.) 

1. Case-Mix Index (CMI) 

 Section 412.96(c)(1) provides that CMS establish updated national and regional 

CMI values in each year’s annual notice of prospective payment rates for purposes of 
CMS-1498-P 491 

determining RRC status. The methodology we used to determine the national and 

regional CMI values is set forth in the regulations at §412.96(c)(1)(ii). The proposed 

national median CMI value for FY 2011 includes data from all urban hospitals 

nationwide, and the proposed regional values for FY 2011 are the median CMI values of 

urban hospitals within each census region, excluding those hospitals with approved 

teaching programs (that is, those hospitals that train residents in an approved GME 

program as provided in §413.75). These proposed values are based on discharges 

occurring during FY 2009 (October 1, 2008 through September 30, 2009), and include 

bills posted to CMS' records through December 2009. 

 We are proposing that, in addition to meeting other criteria, if rural hospitals with 

fewer than 275 beds are to qualify for initial RRC status for cost reporting periods 

beginning on or after October 1, 2010, they must have a CMI value for FY 2009 that is at 

least-- 

● 1.5127; or 

● The median CMI value (not transfer-adjusted) for urban hospitals (excluding 

hospitals with approved teaching programs as identified in §413.75) 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 

Proposed 

Case-Mix 

Index Value 

1. New England (CT, ME, MA, NH, RI, VT) 1.3010

2. Middle Atlantic (PA, NJ, NY) 1.3590

3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV) 1.4559
CMS-1498-P 492 

Region 

Proposed 

Case-Mix 

Index Value 

4. East North Central (IL, IN, MI, OH, WI) 1.4262

5. East South Central (AL, KY, MS, TN) 1.3776

6. West North Central (IA, KS, MN, MO, NE, ND, SD) 1.4404

7. West South Central (AR, LA, OK, TX) 1.5181

8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY) 1.6004

9. Pacific (AK, CA, HI, OR, WA) 1.4826

 The preceding numbers will be revised in the FY 2011 IPPS final rule to the 

extent required to reflect the updated FY 2009 MedPAR file, which will contain data 

from additional bills received through March 2010. 

 A hospital seeking to qualify as an RRC should obtain its hospital-specific CMI 

value (not transfer-adjusted) from its fiscal intermediary or MAC. Data are available on 

the Provider Statistical and Reimbursement (PS&R) System. In keeping with our policy 

on discharges, the CMI values are computed based on all Medicare patient discharges 

subject to the IPPS MS-DRG-based payment. 

2. Discharges 

 Section 412.96(c)(2)(i) provides that CMS 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 
CMS-1498-P 493 

during FY 2008 (that is, October 1, 2007 through September 30, 2008), which are the 

latest cost report data available at the time this proposed rule was developed. 

 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, 2010, must have, as the number of discharges for its cost reporting period that 

began during FY 2008, 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 

Discharges 

1. New England (CT, ME, MA, NH, RI, VT) 7,701

2. Middle Atlantic (PA, NJ, NY) 11,346

3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV) 10,905

4. East North Central (IL, IN, MI, OH, WI) 9,329

5. East South Central (AL, KY, MS, TN) 5,902

6. West North Central (IA, KS, MN, MO, NE, ND, SD) 8,091

7. West South Central (AR, LA, OK, TX) 6,264

8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY) 9,346

9. Pacific (AK, CA, HI, OR, WA) 8,464

 These numbers will be revised in the FY 2011 IPPS final rule based on the latest 

available cost report data. 
CMS-1498-P 494 

 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, 2010, the hospital would be required to 

have at least 3,000 discharges for its cost reporting period that began during FY 2008. 

F. Indirect Medical Education (IME) Adjustment (§412.105)

1. Background 

 Section 1886(d)(5)(B) of the Act provides for an additional payment amount 

under the IPPS for hospitals that have residents in an approved graduate medical 

education (GME) program in order 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. 

 Pub. L. 105-33 (BBA 1987) 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, for cost reporting periods beginning on or after October 1, 1997, a hospital’s 

unweighted FTE count of residents for purposes of direct GME 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, a similar limit on 
CMS-1498-P 495 

the FTE resident count for IME purposes is effective for discharges occurring on or after 

October 1, 1997. 

2. IME Adjustment Factor for FY 2011 

 The IME adjustment to the MS-DRG payment is based in part on the applicable 

IME adjustment factor. The IME adjustment factor is calculated by using a hospital’s 

ratio of residents to beds, which is represented as r, and a formula multiplier, which is 

represented as c, in the following equation: c x [{1 + r} .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. In the FY 2005 IPPS final 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). Section 502(a) 

modified the formula multiplier beginning midway through FY 2004 and provided for a 

new schedule of formula multipliers for FYs 2005 and thereafter as follows: 

● For discharges occurring on or after April 1, 2004, and before October 1, 2004, 

the formula multiplier is 1.47. 

● For discharges occurring during FY 2005, the formula multiplier is 1.42. 

● For discharges occurring during FY 2006, the formula multiplier is 1.37. 

● For discharges occurring during FY 2007, the formula multiplier is 1.32. 
CMS-1498-P 496 

● For discharges occurring during FY 2008 and fiscal years thereafter, the 

formula multiplier is 1.35. 

 Accordingly, for discharges occurring during FY 2011, the formula multiplier is 

1.35. We estimate that application of this formula multiplier for the FY 2011 IME 

adjustment will result in an increase in IPPS payment of 5.5 percent for every 

approximately 10-percent increase in the hospital’s resident-to-bed ratio. 

3. IME-Related Changes in Other Sections of this Proposed Rule 

 We refer readers to section IV.H.2. and IV.H.3. of the preamble of this proposed 

rule for a discussion of proposed changes to the policies for identifying “approved 

medical residency programs” and the electronic submission of Medicare GME affiliation 

agreements. 

G. Payment Adjustment for Medicare Disproportionate Share Hospitals (DSHs): 

Supplemental Security Income (SSI) Fraction (§412.106)

1. Background 

Section 1886(d)(5)(F) of the Act provides for additional Medicare payments to 

subsection (d) hospitals that serve a significantly disproportionate number of low-income 

patients. The Act specifies two methods by which a hospital may qualify for the 

Medicare disproportionate share hospital (DSH) adjustment. Under the first method, 

hospitals that are located in an urban area and have 100 or more beds may receive a 

Medicare DSH payment adjustment if the hospital can demonstrate that, during its cost 

reporting period, more than 30 percent of its net inpatient care revenues are derived from 
CMS-1498-P 497 

State and local government payments for care furnished to needy patients with low 

incomes. This method is commonly referred to as the “Pickle method.” 

The second method for qualifying for the DSH payment adjustment, which is the 

most common, is based on a complex statutory formula under which the DSH payment 

adjustment is based on the hospital’s geographic designation, the number of beds in the 

hospital, and the level of the hospital's disproportionate patient percentage (DPP). A 

hospital's DPP is the sum of two fractions: the “Supplemental Security Income (SSI) 

fraction” and the “Medicaid fraction.” The SSI fraction (also known as the “SSI ratio” or 

the “Medicare fraction”) is computed by dividing the number of the hospital’s inpatient 

days that are furnished to patients who were entitled to both Medicare Part A (including 

patients who are enrolled in a Medicare Advantage (Part C) plan) and SSI benefits by the 

hospital’s total number of patient days furnished to patients entitled to benefits under 

Medicare Part A (including patients who are enrolled in a Medicare Advantage (Part C) 

plan). The Medicaid fraction is computed by dividing the hospital’s number of inpatient 

days furnished to patients who, for such days, were eligible for Medicaid, but were not 

entitled to benefits under Medicare Part A, by the hospital’s total number of inpatient 

days in the same period. 

Because the DSH payment adjustment is part of the IPPS, the DSH statutory 

references (under section 1886(d)(5)(F) of the Act) to “days” apply only to hospital acute 

care inpatient days. Regulations located at 42 CFR 412.106 govern the Medicare DSH 

payment adjustment and specify how the DPP is calculated as well as how beds and 

patient days are counted in determining the DSH payment adjustment. Under 
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§412.106(a)(1)(i), the number of beds for the Medicare DSH payment adjustment is 

determined in accordance with bed counting rules for the IME adjustment under 

§412.105(b). 

2. CMS’ Current Data Matching Process for the SSI Fraction 

From the inception of the Medicare DSH adjustment in 1986, CMS (formerly 

HCFA) has calculated the SSI fraction for each acute care hospital paid under the IPPS. 

This fraction, in combination with the Medicaid fraction, is used to determine whether 

the provider qualifies for a DSH payment adjustment and the amount of any such 

payment (51 FR 16772, 16777, May 6, 1986 interim final rule). In determining the 

number of inpatient days for individuals entitled to both Medicare Part A and SSI, as 

required for calculation of the numerator of the SSI fraction, CMS matches the Medicare 

records and SSI eligibility records for each hospital’s patients during the Federal fiscal 

year, unless the provider requests calculation of the SSI fraction on a cost reporting 

period basis (in which case the provider would receive its SSI fraction based on its own 

cost reporting period). The data underlying the match process are drawn from: (a) the 

Medicare Provider Analysis and Review (MedPAR) data file; and (b) SSI eligibility data 

provided by the Social Security Administration (SSA). CMS has matched Medicare and 

SSI eligibility records using Title II numbers (included in the SSI records) and Health 

Insurance Claims Account Numbers (HICANs) (contained in the MedPAR file). Below 

we provide a more detailed description of both a Title II number and a HICAN. 

 Title II Number: If a person qualifies for retirement or disability benefits under 

Title II of the Act (42 U.S.C. § 401 et seq.), SSA assigns a “Title II number” to the 
CMS-1498-P 499 

individual. If the Title II beneficiary’s own earnings history (or the individual’s 

disability) were the basis for such benefits, the person’s Social Security number (SSN) 

would constitute the “root” of the individual’s Title II number. However, if the person’s 

Title II benefits were based on the earnings history of another individual (for example, a 

spouse), that other person’s SSN would provide the root for the beneficiary’s Title II 

number. In addition to a root SSN, each Title II number ends with a Beneficiary 

Identification Code (BIC) that identifies the basis for an individual’s entitlement to 

benefits. For example, a person who becomes eligible for benefits under his or her own 

account would be described by his or her SSN followed by the BIC “A” whereas a wife 

who becomes eligible for benefits under her husband’s account would be described by his 

SSN followed by the BIC “B.” Children who become eligible under a parent’s account 

would be described by the parent’s SSN followed by the BIC “C1,” “C2,” etc. 

HICAN: When a person becomes entitled to Medicare benefits, he or she is 

assigned a HICAN for purposes of processing claims submitted on his or her behalf for 

Medicare services. A beneficiary’s HICAN (which may not necessarily contain his or 

her SSN) is included on the Medicare inpatient hospital claim. 

Each HICAN for a beneficiary should be identical, at the same point in time, to 

that individual’s Title II number. This is because HICANs and Title II numbers are both 

assigned on the basis of the same data source, the SSA-maintained Master Beneficiary 

Record, and by using the same rules (that is, the rules for determining which person’s 

SSN will serve as the root for an individual’s HICAN and Title II number and for 

determining the BIC for both types of numbers). 
CMS-1498-P 500 

We note that a person’s Title II number and HICAN can change over time. For 

example, if the individual’s entitlement to Title II and Medicare benefits was originally 

based on the earnings history of a first spouse, but the beneficiary later qualified for such 

benefits on the basis of a second spouse’s earnings history, the beneficiary’s HICAN and 

Title II number would change accordingly. Specifically, the first spouse’s SSN would be 

the root of the beneficiary’s original HICAN and Title II number; later, the second 

spouse’s SSN would become the root of the beneficiary’s second HICAN and Title II 

number. 

The SSI eligibility data that CMS receives from SSA contain monthly indicators 

to denote which month(s) each person was eligible for SSI benefits during a specific time 

period. The current matching process uses only one Title II number (which is included in 

the SSI file) and one HICAN (found in the MedPAR file) for each beneficiary. In the 

current matching process, CMS has used the HICAN because it is the patient identifier 

that is provided by hospitals on the Medicare claim. Because SSNs are not included on 

Medicare inpatient claims, CMS has not used SSNs in the match process. 

For a given fiscal year, CMS determines the numerator of the hospital’s SSI 

fraction (that is, the number of the hospital’s inpatient days for all of its patients who 

were simultaneously entitled to Medicare Part A benefits and SSI benefits) by calculating 

the sum of the number of the hospital’s inpatient days that are associated with all of the 

identical Title II numbers and HICANs for the hospital’s claims that are found through 

the data matching process. In turn, CMS determines the denominator of the hospital’s 

SSI fraction by calculating the sum of the number of the hospital’s inpatient days for 
CMS-1498-P 501 

patients entitled to benefits under Medicare Part A (regardless of SSI eligibility) that are 

included in the hospital’s inpatient claims for the period. 

3. Baystate Medical Center v. Leavitt Court Decision 

In Baystate Medical Center v. Leavitt, 545 F. Supp. 2d 20, as amended, 587 F. 

Supp. 2d 37, 44 (D.D.C. 2008), the district court concluded that, in certain respects, 

CMS’ current matching process (as described above) did not use the “best available data” 

to match Medicare patient day information with SSI eligibility data when calculating the 

plaintiff’s SSI fractions for FYs 1993 through 1996. Specifically, the court found that: 

● Stale SSI Records and Forced Pay SSI Records. For the earliest years in 

question in Baystate, the SSI eligibility data did not include “stale” records—that is, 

records for individuals whose SSI records were no longer active from SSA’s perspective. 

(We note that it is our understanding that, as of the year 2000, SSA no longer 

differentiates between inactive and active records and therefore, no longer uses the “stale 

record” indicator in its databases.) The court also found that the SSI data file only 

included SSI eligibility information for SSI payments that were automated (as opposed to 

manual), thereby excluding those people who, for whatever reason, received manual or 

“forced pay” payments. Baystate, 545 F. Supp. 2d at 44-46. 

● Match Based on Only One Title II Number and One HICAN. The court found 

fault with CMS’ use of only a single Title II number and one HICAN in the match 

process. As a beneficiary may receive SSI and Medicare Part A benefits under more than 

one Title II number and HICAN over a period of time, CMS would not have matched a 

beneficiary’s records if there had been a change in the person’s Title II number and 
CMS-1498-P 502 

HICAN between the time of an inpatient stay and when the match process was 

completed. Baystate, 545 F. Supp. 2d at 46-49. 

● Retroactive SSI Eligibility Determinations and Lifting of Payment Suspensions. 

The court found that the match process did not appropriately account for retroactive 

eligibility determinations of SSI eligibility and the lifting of payment suspensions 

because the match process used SSI eligibility data that did not include more recent 

retroactive determinations of SSI eligibility and the lifting of SSI payment suspensions. 

By not using more recent SSI eligibility information that was available to CMS at the 

time of the hospital’s cost report settlement, the court concluded that CMS did not use the 

“best available data” to calculate the provider’s SSI fraction. Baystate, 545 F. Supp. 2d 

at 42-44. 

 CMS continues to believe that its current data matching process and the resultant 

SSI fraction and DSH payments were lawful. Nonetheless, the agency did not appeal the 

Baystate decision. Accordingly, CMS implemented the court’s decision by recalculating 

the plaintiff’s SSI fractions for 1993 through 1996. In recalculating the SSI fractions at 

issue in the Baystate case, we worked closely with SSA to ensure that stale and forced 

pay SSI records were included in the SSI eligibility data. Also, we used a revised data 

matching process (described in more detail below) that comports with the court’s 

decision. As the revised data matching process was completed using SSI eligibility data 

compiled between 13 and 16 years beyond the fiscal years at issue in the Baystate case, 

we believe any issues associated with retroactive determinations of SSI eligibility and the 

lifting of payment suspensions had been long since resolved. Furthermore, because we 
CMS-1498-P 503 

believe that the revised match process used to implement the Baystate decision addressed 

all of the concerns found by the court, we are proposing to use the same revised data 

matching process for calculating hospitals’ SSI fractions for FY 2011 and subsequent 

fiscal years. 

4. CMS’ Proposed Process for Matching Medicare and SSI Eligibility Data 

a. Inclusion of Stale Records and Forced Pay Records in the SSI Eligibility Data Files 

In recalculating the SSI fractions at issue in the Baystate case, stale records and 

forced pay records were included in the SSI eligibility data files that CMS used in the 

revised data match for the four fiscal years at issue. All SSI payment records, whether 

the payments were automated or manual or were for an individual whose record was 

active or stale, are now included in the data files provided by SSA and will continue to be 

included in the future. 

b. Use of SSNs in the Revised Match Process 

As indicated above, the current matching process only uses one Title II number 

and one HICAN in the data match process. By contrast, our revised match process would 

make use of the Medicare Enrollment Database (EDB), which is CMS’ system of records 

for all individuals who have ever been enrolled in Medicare. The EDB includes SSNs as 

well as all of an individual’s HICANs. In our proposed revised match process, the 

individual’s SSN, contained in the SSI eligibility data file, would be compared to the 

SSNs in the Medicare EDB, and each matched SSN would then be “cross-walked” within 

the EDB to find any and all HICANs associated with the individual’s SSN. The resulting 
CMS-1498-P 504 

HICANs would then be matched against those HICANs contained in the MedPAR claims 

data files. 

Before explaining our proposed revised match process in more detail, we believe 

it is appropriate to provide some background regarding SSNs and the three databases that 

would be used in our proposed match process. An individual should have only one SSN, 

which should be unique to that individual. The SSN may be assigned by SSA when the 

individual begins gainful employment (if not earlier). However, if an applicant for SSI 

benefits does not already have a SSN, SSA then assigns a SSN to the person. Thus, in 

the SSI eligibility data that SSA provides to CMS, each individual identified in those data 

should have a unique SSN. 

The first database that we are proposing to use in our revised match process is the 

SSI eligibility data file, which contains a unique SSN for every SSI record and would 

include as many as 10 different historical Title II numbers for the records related to one 

individual. We are proposing to use 10 as the maximum number of Title II numbers for a 

beneficiary because that is likewise the maximum number of HICANs that can be 

attributed to any one individual in our EDB. However, we note that as a practical matter, 

the greatest number of historical HICANs associated with any beneficiary appears to be 

7. The SSI eligibility file serves as the system of record for whether or not SSA made a 

payment of SSI benefits to an individual who applied for SSI benefits. 

The second relevant database, the Medicare EDB, contains a SSN for virtually 

every record in the EDB. Furthermore, the EDB has the capacity to hold up to 10 

historical HICANs for a specific Medicare enrollee. (It is important to note that, of the 
CMS-1498-P 505 

more than 100 million records in the EDB, less than 0.07 percent (that is, fewer than 7 of 

every 10,000 records) relate to individuals for whom the EDB does not include a SSN for 

the person. The EDB might not include a SSN for an individual if, for example, the 

person lives in another country but is entitled to Medicare benefits through his or her 

spouse.) 

The third relevant database that we are proposing to use in our revised match 

process is the MedPAR file. Hospitals submit claims to Medicare for inpatient services 

provided to Medicare beneficiaries. These claims are eventually accumulated in the 

MedPAR database. It is important to note that the MedPAR database does not contain 

SSNs. The MedPAR database contains one HICAN number for each and every record of 

services provided to a Medicare beneficiary who was admitted to a Medicare-certified 

hospital or skilled nursing facility. This database allows us to calculate the number of 

Medicare inpatient hospital days, which we use in determining each hospital’s DSH SSI 

fraction. 

Utilizing the steps set forth below, we are proposing to use these three databases 

in a revised match process for FY 2011 and subsequent fiscal years: 

Step 1 -- Use SSNs to find any and all relevant HICANs. Using the SSI eligibility 

data file provided by SSA, we are proposing to compare the individual SSNs in that file 

to the SSNs contained in the Medicare EDB. Each matched SSN would then be “crosswalked” (within the EDB) to find any and all HICANs associated with the individual’s 

SSN. The resulting HICANs would then be matched against those HICANs contained in 

the MedPAR claims data files. This process should identify all relevant SSI records in 
CMS-1498-P 506 

which a SSN is associated with an individual who is simultaneously enrolled in Medicare 

Part A and in the SSI program. 

Step 2 -- Utilize any and all Title II numbers. In order to provide further 

assurance that all of the Title II numbers and HICANs for SSI-eligible individuals have 

been identified, next we are proposing to compare the complete list of Title II numbers 

from the SSI data file (up to 10 Title II numbers for any one individual) to the list of 

HICANs generated through Step 1 above. If the SSI data file includes any Title II 

numbers that were not already identified in Step 1, the Title II number will be included in 

our revised match process and compared to any and all HICANs in MedPAR. We note 

that by including this second step (that is, adding all Title II numbers not previously 

identified by Step 1), we are addressing the very small universe of individuals for whom 

the EDB does not include a SSN. If an individual is entitled to SSI benefits and Medicare 

benefits, the new format of the SSI eligibility file will contain up to 10 Title II numbers 

and, if they have not already been captured, each of those numbers will be included in our 

revised match process. Even if an individual does not have a SSN in the EDB, this 

second step should ensure that our revised match process will include that individual. 

Step 3 -- Ensure consistency between the HICANs in the EDB, Title II numbers, 

and the HICANs in the MedPAR file. The EDB stores the beneficiary’s record at the 

most specific level of detail. For example, if the beneficiary’s Medicare eligibility was 

originally based on a spouse’s earnings history and the spouse subsequently dies, the 

beneficiary would have two HICANs. Both HICANs, which would have the same root, 

but different BICs, would be stored in the EDB. However, the inpatient claim in the 
CMS-1498-P 507 

MedPAR file will only have the individual’s HICAN at a more general level of detail; in 

the preceding example, the BIC would identify the beneficiary only as a spouse without 

specifying whether the spouse (that is, the “primary” beneficiary) was alive or deceased. 

This third step should ensure consistency between the HICANs from Step 1 and the Title 

II numbers from Step 2 by “equating” (or converting) the BIC identifiers to the identifiers 

that are on the inpatient claim that is included in the MedPAR file. In addition, we are 

proposing that, for any SSI-eligible beneficiary who is receiving Medicare benefits based 

on his or her own account but whose records have not been matched already, we will 

attempt to match the beneficiary’s HICAN in the MedPAR file. Specifically, we are 

proposing to simply add an “A” to all the SSNs in the SSI eligibility data file so that, if 

that individual was not captured by Steps 1 and 2 above (for whatever unlikely reason) 

but MedPAR indicated that the person had received Medicare services, the individual 

would be included in the data match process by this third step. 

Step 4 -- Calculate the SSI fraction. We are not proposing any changes with 

respect to the final step in determining the SSI fraction. To calculate the numerator of the 

SSI fraction, CMS would continue to sum a hospital’s Medicare inpatient days in the 

acute care part of the hospital (excluding IPPS-exempt units such as rehabilitation and 

psychiatric units) where the Medicare beneficiary was simultaneously entitled to SSI 

benefits. To calculate the denominator, CMS would continue to sum a hospital’s total 

Medicare inpatient days in the acute care part of the hospital. 

c. Timing of the Match 
CMS-1498-P 508 

One of the district court’s findings in the Baystate decision was that CMS did not 

use the latest available SSI eligibility file to calculate the provider’s SSI fractions. As a 

result, it might be possible that if a beneficiary treated at the hospital was later 

determined retroactively to be SSI eligible or if a suspension of the individual’s SSI 

payments was later lifted, that inpatient stay might not be included in the numerator of 

the SSI fraction. We believe that, in our recalculation of the Baystate hospital’s SSI 

fractions and DSH payments, retroactive SSI eligibility determinations and the lifting of 

SSI payment suspensions were not an issue due to the long period of time that elapsed 

between the provider’s 1993 through 1996 fiscal years and our use of updated SSI 

eligibility data during our completion of the revised match process in 2009. However, we 

believe that further consideration of the timing of both the SSI eligibility information that 

SSA provides to CMS and our proposed revised match process for FY 2011 and 

subsequent fiscal years is warranted. 

At present, SSA provides an annual file to CMS with SSI eligibility information 

that is current through March 31, or 6 months after the end of the prior Federal fiscal year 

on September 30. (70 FR 47278, 47440, August 12, 2005). Based on this date, for a 

hospital with an October 1 to September 30 cost reporting period, the SSI eligibility 

information we currently use contains 6 to 18 months worth of retroactive SSI eligibility 

determinations and payment suspension closures--6 months from September (that is, the 

end of the cost reporting period) and 18 months from October (that is, the beginning of 

the cost reporting period). The time lag between the close of a hospital’s cost reporting 

period and the date that CMS receives SSI eligibility information could actually be longer 
CMS-1498-P 509 

or shorter for some hospitals, depending on the hospital’s specific cost reporting period. 

We note that SSI fractions are generally based on the Federal fiscal year. However, 

under the regulations at §412.106(b)(3), a hospital with a cost reporting period that 

differs from the Federal fiscal year may request a revised SSI fraction that is based on its 

own cost reporting period rather than the Federal fiscal year. In such a case, we would 

revise the hospital’s SSI fraction using SSI and Medicare data derived from the data 

match process for the two Federal fiscal years that spanned the hospital’s cost reporting 

period. 

As we stated in the FY 2006 final IPPS rule, we believe that administrative 

finality with respect to the calculation of a hospital’s SSI fraction is important 

(70 FR 47440). We continue to believe that it is important to find an appropriate balance 

between administrative finality (that is, the final settlement of a hospital’s cost report) 

and the inclusion of retroactive SSI eligibility determinations and the lifting of SSI 

payment suspensions by using the best and latest available SSI eligibility data at the time 

of cost report settlement. Further, we believe it is important to account for the time 

period in which hospitals are allowed to submit timely Medicare claims in order to ensure 

that the point in time that we perform the match process includes as many timely 

submitted inpatient hospital claims as are administratively practicable. 

 In accordance with the regulations at 42 CFR 424.44 and the Medicare Claims 

Processing Manual (Pub. 100-04), Chapter 1, Section 70, a hospital must generally file a 

claim by December 31 of the following year (for services furnished during the first 9 

months of a calendar year) and by December 31 of the second following year (for 
CMS-1498-P 510 

services provided during the last 3 months of the calendar year). Therefore, Medicare 

claims for hospital services furnished in FY 2011 would have to be submitted no later 

than December 31, 2012. We note that section 6404 of the Patient Protection and 

Affordable Care Act (Pub. L. 111-148), as amended, recently changed these deadlines to 

no more than “1 calendar year after the date of service” effective for services provided on 

or after January 1, 2010. 

Generally speaking, providers have a financial incentive to submit fee-for-service 

claims as close as possible to the date of the patient’s discharge, and providers have no 

incentive to wait until after the end of the fiscal year. Thus, while conducting a data 

match with MedPAR files that were updated 6 months after the end of the Federal fiscal 

year may not capture all of a provider’s Medicare inpatient claims, we believe that, in 

large part, the provider’s fee-for-service claims are included in that MedPAR file. The 

same may not be true for the “information only” or “no pay” claims that hospitals are 

required to submit to their fee-for-service contractor for Medicare Advantage (MA) 

beneficiaries. Because claims for MA beneficiaries are paid by MA plans and not the 

fee-for-service contractor, hospitals may not have the same incentive to file these claims 

as close as possible to the date of the patient’s discharge.14 However, in accordance with 

Transmittal 1396 (issued December 14, 2007) and Transmittal 1695 (issued 

March 6, 2009), which changed the instructions in the Medicare Claims Processing 

 

14 Teaching hospitals have an incentive to submit these claims because they receive an indirect medical 

education payment. The claims are also used for a teaching hospital’s direct medical education payments. 

Non-teaching DSH hospitals do not have the same direct incentives to submit these claims but to the extent 

that the MA beneficiary is also SSI eligible, it would be to the hospital’s advantage to ensure these claims 

are included in the match process. However, nonteaching DSH hospitals are required to submit MA claims 

for all MA beneficiaries, regardless of whether the beneficiaries were eligible for SSI benefits.
CMS-1498-P 511 

Manual (Pub. 100-04), all IPPS hospitals that do not qualify for IME payments, direct 

GME payments, or nursing and allied health (N&AH) payments are required to submit 

informational-only claims for all MA inpatients to ensure that data for MA beneficiaries 

is included in the SSI fraction. Accordingly, we also are considering changes to the 

timing of the data match process to ensure that all of a hospital’s MA claims are included 

in the revised matching process given the lack of incentives that exist to submit these 

claims as soon as possible after the time of the patient’s discharge. 

In addition, in matching eligibility records for Medicare beneficiaries and SSI 

recipients to calculate the SSI fractions for FY 2011 and future fiscal years, we are also 

proposing to use more recent SSI eligibility information from SSA and a more updated 

version of MedPAR that is likely to contain more claims data. We currently use SSI 

eligibility data and MedPAR claims data that are updated 6 months after the close of the 

Federal fiscal year. We are proposing to use, for FY 2011 and subsequent years, SSI 

eligibility data files compiled by SSA and MedPAR claims information that are updated 

15 months after the close of each Federal fiscal year. This proposal would more closely 

align the timing of the match process with the timing of our requirements (described 

above) for the timely submission of claims. For example, to calculate the FY 2011 SSI 

fractions, we would use the December 2012 update of the FY 2011 MedPAR file 

(containing claims information for patient discharges between October 1, 2010 and 

September 30, 2011), and a December 2012 SSI eligibility file (containing FY 2011 SSI 

eligibility data updated through December 2012, with a lag time relative to the Federal 

fiscal year of between 15 and 27 months). We expect that the FY 2011 SSI fractions 
CMS-1498-P 512 

would be published around March 2013 and would be used to settle cost reports for cost 

reporting periods that began in FY 2011. In addition, we would continue our practice of 

using each hospital’s latest available SSI fraction in determining IPPS interim payments 

from the time that the SSI fractions are published until the SSI fractions for the next fiscal 

year are published. 

Under current law as amended by section 6404 of Pub. L. 111-148, Medicare 

inpatient claims for FY 2011 can be submitted no later than 1 calendar year from the date 

of service or by September 30, 2012, for claims with a September 30, 2011 date of 

service. Therefore, we believe that using the version of MedPAR that is updated 15 

months after the end of the fiscal year would contain more accurate and complete 

inpatient claims information, as we would be using claims data from 3 months after the 

filing deadline for claims with a date of service occurring on the last day of the second 

preceding fiscal year. Furthermore, a later update of the SSI eligibility file would contain 

more accurate eligibility information and would account for all retroactive changes in SSI 

eligibility and the lifting of SSI payment suspensions through that date. 

The FY 2011 SSI fractions will be used to determine the hospitals’ Medicare 

DSH payments for cost reporting periods beginning in FY 2011 (that is, October 1, 2010 

through September 30, 2011). The proposed timing of the data match for the SSI 

fractions, effective for FY 2011, would result in FY 2011 SSI fractions being published 

around March 2013 and would generally coincide with the final settlement of cost reports 

for cost reporting periods beginning in FY 2011. 
CMS-1498-P 513 

We believe that, by calculating SSI fractions on the basis of SSI eligibility data 

and MedPAR claims data that are updated 15 months after the end of the Federal fiscal 

year, we would be using the best data available to us, given the deadlines for the 

submission and final settlement of Medicare cost reports. Cost reports must be submitted 

to the Medicare fiscal intermediary or MAC no later than 5 months after the end of the 

provider’s cost reporting period; the fiscal intermediary or MAC must make a 

determination of cost report acceptability within 30 days of receipt of the provider’s cost 

report (42 CFR 413.24(f)(2)(i) and 413.24(f)(5)(iii)). In accordance with the Medicare 

Financial Manual (Pub. 100-06), Chapter 8, Section 90, the fiscal intermediary or MAC 

is expected to settle each cost report that is not scheduled for audit within 12 months of 

the contractor’s acceptance of the cost report. We believe that our proposed timing of the 

data match would achieve an appropriate balance between accounting for additional 

retroactive SSI eligibility determinations and the lifting of SSI payment suspensions 

using all timely submitted Part A inpatient claims, and facilitating administrative finality 

through the timely final settlement of Medicare cost reports. 

Example of Timeline to Calculate FY 2011 SSI Fractions 

Under Current Policy 

Cost 

Reports 

That Use 

the FY 

2011 SSI 

Ratios 

Deadline 

for 

Timely 

Filing of 

Claims 

MedPAR 

File Used 

SSI 

Eligibility 

File Used 

Cost 

Reports 

Normally 

Accepted 

Cost 

Report 

Final 

Settlement

SSI 

Fraction 

Available

Cost 

reports 

December 

2012 

March 

2012 

March 

2012 

Generally 

between 

Generally 

between 

Summer 

2012 
CMS-1498-P 514 

beginning 

October 1, 

2010 

through 

September 

30, 2011 

update of 

FY 2011 

MedPAR 

update of 

FY 2011 

SSI 

eligibility 

March 

2012 and 

February 

2013 

March 

2013 and 

February 

2014 
CMS-1498-P 515 

Example of Timeline to Calculate FY 2011 SSI Fractions 

Under Proposed Rule 

Cost 

Reports 

That Use 

the FY 

2011 SSI 

Ratios 

Deadline 

for 

Timely 

Filing of 

Claims 

MedPAR 

File Used 

SSI 

Eligibility 

File Used 

Cost 

Reports 

Normally 

Accepted 

Cost 

Report 

Final 

Settlement

SSI 

Fraction 

Available

Cost 

reports 

beginning 

October 1, 

2010 

through 

September 

30, 2011 

December 

2012 

December 

2012 

update of 

FY 2011 

MedPAR 

December 

2012 

update of 

FY 2011 

SSI 

eligibility 

Generally 

between 

March 

2012 and 

February 

2013 

Generally 

between 

March 

2013 and 

February 

2014 

Spring 

2013 

5. CMS Ruling 

Tthe CMS Administrator has prepared a CMS Ruling that addresses three 

Medicare DSH issues, including CMS’ process for matching Medicare and SSI eligibility 

data and calculating hospitals’ SSI fractions. With respect to the data matching process 

issue, the Ruling requires the Medicare administrative appeals tribunal (that is, the 

Administrator of CMS, the PRRB, the fiscal intermediary hearing officer, or the CMS 

reviewing official) to remand each qualifying appeal to the appropriate Medicare 

contractor. The Ruling also explains how, on remand, CMS and the contractor will 

recalculate the provider’s DSH payment adjustment and make any payment deemed 

owing. The Ruling further provides that CMS and the Medicare contractors will apply 

the provisions of the Ruling, on the data matching process issue (and two other DSH 
CMS-1498-P 516 

issues, as applicable), in calculating the DSH payment adjustment for each hospital cost 

reporting period where the contractor has not yet final settled the provider’s Medicare 

cost report through the issuance of an initial notice of program reimbursement (NPR) (42 

CFR 405.1801(a) and 405.1803). 

 More specifically, the Ruling provides that, for qualifying appeals of the data 

matching issue and for cost reports not yet final settled by an initial NPR, CMS will 

apply any new data matching process that is adopted in the forthcoming FY 2011 IPPS 

final rule for each appeal that is subject to the Ruling. The data matching process 

provisions of the Ruling would apply to properly pending appeals and open cost reports 

for cost reporting periods beginning prior to October 1, 2010 (that is those preceding the 

effective date of the FY 2011 IPPS final rule). 

 The Ruling further states that, if a new data matching process is not adopted in the 

forthcoming FY 2011 IPPS final rule, CMS would apply to claims subject to the Ruling 

the same data matching process as the agency used to implement the Baystate decision by 

recalculating that provider’s SSI fractions. 

6. Clarification of Language on Inclusion of Medicare Advantage Days in the SSI 

Fraction of the Medicare DSH Calculation 

In the FY 2005 IPPS final rule (69 FR 49099), we discussed in the preamble our 

policy change to reflect the inclusion of the days associated with Medicare + Choice 

(now Medicare Advantage (MA)) beneficiaries under Medicare Part C in the SSI fraction 

of the DSH calculation. In that rule, we indicated that we were revising the regulation 

text at §412.106(b)(2)(i) to incorporate this policy. However, we inadvertently did not 
CMS-1498-P 517 

make a change in the regulation text to conform to the preamble language. We also 

inadvertently did not propose to change §412.106(b)(2)(iii) in the FY 2005 final rule, 

although we intended to do so. Accordingly, in the FY 2007 IPPS rule (72 FR 47384), 

we made a technical correction to amend the regulations at §412.106(b)(2)(i) and to 

§412.106(b)(2)(iii) to make them consistent with the preamble language of the FY 2005 

IPPS final rule and to conform to the policy implemented in that rule. Section 

412.106(b)(2)(i) of the regulations discusses the numerator of the SSI fraction of the 

Medicare disproportionate patient percentage (DPP) calculation, while 

§412.106(b)(2)(iii) of the regulations discusses the denominator of the SSI fraction of the 

Medicare DPP. 

We are aware that there might be some confusion about our policy to include MA 

days in the SSI fraction, specifically regarding whether we have implied that MA 

beneficiaries are not actually “entitled to receive benefits under Part A” by using the 

word “or” in §412.106(b)(2)(i)(B) and §412.106 (b)(2)(iii)(B) with respect to MA days. 

We note that in the FY 2005 final rule, we stated that we believed that Medicare + Choice 

(now MA) beneficiaries are patients who are entitled to benefits under Medicare Part A. 

With respect to the change to the regulatory text that we intended to make in the FY 2005 

IPPS final rule, we stated “...we are adopting a policy to include patient days for M+C 

beneficiaries in the Medicare fraction” (69 FR 49099) (emphasis added). In order to 

further clarify our policy that patients days associated with MA beneficiaries are to be 

included in the SSI fraction because they are still entitled to benefits under Medicare Part 
CMS-1498-P 518 

A, we are proposing to replace the word “or” with the word “including” in 

§412.106(b)(2)(i)(B) and §412.106 (b)(2)(iii)(B). 

H. Payments for Direct Graduate Medical Education (GME) (§413.75)

1. Background 

 Under section 1886(a)(4) of the Act, costs of approved educational activities are 

excluded from the operating costs of hospital inpatient services. Section 1886(h) of the 

Act, as implemented in regulations at §413.75 through §413.83, establishes a 

methodology for determining payments to hospitals for the direct costs of approved GME 

programs. Section 1886(h)(2) of the Act sets forth a methodology for the determination 

of a hospital-specific, base-period per resident amount (PRA) that is calculated by 

dividing a hospital’s allowable direct costs of GME for a base period by its number of 

residents in the base period. The base period is, for most hospitals, the hospital’s cost 

reporting period beginning in FY 1984 (that is, the period of October 1, 1983, through 

September 30, 1984). Medicare direct GME payments are calculated by multiplying the 

PRA by the weighted number of full-time equivalent (FTE) residents working in all areas 

of the hospital complex (and nonhospital sites, when applicable), and the hospital’s 

Medicare share of total inpatient days. The base year PRA is updated annually for 

inflation. 

 Hospitals may receive direct GME and IME payments for residents in “approved 

medical residency training programs.” Section 1886(h)(5)(A) of the Act defines an 

“approved medical residency training program” as “a residency or other postgraduate 

medical training program participation in which may be counted toward certification in a 
CMS-1498-P 519 

specialty or subspecialty and includes formal postgraduate training programs in geriatric 

medicine approved by the Secretary.” Section 1886(h)(4)(F) of the Act established a 

limit on the number of allopathic and osteopathic FTE residents that a hospital may 

include in its FTE resident count for purposes of calculating direct GME payments. For 

most hospitals, the limit, or cap, is the unweighted number of allopathic and osteopathic 

FTE residents training in the hospital's most recent cost reporting period ending on or 

before December 31, 1996. 

2. Identifying “Approved Medical Residency Programs” 

 Despite the fact that current policies regarding the counting of FTE residents for 

IME and direct GME purposes have been in effect since October 1985, we continue to 

receive questions as to whether certain residents are training in approved medical 

residency programs, and whether these residents should be included in the Medicare 

direct GME and IME FTE counts. Although the fundamental rules defining an approved 

medical residency training program seem straightforward, some confusion apparently 

exists regarding whether certain trainees in a teaching hospital should be included in the 

FTE count for IME and direct GME purposes, or whether certain trainees should be 

treated as physicians and should instead bill for their services under Medicare Part B. 

These questions arise most often with regard to subspecialty training and “fellows.” It is 

important for hospitals to understand when each of these types of payment applies. 

a. Residents in Approved Medical Residency Programs 

As stated earlier, section 1886(h)(5)(A) of the Act defines an “approved medical 

residency training program” as “a residency or other postgraduate medical training 
CMS-1498-P 520 

program participation in which may be counted toward certification in a specialty or 

subspecialty and includes formal postgraduate training programs in geriatric medicine 

approved by the Secretary.” The regulations at §413.75(b) define an “approved medical 

residency program” as a program that meets one of the following criteria (emphasis 

added): 

(1) Is approved by one of the national organizations listed in §415.152 of the 

regulations. 

(2) May count towards certification of the participant in a specialty or 

subspecialty listed in the current edition of either of the following publications: 

(i) The Directory of Graduate Medical Education Programs published by the 

American Medical Association; or 

(ii) The Annual Report and Reference Handbook published by the American 

Board of Medical Specialties. 

(3) Is approved by the Accreditation Council for Graduate Medical Education 

(ACGME) as a fellowship program in geriatric medicine. 

(4) Is a program that would be accredited except for the accrediting agency's 

reliance upon an accreditation standard that requires an entity to perform an induced 

abortion or require, provide, or refer for training in the performance of induced abortions, 

or make arrangements for such training, regardless of whether the standard provides 

exceptions or exemptions. 

The regulations at §415.152 define an “approved graduate medical education 

program” as a residency program approved by one of the following national 
CMS-1498-P 521 

organizations (or their predecessors): the Accreditation Council for Graduate Medical 

Education (ACGME) of the American Medical Association, the American Osteopathic 

Association (AOA), the Commission on Dental Accreditation (CODA) of the American 

Dental Association, and the Council on Podiatric Medical Education (CPME) of the 

American Podiatric Medical Association. The statutory basis for this regulation is at 

section 1861(b)(6) of the Act, which cites these accrediting bodies for residency 

programs. Thus, in general, under §413.75(b), an “approved” program can be a program 

that is accredited by one of these national organizations, or one that leads toward board 

certification by the American Board of Medical Specialties (ABMS). In the 

September 29, 1989 final rule (54 FR 40295), we explained that, in order to reconcile the 

two statutory definitions of approved programs at sections 1861(b)(6) and 1886(h)(5)(A) 

of the Act, we did not limit our regulatory definition of “approved medical residency 

program” to one that may count toward certification in a specialty, but added that a 

program is also “approved” for purposes of IME and direct GME if it is approved by one 

of the national accrediting bodies. Furthermore, we understood that, especially with 

respect to subspecialty training, there historically were some formal programs for which 

none of the listed national accrediting bodies had established standards. However, the 

ABMS had established a national board examination for some of those unaccredited 

programs and, consequently, those programs do count toward certification. Accordingly, 

such programs also meet the definition of an “approved medical residency training 

program.” 

b. Determining Whether an Individual Is a Resident or a Physician 
CMS-1498-P 522 

The statute and the regulations (in at least two places in the teaching context) 

define the term “resident.” Section 1861(b)(6) of the Act refers to services provided in a 

hospital by an “intern or resident-in-training under a teaching program approved” by one 

of the listed accrediting bodies for residency programs. In addition, section 1886(h)(5)(I) 

of the Act states that the term “resident” includes “an intern or other participant in an 

approved medical residency training program.” The regulations at §413.75(b) state that 

the term resident means “an intern, resident, or fellow who participates in an approved 

medical residency program, including programs in osteopathy, dentistry, and podiatry, as 

required in order to become certified by the appropriate specialty board.” 

As discussed above, an “approved” program is one that is accredited by one of the 

listed national organizations, or one that may count towards board certification. 

Generally, residency programs today, whether they are core or subspecialty programs, are 

both accredited, and lead toward board certification through an explicit board 

examination for that field. Thus, in the typical instance, a resident is accepted into an 

accredited program in a particular specialty, completes that program over the course of 

what is typically 3 to 5 years, and then qualifies to take the board certifying examination 

in the particular specialty of that program. This resident may or may not train in an 

additional accredited subspecialty program, which would typically last for 1 to 3 years, 

and which would also lead to board certification through an additional board certifying 

examination which the individual would be qualified to take upon completion. 

We receive questions from time to time regarding whether individuals are 

considered to be trainees in approved programs or whether they are considered to be 
CMS-1498-P 523 

physicians and should bill accordingly. These questions frequently involve programs of 

further training that certain senior and junior faculty at hospitals, typically at large 

academic medical centers, undertake on their own, not under the auspices of any 

accrediting body, and in an area of practice for which there is no board certification. 

Therefore, there is no actual standardized curriculum or formally organized “program” in 

which the individual trainee is participating. Another type of trainee about which we 

have received questions is one that has completed an accredited program in a certain 

specialty, but subsequently participates in additional training in that specialty that he or 

she could have participated in while still within the accredited program. Sometimes this 

individual may even train with residents who are actually still training in that accredited 

program (for example, an individual who has completed a dermatology residency may 

choose to do additional training with PGY4 dermatology residents). In these scenarios, 

in order to decide whether an individual is considered a resident or a physician for 

purposes of Medicare payment, the pertinent questions are whether-- 

(1) The individual actually needs the training in order to meet board certification 

requirements in that specialty; and

(2) Whether the individual is formally participating in an organized, 

standardized, structured course of study. 

With regard to the junior faculty who are “training” with senior faculty to learn 

highly specialized skills, we believe that individuals participating in a course of training 

that one or more senior physicians creates absent the involvement and approval of an 

accrediting body, and for which there is no specific existing board certification 
CMS-1498-P 524 

examination, should not be considered “residents” or counted for IME and direct GME 

purposes. Similarly, individuals that already completed an accredited residency 

program, but subsequently participate in additional training in that same specialty that 

they could have participated in while still within that accredited program, should also 

not be considered “residents” or be included in the IME and direct GME count. This is 

because these individuals have already completed accredited residency programs in a 

particular specialty or subspecialty, and do not need to complete the additional training 

in order to meet board certification requirements in that field in which they continue to 

“train.” The definition of “resident” at §413.75(b) is “an intern, resident, or fellow who 

participates in an approved medical residency program, including programs in 

osteopathy, dentistry, and podiatry, as required in order to become certified by the 

appropriate specialty board” (emphasis added). Accordingly, the individuals described 

in the scenarios above do not meet the definition of “resident” at §413.75(b) for IME 

and direct GME purposes. Instead, these individuals should be treated and receive 

payment as physicians. 

 As we explained in the September 29, 1989 Federal Register rule: “The costs 

relating to patient care services of licensed physicians who are classified as “fellows” but 

who are not in an identifiable formal program leading to certification as defined in 

section 1886(h)(5) of the Act but remain at a teaching hospital/medical school complex to 

enhance their expertise in a field of study are payable on a Part B reasonable charge basis 

[now under the Medicare physician fee schedule] as physicians’ services” (54 FR 40295). 

Similarly, in the Provider Reimbursement Manual, Part I, section 2405.3.F.2, we state, 
CMS-1498-P 525 

“Intermediaries must not count an individual in the indirect medical education adjustment 

if . . . [A]n individual designated as a “fellow” has elected to remain at a teaching 

hospital/university complex for additional work to gain expertise in a particular field but 

is no longer in a formally organized program to fulfill certification requirements. The 

services of such an individual are generally covered as physicians' services payable on a 

reasonable charge basis” (emphasis added). (Note: Although we used the term “fellow,” 

which is defined synonymously with “resident” in the regulations at §413.75, in these 

paragraphs in the September 29, 1989 Federal Register and in the PRM-I, by stating that 

such “fellows” are not in identifiable, formally organized programs and their services 

should be billed under Part B as physician services, we clearly were indicating that these 

“fellows” are licensed physicians, not residents, and should not be included in the IME 

and direct GME FTE counts. Perhaps “junior faculty” would have been a more apt 

characterization of these individuals.) 

The passage from the September 29, 1989 Federal Register also mentions an 

“identifiable formal program leading to certification as defined in section 1886(h)(5) of 

the Act” which refers to the statutory definition of “approved medical residency 

program.” The word “approved” connotes formality; a planned, structured course of 

study with a curriculum based on national (rather than individual physician or hospital) 

standards with a standardized outcome based on standardized evaluations. Since the 

early days of Medicare, prior to the enactment of section 1886(h) of the Act, when 

hospitals received payment on a reasonable cost basis for “approved educational 

activities,” we defined such activities as “formally organized or planned programs of 
CMS-1498-P 526 

study operated or supported by an institution, as distinguished from ‘on-the-job,’ 

‘inservice,’ or similar work-learning programs” (emphasis added) (PRM-I, section 

402.1). We believe the education that junior faculty receive when working closely with 

senior faculty to gain highly specialized skills is more appropriately characterized as onthe-job, or inservice training, rather than training in an “approved medical residency 

program.”

In order for the training to be considered an “approved medical residency 

program,” the training must prepare the individual for certification in the particular 

specialty or subspecialty in which the individual is training. The mere possibility that the 

training could be construed as leading toward or counting toward certification in some 

existing board examination is insufficient. For example, an individual who is enrolled 

and participating in a two year accredited subspecialty program in allergy and 

immunology and, as part of that program, completes an elective in allergic reactions to 

insect stings is considered a resident during that elective, and may be included in the IME 

and direct GME FTE count (assuming all other requirements are met). However, if, after 

completion of the 2-year allergy and immunology subspecialty program, this individual 

decides to remain at the teaching hospital for a year to shadow a physician who has 

unique expertise in allergic reactions to insect stings, this individual would not be 

considered a resident, nor would this training be considered an approved program, 

because this individual is not formally enrolled in a planned, structured, standardized 

course of study, nor is this year of training required for any individual to qualify to take 

the board examination in allergy and immunology. This individual already completed the 
CMS-1498-P 527 

2-year subspecialty program, and therefore, the extra year spent studying allergic 

reactions to insect stings is extraneous. Accordingly, this individual would not be viewed 

as a resident participating in an approved medical residency training program. Rather, 

this individual is considered a physician and should bill Medicare for services furnished 

under the physician fee schedule. 

c. Formal Enrollment and Participation in a Program 

We understand that the participation of individuals in an approved medical 

residency program under which they would be considered residents as defined at §413.75 

is marked by a formal application, acceptance, and enrollment process. We believe that 

in order for an individual to be considered a resident for purposes of inclusion in the IME 

and direct GME counts, whether the individual is a graduate of an allopathic medical 

school, an osteopathic medical school, or a school of podiatry or dentistry, the individual 

must be: 

(1) Formally accepted and enrolled in the training program, and 

(2) Fully participating in that training (unless there is a documented arrangement 

for the resident to work part time). 

In general, we would expect formal acceptance to include an application process 

(for example, the national residency match process), and an enrollment process which 

would include letters or other official notifications from the hospital or program sponsor 

regarding the resident's acceptance to train in a particular program. We would also expect 

the resident to have an employment contract with the institution(s) sponsoring the 

program and/or the institution(s) in which he or she is training. A hospital must be able 
CMS-1498-P 528 

to document that the individual’s participation in the particular course of training 

represents a definitive (not hypothetical) path for that individual’s certification, and that 

satisfactory completion of such training would fulfill all required elements in order for 

the individual to qualify to take a specific board examination. 

In order to make these rules clearer for the future, we are proposing to revise the 

definition of “resident” to specify that the trainee must be “formally accepted and 

enrolled” in the approved program in order to be considered a resident for IME and direct 

GME purposes. Specifically, we are proposing to revise the definition of “resident” at 

§413.75(b) to mean “an intern, resident, or fellow who is formally accepted, enrolled, and 

participating in an approved medical residency program, including programs in 

osteopathy, dentistry, and podiatry, as required in order to become certified by the 

appropriate specialty board.” We also are proposing to make a similar conforming 

change to the definition of “primary care resident” at §413.75(b). This change in the 

definitions of “resident” and “primary care resident” would be effective for IME and 

direct GME for cost reporting periods beginning on or after October 1, 2010. 

In summary, we are proposing to clarify that individuals participating in a 

specialized course of training created by a senior physician, and not under the auspices of 

a national accrediting body, and for which there is no explicit existing board certification 

examination, should not be counted for IME and direct GME purposes. Such individuals 

should be treated as physicians, and their services should be billed to Medicare for 

payment as physicians’ services. If an individual has already successfully completed at 

least one residency program and has met the requirements to be board eligible in a 
CMS-1498-P 529 

specialty (regardless of whether the individual has passed the board examination for that 

specialty), and is engaged in subsequent training that will not provide additional 

knowledge or skills that could be applied for board certification in a subspecialty, the 

individual should be treated and bill for services provided as a physician. We also are 

proposing to revise the definition of “resident” at §413.75(b) to mean “an intern, resident, 

or fellow who is formally accepted, enrolled, and participating in an approved medical 

residency program, including programs in osteopathy, dentistry, and podiatry, as required 

in order to become certified by the appropriate specialty board.” We are proposing to 

make a conforming change to the definition of “primary care resident” to mean “a 

resident who is formally accepted, enrolled, and participating in an approved medical 

residency training program in family medicine, general internal medicine, general 

pediatrics, preventive medicine, geriatric medicine or osteopathic general practice.” This 

change in the definitions of “resident” and “primary care resident” would be effective for 

IME and direct GME for cost reporting periods beginning on or after October 1, 2010. 

3. Electronic Submission of Affiliation Agreements 

Sections 1886(h)(4)(F) and 1886(d)(5)(B)(v) of the Act establish limits on the 

number of allopathic and osteopathic FTE residents that hospitals may count for purposes 

of calculating direct GME payments and the IME adjustment. In addition, under the 

authority granted by section 1886(h)(4)(H)(ii) of the Act, the Secretary issued regulations 

on May 12, 1998 (63 FR 26358) to allow institutions that are members of the same 

Medicare GME affiliated group to elect to apply their direct GME and IME FTE resident 

caps based on the aggregate cap of all hospitals that are part of a Medicare GME 
CMS-1498-P 530 

affiliation group. Under those regulations, specified at §413.79(f) for direct GME and at 

§412.105(f)(1)(vi) for IME, hospitals that are part of the same Medicare GME affiliated 

group are permitted to adjust each hospital's caps to reflect the rotation of residents 

among affiliated hospitals during an academic year. Under §413.75(b), a Medicare GME 

affiliated group may be formed by two or more hospitals if: (1) the hospitals are located 

in the same urban or rural area or in a contiguous area and have a shared rotational 

arrangement as specified at §413.79(f)(2); (2) the hospitals are not located in the same or 

in a contiguous area, but have a shared rotational arrangement and they are jointly listed 

as the sponsor, primary clinical site, or major participating institution for one or more 

programs as these terms are used in the most recent publication of the Graduate Medical 

Education Directory, or as the sponsor or is listed under “affiliations and outside 

rotations” for one or more programs in Opportunities, Directory of Osteopathic Postdoctoral Education Programs; or (3) effective beginning July 1, 2003, two or more 

hospitals are under common ownership and have a shared rotational arrangement under 

§413.79(f)(2). 

The existing regulations at §413.79(f)(1) specify that each hospital in a Medicare 

GME affiliated group must submit a Medicare GME affiliation agreement (as defined 

under §413.75(b)) to the CMS fiscal intermediary or MAC servicing the hospital and 

send a copy of the agreement to CMS’ Central Office no later than July 1 of the residency 

program year during which the Medicare GME affiliation agreement will be in effect. 

For example, in order for a hospital to receive a temporary adjustment to its FTE resident 

caps to reflect participation in a Medicare GME affiliated group for the academic year 
CMS-1498-P 531 

beginning July 1, 2009, through June 30, 2010, the hospital in the affiliated group had to 

submit a Medicare GME affiliation agreement to the fiscal intermediary or MAC 

servicing the hospital and send a copy of the agreement to CMS’ Central Office no later 

than July 1, 2009. 

Over the last several years, we have received numerous inquiries regarding the 

possibility of submitting the Medicare GME affiliation agreement electronically. To 

date, CMS has only accepted signed hard copies of Medicare GME affiliation agreements 

that are received through the mail. Facsimile (FAX) and other electronic submissions of 

affiliation agreements have not been acceptable means of transmission of affiliation 

agreements to CMS Central Office in order for a hospital to meet the requirements of 

§§413.79(f) and 412.105(f)(1)(vi). 

The increasing frequency of these inquiries and our concerns regarding 

environmental and paperwork reduction have prompted us to reconsider our procedure 

for hospitals to submit Medicare GME affiliation agreements to the CMS Central Office. 

Accordingly, we are proposing to change our policy to provide for electronic submission 

of the affiliation agreement that is required to be sent to the CMS Central Office. This 

proposal would not affect the authority of the fiscal intermediary or MAC to continue to 

specify its requirements for submission for hospitals in its servicing area. 

We are proposing an electronic submission process that would consist of either an 

e-mail mailbox or a Web site where hospitals would submit their Medicare GME 

affiliation agreements to the CMS Central Office. As part of this process, a copy of the 

Medicare GME affiliation agreement would need to be received through the electronic 
CMS-1498-P 532 

system no later than 11:59 p.m. on July 1 of each academic year. We are proposing that 

the electronic affiliation agreement would need to be submitted either as a scanned copy 

or a Printer-Friendly Display (PDF) version of that hard copy agreement; we are 

proposing not to accept an agreement in any electronic format that could be subject to 

manipulation. The scanned and/or PDF format will enable CMS to ensure that the 

agreements are signed and dated as required in the regulations at §413.75. 

We believe that allowing an electronic submission of the affiliation agreement to 

the CMS Central Office would assist us in more effectively tracking the groups of 

hospitals that affiliate as well as the numbers of FTE cap slots that are being transferred 

within those groups. In addition, we believe an electronic submission process would 

minimize the paperwork burden for hospitals. 

I. Certified Registered Nurse Anesthetist (CRNA) Services Furnished in Rural Hospitals 

and CAHs

 Section 2312 of the Deficit Reduction Act of 1984 (Pub. L. 98-369) provided for 

reimbursement to hospitals on a reasonable cost basis for the costs that hospitals incur in 

connection with the services of certified registered nurse anesthetists (CRNAs). Section 

2312(c) provided that pass-through of CRNA costs was effective for cost reporting 

periods beginning on or after October 1, 1984, and before October 1, 1987. Section 9320 

of the Omnibus Budget Reconciliation Act of 1986 (Pub. L. 99–509) (which established a 

fee schedule for the services of nurse anesthetists) amended section 2312(c) of Pub. L. 

98-369 by extending the CRNA pass-through provision through cost reporting periods 

beginning before January 1, 1989. In addition, Pub. L. 99-509 amended section 1861 of 
CMS-1498-P 533 

the Act to add a new subsection (bb), which provides that CRNA services include 

anesthesia services and related care furnished by a CRNA. Section 608 of the Family 

Support Act of 1988 (Pub. L. 100-485) extended pass-through payments for CRNA 

services through 1991 and amended section 9320 of Pub. L. 99-509 by including 

language referring to eligibility for pass-through payments for CRNA services if the 

facility is “...a hospital located in a rural area (as defined for purposes of section 1886(d) 

of the Social Security Act)....” Reasonable cost-based payment for CRNA services was 

extended indefinitely by section 6132 of the Omnibus Budget Reconciliation Act of 1989 

(Pub. L. 101–239). 

Section 1886(d)(2)(D) of the Act defines “rural” as any area outside an urban 

area. This definition of “rural” was in effect when Pub. L. 100-485 was implemented. In 

1999, the Balanced Budget Refinement Act (Pub. L. 106-113) amended section 

1886(d)(8) of the Act by adding a new subparagraph (E), which permits a hospital 

physically located in an urban area to apply for reclassification to be treated as rural. In 

addition, Pub. L. 106-113 made a corresponding change to section 1820(c)(2)(B)(i) of the 

Act, which specifies the location requirements for CAH designation, by adding the phrase 

“or is treated as being located in a rural area pursuant to section 1886(d)(8)(E).” 

 The regulations implementing pass-through payments for anesthesia services and 

related care furnished by qualified nonphysician anesthetists employed by a hospital or 

CAH, including CRNAs, are located at §412.113(c). Section 412.113(c)(2)(i)(A) 

specifies the location requirement for facilities that furnish these services and are eligible 

to be paid based on reasonable cost for the services. The regulations require that the 
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hospital or CAH be located in a rural area as defined at §412.62(f) and not be deemed to 

be located in an urban area under the provisions of §412.64(b)(3). The regulations at 

§412.62(f) mirror section 1886(d)(2)(D) of the Act and define a rural area as “... any area 

outside an urban area.” The regulations at §412.64(b)(3) implement section 

1886(d)(8)(B) of the Act, also known as the “Lugar” provision, which requires a hospital 

located in a rural county adjacent to one or more urban areas to be treated as being 

located in the urban metropolitan statistical area to which the greatest number of workers 

in the county commute. 

 Under existing regulations, neither CAHs/hospitals that have reclassified from 

urban to rural under the regulations at §412.103 nor CAHs/hospitals located in Lugar 

counties are eligible to receive pass-through payments for anesthesia services and related 

care furnished by qualified nonphysician anesthetists. We believe that because the 

statute, as revised by section 608 of Pub. L. 100–485, allows for reasonable cost 

payments for CRNA services if the facility is a hospital located in a rural area as defined 

for purposes of section 1886(d) of the Act, it is appropriate for us to make the regulations 

consistent by permitting urban hospitals that have been reclassified as rural to qualify for 

these payments. Therefore, we are proposing to revise §412.113(c)(2)(i)(A) to state that 

effective for cost reporting periods beginning on or after October 1, 2010, CAHs and 

hospitals that have reclassified pursuant to section 1886(d)(8)(E) of the Act and §412.103 

of the regulations are also rural for purposes of section 1886(d) of the Act and, therefore, 

are eligible to be paid based on reasonable cost for anesthesia services and related care 

furnished by a qualified nonphysician anesthetist. 
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We are not proposing to change our regulations to permit Lugar facilities to be 

paid based on reasonable cost for anesthesia services and related care furnished by 

qualified nonphysician anesthetists. As noted above, in order to be paid based on 

reasonable cost for anesthesia services and related care furnished by a qualified 

nonphysician anesthetist, a hospital or CAH must be considered rural for purposes of 

section 1886(d) of the Act. Lugar facilities (facilities that have been reclassified under 

§§412.63(b)(3) and 412.64(b)(3)) are considered urban for purposes of section 1886(d) of 

the Act. As a result, we do not believe it would be consistent with the statute and our 

regulations to permit these facilities to be paid on a reasonable cost basis for anesthesia 

services and related care furnished by qualified nonphysician anesthetists. 

J. Rural Community Hospital Demonstration Program

 Section 410A(a) of Pub. L. 108-173 required the Secretary to establish a 

demonstration program to test the feasibility and advisability of establishing "rural 

community hospitals" to furnish covered inpatient hospital services to Medicare 

beneficiaries. The demonstration pays rural community hospitals for such services under 

a cost-based methodology 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; 
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● Provides 24-hour emergency care services; and 

● Is not designated or eligible for designation as a CAH under section 1820 of 

the Act. 

Section 410A(a)(4) of Pub. L. 108-173 (MMA) specified that the Secretary was to 

select for participation no more than 15 rural community hospitals in rural areas of States 

that the Secretary identified as having low population densities. Using 2002 data from 

the U.S Census Bureau, we identified the 10 States with the lowest population density in 

which rural community hospitals were to be located in order to participate in the 

demonstration: 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). 

CMS originally solicited applicants for the demonstration in May 2004; 13 

hospitals began participation with cost report years beginning on or after 

October 1, 2004. (Four of these 13 hospitals withdrew from the program and became 

CAHs). In a notice published in the Federal Register on February 6, 2008 

(73 FR 6971), we announced a solicitation for up to 6 additional hospitals to participate 

in the demonstration program. Four additional hospitals were selected to participate 

under this solicitation. These four additional hospitals began under the demonstration 

payment methodology with the hospital’s first cost reporting period starting on or after 

July 1, 2008. Three hospitals (2 of the hospitals were among the 13 hospitals that 

originally participated in the demonstration and 1 of the hospitals was among the 

4 hospitals that began the demonstration in 2008) withdrew from the demonstration 
CMS-1498-P 537 

during CY 2009. (Two of these hospitals indicated that they will be paid more for 

Medicare inpatient services under the rebasing allowed under the SCH methodology 

allowed by the Medicare Improvement for Patients and Providers Act of 2008 (Pub. L. 

110-275). The other hospital restructured to become a CAH.) There are currently 10 

hospitals participating in the demonstration. 

Section 410A(a)(5) of Pub. L. 108-173 required a 5-year demonstration period of 

participation. For the seven currently participating hospitals that began the demonstration 

during FY 2005, the demonstration was scheduled to end for each of these hospitals on 

the last day of its cost reporting period that ends in FY 2010. The end of the participation 

for the three participating hospitals that began the demonstration in CY 2008 was 

scheduled to be September 30, 2010. A 5-year extension of the demonstration was 

mandated in the Patient Protection and Affordable Care Act (PPACA, Pub. L. 111-148). 

We note that this proposed rule does not address the relevant changes mandated by 

Pub. L. 111-148. Pub. L. 111-148 does affect our proposed FY 2011 policy with regard 

to the rural community hospital demonstration. However, we will address that provision 

of Pub. L. 111-148 and any revised policy proposals in a separate rulemaking document 

in the Federal Register. 

Section 410A of Pub. L. 108-173 required 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.” This requirement is 

commonly referred to as “budget neutrality.” 
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 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 hospitals do not exceed the amount that would be 

paid to those same hospitals in the absence of the demonstration program. Typically, 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 

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 same hospitals. 

 In the past six IPPS final regulations, spanning the period for which the 

demonstration has been implemented, we have adjusted the national inpatient PPS rates 

by an amount sufficient to account for the added costs of this demonstration program, 

thus applying budget neutrality across the payment system as a whole rather than merely 
CMS-1498-P 539 

across the participants in this demonstration program. As we discussed in the FY 2005, 

FY 2006, FY 2007, FY 2008, FY 2009, and FY 2010 IPPS final rules (69 FR 49183; 

70 FR 47462; 71 FR 48100; 72 FR 47392; 73 FR 48670; and 74 FR 43922), we believe 

that the language of the statutory budget neutrality requirements permits the agency to 

implement the budget neutrality provision in this manner. 

 In this proposed rule, in order to ensure that the demonstration in FY 2007 is 

budget neutral, we are proposing to incorporate a component into the adjustment factor to 

the FY 2011 national IPPS rates that would offset the amount by which the costs of the 

demonstration program, as indicated by settled cost reports beginning in FY 2007 for 

hospitals participating in the demonstration during FY 2007, exceeded the amount that 

was identified in the FY 2007 final rule as the budget neutrality offset for FY 2007. 

Specifically, we are proposing the following methodology: (1) Calculate the FY 2007 

costs of the demonstration program according to the settled cost reports that began in 

FY 2007 for the then participating hospitals (which represent the third year in the 

demonstration for each of the then participating hospitals); (2) Subtract the amount that 

was offset by the budget neutrality adjustment for FY 2007 ($9,197,870) from the costs 

of the demonstration in FY 2007 as calculated in step 1; and (3) Calculate an adjustment 

factor for the standardized amount for FY 2011 based on the dollar amount calculated in 

step 2 of this proposed methodology. This factor would represent the component of the 

proposed overall budget neutrality offset amount for FY 2011 that accounts for the 

difference between the cost of the demonstration in FY 2007 and the amount of the 

budget neutrality adjustment published in the FY 2007 final rule. 
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 With respect to the first step of this proposed methodology, we note that we are 

proposing to use settled cost reports beginning in FY 2007 for hospitals participating in 

the demonstration during FY 2007 because we believe that these settled cost reports 

correspond most accurately to FY 2007 and because all such costs reports also began in 

FY 2007. Therefore, we believe they correctly represent FY 2007 inpatient costs for the 

demonstration during that period. In addition, in the process of making adjustments 

comparing the demonstration’s costs to the amounts estimated annually for the budget 

neutrality offset over the demonstration’s entire period of performance, the cost amounts 

from these hospitals’ cost reports correspond most precisely to FY 2007. In addition, the 

settlement process for the demonstration hospitals’ third year cost reports, that is, cost 

reporting periods starting in FY 2007, has experienced a delay. Therefore, for this 

FY 2011 IPPS proposed rule, we are unable to calculate the costs of the demonstration 

corresponding to FY 2007 and as a result are unable to propose the specific numeric 

adjustment that would be applied to the national IPPS rates. However, we expect cost 

reports beginning in FY 2007 for hospitals that participated in the demonstration during 

FY 2007 to be settled before the FY 2011 IPPS final rule is published. Therefore, for the 

FY 2011 IPPS final rule, we will be able to calculate the amount by which the costs 

corresponding to FY 2007 exceeded the amount offset by the budget neutrality 

adjustment for FY 2007. 

V. Proposed Changes to the IPPS for Capital-Related Costs 

 On March 23, 2010, the Patient Protection and Affordable Care Act (PPACA), 

Pub. L. 111-148 was enacted. Following the enactment of Pub. L. 111-148, the Health 
CMS-1498-P 541 

Care and Education Reconciliation Act of 2010, Public L. 111-152 (enacted on 

March 30, 2010), amended certain provisions of Pub. L. 111-148. A number of the 

provisions of Pub. L. 111-148, as amended by Pub. L. 111-152, affect the IPPS and the 

LTCH PPS and the providers and suppliers addressed in this proposed rule. However, 

due to the timing of the passage of the legislation, we are unable to address those 

provisions in this proposed rule. Therefore, the proposed policies and payment rates in 

this proposed rule do not reflect the new legislation. We plan to issue separate 

rulemaking documents in the Federal Register addressing the provisions of 

Pub. L. 111-148, as amended, that affect our proposed policies and payment rates for FY 

2011 under the IPPS and LTCH PPS, as well as the provisions of Pub. L. 111-148, as 

amended, that affect the policies and payment rates for FY 2010 under the IPPS and 

LTCH PPS. 
CMS-1498-P 542 

A. Overview

 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 Federal fiscal 

year (FY) 1992 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). 

 FY 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 almost all 

acute care hospitals (other than hospitals receiving certain exception payments and 

certain new hospitals). (We refer readers to the FY 2002 IPPS final rule (66 FR 39910 

through 39914) for additional information on the methodology used to determine capital 

IPPS payments to hospitals both during and after the transition period.) The basic 

methodology for determining capital prospective payments using the Federal rate is set 

forth in §412.312 of the regulations. For the purpose of calculating payments for each 

discharge, currently the standard Federal rate is adjusted as follows: 
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 (Standard Federal Rate) x (DRG Weight) x (Geographic Adjustment Factor 

(GAF)) x (COLA for hospitals located in Alaska and Hawaii) x (1 + Capital DSH 

Adjustment Factor + Capital IME Adjustment Factor, if applicable). 

B. Exception Payments

 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 FY 2003 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 the 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 
CMS-1498-P 544 

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 are required to submit documentation to the fiscal intermediary or MAC 

indicating the completion date of their project. (For more detailed information regarding 

the special exceptions policy under §412.348(g), we refer readers to the FY 2002 IPPS 

final rule (66 FR 39911 through 39914) and the FY 2003 IPPS final rule (67 FR 50102).) 

C. New Hospitals

 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 example, the following hospitals are not considered new hospitals: 

(1) a hospital that builds new or replacement facilities at the same or another location, 

even if coincidental with a change of ownership, a change in management, or a lease 

arrangement; (2) a hospital that closes and subsequently reopens; (3) a hospital that has 

been in operation for more than 2 years but has participated in the Medicare program for 

less than 2 years; and (4) a hospital that changes its status from a hospital that is excluded 

from the IPPS to a hospital that is subject to the capital IPPS. For more detailed 

information, we refer readers to the FY 1992 IPPS final rule (56 FR 43418). During the 
CMS-1498-P 545 

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, as discussed in the 

FY 2003 IPPS final rule (67 FR 50101), we believe that special protection to new 

hospitals is also appropriate even after the transition period, 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 full prospective payment based on 100 percent of the 

Federal rate. (We refer readers to the FY 2003 IPPS final rule (67 FR 50101 through 

50102) for a detailed discussion of the special payment provisions for new hospitals 

under the capital IPPS after the 10-year transition period.) 

D. Hospitals Located in Puerto Rico

Section 412.374 of the regulations 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. 
CMS-1498-P 546 

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 hospitals located 

in Puerto Rico 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 located 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 

located 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. 

E. Proposed Changes for FY 2011: MS-DRG Documentation and Coding 

Adjustment

1. Background on the Prospective MS-DRG Documentation and Coding Adjustments for 

FY 2008 and FY 2009 

 In the FY 2008 IPPS final rule with comment period (72 FR 47175 through 

47186), we adopted the MS-DRG patient classification system for the IPPS, effective 

October 1, 2007, to better recognize patients’ severity of illness in Medicare payment 

rates. Adoption of the MS-DRGs resulted in the expansion of the number of DRGs from 

538 in FY 2007 to 745 in FY 2008. (Currently, there are 746 MS-DRGs, including one 
CMS-1498-P 547 

additional MS-DRG created in FY 2009. For FY 2011, there would be 747 DRGs with 

our proposals in this proposed rule to delete one MS- DRG and to create two new 

MS-DRGs.) By increasing the number of DRGs and more fully taking into account 

patients’ severity of illness in Medicare payment rates, the MS-DRGs encourage 

hospitals to change their documentation and coding of patient diagnoses. In that same 

final rule with comment period (72 FR 47183), we indicated that we believe the adoption 

of the MS-DRGs had the potential to lead to increases in aggregate payments without a 

corresponding increase in actual patient severity of illness due to the incentives for 

changes in documentation and coding. Accordingly, we established adjustments to both 

the national operating standardized amount and the national capital Federal rate to 

eliminate the estimated effect of changes in documentation and coding resulting from the 

adoption of the MS-DRGs that do not reflect real changes in case-mix. Specifically, we 

established prospective documentation and coding adjustments of -1.2 percent for 

FY 2008, -1.8 percent for FY 2009, and -1.8 percent for FY 2010. However, to comply 

with section 7(a) of Pub. L. 110-90, enacted on September 29, 2007, in a final rule 

published in the Federal Register on November 27, 2007 (72 FR 66886 through 66888), 

we modified the documentation and coding adjustment for FY 2008 to -0.6 percent, and 

consequently revised the FY 2008 IPPS operating and capital payment rates, factors, and 

thresholds accordingly, with these revisions effective October 1, 2007. 

 For FY 2009, section 7(a) of Pub. L. 110-90 required a documentation and coding 

adjustment of -0.9 percent instead of the -1.8 percent adjustment established in the 

FY 2008 IPPS final rule with comment period. As discussed in the FY 2008 IPPS final 
CMS-1498-P 548 

rule with comment period (72 FR 48447 and 48733 through 48774), we applied a 

documentation and coding adjustment of -0.9 percent to the FY 2009 IPPS national 

standardized amounts and the capital Federal rate. The documentation and coding 

adjustments established in the FY 2009 IPPS final rule, as amended by Pub. L. 110-90, 

are cumulative. As a result, the -0.9 percent documentation and coding adjustment in 

FY 2009 was in addition to the -0.6 percent adjustment in FY 2008, yielding a combined 

effect of -1.5 percent. (For additional details on the development and implementation of 

the documentation and coding adjustments for FY 2008 and FY 2009, we refer readers to 

section II.D. of this preamble and the following rules published in the Federal Register: 

August 22, 2007 (72 FR 47175 through 47186 and 47431 through 47432); 

November 27, 2007 (72 FR 66886 through 66888); and August 19, 2008 (73 FR 48447 

through 48450 and 48773 through 48775).) 

2. Retrospective Evaluation of FY 2008 Claims Data 

 In the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule, we presented the results 

of a retrospective evaluation of the FY 2008 data for claims paid through 

December 2008. Based on this evaluation, our actuaries determined that implementation 

of the MS-DRG system resulted in a 2.5 percent change due to documentation and coding 

that did not reflect real changes in case-mix for discharges occurring during FY 2008 

(74 FR 24092 through 24101). We also sought public comment on our methodology and 

analysis and the proposed -1.9 percent prospective adjustment to address the effect of 

documentation and coding changes unrelated to changes in real case-mix in FY 2008 

(that is, the estimated -2.5 percent documentation and coding effect for FY 2008 minus 
CMS-1498-P 549 

the -0.6 percent documentation and coding adjustment that was applied to the national 

capital Federal rate for FY 2008). In addition, we sought public comment on addressing 

in the FY 2011 rulemaking cycle any differences between the increase in FY 2009 

case-mix due to documentation and coding changes that do not reflect real changes in 

case-mix for discharges occurring during FY 2009 and the -0.9 percent prospective 

documentation and coding adjustment applied in determining the FY 2009 capital Federal 

rate established in the FY 2009 IPPS final rule. However, after consideration of the 

public comments received on the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule, 

consistent with the application of the documentation and coding adjustment to the 

operating IPPS standardized amounts, we determined that it would be appropriate to 

postpone the adoption of any additional documentation and coding adjustments to the 

capital IPPS rates until a full analysis of FY 2009 case-mix changes could be completed. 

We stated that although we only proposed to make a -1.9 percent adjustment to account 

for the portion of the estimated 2.5 percent change in FY 2008 case-mix due to 

documentation and coding changes that exceeds the -0.6 percent prospective 

documentation and coding adjustment applied to the FY 2008 capital Federal rate (that is, 

-2.5 percent minus -0.6 percent = -1.9 percent), our then current estimate of the MS-DRG 

documentation and coding effect for FY 2009 was 2.3 percent (that is, the 4.8 percent 

total increase minus the 2.5 percent increase from FY 2008). We indicated that if the 

estimated documentation and coding effect determined based on a full analysis of 

FY 2009 claims data is more or less than our then current estimates, it would change the 

anticipated cumulative adjustments that we then estimated we would have to make for 
CMS-1498-P 550 

FY 2008 and FY 2009 combined. We indicated that, in future rulemaking, we would 

consider applying a prospective documentation and coding adjustment to the capital IPPS 

rates based on a complete analysis of FY 2008 and FY 2009 claims data (74 FR 43926 

through 43928). 

3. Retrospective Analysis of FY 2009 Claims Data 

 For this proposed rule, we have performed a thorough retrospective evaluation of 

the most recent available claims data, and the results of this evaluation were used by our 

actuaries to determine any necessary payment adjustments beyond the cumulative 

-1.5 percent adjustment that has already been applied to the national capital Federal rate 

to ensure budget neutrality for the implementation of MS-DRGs. Specifically, as 

discussed in greater detail in section II.D.5. of the preamble of this proposed rule, we 

performed a retrospective evaluation of the FY 2009 claims data updated through 

December 2009 using the same analysis methodology as we did for FY 2008 claims in 

the FY 2010 IPPS/RY 2010 LTCH PPS proposed and final rules. Based on this 

evaluation, our actuaries have determined that the implementation of the MS-DRG 

system resulted in a 5.4 percent change in case-mix due to documentation and coding that 

did not reflect real changes in case-mix for discharges occurring during FY 2009. 

The 5.4 percent estimate of the cumulative effect of changes in documentation 

and coding under the MS-DRG system that did not reflect real changes in case-mix for 

FYs 2008 and 2009 exceeds the cumulative -1.5 percent prospective documentation and 

coding adjustment that has already been applied to the national capital Federal rate by 

3.9 percentage points (5.4 percent minus 1.5 percent). An additional cumulative 
CMS-1498-P 551 

adjustment of -3.9 percent to the national capital Federal rate would be necessary to 

eliminate the full effect of the documentation and coding changes due to the adoption of 

the MS-DRGs on future payments. We intend to update our analysis with FY 2009 data 

on claims paid through March 2009 for the FY 2011 IPPS/LTCH PPS final rule. 

4. Proposed Prospective MS-DRG Documentation and Coding Adjustment to the 

National Capital Federal Rate for FY 2011 and Subsequent Years 

We continue to believe that it is appropriate to make adjustments to the capital 

IPPS rates to eliminate the effect of any documentation and coding changes as a result of 

the implementation of the MS-DRGs. These adjustments are intended to ensure that 

future annual aggregate IPPS payments are the same as payments that otherwise would 

have been made had the prospective adjustments for documentation and coding applied in 

FY 2008 and FY 2009 accurately reflected the change due to documentation and coding 

that occurred in those years. As noted in section V.A. of this preamble, under section 

1886(g) of the Act, the Secretary has broad authority in establishing and implementing 

the IPPS for acute care hospital inpatient capital-related costs (that is, the capital IPPS). 

We have consistently stated since the initial implementation of the MS-DRG system that 

we do not believe it is appropriate for Medicare expenditures under the capital IPPS to 

increase due to MS-DRG related changes in documentation and coding. Accordingly, we 

believe that it is appropriate under the Secretary’s broad authority under section 1886(g) 

of the Act, in conjunction with section 1886(d)(3)(A)(vi) of the Act and section 7(b) of 

Pub. L. 110-90, to make adjustments to the capital Federal rate to eliminate the full effect 

of the documentation and coding changes resulting from the adoption of the MS-DRGs. 
CMS-1498-P 552 

We believe that this is appropriate because, in absence of such adjustments, the effect of 

the documentation and coding changes resulting from the adoption of the MS-DRGs 

results in inappropriately high capital IPPS payments because that portion of the increase 

in aggregate payments is not due to an increase in patient severity of illness (and costs). 

As discussed in greater detail in section II.D.7. of this preamble, we explain that 

we are proposing a -2.9 percent adjustment for FY 2011 under the authority of section 

7(b)(1)(B) of Pub. L. 110-90. We refer readers to that section of the preamble for a 

detailed discussion of the issue. In section II.D.6. of this preamble, we also discuss our 

retrospective evaluation of the FY 2009 claims, and our actuaries’ determination that 

implementation of the MS-DRG system resulted in a 5.4 percent change in case-mix due 

to documentation and coding that did not reflect real changes in case-mix for discharges 

occurring during FY 2009. The estimated 5.4 percent cumulative documentation and 

coding effect for FYs 2008 and 2009 exceeds the cumulative -1.5 percent prospective 

documentation and coding adjustment that has already been applied to the national capital 

Federal rate. Thus, an additional cumulative adjustment of -3.9 percent would be 

necessary to meet the requirements of section 7(b)(1)(A) of Pub. L. 110-90 to make an 

appropriate prospective adjustment to the IPPS operating average standardized amounts 

in order to eliminate the full effect of the documentation and coding changes on future 

payments. However, we are not proposing a prospective adjustment to the IPPS 

operating average standardized amounts under section 7(b)(1)(A) of Pub. L. 110-90 for 

FY 2011. 
CMS-1498-P 553 

 As discussed above in this section, given the increase in payments that we have 

determined is due to documentation and coding, we believe it is necessary and 

appropriate under the Secretary’s broad authority under section 1886(g) of the Act, in 

conjunction with section 1886(d)(3)(A)(vi) of the Act and section 7(b) of Pub. L. 110-90, 

to make further adjustments to the capital Federal rate to eliminate the full effect of the 

documentation and coding changes resulting from the adoption of the MS-DRGs. 

It is often our practice to phase in rate adjustments over more than one year in 

order to moderate the effect on rates in any one year. Therefore, consistently with 

transitional policies we have adopted in many similar cases and in order to maintain 

consistency as far as possible with the adjustments that we are proposing to apply to IPPS 

hospitals, we are proposing an adjustment of -2.9 percent in FY 2011 to the national 

capital Federal rate. We believe that this proposed adjustment allows us to moderate the 

effects to hospitals in one year and to maintain equity between hospitals paid on the basis 

of different prospective rates. We are seeking public comment on the proposed 

-2.9 percent prospective adjustment to the national capital Federal rate for FY 2011 and 

our plans to address in future rulemaking cycles the cumulative effect of changes in 

case-mix due to changes in documentation and coding that do not reflect real changes in 

case-mix for discharges occurring during FY 2008 and FY 2009, noting that our current 

estimates of the remaining adjustment to the national capital Federal rate is -1.0 percent. 

We intend to update our analysis with FY 2009 data on claim paid through March 2009 

for the FY 2011 IPPS/LTCH PPS final rule. 
CMS-1498-P 554 

Therefore, in this proposed rule, under the Secretary’s broad authority under 

section 1886(g) of the Act, in conjunction with section 1886(d)(3)(A)(vi) of the Act and 

section 7(b) of Pub. L. 110-90, we are proposing to reduce the capital Federal rate in 

FY 2011 by -2.9 percent to account for the cumulative effect of the estimated changes in 

documentation and coding changes under the MS-DRG system in FYs 2008 and 2009 

that did not reflect real changes in case-mix. Furthermore, consistent with our proposal 

for the hospital-specific rates under the operating IPPS, we are proposing to leave that 

proposed -2.9 percent adjustment in place for subsequent fiscal years to account for the 

effect in FY 2011 and subsequent years. As noted above, we intend to address in future 

rulemaking cycles the remaining estimated adjustment to the national capital Federal rate 

of -1.0 percent (that is, the estimated cumulative effect of documentation and coding 

changes under the MS-DRG system for FYs 2008 and 2009 of -5.4 percent minus the 

existing -0.6 percent and -0.9 adjustments and the proposed FY 2011 of -2.9 percent 

adjustment). 

5. Proposed Documentation and Coding Adjustment to the Puerto Rico-Specific Capital 

Rate 

 Under §412.74, Puerto Rico hospitals are currently paid based on 75 percent of 

the national capital Federal rate and 25 percent of the Puerto Rico-specific capital rate. In 

the FY 2009 IPPS final rule (73 FR 48775), consistent with our development of the 

FY 2009 Puerto Rico-specific operating standardized amount, we did not apply the 

additional -0.9 percent documentation and coding adjustment (or the cumulative 

-1.5 percent adjustment) to the FY 2009 Puerto Rico-specific capital rate. However, the 
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statute gives broad authority to the Secretary under section 1886(g) of the Act, with 

respect to the development of and adjustments to a capital PPS, and therefore we would 

not be outside the authority of section 1886(g) of the Act in applying the documentation 

and coding adjustment to the Puerto Rico-specific portion of the capital payment rate. To 

date, we had not applied a documentation and coding adjustment to the Puerto 

Rico-specific capital rate because we have historically made changes to the capital IPPS 

consistent with those changes made to the operating IPPS. We stated that we may 

propose to apply such an adjustment to the Puerto Rico capital rates in the future. 

 As discussed in the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43928), 

when we performed a retrospective evaluation of the FY 2008 claims data of hospitals 

located in Puerto Rico using the same methodology discussed above, we found that the 

change in case-mix due to documentation and coding that did not reflect real changes in 

case-mix for discharges occurring during FY 2008 from hospitals located in Puerto Rico 

was approximately 1.3 percent. Given this case-mix increase due to changes in 

documentation and coding under the MS-DRGs, we had proposed to adjust the Puerto 

Rico-specific capital rate by –1.3 percent in FY 2010 for the FY 2008 increase in casemix due to changes in documentation and coding under the MS-DRGs. However, in that 

same final rule, postponed the adoption of any documentation and coding adjustments to 

the capital IPPS rates until a full analysis of FY 2009 case-mix changes could be 

completed. We indicated that any future documentation and coding adjustment to the 

capital Puerto Rico-specific IPPS rates based on a complete analysis of FY 2008 and 
CMS-1498-P 556 

FY 2009 claims data for Puerto Rico hospitals would be established through the notice 

and comment rulemaking process.

As discussed in section II.D.9. of this preamble, when we performed a 

retrospective evaluation of the FY 2009 claims data of hospitals located in Puerto Rico 

using the same methodology discussed above, we found that the change in case-mix due 

to documentation and coding that did not reflect real changes in case-mix for discharges 

occurring during FY 2008 from hospitals located in Puerto Rico was approximately 

2.4 percent. Given this case-mix increase due to changes in documentation and coding 

under the MS-DRGs, consistent with our proposal to adjust the FY 2011 capital Federal 

rate presented above and consistent with our proposed adjustment to the FY 2011 Puerto 

Rico-specific standardized amount discussed in section II.D.9. of the preamble of this 

proposed rule, under the Secretary’s broad authority under section 1886(g) of the Act, we 

are proposing to adjust the Puerto Rico-specific capital rate by –2.4 percent in FY 2011 

for the cumulative increase in case-mix due to changes in documentation and coding 

under the MS-DRGs for FYs 2008 and 2009. In addition, consistent with our other 

proposals concerning prospective MS-DRG documentation and coding adjustments to the 

capital Federal rate and operating IPPS standardized amounts presented in this proposed 

rule, we are proposing to leave that proposed –2.4 percent adjustment in place for 

subsequent fiscal years in order to ensure that changes in documentation and coding 

resulting from the adoption of the MS-DRGs do not lead to an increase in aggregate 

payments not reflective of an increase in real case-mix. We are proposing that the 

proposed -2.4 percent documentation and coding adjustment would be applied to the 
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capital Puerto Rico-specific rate that accounts for 25 percent of payments to hospitals 

located in Puerto Rico, with the remaining 75 percent based on the proposed national 

capital Federal rate, which we are proposing to adjust for documentation and coding as 

described above. Consequently, the proposed overall reduction to the FY 2011 payment 

rates for hospitals located in Puerto Rico to account for documentation and coding 

changes would be slightly less than the reduction for IPPS hospitals paid based on 

100 percent of the national capital Federal rate. As noted above, the Puerto Rico-specific 

capital rate was not adjusted for the cumulative effects of documentation and coding 

changes in FY 2008 or FY 2009 as is the case with the national capital Federal rate. 

F. Other Proposed Changes for FY 2011

 The proposed annual update to the capital IPPS national and Puerto Rico-specific 

rates, as provided for at §412.308(c), for FY 2011 is discussed in section III. of the 

Addendum to this proposed rule. 

VI. Proposed Changes for Hospitals Excluded from the IPPS 

A. Excluded Hospitals

 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. A 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, and updated annually by a rate-ofincrease percentage. The updated target amount was multiplied by total Medicare 

discharges during that period and applied as an aggregate upper limit (the ceiling as 
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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, which included 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 to 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.) 

For FY 2011, we are proposing that the rate-of-increase percentage to be applied 

to the target amount for cancer and children's hospitals and RNHCIs would be the 

proposed FY 2011 percentage increase in the IPPS operating market basket. Beginning 

with FY 2006, we have used the percentage increase in the IPPS operating market basket 

to update the target amounts for children’s and cancer hospitals. As explained in the 

FY 2006 IPPS final rule (70 FR 47396 through 47398), with IRFs, IPFs, and LTCHs 

being paid under their own PPS, the remaining number of providers being paid based on 

reasonable cost subject to a ceiling (that is, children’s and cancer hospitals and RNHCIs) 

is too small and the cost report data are too limited to be able to create a market basket 

solely for these hospitals. We are proposing to continue to use the IPPS market basket to 

update the target amounts for children’s and cancer hospitals and RNHCIs for the reasons 

discussed in the FY 2006 IPPS final rule. 
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We are proposing to use the revised and rebased FY 2006-based IPPS operating 

market baskets to update the target amounts for children’s and cancer hospitals and 

RNHCIs for FY 2011. Based on IHS Global Insight, Inc.'s 2010 first quarter forecast, 

with historical data through the 2009 fourth quarter, we are estimating that the FY 2011 

update to the IPPS operating market basket would be 2.4 percent (that is, the current 

estimate of the market basket rate-of-increase). 

We calculated the proposed rate-of-increase in the IPPS operating market basket 

for FY 2011 using the most recent data available. However, if data that are more recent 

become available for the final rule, we will use them to calculate the IPPS operating 

market basket update for FY 2011. Therefore, consistent with our proposal that the 

rate-of-increase percentage for cancer and children's hospitals and RNHCIs would be the 

proposed percentage increase in the FY 2011 IPPS operating market basket, the proposed 

FY 2011 rate-of-increase percentage that would be applied to FY 2010 target amounts in 

order to calculate the FY 2011 target amounts for cancer and children's hospitals and 

RNHCIs would be 2.4 percent, in accordance with the applicable regulations in 42 CFR 

413.40. 

We note that IRFs, IPFs, and LTCHs, which were paid previously under the 

reasonable cost methodology, now receive payment under their own prospective payment 

systems, in accordance with changes made to the statute. In general, the prospective 

payment systems for IRFs, IPFs, and LTCHs provided transition periods of varying 

lengths during which time a portion of the prospective payment was based on cost-based 

reimbursement rules under Part 413. (However, certain providers do not receive a 
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transition period or may elect to bypass the transition period as applicable under 

42 CFR Part 412, Subparts N, O, and P.) We note that the various transition periods 

provided for under the IRF PPS, the IPF PPS, and the LTCH PPS have ended. 

The IRF PPS, the IPF PPS, and the LTCH PPS are updated annually. We refer 

readers to section IV. of the Addendum to this proposed rule for the specific proposed 

update changes to the Federal payment rates for LTCHs under the LTCH PPS for 

RY 2011. The annual updates for the IRF PPS and the IPF PPS are issued by the agency 

in separate Federal Register documents. 

B. Critical Access Hospitals (CAHs)

1. Background 

 Section 1820 of the Act provides for the establishment of Medicare Rural 

Hospital Flexibility Programs (MRHFPs) under which individual States may designate 

certain facilities as critical access hospitals (CAHs). Facilities that are so designated and 

that meet the CAH conditions of participation under 42 CFR Part 485, Subpart F, will be 

certified as CAHs by CMS. Regulations governing payments to CAHs for services to 

Medicare beneficiaries are located in 42 CFR Part 413. 

2. CAH Optional Method Election for Payment of Outpatient Services 

 Section 1834(g) of the Act establishes the payment rules for outpatient services 

furnished by a CAH. Section 403(d) of Pub. L. 106-113 (BBRA) amended section 

1834(g) of the Act to provide for two methods of payment for outpatient services 

furnished by a CAH. Specifically, section 1834(g)(1) of the Act, as amended by 

Pub. L. 106-113, provided that the amount of payment for outpatient services furnished 
CMS-1498-P 561 

by a CAH is equal to the reasonable cost of providing such services, unless the CAH 

made an election, under section 1834(g)(2) of the Act, to receive amounts that were equal 

to the reasonable cost of the CAH for facility services plus, with respect to the 

professional services, the amount otherwise paid for professional services under 

Medicare, less the applicable Medicare deductible and coinsurance amount. The election 

made under section 1834(g)(2) of the Act is sometimes referred to as "method II." 

Throughout this section of this preamble, we refer to this election as the "optional 

method." Section 202 of Pub. L. 106-554 (BIPA) amended section 1834(g)(2)(B) of the 

Act to increase the payment for professional services under the optional method to 

115 percent of the amount otherwise paid for professional services under Medicare. In 

addition, section 405(a)(1) of Pub. L. 108-173 (MMA) amended section 1834(g)(l) of the 

Act by inserting the phrase "equal to 101 percent of" before the phrase “the reasonable 

costs.” However, the MMA made no changes to the amount of payment under the 

optional method at section 1834(g)(2)(A) of the Act. As stated earlier, the proposed 

policies and payment rates in this proposed rule do not reflect the provisions of the 

recently enacted Pub. L. 111-148, as amended by Pub. L. 111-152. We plan to address 

the provisions of Pub. L. 111-148, as amended, as they affect payments to CAHs in 

separate documents in the Federal Register or through further instructions. 

 Accordingly, section 1834(g) of the Act currently provides for two methods of 

payment for outpatient CAH services. Under the method specified at section 1834(g)(1) 

of the Act, facility services are paid at 101 percent of reasonable costs to the CAH 

through the Medicare fiscal intermediary or the Medicare Part A/B MAC, while 
CMS-1498-P 562 

payments for physician and other professional services are made to the physician or other 

practitioner under the Medicare Physician Fee Schedule (MPFS) through the Medicare 

carriers. Under section 1834(g)(2) of the Act (the optional method), a CAH submits bills 

for both the facility and the professional services to its Medicare fiscal intermediary or its 

Medicare Part A/B MAC. If a CAH chooses this optional method for outpatient services, 

the physician or other practitioner must reassign his or her billing rights to the CAH to 

bill the Medicare program for those services. In accordance with section 1834(g)(2) of 

the Act, under this optional method, the CAH receives reasonable cost payment for its 

facility costs and, with respect to the professional services, 115 percent of the amount 

otherwise paid for professional services under Medicare. 

 The existing regulations at §413.70(b)(3)(i)(A) require that if a CAH wishes to 

elect the optional method, that election must be made in writing, made on an annual 

basis, and delivered to the fiscal intermediary servicing the CAH at least 30 days before 

the start of the cost reporting period for which the election is made. The regulations at 

§413.70(b)(3)(i)(B) specify that once an election is made for a cost reporting period, that 

election remains in effect for all of that period. Therefore, under the existing regulations, 

a CAH that is being paid under the optional method is required to submit an election on 

an annual basis if it wishes to continue to be paid under the optional method for a 

subsequent cost reporting period. 

We have been informed that, in past years, some CAHs have submitted their 

elections several days late, which has caused these CAHs to lose their optional method 

election for the entire cost reporting year and has resulted in financial hardship for these 
CMS-1498-P 563 

providers. Such untimely submission of the optional method election may be due to 

staffing turnovers at the CAH as well as a change in fiscal intermediary or MAC 

assignments because, in the past, some CAHs received correspondence from their fiscal 

intermediaries or MACs reminding them to elect the optional method on an annual basis. 

Due to the significant consequences if a CAH fails to make a timely election, we are 

proposing to amend the regulations at §413.70(b)(3)(i) to state that, effective for CAH 

cost reporting periods beginning on or after October 1, 2010, if a CAH has elected the 

optional method for its most recent cost reporting period beginning prior to 

October 1, 2010 or chooses to elect the optional method for its upcoming cost reporting 

period, that election will remain in place until it is terminated. 

We believe that removing the annual election requirement will reduce any 

perceived burden associated with the election process and make it easier for CAHs to 

maintain their election if they experience administrative staffing changes. If a CAH is 

being paid under the traditional method and wishes to elect the optional method, it must 

submit its election in writing to its servicing fiscal intermediary or MAC at least 30 days 

prior to the first cost reporting period for which the election is effective. Once that initial 

election is made, it will remain in place until it is terminated. 

We are proposing to revise the regulations to include a mechanism for CAHs that 

are being paid under the optional method to terminate that election. Specifically, we are 

proposing that if a CAH is being paid under the optional method and wishes to terminate 

that election, it must submit its termination request to the fiscal intermediary or MAC 

servicing the CAH at least 30 days prior to the start of the next cost reporting period. 
CMS-1498-P 564 

Because the proposed effective date for this provision is for cost reporting periods 

beginning on or after October 1, 2010, CAHs that have cost reporting periods beginning 

in October 2010 or November 2010 may not have sufficient time to terminate their 

optional method election at least 30 days prior to the start of the cost reporting period. 

Therefore, we are proposing that CAHs that have cost reporting periods beginning in 

October 2010 or November 2010 and elected the optional method in 2009 that wish to 

terminate that election will have until December 1, 2010, to terminate their prior year 

election. The termination will be effective for the entire FY 2011 cost reporting period. 

Thus, if a CAH with a cost reporting period beginning in October 2010 or November 

2010 terminates its optional method election after the beginning of its cost reporting 

period but before December 1, 2010, the fiscal intermediary or MAC would be instructed 

to reprocess any payments made under the optional method for services provided during 

that period as efficiently as possible. 

 Section 1834(g)(2)(B) of the Act provides that if a CAH elects the optional 

method, it is not required that each physician or other practitioner providing professional 

services in the CAH must reassign billing rights with respect to the services. Rather, the 

reassignment of billing rights is physician/practitioner specific. For this reason, the 

optional payment method should not apply to the computation of payments to the CAH 

for its facility services in conjunction with services furnished by physicians and 

practitioners who have not reassigned such billing rights. Accordingly, if a physician or 

practitioner has not reassigned his or her billing rights to the CAH, the CAH will be paid 

for its facility services at 101 percent of reasonable cost, as specified at §413.70(b)(2)(i) 
CMS-1498-P 565 

of the regulations. If a CAH experiences changes in its physician or practitioner staffing, 

there may be a change in which physicians or practitioners choose to reassign their billing 

rights in order to permit the CAH to bill for their professional services. In order to ensure 

appropriate payments, and specifically, in order to ensure that there is no duplicate billing 

for a physician’s or practitioner’s professional services by the CAH to the fiscal 

intermediary or MAC and by the physician or practitioner providing the service to the 

carrier, a CAH must continue to notify its fiscal intermediary or MAC when changes in 

reassignment occur. 

 In summary, we are proposing to revise §413.70(b)(3)(i) to specify, under 

paragraphs (A)(1) and (A)(2), that for CAH cost reporting periods beginning on or after 

October 1, 2010, once a CAH elects the optional method, including an election made for 

its most recent cost reporting period beginning prior to October 1, 2010, its election will 

remain in place until it is terminated. That is, CAHs would no longer be required to 

make an annual election in order to continue to be paid under the optional method in a 

subsequent year. If a CAH has not elected the optional method for its most recent cost 

reporting period beginning prior to October 1, 2010, and would like to be paid for 

outpatient services under the optional method for a cost reporting period beginning on or 

after October 1, 2010, consistent with our existing regulations, it would be required to 

provide its election in writing to its servicing fiscal intermediary or MAC at least 30 days 

prior to the start of the first cost reporting period for which the election is effective. In 

addition, we are proposing to revise the regulations to specify that if a CAH wishes to 

terminate its optional method election, it must submit its termination request to the fiscal 
CMS-1498-P 566 

intermediary or MAC servicing the CAH at least 30 days prior to the start of the next cost 

reporting period. We are proposing that CAHs that have cost reporting periods beginning 

in October 2010 or November 2010 and elected the optional method in 2009, that wish to 

terminate that election, will have until December 1, 2010, to terminate their prior year 

election. The termination would be effective for the entire FY 2011 cost reporting 

period. We also are proposing to make a conforming change to paragraph (b)(3)(i)(D). 

3. Costs of Provider Taxes as Allowable Costs for CAHs 

a. Background and Statutory Basis 

Currently, certain taxes assessed against a provider may be allowable costs under 

Medicare to the extent that such taxes are related to the reasonable and necessary cost of 

providing patient care and represent costs actually incurred. Reasonable cost 

reimbursement is addressed in section 1861(v)(1)(A) of the Act. Section 1861(v)(1)(A) 

of the Act defines “reasonable cost,” in part, as the cost actually incurred, excluding costs 

found to be unnecessary in the efficient delivery of needed health services and are 

determined in accordance with regulations establishing the method or methods to be used 

and the items to be included. Section 1861(v)(1)(A) of the Act does not specifically 

address the determination of reasonable costs, but authorizes the Secretary to promulgate 

regulations and principles to be applied in determining reasonable costs. 

We have issued regulations implementing this provision of the Act, including 

42 CFR 413.9(a) which provide that the determination of reasonable cost “must be based 

on the reasonable cost of services covered under Medicare and related to the care of 

beneficiaries.” In addition, §413.9(c) requires that the provision for payment of 
CMS-1498-P 567 

reasonable cost of services is intended to meet the actual costs incurred in providing 

services. Therefore, in accordance with the statute, the regulations include two principles 

that help guide the determination of which expenses may be considered allowable 

reasonable costs that can be paid under Medicare; that is, such costs must be “related” to 

the care of Medicare beneficiaries, and such costs must actually be “incurred.” 

Consistent with these provisions, we also have issued policy instructions in the 

Provider Reimbursement Manual (PRM) for determining allowable reasonable costs 

under Medicare. Specifically, section 2122 of the PRM sets forth Medicare policy on 

determining when taxes levied on providers are allowable costs and provides a list of 

taxes that are considered unallowable costs. Specifically, section 2122.1 (General Rule) 

of the PRM states: “The general rule is that taxes assessed against the provider, in 

accordance with the levying enactments of the several States and lower levels of 

government and for which the provider is liable for payment, are allowable costs. Tax 

expenses should not include fines and penalties.” Section 2122.2 (Taxes Not Allowable 

as Costs) of the PRM lists certain taxes that are levied on providers that are not allowable 

costs. The listed taxes are: 

● Federal income and excess profit taxes, including any interest or penalties paid 

thereon (A). 

● State or local income and excess profit taxes (B). 

● Taxes in connection with financing, refinancing, or refunding operations, such 

as taxes on the issuance of bonds, property transfers, issuance or transfer of stocks, etc. 
CMS-1498-P 568 

Generally, these costs are either amortized over the life of the securities or depreciated 

over the life of the asset. They are not, however, recognized as tax expense. (C) 

● Taxes from which exemptions are available to the provider. (D) 

● Special assessments on land which represent capital improvements such as 

sewers, water, and pavements should be capitalized and depreciated over their estimated 

useful lives. (E) 

● Taxes on property which is not used in the rendition of covered services. (F) 

● Taxes, such as sales taxes, levied against the patient and collected and remitted 

by the provider. (G) 

● Self-employment (FICA) taxes applicable to individual proprietors, partners, 

members of a joint venture, etc. (H) 

b. Proposed Clarification of Payment Policy for Provider Taxes 

We have learned that there is some confusion relating to the determination of 

whether a tax is an allowable cost. We believe that much of this confusion has arisen 

because it may be possible to read sections 2122.1 and 2122.2 of the PRM as permitting 

all taxes assessed on a provider by a State that are not specifically listed in section 2122.2 

to be treated as allowable costs. Section 2122 of the PRM was last updated in 1979 when 

States typically raised revenue only from income, sales, and property taxes. The list in 

section 2212.2 is incomplete now, as it does not reflect the variety of provider taxes 

imposed by States. In addition, we are concerned that, even if a particular tax may be an 

allowable cost that is related to the care of Medicare beneficiaries, providers may not, in 

fact, “incur” the entire amount of these assessed taxes. For example, in accordance with 
CMS-1498-P 569 

the Medicaid statute and regulations, some States levy tax assessments on hospitals. The 

assessed taxes may be paid by the hospitals into a fund that includes all taxes paid, all 

Federal matching monies, and any penalties for nonpayment. The State is then 

authorized to disburse monies from the fund to the hospitals. We believe that these types 

of subsequent disbursements to providers are associated with the assessed taxes and may, 

in fact, offset some, if not all, of the taxes originally paid by the hospitals. 

We believe that the treatment of these types of payments on the Medicare cost 

report should be analogous to the adjustments described at §413.98 of the regulations. 

Specifically, §413.98(d) provides that the “true cost of the goods or services is the net 

amount actually paid for them.” Section 413.98 specifically addresses the purchase of 

goods and services and reflects the statutory mandate that a provider’s allowable costs are 

the net expenses it incurs for items and services. In situations in which payments that are 

associated with the assessed tax are made to providers specifically to make the provider 

whole or partly whole for the tax expenses, Medicare should similarly recognize only the 

net expense incurred by the provider. Thus, while a tax may be an allowable Medicare 

cost in that it is related to beneficiary care, the provider may only treat as a reasonable 

cost the net tax expense; that is, the tax paid by the provider, reduced by payments the 

provider received that are associated with the assessed tax. In addition, we do not believe 

that determinations made regarding whether the structure of specific taxes and 

subsequent reimbursements are consistent with Medicaid “hold harmless” provisions 

necessarily require the Medicare program to find that the same tax is an allowable cost. 

The Medicare statute and regulations set forth a different standard that requires a 
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determination of how much of the allowable tax expense is actually “incurred” by the 

provider. 

In this proposed rule, we are proposing to clarify our policy concerning when 

provider taxes may be considered allowable costs under Medicare. As stated above, 

section 2122 of the PRM was last updated in 1979, and it no longer reflects the variety of 

provider taxes that may be imposed by States. Although some of the more recently 

enacted provider taxes may be allowable costs, we are concerned that some of these taxes 

may not be “related to the care of beneficiaries” and that some, if not all, of the costs of 

these taxes might not be actually “incurred” by the providers. This payment policy may 

not directly affect providers that are paid under a Medicare prospective payment system 

unless a cost-based prospective payment system is rebased on more current reported 

reasonable costs. However, this policy clarification could impact certain providers that 

are paid on the basis of their incurred reasonable costs, such as CAHs. 

Therefore, we are proposing to clarify the policy set forth in sections 2122.1 and 

2122.2 of the PRM to reflect our concerns set forth above regarding when certain 

provider taxes may be allowable costs under the Medicare program. We will modify the 

PRM consistent with these principles. We believe that the proposed revision would 

clarify that our Medicare contractors will determine the allowability of provider taxes on 

a case-by-case basis, based on reasonable cost principles, and will determine if a 

reduction of the allowable tax expenses is proper to account for payments providers 

receive that are associated with the assessed tax. 
CMS-1498-P 571 

VII. Proposed Changes to the Long-Term Care Hospital Prospective 

Payment System (LTCH PPS) for FY 2011 

A. Background of the LTCH PPS

1. Legislative and Regulatory Authority 

Section 123 of the Medicare, Medicaid, and SCHIP (State Children's Health 

Insurance Program) Balanced Budget Refinement Act of 1999 (BBRA) 

(Pub. L. 106-113) as amended by section 307(b) of the Medicare, Medicaid, and SCHIP 

Benefits Improvement and Protection Act of 2000 (BIPA) (Pub. L. 106-554) provides for 

payment for both the operating and capital-related costs of hospital inpatient stays in 

long-term care hospitals (LTCHs) under Medicare Part A based on prospectively set 

rates. The Medicare prospective payment system (PPS) for LTCHs applies to hospitals 

that are described in section 1886(d)(1)(B)(iv) of the Social Security Act (the Act), 

effective for cost reporting periods beginning on or after October 1, 2002. 

Section 1886(d)(1)(B)(iv)(I) of the Act defines a LTCH as "a hospital which has 

an average inpatient length of stay (as determined by the Secretary) of greater than 

25 days." Section 1886(d)(1)(B)(iv)(II) of the Act also provides an alternative definition 

of LTCHs: specifically, a hospital that first received payment under section 1886(d) of 

the Act in 1986 and has an average inpatient length of stay (LOS) (as determined by the 

Secretary of Health and Human Services (the Secretary)) of greater than 20 days and has 

80 percent or more of its annual Medicare inpatient discharges with a principal diagnosis 

that reflects a finding of neoplastic disease in the 12-month cost reporting period ending 

in FY 1997. 
CMS-1498-P 572 

Section 123 of the BBRA requires the PPS for LTCHs to be a "per discharge" 

system with a diagnosis-related group (DRG) based patient classification system that 

reflects the differences in patient resources and costs in LTCHs. 

Section 307(b)(1) of the BIPA, among other things, mandates that the Secretary 

shall examine, and may provide for, adjustments to payments under the LTCH PPS, 

including adjustments to DRG weights, area wage adjustments, geographic 

reclassification, outliers, updates, and a disproportionate share adjustment. 

In the August 30, 2002 Federal Register, we issued a final rule that implemented 

the LTCH PPS authorized under the BBRA and BIPA (67 FR 55954). This system 

currently uses information from LTCH patient records to classify patients into distinct 

MS-long-term care diagnosis-related groups (MS-LTC-DRGs) based on clinical 

characteristics and expected resource needs. Payments are calculated for each 

MS-LTC-DRG and provisions are made for appropriate payment adjustments. Payment 

rates under the LTCH PPS are updated annually and published in the Federal Register. 

The LTCH PPS replaced the reasonable cost-based payment system under the Tax 

Equity and Fiscal Responsibility Act of 1982 (TEFRA) (Pub. L. 97-248) for payments for 

inpatient services provided by a LTCH with a cost reporting period beginning on or after 

October 1, 2002. (The regulations implementing the TEFRA reasonable cost-based 

payment provisions are located at 42 CFR Part 413.) With the implementation of the PPS 

for acute care hospitals authorized by the Social Security Amendments of 1983 

(Pub. L. 98-21), which added section 1886(d) to the Act, certain hospitals, including 

LTCHs, were excluded from the PPS for acute care hospitals and were paid their 
CMS-1498-P 573 

reasonable costs for inpatient services subject to a per discharge limitation or target 

amount under the TEFRA system. For each cost reporting period, a hospital-specific 

ceiling on payments was determined by multiplying the hospital's updated target amount 

by the number of total current year Medicare discharges. (Generally, in section VIII. of 

this preamble, when we refer to discharges, the intent is to describe Medicare discharges.) 

The August 30, 2002 final rule further details the payment policy under the TEFRA 

system (67 FR 55954). 

In the August 30, 2002 final rule, we provided for a 5-year transition period. 

During this 5-year transition period, a LTCH's total payment under the PPS was based on 

an increasing percentage of the Federal rate with a corresponding decrease in the 

percentage of the LTCH PPS payment that is based on reasonable cost concepts. 

However, effective for cost reporting periods beginning on or after October 1, 2006, total 

LTCH PPS payments are based on 100 percent of the Federal rate. 

 In addition, in the August 30, 2002 final rule, we presented an in-depth discussion 

of the LTCH PPS, including the patient classification system, relative weights, payment 

rates, additional payments, and the budget neutrality requirements mandated by section 

123 of the BBRA. The same final rule that established regulations for the LTCH PPS 

under 42 CFR Part 412, Subpart O also contained LTCH provisions related to covered 

inpatient services, limitation on charges to beneficiaries, medical review requirements, 

furnishing of inpatient hospital services directly or under arrangement, and reporting and 

recordkeeping requirements. We refer readers to the August 30, 2002 final rule for a 
CMS-1498-P 574 

comprehensive discussion of the research and data that supported the establishment of the 

LTCH PPS (67 FR 55954). 

In the June 6, 2003 Federal Register, we published a final rule that set forth the 

FY 2004 annual update of the payment rates for the Medicare PPS for inpatient hospital 

services furnished by LTCHs (68 FR 34122). It also changed the annual period for which 

the payment rates were to be effective, such that the annual updated rates were effective 

from July 1 through June 30 instead of from October 1 through September 30. We 

referred to the July through June time period as a "long-term care hospital rate year" 

(LTCH PPS rate year). In addition, we changed the publication schedule for the annual 

update to allow for an effective date of July 1. The payment amounts and factors used to 

determine the annual update of the LTCH PPS Federal rate are based on a LTCH PPS 

rate year. In the past, while the LTCH payment rate updates were effective July 1, the 

annual update of the DRG classifications and relative weights for LTCHs continued to be 

linked to the annual adjustments of the acute care hospital inpatient DRGs and were 

effective each October 1. 

As discussed in detail in section VIII.A.1. of the May 9, 2008 RY 2009 LTCH 

PPS final rule (73 FR 26788), we again changed the schedule for the annual updates of 

the LTCH PPS Federal payment rates beginning with RY 2010. We consolidated the 

rulemaking cycle for the annual update of the LTCH PPS Federal payment rates and 

description of the methodology and data used to calculate these payment rates with the 

annual update of the MS-LTC-DRG classifications and associated weighting factors for 

LTCHs so that the updates to the rates and the weights now occur on the same schedule 
CMS-1498-P 575 

and appear in the same publication. As a result, the updates to the rates and the weights 

are now effective on October 1 (on a Federal fiscal year schedule), and the annual 

updates to the LTCH PPS Federal rates are no longer published with a July 1 effective 

date (73 FR 26797 through 26798). 

 Pub. L. 110-173 (MMSEA), enacted on December 29, 2007, included provisions 

that have various effects on the LTCH PPS. In addition to amending section 1861 of the 

Act to add a subsection (ccc) which provided an additional definition of LTCHs, 

Pub. L. 110-173 also required the Secretary to submit, no later than 18 months after the 

date of enactment of the law, a report to Congress on a study of national long-term care 

hospital facility and patient criteria that included “recommendations for such legislation 

and administrative actions, including timelines for the implementation of LTCH patient 

criteria or other actions, as the Secretary determines appropriate.” The payment policy 

provisions under sections 114(c)(1) and 114(c)(2) of Pub. L. 110-173 focused on 

providing 3 years of relief for certain LTCHs from the percentage threshold payment 

adjustment policy at 42 CFR 412.534 and 412.536. However, because of the original 

implementation schedule of those sections of the regulations, the payment provisions had 

varying timeframes of applicability (73 FR 29701 through 29704). In addition, section 

114(c)(3) of Pub. L. 110-173 provided that the Secretary shall not apply, for the 3-year 

period beginning on the date of enactment of the Act the revision to the short-stay outlier 

(SSO) policy that was finalized in the RY 2008 LTCH PPS final rule (72 FR 26904 and 

26992). In addition, section 114(c)(4) of Pub. L. 110-173 provided that the Secretary 

shall not, for the 3-year period beginning on the date of enactment of the Act, make the 
CMS-1498-P 576 

one-time adjustment to the payment rates provided for in §412.523(d)(3) or any similar 

provision (73 FR 26800 through 26804). The statute also provided that the base rate for 

RY 2008 be the same as the base rate for RY 2007 (the revised base rate, however, does 

not apply to discharges occurring on or after July 1, 2007, and before April 1, 2008) (73 

FR 24875 through 24877). Section 114(d) of Pub. L. 110-173 established a 3-year 

moratorium (with specified exceptions) on the establishment and classification of new 

LTCHs, LTCH satellites, and on the increase in the number of LTCH beds in existing 

LTCHs or satelitte facilities. Finally, section 114(f) of Pub. L. 110-173 provided for an 

expanded review of medical necessity for admission and continued stay at LTCHs. 

 In the RY 2009 LTCH PPS final rule (73 FR 26804 through 26812), we 

established the applicable Federal rates for RY 2009, consistent with section 1886(m)(2) 

of the Act as amended by Pub. L. 110-173. We also revised the regulations at 

§412.523(d)(3) to change the methodology for the one-time budget neutrality adjustment 

and to comply with section 114(c)(4) of Pub. L. 110-173. Other policy revisions that 

were necessary as a result of the statutory changes of Pub. L. 110-173 were addressed in 

separate interim final rules with comment period (73 FR 24871 and 73 FR 29699). In the 

FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43976 through 43990), we address 

all of the public comments received and finalized these two interim final rules with 

comment period. 

Section 4302 of the ARRA, Pub. L. 111-5, enacted on February 17, 2009, 

included several amendments to the provisions set forth in section 114 of 

Pub. L. 110-173. Specifically, section 4302(a) modified the effective dates of the 
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provisions of section 114(c) of Pub. L. 110-173, described above, and added an 

additional category of LTCHs or satellite facilities that would not be subject to the 

percentage threshold payment adjustment at §412.536 for a 3-year period. In addition, 

section 4302(a)(2)(A) of Pub. L. 111-5 added “grandfathered” satellites (specified in 

§412.22(h)(3)(i) of the regtulations) to those “applicable” LTCHs (specified in 

§412.534(g) of the regulations) originally granted relief under section 114(c) of 

Pub. L. 110-173. We issued instructions to the fiscal intermediaries and MACs 

interpreting the provisions of section 4302 of Pub. L. 111-5 (Change Request 6444). In 

addition, in the FY 2010 IPPS/RY 2010 LTCH PPS final rule (43990 through 43992), we 

implemented the provisions of section 4302 of Pub. L. 111-5 through an interim final rule 

with comment period. We received one piece of timely correspondence regarding the 

provisions of section 4302 of Pub. L. 111-5 that were implemented through the interim 

final rule with comment period that was included in the FY 2010 IPPS/RY 2010 LTCH 

PPS final rule. We plan to address this public comment and finalize the interim final rule 

with comment period in the FY 2011 IPPS/LTCH PPS final rule, which is scheduled to 

be issued by August l, 2010. 

 On March 23, 2010, the Patient Protection and Affordable Care Act (PPACA), 

Pub. L. 111-148 was enacted. Following the enactment of Pub. L. 111-148, the Health 

Care and Education Reconciliation Act of 2010, Public L. 111-152 (enacted on 

March 30, 2010), amended certain provisions of Pub. L. 111-148. A number of the 

provisions of Pub. L. 111-148, as amended by Pub. L. 111-152, affect the IPPS and the 

LTCH PPS and the providers and suppliers addressed in this proposed rule. However, 
CMS-1498-P 578 

due to the timing of the passage of the legislation, we are unable to address those 

provisions in this proposed rule. Therefore, the proposed policies and payment rates in 

this proposed rule do not reflect the new legislation. We plan to issue separate 

documents in the Federal Register addressing the provisions of Pub. L. 111-148, as 

amended, that affect our proposed policies and payment rates for FY 2011 under the IPPS 

and the LTCH PPS. In addition, we plan to issue further instructions implementing the 

provisions of Pub. L. 111-148, as amended, that affect the policies and payment rates for 

FY 2010 under the IPPS and for RY 2010 under the LTCH PPS. 

2. Criteria for Classification as a LTCH 

a. Classification as a LTCH 

 Under the existing regulations at §412.23(e)(1) and (e)(2)(i), which implement 

section 1886(d)(1)(B)(iv)(I) of the Act, to qualify to be paid under the LTCH PPS, a 

hospital must have a provider agreement with Medicare and must have an average 

Medicare inpatient length of stay (LOS) of greater than 25 days. Alternatively, 

§412.23(e)(2)(ii) states that for cost reporting periods beginning on or after 

August 5, 1997, a hospital that was first excluded from the PPS in 1986 and can 

demonstrate that at least 80 percent of its annual Medicare inpatient discharges in the 

12-month cost reporting period ending in FY 1997 have a principal diagnosis that reflects 

a finding of neoplastic disease must have an average inpatient length of stay for all 

patients, including both Medicare and non-Medicare inpatients, of greater than 20 days. 

b. Hospitals Excluded from the LTCH PPS 
CMS-1498-P 579 

 The following hospitals are paid under special payment provisions, as described 

in §412.22(c), and therefore, are not subject to the LTCH PPS rules: 

● Veterans Administration hospitals. 

● Hospitals that are reimbursed under State cost control systems approved under 

42 CFR Part 403. 

● Hospitals that are reimbursed in accordance with demonstration projects 

authorized under section 402(a) of the Social Security Amendments of 1967 

(Pub. L. 90-248) (42 U.S.C. 1395b-1) or section 222(a) of the Social Security 

Amendments of 1972 (Pub. L. 92-603) (42 U.S.C. 1395b-1 (note)) (Statewide all-payer 

systems, subject to the rate-of-increase test at section 1814(b) of the Act). 

● Nonparticipating hospitals furnishing emergency services to Medicare 

beneficiaries. 

3. Limitation on Charges to Beneficiaries 

 In the August 30, 2002 final rule, we presented an in-depth discussion of 

beneficiary liability under the LTCH PPS (67 FR 55974 through 55975). In the RY 2005 

LTCH PPS final rule (69 FR 25676), we clarified that the discussion of beneficiary 

liability in the August 30, 2002 final rule was not meant to establish rates or payments 

for, or define Medicare-eligible expenses. Under §412.507, if the Medicare payment to 

the LTCH is the full LTC-DRG payment amount, as consistent with other established 

hospital prospective payment systems, a LTCH may not bill a Medicare beneficiary for 

more than the deductible and coinsurance amounts as specified under §409.82, §409.83, 

and §409.87 and for items and services as specified under §489.30(a). However, under 
CMS-1498-P 580 

the LTCH PPS, Medicare will only pay for days for which the beneficiary has coverage 

until the SSO threshold is exceeded. Therefore, if the Medicare payment was for a SSO 

case (§412.529) that was less than the full LTC-DRG payment amount because the 

beneficiary had insufficient remaining Medicare days, the LTCH could also charge the 

beneficiary for services delivered on those uncovered days (§412.507). 

4. Administrative Simplification Compliance Act (ASCA) and Health Insurance 

Portability and Accountability Act (HIPAA) Compliance 

Claims submitted to Medicare must comply with both the Administrative 

Simplification Compliance Act (ASCA) (Pub. L. 107-105), and the Health Insurance 

Portability and Accountability Act of 1996 (HIPAA) (Pub. L. 104-191). Section 3 of the 

ASCA requires that the Medicare Program deny payment under Part A or Part B for any 

expenses incurred for items or services "for which a claim is submitted other than in an 

electronic form specified by the Secretary." Section 1862(h) of the Act (as added by 

section 3(a) of the ASCA) provides that the Secretary shall waive such denial in two 

specific types of cases and may also waive such denial "in such unusual cases as the 

Secretary finds appropriate" (68 FR 48805). Section 3 of the ASCA operates in the 

context of the HIPAA regulations, which include, among other provisions, the 

transactions and code sets standards requirements codified as 45 CFR parts 160 and 162, 

subparts A and I through R (generally known as the Transactions Rule). The 

Transactions Rule requires covered entities, including covered health care providers, to 

conduct certain electronic healthcare transactions according to the applicable transactions 

and code sets standards. 
CMS-1498-P 581 

B. Proposed Medicare Severity Long-Term Care Diagnosis-Related Group 

(MS-LTC-DRG) Classifications and Relative Weights

1. Background 

 Section 123 of the BBRA requires that the Secretary implement a PPS for LTCHs 

(that is, a per discharge system with a diagnosis-related group (DRG)-based patient 

classification system reflecting the differences in patient resources and costs). Section 

307(b)(1) of the BIPA modified the requirements of section 123 of the BBRA by 

requiring that the Secretary examine "the feasibility and the impact of basing payment 

under such a system [the long-term care hospital (LTCH) PPS] on the use of existing (or 

refined) hospital DRGs that have been modified to account for different resource use of 

LTCH patients, as well as the use of the most recently available hospital discharge data." 

 When the LTCH PPS was implemented for cost reporting periods beginning on or 

after October 1, 2002, we adopted the same DRG patient classification system (that is, 

the CMS DRGs) that was utilized at that time under the IPPS. As a component of the 

LTCH PPS, we refer to this patient classification system as the "long-term care 

diagnosis-related groups (LTC-DRGs). Although the patient classification system used 

under both the LTCH PPS and the IPPS are the same, the relative weights are different. 

The established relative weight methodology and data used under the LTCH PPS result in 

relative weights under the LTCH PPS that reflect “the differences in patient resource use 

. . ." of LTCH patients (section 123(a)(1) of the BBRA (Pub. L. 106-113)). 

 As part of our efforts to better recognize severity of illness among patients, in the 

FY 2008 IPPS final rule with comment period (72 FR 47130), the MS-DRGs and the 
CMS-1498-P 582 

Medicare severity long-term care diagnosis-related groups (MS-LTC-DRGs) were 

adopted under the IPPS and the LTCH PPS, respectively, effective beginning 

October 1, 2007 (FY 2008). For a full description of the development and 

implementation and rationale for the use of the MS-DRGs and MS-LTC-DRGs, we refer 

readers to the FY 2008 IPPS final rule with comment period (72 FR 47141 through 

47175 and 47277 through 47299). (We note that, in that same final rule, we revised the 

regulations at §412.503 to specify that for LTCH discharges occurring on or after 

October 1, 2007, when applying the provisions of 42 CFR Part 412, Subpart O applicable 

to LTCHs for policy descriptions and payment calculations, all references to LTC-DRGs 

would be considered a reference to MS-LTC-DRGs. For the remainder of this section, 

we present the discussion in terms of the current MS-LTC-DRG patient classification 

system unless specifically referring to the previous LTC-DRG patient classification 

system that was in effect before October 1, 2007.) We believe the MS-DRGs (and by 

extension, the MS-LTC-DRGs) represent a substantial improvement over the previous 

CMS DRGs in their ability to differentiate cases based on severity of illness and resource 

consumption. 

 The MS-DRGs adopted in FY 2008 represent an increase in the number of DRGs 

by 207 (that is, from 538 to 745) (72 FR 47171). In FY 2009, an additional MS-DRG 

was adopted for a total of 746 distinct groupings (73 FR 48497). For FY 2011, we are 

proposing to delete one MS-DRG and create two new MS-DRGs, for a net gain of one 

MS-DRG, as noted in section II. of the preamble of this proposed rule. This would result 

in 747 distinct MS-DRG groupings for FY 2011. Consistent with section 123 of the 
CMS-1498-P 583 

BBRA, as amended by section 307(b)(1) of the BIPA, and §412.515, we use information 

derived from LTCH PPS patient records to classify LTCH discharges into distinct 

MS-LTC-DRGs based on clinical characteristics and estimated resource needs. We then 

assign an appropriate weight to the MS-LTC-DRGs to account for the difference in 

resource use by patients exhibiting the case complexity and multiple medical problems 

characteristic of LTCHs. 

In a departure from the IPPS, and as discussed in greater detail below in section 

VII.B.3.f. of this preamble, we use low-volume MS-LTC-DRGs (that is, MS-LTC-DRGs 

with less than 25 LTCH cases) in determining the MS-LTC-DRG relative weights 

because LTCHs do not typically treat the full range of diagnoses as do acute care 

hospitals. For purposes of determining the relative weights for the large number of lowvolume MS-LTC-DRGs, we group all of the low-volume MS-LTC-DRGs into five 

quintiles based on average charge per discharge. (A detailed discussion of the initial 

development and application of the quintile methodology appears in the August 30, 2002 

LTCH PPS final rule (67 FR 55978).) We also account for adjustments to payments for 

short-stay outlier (SSO) cases (that is, cases where the covered LOS at the LTCH is less 

than or equal to five-sixths of the geometric ALOS for the MS-LTC-DRG). Furthermore, 

we make adjustments to account for nonmonotonically increasing weights, when 

necessary. That is, theoretically, cases under the MS-LTC-DRG system that are more 

severe require greater expenditure of medical care resources and will result in higher 

average charges such that, in the severity levels within a base MS-LTC-DRG, the weights 

should increase monotonically with severity from the lowest to highest severity level. 
CMS-1498-P 584 

(We discuss nonmonotonicity in greater detail and our methodology to adjust the 

RY 2010 MS-LTC-DRG relative weights to account for nonmonotonically increasing 

relative weights in section VII.B.3.g. (Step 6) of this preamble.) 

2. Patient Classifications into MS-LTC-DRGs 

a. Background 

 The MS-DRGs (used under the IPPS) and the MS-LTC-DRGs (used under the 

LTCH PPS) are based on the CMS DRG structure. As noted above in this section, we 

refer to the DRGs under the LTCH PPS as MS-LTC-DRGs although they are structurally 

identical to the MS-DRGs used under the IPPS. 

 The MS-DRGs are organized into 25 major diagnostic categories (MDCs), most 

of which are based on a particular organ system of the body; the remainder involve 

multiple organ systems (such as MDC 22, Burns). Within most MDCs, cases are then 

divided into surgical DRGs and medical DRGs. Surgical DRGs are assigned based on a 

surgical hierarchy that orders operating room (O.R.) procedures or groups of O.R. 

procedures by resource intensity. The GROUPER software program does not recognize 

all ICD-9-CM procedure codes as procedures affecting DRG assignment. That is, 

procedures that are not surgical (for example, EKG), or minor surgical procedures (for 

example, biopsy of skin and subcutaneous tissue (procedure code 86.11)) do not affect 

the MS-LTC-DRG assignment based on their presence on the claim. 

 Generally, under the LTCH PPS, a Medicare payment is made at a predetermined 

specific rate for each discharge and that payment varies by the MS-LTC-DRG to which a 
CMS-1498-P 585 

beneficiary's stay is assigned. Cases are classified into MS-LTC-DRGs for payment 

based on the following six data elements: 

● Principal diagnosis; 

● Additional or secondary diagnoses; 

● Surgical procedures; 

● Age; 

● Sex; and 

● Discharge status of the patient. 

 Through FY 2010, the number of secondary or additional diagnoses and the 

number of surgical procedures considered for MS-DRG assignment was limited to eight 

and six, respectively. Elsewhere in this proposed rule, however, we are proposing that, 

for claims submitted on the 5010 format beginning January 1, 2011, we would increase 

the capacity to process diagnosis and procedure codes up to 25 diagnoses and 25 

procedures. This will include one principal diagnosis and up to 24 secondary diagnoses 

for severity of illness determinations. We refer readers to section II.G.11.c. of this 

preamble for a complete discussion of this proposed change. 

 Upon the discharge of the patient from a LTCH, the LTCH must assign 

appropriate diagnosis and procedure codes from the most current version of the 

International Classification of Diseases, Ninth Revision, Clinical Modification 

(ICD-9-CM). HIPAA Transactions and Code Sets Standards regulations at 

45 CFR Parts 160 and 162 require that no later than October 16, 2003, all covered entities 

must comply with the applicable requirements of Subparts A and I through R of Part 162. 
CMS-1498-P 586 

Among other requirements, those provisions direct covered entities to use the ASC X12N 

837 Health Care Claim: Institutional, Volumes 1 and 2, Version 4010, and the applicable 

standard medical data code sets for the institutional health care claim or equivalent 

encounter information transaction (45 CFR 162.1002 and 45 CFR 162.1102). For 

additional information on the ICD-9-CM Coding System, we refer readers to the FY 2008 

IPPS final rule with comment period (72 FR 47241 through 47243 and 47277 through 

47281). We also refer readers to the detailed discussion on correct coding practices in the 

August 30, 2002 LTCH PPS final rule (67 FR 55981 through 55983). Additional coding 

instructions and examples are published in the Coding Clinic for ICD-9-CM, a product of 

the American Hospital Association. (We refer readers to section II.G.11. of this 

preamble for additional information on the annual revisions to the ICD-9-CM codes.) 

 With respect to the ICD-9-CM coding system, we have been discussing the 

conversion to the ICD-10-CM and the ICD-10-PCS coding systems for many years. As 

is discussed in detail in section II.G.11. of this preamble, the ICD-10 coding systems 

applicable to hospital inpatient services will be implemented on October 1, 2013. In 

order for the industry to make the necessary conversions from ICD-9-CM to ICD-10-CM 

and ICD-10-PCS, we proposed, through the ICD-9-CM Coordination and Maintenance 

Committee, to consider a moratorium on updates to the ICD-9-CM and ICD-10 coding 

sets. We refer readers to section II.G.11. of this preamble for additional information on 

the adoption of ICD-10-CM and ICD-10-PCS. 

 To create the MS-DRGs (and by extension, the MS-LTC-DRGs), individual 

DRGs were subdivided according to the presence of specific secondary diagnoses 
CMS-1498-P 587 

designated as complications or comorbidities (CCs) into three, two, or one level, 

depending on the impact of the CCs on resources used for those cases. Specifically, there 

are sets of MS–DRGs that are split into 2 or 3 subgroups based on the presence or 

absence of a CC or a major complication and comorbidity (MCC). We refer readers to 

section II.D. of the FY 2008 IPPS final rule with comment period for a detailed 

discussion about the creation of MS-DRGs based on severity of illness levels 

(72 FR 47141 through 47175). 

 Medicare contractors (that is, fiscal intermediaries and MACs) enter the clinical 

and demographic information submitted by LTCHs into their claims processing systems 

and subject this information to a series of automated screening processes called the 

Medicare Code Editor (MCE). These screens are designed to identify cases that require 

further review before assignment into a MS-LTC-DRG can be made. During this 

process, certain cases are selected for further development (74 FR 43949). 

 After screening through the MCE, each claim is classified into the appropriate 

MS-LTC-DRG by the Medicare LTCH GROUPER software on the basis of diagnosis 

and procedure codes and other demographic information (age, sex, and discharge status). 

The GROUPER software used under the LTCH PPS is the same GROUPER software 

program used under the IPPS. Following the MS-LTC-DRG assignment, the Medicare 

contractor determines the prospective payment amount by using the Medicare PRICER 

program, which accounts for hospital-specific adjustments. Under the LTCH PPS, we 

provide an opportunity for LTCHs to review the MS-LTC-DRG assignments made by the 
CMS-1498-P 588 

Medicare contractor and to submit additional information within a specified timeframe as 

provided in §412.513(c). 

 The GROUPER software is used both to classify past cases to measure relative 

hospital resource consumption to establish the 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 MS-DRG and MS-LTC-DRG classification changes and to recalibrate 

the MS-DRG and MS-LTC-DRG relative weights during our annual update under both 

the IPPS (§412.60(e)) and the LTCH PPS (§412.517), respectively. 

b. Proposed Changes to the MS-LTC-DRGs for FY 2011 

 As specified by our regulations at §412.517(a), which requires that the 

LTC-MS-DRG classifications and relative weights be updated annually and consistent 

with our historical practice of using the same patient classification system under the 

LTCH PPS as is used under the IPPS, in this proposed rule, we are proposing to modify 

and revise the MS-LTC-DRG classifications effective October 1, 2010, through 

September 30, 2011 (FY 2011) consistent with the proposed changes to specific 

MS-DRG classifications presented above in section II.G. of this proposed rule (that is, 

proposed GROUPER Version 28.0). Therefore, the MS-LTC-DRGs for FY 2011 

presented in this proposed rule are the same as the proposed MS-DRGs that would be 

used under the IPPS for FY 2011. In addition, because the proposed MS-LTC-DRGs for 

FY 2011 are the same as the proposed MS-DRGs for FY 2011, the other changes that 

would affect MS-DRG (and by extension MS-LTC-DRG) assignments under Version 
CMS-1498-P 589 

28.0 of the GROUPER discussed in section II.G. of the preamble of this proposed rule, 

including the proposed changes to the MCE software and proposed changes to the 

ICD-9-CM coding system, would also be applicable under the LTCH PPS for FY 2011. 

3. Development of the Proposed FY 2011 MS-LTC-DRG Relative Weights 

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

 As we stated in the August 30, 2002 LTCH PPS final rule (67 FR 55984), 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 relative weight in determining payment to LTCHs for each case. 

 Although the adoption of the MS-LTC-DRGs resulted in some modifications of 

existing procedures for assigning weights in cases of zero volume and/or 

nonmonotonicity (as discussed in the FY 2008 IPPS final rule with comment period 

(72 FR 47289 through 47295) and the FY 2009 IPPS final rule (73 FR 48542 through 

48550)), the basic methodology for developing the proposed FY 2011 MS-LTC-DRG 

relative weights in this proposed rule continues to be determined in accordance with the 

general methodology established in the August 30, 2002 LTCH PPS final rule 

(67 FR 55989 through 55991). Under the LTCH PPS, relative weights for each 

MS-LTC-DRG are a primary element used to account for the variations in cost per 
CMS-1498-P 590 

discharge and resource utilization among the payment groups (§412.515). To ensure that 

Medicare patients classified to each MS-LTC-DRG have access to an appropriate level of 

services and to encourage efficiency, we calculate a relative weight for each 

MS-LTC-DRG that represents the resources needed by an average inpatient LTCH case 

in that MS-LTC-DRG. For example, cases in an MS-LTC-DRG with a relative weight 

of 2 will, on average, cost twice as much to treat as cases in an MS-LTC-DRG with a 

weight of 1. 

b. Development of the Proposed MS-LTC-DRG Relative Weights for FY 2011 

Beginning with the FY 2008 update, we established a budget neutral requirement 

for the annual update to the MS-LTC-DRG classifications and relative weights at 

42 CFR 412.517(b) (in conjunction with §412.503), 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 

classification and relative weight changes (May 11, 2007 LTCH PPS final rule, 

72 FR 26882 through 26884). 

 Consistent with §412.517(b), we apply a two-step budget neutrality methodology, 

which is based on the current year MS-LTC-DRG classifications and relative weights. 

(For additional information on the established two-step budget neutrality methodology, 

we refer readers to the FY 2008 IPPS final rule (72 FR 47295 through 47296).) Thus, the 

proposed annual update to the MS-LTC-DRG classifications and relative weights for 

FY 2011 is based on the FY 2010 MS-LTC-DRG classifications and relative weights. 
CMS-1498-P 591 

c. Data 

 In this proposed rule, to calculate the proposed MS-LTC-DRG relative weights 

for FY 2011, we are proposing to obtain total Medicare allowable charges from FY 2009 

Medicare LTCH bill data from the December 2009 update of the MedPAR file, which are 

the best available data at this time, and to use the proposed Version 28.0 of the 

GROUPER to classify LTCH cases (as discussed above). We also are proposing that if 

more recent data become available, we would use those data and the finalized Version 

28.0 of the GROUPER in establishing the FY 2011 MS-LTC-DRG relative weights in the 

final rule. 

 Consistent with our historical methodology, we excluded the data from LTCHs 

that are all-inclusive rate providers and LTCHs that are reimbursed in accordance with 

demonstration projects authorized under section 402(a) of Pub. L. 90-248 or 

section 222(a) of Pub. L. 92-603. In addition, as is the case with the IPPS, Medicare 

Advantage (Part C) claims are now included in the MedPAR files (74 FR 43808). 

Consistent with IPPS policy, we are proposing to exclude such claims in the calculations 

for the relative weights under the LTCH PPS that are used to determine payments for feefor-service Medicare claims. Specifically, we have added an edit to the relative weight 

calculation to remove any claims from the MedPAR files that have a GHO Paid indicator 

value of “1,” which effectively removes Medicare Advantage claims from the relative 

weight calculations (73 FR 48532). Accordingly, in the development of the proposed 

FY 2011 MS-LTC-DRG relative weights in this proposed rule, we excluded the data of 

13 all-inclusive rate providers and the 2 LTCHs that are paid in accordance with 
CMS-1498-P 592 

demonstration projects that had claims in the FY 2009 MedPAR file, as well as any 

Medicare Advantage claims. 

d. Hospital-Specific Relative Value (HSRV) 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 nonrandom distribution of cases with relatively high (or low) charges in 

specific 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, consistent with the methodology we have used since the implementation 

of the LTCH PPS, we are proposing to continue to use a hospital-specific relative value 

(HSRV) methodology to calculate the proposed MS-LTC-DRG relative weights. We 

believe this method removes this hospital-specific source of bias in measuring LTCH 

average charges (67 FR 55985). Specifically, we are reducing the impact of the variation 

in charges across providers on any particular proposed MS-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 methodology, we standardize charges for each LTCH by 

converting its charges for each case to hospital-specific relative charge values and then 

adjust 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 
CMS-1498-P 593 

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 our established methodology, we continue to standardize 

charges for each case by first dividing the adjusted charge for the case (adjusted for SSOs 

under §412.529 as described in section VII.B.3.g. (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. SSO cases are cases with a length of stay that is less than or equal to 

five-sixths the average length of stay of the MS-LTC-DRG (§412.529 and §412.503). 

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. (67 FR 55989) 

 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 
CMS-1498-P 594 

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. 

e. Treatment of Severity Levels in Developing the Proposed MS-LTC-DRG Relative 

Weights 

For purposes of determining the proposed MS-LTC-DRG relative weights, there 

are three different categories of DRGs based on volume of cases within specific MSLTC-DRGs. MS-LTC-DRGs with at least 25 cases are each assigned a unique proposed 

relative weight; low-volume proposed MS-LTC-DRGs (that is, proposed MS-LTC-DRGs 

that contain between 1 and 24 cases based on a given year’s claims data) are grouped into 

quintiles (as described below) and assigned the proposed relative weight of the quintile. 

No-volume proposed MS-LTC-DRGs (that is, no cases in the given year's claims data 

were assigned to those proposed MS-LTC-DRGs) are crosswalked to other proposed 

MS-LTC-DRGs based on the clinical similarities and assigned the relative weight of the 

crosswalked MS-LTC-DRG (as described in greater detail below). (We provide in-depth 

discussions of our policy regarding weight-setting for low-volume MS-LTC-DRGs in 

section VII.B.3.f. of the preamble of this proposed rule and for no-volume 

MS-LTC-DRGs, under Step 5 in section VII.B.3.g. of the preamble of this proposed 

rule.) 
CMS-1498-P 595 

As also noted above, while the LTCH PPS and the IPPS use the same patient 

classification system, the methodology that is used to set the DRG relative 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. In general, consistent with our existing methodology, we 

are proposing to determine the proposed FY 2011 relative weights for the proposed 

MS-LTC-DRGs using the following steps: (1) if a proposed MS-LTC-DRG has at least 

25 cases, it is assigned its own proposed relative weight; (2) if a proposed MS-LTC-DRG 

has between 1 and 24 cases, it is assigned to a quintile for which we compute a proposed 

relative weight for all of the proposed MS-LTC-DRGs assigned to that quintile; and (3) if 

a proposed MS-LTC-DRG has no cases, it is crosswalked to another proposed 

MS-LTC-DRG based upon clinical similarities to assign an appropriate proposed relative 

weight (as described below in detail in Step 5 of section VII.B.3.g. of this preamble). 

Furthermore, in determining the proposed FY 2011 MS-LTC-DRG relative weights, 

when necessary, we are proposing to make adjustments to account for nonmonotonicity, 

as discussed in greater detail below in Step 6 of section VII.B.3.g. of this preamble. We 

refer readers to the discussion in the FY 2010 IPPS/RY LTCH PPS final rule for our 

rationale for including an adjustment for nonmonotonicity (74 FR 43953 through 43954). 

f. Low-Volume MS-LTC-DRGs 

 In order to account for proposed MS-LTC-DRGs with low volume (that is, with 

fewer than 25 LTCH cases), consistent with our existing methodology, for purposes of 

determining the MS-LTC-DRG relative weights, we are proposing to continue to employ 

this quintile methodology for low-volume proposed MS-LTC-DRGs, such that we group 
CMS-1498-P 596 

those "low-volume MS-LTC-DRGs" (that is, MS-LTC-DRGs that contained between 

1 and 24 cases annually) into one of five categories (quintiles) based on average charges 

(67 FR 55984 through 55995 and 72 FR 47283 through 47288). In determining the 

proposed FY 2011 MS-LTC-DRG relative weights in this proposed rule, in cases where 

the initial assignment of a low-volume proposed MS-LTC-DRG to quintiles results in 

nonmonotonicity within a base-DRG, in order to ensure appropriate Medicare payments, 

consistent with our historical methodology, we are proposing to make adjustments to the 

treatment of low-volume proposed MS-LTC-DRGs to preserve monotonicity, as 

discussed in detail below in section VII.B.3.g. (Step 6) in this preamble. 

In this proposed rule, using LTCH cases from the December 2009 update of the 

FY 2009 MedPAR file, we identified 283 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 56 proposed MS-LTC-DRGs 

(283/5 = 56 with 3 proposed MS-LTC-DRG as the remainder). We are proposing to 

assign a low-volume proposed MS-LTC-DRG to a specific low-volume quintile by 

sorting the low-volume proposed MS-LTC-DRGs in ascending order by average charge 

in accordance with our established methodology. Furthermore, because the number of 

proposed MS-LTC-DRGs with less than 25 cases was not evenly divisible by 5, the 

average charge of the low-volume quintile was used to determine which of the lowvolume quintiles would contain the 3 additional low-volume proposed MS-LTC-DRGs. 

Specifically, after sorting the 283 low-volume proposed MS-LTC-DRGs by ascending 

order by average charge, we are proposing to assign the first fifth (1st through 56th) of 
CMS-1498-P 597 

low-volume proposed MS-LTC-DRGs (with the lowest average charge) into Quintile 1. 

The proposed MS-LTC-DRGs with the highest average charge cases would be assigned 

into Quintile 5. Because the average charge of the 113th low-volume proposed 

MS-LTC-DRG in the sorted list is closer to the average charge of the 112th low-volume 

proposed MS-LTC-DRG (assigned to Quintile 2) than to the average charge of the 114th

low-volume MS-LTC-DRG (assigned to Quintile 3), we are proposing to place it into 

Quintile 2 (such that Quintile 2 would contain 57 low-volume proposed MS-LTC-DRGs 

before any adjustments for nonmonotonicity, as discussed below). This process was 

repeated through the remaining low-volume proposed MS-LTC-DRGs so that 2 of the 

5 low-volume quintiles contain 56 MS-LTC-DRGs (Quintiles 1 and 4) and the other 

3 low-volume quintiles contain 57 MS-LTC-DRGs (Quintiles 2, 3, and 5). 

 Accordingly, in order to determine the proposed FY 2011 relative weights for the 

proposed MS-LTC-DRGs with low volume, we are proposing to use the 5 low-volume 

quintiles described above. The composition of each of the 5 low-volume quintiles shown 

in the chart below was used in determining the proposed FY 2011 MS-LTC-DRG relative 

weights (as shown in Table 11 of the Addendum to this proposed rule). We determined a 

proposed relative weight and (geometric) average length of stay for each of the 5 lowvolume quintiles using the methodology that we applied to the proposed MS-LTC-DRGs 

(25 or more cases), as described in section VII.B.3.g. of the preamble of this proposed 

rule. We are proposing to assign the same proposed relative weight and average length of 

stay to each of the low-volume proposed MS-LTC-DRGs that make up an individual 

low-volume quintile. We note that, as this system is dynamic, it is possible that the 
CMS-1498-P 598 

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 lowvolume MS-LTC-DRGs and to calculate the proposed relative weights based on our 

methodology. 

Proposed Composition of Low-Volume Quintiles for FY 2011*

Proposed 

MSLTCDRG Proposed MS-LTC-DRG Description 

Quintile 1 

26 Craniotomy & endovascular intracranial procedures w CC 

42 Periph & cranial nerve & other nerv syst proc w/o CC/MCC 

60 Multiple sclerosis & cerebellar ataxia w/o CC/MCC 

66 Intracranial hemorrhage or cerebral infarction w/o CC/MCC 

68 Nonspecific cva & precerebral occlusion w/o infarct w/o MCC 

81 Nontraumatic stupor & coma w/o MCC 

84 Traumatic stupor & coma, coma >1 hr w/o CC/MCC 

87 Traumatic stupor & coma, coma <1 hr w/o CC/MCC 

93 Other disorders of nervous system w/o CC/MCC 

99 Non-bacterial infect of nervous sys exc viral meningitis w/o CC/MCC 

122 Acute major eye infections w/o CC/MCC 

148 Ear, nose, mouth & throat malignancy w/o CC/MCC 

149 Dysequilibrium 

151 Epistaxis w/o MCC 

188 Pleural effusion w/o CC/MCC 

198 Interstitial lung disease w/o CC/MCC 

201 Pneumothorax w/o CC/MCC 

244 Permanent cardiac pacemaker implant w/o CC/MCC 

282 Circulatory disorders w AMI, discharged alive w/o CC/MCC 

310 Cardiac arrhythmia & conduction disorders w/o CC/MCC 

354 Hernia procedures except inguinal & femoral w CC 

376 Digestive malignancy w/o CC/MCC 

379 G.I. hemorrhage w/o CC/MCC 

383 Uncomplicated peptic ulcer w MCC 

387 Inflammatory bowel disease w/o CC/MCC 

390 G.I. obstruction w/o CC/MCC 

437 Malignancy of hepatobiliary system or pancreas w/o CC/MCC 

440 Disorders of pancreas except malignancy w/o CC/MCC 
CMS-1498-P 599 

Proposed 

MSLTCDRG Proposed MS-LTC-DRG Description 

491 Back & neck procedures except spinal fusion w/o CC/MCC 

537 Sprains, strains, & dislocations of hip, pelvis & thigh w CC/MCC 

547 Connective tissue disorders w/o CC/MCC 

553 Bone diseases & arthropathies w MCC 

555 Signs & symptoms of musculoskeletal system & conn tissue w MCC 

578 Skin graft &/or debrid exc for skin ulcer or cellulitis w/o CC/MCC 

601 Non-malignant breast disorders w/o CC/MCC 

645 Endocrine disorders w/o CC/MCC 

656 Kidney & ureter procedures for neoplasm w MCC 

694 Urinary stones w/ot esw lithotripsy w/o MCC 

696 Kidney & urinary tract signs & symptoms w/o MCC 

730 Other male reproductive system diagnoses w/o CC/MCC 

759 Infections, female reproductive system w/o CC/MCC 

781 Other antepartum diagnoses w medical complications 

821 Lymphoma & leukemia w major O.R. procedure w CC 

824 Lymphoma & non-acute leukemia w other O.R. proc w CC 

842 Lymphoma & non-acute leukemia w/o CC/MCC 

845 Other myeloprolif dis or poorly diff neopl diag w/o CC/MCC 

864 Fever of unknown origin 

869 Other infectious & parasitic diseases diagnoses w/o CC/MCC 

882 Neuroses except depressive 

887 Other mental disorder diagnoses 

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

915 Allergic reactions w MCC 

918 Poisoning & toxic effects of drugs w/o MCC 

923 Other injury, poisoning & toxic effect diag w/o MCC 

965 Other multiple significant trauma w/o CC/MCC 

976 HIV w major related condition w/o CC/MCC 

Quintile 2 

59 Multiple sclerosis & cerebellar ataxia w CC 

83 Traumatic stupor & coma, coma >1 hr w CC 

98 Non-bacterial infect of nervous sys exc viral meningitis w CC 

121 Acute major eye infections w CC/MCC 

158 Dental & Oral Diseases w CC 

159 Dental & Oral Diseases w/o CC/MCC 

182 Respiratory neoplasms w/o CC/MCC 

200 Pneumothorax w CC 

203 Bronchitis & asthma w/o CC/MCC 

225 Cardiac defib implant w cardiac cath w/o AMI/HF/shock w/o MCC 
CMS-1498-P 600 

Proposed 

MSLTCDRG Proposed MS-LTC-DRG Description 

236 Coronary bypass w/o cardiac cath w/o MCC 

249 Percutaneous cardiovasc proc w non-drug-eluting stent w/o MCC 

254 Other vascular procedures w/o CC/MCC 

262 Cardiac pacemaker revision except device replacement w/o CC/MCC 

284 Circulatory disorders w AMI, expired w CC 

305 Hypertension w/o MCC 

369 Major esophageal disorders w CC 

384 Uncomplicated peptic ulcer w/o MCC 

395 Other digestive system diagnoses w/o CC/MCC 

419 Laparoscopic cholecystectomy w/o c.d.e. w/o CC/MCC 

433 Cirrhosis & alcoholic hepatitis w CC 

436 Malignancy of hepatobiliary system or pancreas w CC 

446 Disorders of the biliary tract w/o CC/MCC 

476 Amputation for musculoskeletal sys & conn tissue dis w/o CC/MCC 

487 Knee procedures w pdx of infection w/o CC/MCC 

502 Soft tissue procedures w/o CC/MCC 

536 Fractures of hip & pelvis w/o MCC 

544 Pathological fractures & musculoskelet & conn tiss malig w/o CC/MCC 

554 Bone diseases & arthropathies w/o MCC 

556 Signs & symptoms of musculoskeletal system & conn tissue w/o MCC 

584 Breast biopsy, local excision & other breast procedures w CC/MCC 

598 Malignant breast disorders w CC 

624 Skin grafts & wound debrid for endoc, nutrit & metab dis w/o CC/MCC 

625 Thyroid, parathyroid & thyroglossal procedures w MCC 

643 Endocrine disorders w MCC 

644 Endocrine disorders w CC 

669 Transurethral procedures w CC 

687 Kidney & urinary tract neoplasms w CC 

700 Other kidney & urinary tract diagnoses w/o CC/MCC 

710 Penis procedures w/o CC/MCC 

723 Malignancy, male reproductive system w CC 

755 Malignancy, female reproductive system w CC 

760 Menstrual & other female reproductive system disorders w CC/MCC 

776 Postpartum & post abortion diagnoses w/o O.R. procedure 

809 Major hematol/immun diag exc sickle cell crisis & coagul w CC 

815 Reticuloendothelial & immunity disorders w CC 

836 Acute leukemia w/o major O.R. procedure w/o CC/MCC 

880 Acute adjustment reaction & psychosocial dysfunction 

883 Disorders of personality & impulse control 
CMS-1498-P 601 

Proposed 

MSLTCDRG Proposed MS-LTC-DRG Description 

903 Wound debridements for injuries w/o CC/MCC 

906 Hand procedures for injuries 

909 Other O.R. procedures for injuries w/o CC/MCC 

933 Extensive burns or full thickness burns w MV 96+ hrs w/o skin graft 

941 O.R. proc w diagnoses of other contact w health services w/o CC/MCC 

957 Other O.R. procedures for multiple significant trauma w MCC 

983 Extensive O.R. procedure unrelated to principal diagnosis w/o CC/MCC 

989 Non-extensive O.R. proc unrelated to principal diagnosis w/o CC/MCC 

Quintile 3 

29 Spinal procedures w CC 

75 Viral meningitis w CC/MCC 

77 Hypertensive encephalopathy w MCC 

78 Hypertensive encephalopathy w CC 

82 Traumatic stupor & coma, coma >1 hr w MCC 

90 Concussion w/o CC/MCC 

96 Bacterial & tuberculous infections of nervous system w/o CC/MCC 

102 Headaches w MCC 

124 Other disorders of the eye w MCC 

156 Nasal trauma & deformity w/o CC/MCC 

243 Permanent cardiac pacemaker implant w CC 

247 Percutaneous cardiovascular proc w drug-eluting stent w/o MCC 

258 Cardiac pacemaker device replacement w MCC 

287 Circulatory disorders except AMI, w card cath w/o MCC 

311 Angina pectoris 

313 Chest pain 

327 Stomach, esophageal & duodenal proc w CC 

328 Stomach, esophageal & duodenal proc w/o CC/MCC 

344 Minor small & large bowel procedures w MCC 

348 Anal & stomal procedures w CC 

370 Major esophageal disorders w/o CC/MCC 

381 Complicated peptic ulcer w CC 

382 Complicated peptic ulcer w/o CC/MCC 

443 Disorders of liver except malig,cirr,alc hepa w/o CC/MCC 

465 Wnd debrid & skn grft exc hand, for musculo-conn tiss dis w/o CC/MCC 

467 Revision of hip or knee replacement w CC 

494 Lower extrem & humer proc except hip,foot,femur w/o CC/MCC 

499 Local excision & removal int fix devices of hip & femur w/o CC/MCC 

506 Major thumb or joint procedures 

516 Other musculoskelet sys & conn tiss O.R. proc w CC 
CMS-1498-P 602 

Proposed 

MSLTCDRG Proposed MS-LTC-DRG Description 

562 Fx, sprn, strn & disl except femur, hip, pelvis & thigh w MCC 

563 Fx, sprn, strn & disl except femur, hip, pelvis & thigh w/o MCC 

581 Other skin, subcut tiss & breast proc w/o CC/MCC 

630 Other endocrine, nutrit & metab O.R. proc w/o CC/MCC 

659 Kidney & ureter procedures for non-neoplasm w MCC 

671 Urethral procedures w CC/MCC 

675 Other kidney & urinary tract procedures w/o CC/MCC 

686 Kidney & urinary tract neoplasms w MCC 

693 Urinary stones w/o esw lithotripsy w MCC 

695 Kidney & urinary tract signs & symptoms w MCC 

697 Urethral stricture 

713 Transurethral prostatectomy w CC/MCC 

726 Benign prostatic hypertrophy w/o MCC 

808 Major hematol/immun diag exc sickle cell crisis & coagul w MCC 

827 Myeloprolif disord or poorly diff neopl w maj O.R. proc w CC 

834 Acute leukemia w/o major O.R. procedure w MCC 

835 Acute leukemia w/o major O.R. procedure 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 

858 Postoperative or post-traumatic infections w O.R. proc w/o CC/MCC 

866 Viral illness w/o MCC 

896 Alcohol/drug abuse or dependence w/o rehabilitation therapy w MCC 

905 Skin grafts for injuries w/o CC/MCC 

922 Other injury, poisoning & toxic effect diag w MCC 

963 Other multiple significant trauma w MCC 

970 HIV w extensive O.R. procedure w/o MCC 

Quintile 4 

11 Tracheostomy for face,mouth & neck diagnoses w MCC 

25 Craniotomy & endovascular intracranial procedures w MCC 

28 Spinal procedures w MCC 

31 Ventricular shunt procedures w MCC 

37 Extracranial procedures w MCC 

69 Transient ischemia 

80 Nontraumatic stupor & coma w MCC 

89 Concussion w CC 

113 Orbital procedures w CC/MCC 

125 Other disorders of the eye w/o MCC 

157 Dental & Oral Diseases w MCC 
CMS-1498-P 603 

Proposed 

MSLTCDRG Proposed MS-LTC-DRG Description 

250 Perc cardiovasc proc w/o coronary artery stent or AMI w MCC 

256 Upper limb & toe amputation for circ system disorders w CC 

261 Cardiac pacemaker revision except device replacement w CC 

336 Peritoneal adhesiolysis w CC 

347 Anal & stomal procedures w MCC 

353 Hernia procedures except inguinal & femoral w MCC 

358 Other digestive system O.R. procedures w/o CC/MCC 

380 Complicated peptic ulcer w MCC 

406 Pancreas, liver & shunt procedures w CC 

409 Biliary tract proc except only cholecyst w or w/o c.d.e. w CC 

460 Spinal fusion except cervical w/o MCC 

472 Cervical spinal fusion w CC 

478 Biopsies of musculoskeletal system & connective tissue w CC 

480 Hip & femur procedures except major joint w MCC 

485 Knee procedures w pdx of infection w MCC 

486 Knee procedures w pdx of infection w CC 

490 Back & neck procedures except spinal fusion w CC/MCC or disc devices 

496 Local excision & removal int fix devices exc hip & femur w CC 

497 Local excision & removal int fix devices exc hip & femur w/o CC/MCC 

504 Foot procedures w CC 

505 Foot procedures w/o CC/MCC 

513 Hand or wrist proc, except major thumb or joint proc w CC/MCC 

517 Other musculoskelet sys & conn tiss O.R. proc w/o CC/MCC 

533 Fractures of femur w MCC 

534 Fractures of femur w/o MCC 

619 O.R. procedures for obesity w MCC 

642 Inborn errors of metabolism 

660 Kidney & ureter procedures for non-neoplasm w CC 

663 Minor bladder procedures w CC 

665 Prostatectomy w MCC 

668 Transurethral procedures w MCC 

685 Admit for renal dialysis 

709 Penis procedures w CC/MCC 

711 Testes procedures w CC/MCC 

718 Other male reproductive system O.R. proc exc malignancy w/o 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 

754 Malignancy, female reproductive system w MCC 
CMS-1498-P 604 

Proposed 

MSLTCDRG Proposed MS-LTC-DRG Description 

802 Other O.R. proc of the blood & blood forming organs w MCC 

917 Poisoning & toxic effects of drugs w MCC 

928 Full thickness burn w skin graft or inhal inj w CC/MCC 

929 Full thickness burn w skin graft or inhal inj w/o CC/MCC 

964 Other multiple significant trauma w CC 

985 Prostatic O.R. procedure unrelated to principal diagnosis w CC 

Quintile 5 

20 Intracranial vascular procedures w PDX hemorrhage w MCC 

38 Extracranial procedures w CC 

53 Spinal disorders & injuries w/o CC/MCC 

58 Multiple sclerosis & cerebellar ataxia w MCC 

72 Nonspecific cerebrovascular disorders w/o CC/MCC 

131 Cranial/facial procedures w CC/MCC 

133 Other ear, nose, mouth & throat O.R. procedures w CC/MCC 

164 Major chest procedures w CC 

168 Other resp system O.R. procedures w/o CC/MCC 

220 Cardiac valve & oth maj cardiothoracic proc w/o card cath 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 

248 Percutaneous cardiovasc proc w non-drug-eluting stent w MCC 

260 Cardiac pacemaker revision except device replacement w MCC 

263 Vein ligation & stripping 

286 Circulatory disorders except AMI, w card cath w MCC 

294 Deep vein thrombophlebitis w CC/MCC 

304 Hypertension w MCC 

326 Stomach, esophageal & duodenal proc w MCC 

330 Major small & large bowel procedures w CC 

335 Peritoneal adhesiolysis w MCC 

345 Minor small & large bowel procedures w CC 

350 Inguinal & femoral hernia procedures w MCC 

405 Pancreas, liver & shunt procedures w MCC 

408 Biliary tract proc except only cholecyst w or w/o c.d.e. w MCC 

411 Cholecystectomy w c.d.e. w MCC 

416 Cholecystectomy except by laparoscope w/o c.d.e. w/o CC/MCC 

417 Laparoscopic cholecystectomy w/o c.d.e. w MCC 

418 Laparoscopic cholecystectomy w/o c.d.e. w CC 

423 Other hepatobiliary or pancreas O.R. procedures w MCC 
CMS-1498-P 605 

Proposed 

MSLTCDRG Proposed MS-LTC-DRG Description 

424 Other hepatobiliary or pancreas O.R. procedures w CC 

456 Spinal fusion exc cerv w spinal curv, malig or 9+ fusions w MCC 

459 Spinal fusion except cervical w MCC 

466 Revision of hip or knee replacement w MCC 

469 Major joint replacement or reattachment of lower extremity w MCC 

470 Major joint replacement or reattachment of lower extremity w/o MCC 

479 Biopsies of musculoskeletal system & connective tissue w/o CC/MCC 

481 Hip & femur procedures except major joint w CC 

482 Hip & femur procedures except major joint w/o CC/MCC 

492 Lower extrem & humer proc except hip,foot,femur w MCC 

493 Lower extrem & humer proc except hip,foot,femur w CC 

498 Local excision & removal int fix devices of hip & femur w CC/MCC 

507 Major shoulder or elbow joint procedures w CC/MCC 

509 Arthroscopy 

597 Malignant breast disorders w MCC 

653 Major bladder procedures w MCC 

717 Other male reproductive system O.R. proc exc malignancy w CC/MCC 

725 Benign prostatic hypertrophy w MCC 

761 Menstrual & other female reproductive system disorders w/o CC/MCC 

769 Postpartum & post abortion diagnoses w O.R. procedure 

823 Lymphoma & non-acute leukemia w other O.R. proc w MCC 

829 Myeloprolif disord or poorly diff neopl w other O.R. proc w CC/MCC 

876 O.R. procedure w principal diagnoses of mental illness 

969 HIV w extensive O.R. procedure w MCC 

984 Prostatic O.R. procedure unrelated to principal diagnosis w MCC 

* Initial composition of proposed low-volume quintiles prior to adjusting for nonmonotonicity (as 

discussed in step 6 in section VII.B.3.g. of this preamble). Any adjustments to the proposed low volume 

quintile assignments to address nonmonotonicity are identified in Table 11 of the Addendum of this 

proposed rule.

 We note that we will continue to monitor the volume (that is, the number of 

LTCH cases) in the low-volume quintiles to ensure that our quintile assignments used in 

determining the proposed MS-LTC-DRG relative weights result in appropriate payment 

for such cases and do not result in an unintended financial incentive for LTCHs to 

inappropriately admit these types of cases. 
CMS-1498-P 606 

g. Steps for Determining the Proposed FY 2011 MS-LTC-DRG Relative Weights 

 In general, we are proposing to determine the FY 2011 MS-LTC-DRG relative 

weights based on our existing methodology. For additional information on the original 

development of this methodology, and modifications to it since the adoption of the 

MS-LTC-DRGs, we refer readers to the August 30, 2002 LTCH PPS final rule 

(67 FR 55989 through 55995) and the FY 2010 IPPS/RY 2010 LTCH PPS final rule 

(74 FR 43951 through 43966). 

 In summary, for FY 2011, to determine the proposed FY 2011 MS-LTC-DRG 

relative weights, we are proposing to group LTCH cases to the appropriate proposed 

MS-LTC-DRG, while taking into account the low-volume proposed MS-LTC-DRGs (as 

described above). After grouping the cases to the appropriate MS-LTC-DRG (or 

low-volume quintile), we calculate the proposed FY 2011 relative weights 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 adjust the number of cases in each proposed 

MS-LTC-DRG (or low-volume quintile) for the effect of SSO cases (step 3 below). 

After removing statistical outliers (step 1 below) and cases with a length of stay of less 

than 8 days (step 2 below), the SSO adjusted discharges and corresponding charges are 

then used to calculate "relative adjusted weights" for each proposed MS-LTC-DRG (or 

low-volume quintile) using the HSRV method. 

 Below we discuss in detail the steps for calculating the proposed FY 2011 

MS-LTC-DRG relative weights. We note that, as we stated in section VII.B.3.c. of this 

preamble, we excluded the data of all-inclusive rate LTCHs, LTCHs that are paid in 
CMS-1498-P 607 

accordance with demonstration projects, and any Medicare Advantage claims in the 

FY 2009 MedPAR file. 

 Step 1--Remove statistical outliers. 

 The first step in the calculation of the proposed FY 2011 MS-LTC-DRG relative 

weights is to remove statistical outlier cases. Consistent with our historical relative 

weight methodology, we are proposing to continue to 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 MS-LTC-DRG. These statistical 

outliers are removed prior to calculating the proposed relative weights because 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 MS-LTC-DRGs. (For additional information on this step of the 

relative weight methodology, we refer readers to 67 FR 55989 and 74 FR 43959.) 

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

 The 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. If we were to include stays of 7 days or less in the 

computation of the proposed FY 2011 MS-LTC-DRG relative weights, the value of many 

proposed relative weights would decrease and, therefore, payments would decrease to a 
CMS-1498-P 608 

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. Therefore, consistent with our historical relative weight 

methodology, in determining the proposed FY 2011 MS-LTC-DRG relative weights, we 

are proposing to remove LTCH cases with a length of stay of 7 days or less. (For 

additional information on this step of the relative weight methodology, we refer readers 

to 67 FR 55989 and 74 FR 43959.) 

 Step 3--Adjust charges for the effects of SSOs. 

 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. As the next step in the 

calculation of the proposed FY 2011 MS-LTC-DRG relative weights, consistent with our 

historical relative weight methodology, we are proposing to adjust each LTCH's charges 

per discharge for those remaining cases for the effects of SSOs (as defined in §412.529(a) 

in conjunction with §412.503). 

 We make this adjustment by counting an SSO case 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 

MS-LTC-DRG for non-SSO cases. This has the effect of proportionately reducing the 

impact of the lower charges for the SSO cases in calculating the average charge for the 

MS-LTC-DRG. This process produces the same result as if the actual charges per 

discharge of an SSO 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 MS-LTC-DRG. 
CMS-1498-P 609 

 Counting SSO cases as full discharges with no adjustment in determining the 

proposed RY 2011 MS-LTC-DRG relative weights would lower the proposed FY 2011 

MS-LTC-DRG relative weight for affected MS-LTC-DRGs because the relatively lower 

charges of the SSO cases would bring down the average charge for all cases within an 

MS-LTC-DRG. This would result in an "underpayment" for non-SSO cases and an 

"overpayment" for SSO cases. Therefore, we are proposing to adjust for SSO cases 

under §412.529 in this manner because it results in more appropriate payments for all 

LTCH cases. (For additional information on this step of the relative weight 

methodology, we refer readers to 67 FR 55989 and 74 FR 43959.) 

 Step 4--Calculate the proposed FY 2011 MS-LTC-DRG relative weights on an 

iterative basis. 

 Consistent with our historical relative weight methodology, we are proposing to 

calculate the proposed FY 2011 MS-LTC-DRG relative weights using the HSRV 

methodology, which is an iterative process. First, for each LTCH case, we calculate a 

hospital-specific relative charge value by dividing the SSO 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 MS-LTC-DRG, the proposed FY 2011 relative weight was 

calculated by dividing the average of the adjusted hospital-specific relative charge values 
CMS-1498-P 610 

(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 recalculated proposed 

MS-LTC-DRG relative weights, each LTCH's average relative weight for all of its cases 

(that is, its case-mix) is calculated by dividing the sum of all the LTCH’s proposed MSLTC-DRG relative weights by its total number of cases. The LTCHs' hospital-specific 

relative charge values above is multiplied by these hospital-specific case-mix indexes. 

These hospital-specific case-mix adjusted relative charge values are then used to 

calculate a new set of proposed MS-LTC-DRG relative weights across all LTCHs. This 

iterative process was 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 2011 relative weight for MS-LTC-DRGs with 

no LTCH cases. 

 As we stated above, we are proposing to determine the proposed FY 2011 relative 

weight for each proposed MS-LTC-DRG using total Medicare allowable charges reported 

in the best available LTCH claims data (that is, the December 2009 update of the 

FY 2009 MedPAR file for this proposed rule). Using these data, we identified a number 

of proposed MS-LTC-DRGs for which there were no LTCH cases in the database, such 

that no patients who would have been classified to those proposed MS-LTC-DRGs were 

treated in LTCHs during FY 2009 and, therefore, no charge data were available for these 

proposed MS-LTC-DRGs. Thus, in the process of determining the proposed 

MS-LTC-DRG relative weights, we were unable to calculate proposed relative weights 

for the proposed MS-LTC-DRGs with no LTCH cases using the methodology described 
CMS-1498-P 611 

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, consistent with our 

historical methodology, we are proposing to assign a proposed relative weight to each of 

the no-volume proposed MS-LTC-DRGs based on clinical similarity and relative 

costliness (with the exception of “transplant” proposed MS-LTC-DRGs and “error” 

proposed MS-LTC-DRGs, as discussed below). (For additional information on this step 

of the relative weight methodology, we refer readers to 67 FR 55991 and 74 FR 43959 

through 43960.) 

 In general, we determined proposed FY 2011 relative weights for the proposed 

MS-LTC-DRGs with no LTCH cases in the FY 2009 MedPAR file used in this proposed 

rule (that is, “no-volume” proposed MS-LTC-DRGs) by crosswalking each no-volume 

proposed MS-LTC-DRG to another proposed MS-LTC-DRG with a calculated proposed 

relative weight (determined in accordance with the methodology described above). Then, 

the “no-volume” proposed MS-LTC-DRG is assigned the same proposed relative weight 

(and average length of stay) of the proposed MS-LTC-DRG to which it was crosswalked 

(as described in greater detail below). 

 Of the 747 proposed MS-LTC-DRGs for FY 2011, we identified 223 proposed 

MS-LTC-DRGs for which there were no LTCH cases in the database (including the 

8 “transplant” proposed MS-LTC-DRGs and 2 “error” proposed MS-LTC-DRGs). As 

stated above, we are proposing to assign proposed relative weights for each of the 213 

no-volume proposed MS-LTC-DRGs (with the exception of the 8 “transplant” proposed 

MS-LTC-DRGs and the 2 “error” proposed MS-LTC-DRGs, which are discussed below) 
CMS-1498-P 612 

based on clinical similarity and relative costliness to one of the remaining 

524 (747 - 223 = 524) proposed MS-LTC-DRGs for which we were able to determine 

proposed relative weights based on FY 2009 LTCH claims data using the steps described 

above. (For the remainder of this discussion, we refer to the proposed “crosswalked” 

MS-LTC-DRGs as the proposed MS-LTC-DRGs to which we are proposing to crosswalk 

one of the 213 “no volume” proposed MS-LTC-DRGs for purposes of determining a 

proposed relative weight.) Then, we are proposing to assign the no-volume proposed 

MS-LTC-DRG the proposed relative weight of the proposed crosswalked MS-LTC-DRG. 

(As explained below in Step 6, when necessary, we made adjustments to account for 

nonmonotonicity.) 

 In this proposed rule, we are proposing to use the following methodology for 

determining the proposed FY 2011 relative weights for the no-volume proposed 

MS-LTC-DRGs: We crosswalk the no-volume proposed MS-LTC-DRG to a proposed 

MS-LTC-DRG for which there were LTCH cases in the FY 2009 MedPAR file and to 

which it is similar clinically in intensity of use of resources and relative costliness as 

determined by criteria such as 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. We evaluate the relative costliness in determining 

the applicable proposed MS-LTC-DRG to which a no-volume proposed MS-LTC-DRG 

was crosswalked in order to assign an appropriate proposed relative weight for the 

no-volume MS-LTC-DRGs in FY 2011. (For more detail on our process for evaluating 

relative costliness, we refer readers to the FY 2010 IPPS/RY 2010 LTCH PPS final rule 
CMS-1498-P 613 

(73 FR 48543).) We believe in the rare event that there would be a few LTCH cases 

grouped to one of the no-volume proposed MS-LTC-DRGs in FY 2011, the proposed 

relative weights assigned based on the crosswalked proposed MS-LTC-DRGs would 

result in an appropriate LTCH PPS payment because the proposed crosswalks, which are 

based on similar clinical similarity and relative costliness, generally require equivalent 

relative resource use. 

 We then assign the proposed relative weight of the crosswalked proposed MSLTC-DRG as the proposed relative weight for the no-volume proposed MS-LTC-DRG 

such that both of these MS-LTC-DRGs (that is, the no-volume proposed MS-LTC-DRG 

and the crosswalked proposed MS-LTC-DRG) would have the same proposed relative 

weight for FY 2011. We note that if the crosswalked proposed MS-LTC-DRG had 25 

cases or more, its proposed relative weight, which is calculated using the methodology 

described in Steps 1 through 4 above, is assigned to the no-volume proposed MS-LTCDRG as well. Similarly, if the MS-LTC-DRG to which the no-volume proposed 

MS-LTC-DRG is crosswalked has 24 or less cases and, therefore, is designated to one of 

the low-volume quintiles for purposes of determining the proposed relative weights, we 

assign the proposed relative weight of the applicable low-volume quintile to the 

no-volume proposed MS-LTC-DRG such that both of these proposed MS-LTC-DRGs 

(that is, the no-volume proposed MS-LTC-DRG and the crosswalked proposed 

MS-LTC-DRG) have the same proposed relative weight for FY 2011. (As we noted 

above, in the infrequent case where nonmonotonicity involving a no-volume proposed 
CMS-1498-P 614 

MS-LTC-DRG results, additional measures as described in Step 6 are required in order to 

maintain monotonically increasing proposed relative weights.) 

 For this proposed rule, a list of the no-volume MS-LTC-DRGs and the proposed 

MS-LTC-DRG to which it is crosswalked (that is, the crosswalked MS-LTC-DRG) for 

FY 2011 is shown in the chart below. 

Proposed No-Volume MS-LTC-DRG Crosswalk for FY 2011 

Proposed 

MSLTCDRG Proposed MS-LTC-DRG Description 

Proposed 

CrossWalked 

MS-LTCDRG 

12 Tracheostomy for face,mouth & neck diagnoses w CC 147 

13 Tracheostomy for face,mouth & neck diagnoses w/o CC/MCC 148 

14 Allogeneic bone marrow transplant 812 

15 Autologous bone marrow transplant 812 

21 Intracranial vascular procedures w PDX hemorrhage w CC 65 

22 Intracranial vascular procedures w PDX hemorrhage w/o CC/MCC 66 

23 

Craniotomy w major device implant or acute complex CNS PDX w 

MCC 25 

24 

Craniotomy w major device implant or acute complex CNS PDX w/o 

MCC 26 

27 Craniotomy & endovascular intracranial procedures w/o CC/MCC 26 

30 Spinal procedures w/o CC/MCC 29 

32 Ventricular shunt procedures w CC 31 

33 Ventricular shunt procedures w/o CC/MCC 31 

34 Carotid artery stent procedure w MCC 37 

35 Carotid artery stent procedurew CC 38 

36 Carotid artery stent procedure w/o CC/MCC 38 

39 Extracranial procedures w/o CC/MCC 38 

61 Acute ischemic stroke w use of thrombolytic agent w MCC 70 

62 Acute ischemic stroke w use of thrombolytic agent w CC 71 

63 Acute ischemic stroke w use of thrombolytic agent w/o CC/MCC 72 

67 Nonspecific cva & precerebral occlusion w/o infarct w MCC 68 

76 Viral meningitis w/o CC/MCC 75 

79 Hypertensive encephalopathy w/o CC/MCC 305 

88 Concussion w MCC 89 

103 Headaches w/o MCC 149 
CMS-1498-P 615 

Proposed 

MSLTCDRG Proposed MS-LTC-DRG Description 

Proposed 

CrossWalked 

MS-LTCDRG 

114 Orbital procedures w/o CC/MCC 125 

115 Extraocular procedures except orbit 125 

116 Intraocular procedures w CC/MCC 124 

117 Intraocular procedures w/o CC/MCC 125 

123 Neurological eye disorders 125 

129 Major head & neck procedures w CC/MCC or major device 146 

130 Major head & neck procedures w/o CC/MCC 148 

132 Cranial/facial procedures w/o CC/MCC 156 

134 Other ear, nose, mouth & throat O.R. procedures w/o CC/MCC 148 

135 Sinus & mastoid procedures w CC/MCC 133 

136 Sinus & mastoid procedures w/o CC/MCC 148 

137 Mouth procedures w CC/MCC 158 

138 Mouth procedures w/o CC/MCC 159 

139 Salivary gland procedures 159 

150 Epistaxis w MCC 152 

165 Major chest procedures w/o CC/MCC 168 

183 Major chest trauma w MCC 163 

184 Major chest trauma w CC 164 

185 Major chest trauma w/o CC/MCC 168 

215 Other heart assist system implant 254 

216 Cardiac valve & oth maj cardiothoracic proc w card cath w MCC 237 

217 Cardiac valve & oth maj cardiothoracic proc w card cath w CC 253 

218 Cardiac valve & oth maj cardiothoracic proc w card cath w/o CC/MCC 254 

219 Cardiac valve & oth maj cardiothoracic proc w/o card cath w MCC 237 

221 

Cardiac valve & oth maj cardiothoracic proc w/o card cath w/o 

CC/MCC 254 

222 Cardiac defib implant w cardiac cath w AMI/HF/shock w MCC 242 

223 Cardiac defib implant w cardiac cath w AMI/HF/shock w/o MCC 243 

224 Cardiac defib implant w cardiac cath w/o AMI/HF/shock w MCC 242 

228 Other cardiothoracic procedures w MCC 252 

229 Other cardiothoracic procedures w CC 253 

230 Other cardiothoracic procedures w/o CC/MCC 254 

231 Coronary bypass w PTCA w MCC 237 

232 Coronary bypass w PTCA w/o MCC 254 

233 Coronary bypass w cardiac cath w MCC 237 

234 Coronary bypass w cardiac cath w/o MCC 254 

235 Coronary bypass w/o cardiac cath w MCC 237 

238 Major cardiovascular procedures w/o MCC 254 
CMS-1498-P 616 

Proposed 

MSLTCDRG Proposed MS-LTC-DRG Description 

Proposed 

CrossWalked 

MS-LTCDRG 

241 Amputation for circ sys disorders exc upper limb & toe w/o CC/MCC 254 

245 AICD generator procedures 244 

246 Percutaneous cardiovascular proc w drug-eluting stent w MCC 252 

251 Perc cardiovasc proc w/o coronary artery stent or AMI w/o MCC 250 

257 Upper limb & toe amputation for circ system disorders w/o CC/MCC 254 

259 Cardiac pacemaker device replacement w/o MCC 262 

265 AICD lead procedures 264 

285 Circulatory disorders w AMI, expired w/o CC/MCC 284 

295 Deep vein thrombophlebitis w/o CC/MCC 301 

296 Cardiac arrest, unexplained w MCC 291 

297 Cardiac arrest, unexplained w CC 292 

298 Cardiac arrest, unexplained w/o CC/MCC 293 

331 Major small & large bowel procedures w/o CC/MCC 358 

332 Rectal resection w MCC 347 

333 Rectal resection w CC 348 

334 Rectal resection w/o CC/MCC 348 

337 Peritoneal adhesiolysis w/o CC/MCC 336 

338 Appendectomy w complicated principal diag w MCC 372 

339 Appendectomy w complicated principal diag w CC 372 

340 Appendectomy w complicated principal diag w/o CC/MCC 373 

341 Appendectomy w/o complicated principal diag w MCC 371 

342 Appendectomy w/o complicated principal diag w CC 372 

343 Appendectomy w/o complicated principal diag w/o CC/MCC 373 

346 Minor small & large bowel procedures w/o CC/MCC 344 

349 Anal & stomal procedures w/o CC/MCC 348 

351 Inguinal & femoral hernia procedures w CC 354 

352 Inguinal & femoral hernia procedures w/o CC/MCC 354 

355 Hernia procedures except inguinal & femoral w/o CC/MCC 354 

407 Pancreas, liver & shunt procedures w/o CC/MCC 419 

410 Biliary tract proc except only cholecyst w or w/o c.d.e. w/o CC/MCC 419 

412 Cholecystectomy w c.d.e. w CC 418 

413 Cholecystectomy w c.d.e. w/o CC/MCC 419 

414 Cholecystectomy except by laparoscope w/o c.d.e. w MCC 417 

415 Cholecystectomy except by laparoscope w/o c.d.e. w CC 418 

420 Hepatobiliary diagnostic procedures w MCC 423 

421 Hepatobiliary diagnostic procedures w CC 424 

422 Hepatobiliary diagnostic procedures w/o CC/MCC 424 

425 Other hepatobiliary or pancreas O.R. procedures w/o CC/MCC 424 
CMS-1498-P 617 

Proposed 

MSLTCDRG Proposed MS-LTC-DRG Description 

Proposed 

CrossWalked 

MS-LTCDRG 

434 Cirrhosis & alcoholic hepatitis w/o CC/MCC 433 

453 Combined anterior/posterior spinal fusion w MCC 459 

454 Combined anterior/posterior spinal fusion w CC 459 

455 Combined anterior/posterior spinal fusion w/o CC/MCC 460 

457 Spinal fusion exc cerv w spinal curv, malig or 9+ fusions w CC 459 

458 

Spinal fusion exc cerv w spinal curv, malig or 9+ fusions w/o 

CC/MCC 460 

461 Bilateral or multiple major joint procs of lower extremity w MCC 480 

462 Bilateral or multiple major joint procs of lower extremity w/o MCC 482 

468 Revision of hip or knee replacement w/o CC/MCC 467 

471 Cervical spinal fusion w MCC 472 

473 Cervical spinal fusion w/o CC/MCC 472 

483 Major joint & limb reattachment proc of upper extremity w CC/MCC 480 

484 Major joint & limb reattachment proc of upper extremity w/o CC/MCC 482 

488 Knee procedures w/o pdx of infection w CC/MCC 485 

489 Knee procedures w/o pdx of infection w/o CC/MCC 487 

508 Major shoulder or elbow joint procedures w/o CC/MCC 517 

510 Shoulder,elbow or forearm proc,exc major joint proc w MCC 515 

511 Shoulder,elbow or forearm proc,exc major joint proc w CC 516 

512 Shoulder,elbow or forearm proc,exc major joint proc w/o CC/MCC 517 

514 Hand or wrist proc, except major thumb or joint proc w/o CC/MCC 517 

538 Sprains, strains, & dislocations of hip, pelvis & thigh w/o CC/MCC 537 

582 Mastectomy for malignancy w CC/MCC 597 

583 Mastectomy for malignancy w/o CC/MCC 596 

585 Breast biopsy, local excision & other breast procedures w/o CC/MCC 605 

599 Malignant breast disorders w/o CC/MCC 601 

614 Adrenal & pituitary procedures w CC/MCC 629 

615 Adrenal & pituitary procedures w/o CC/MCC 630 

618 

Amputat of lower limb for endocrine,nutrit,& metabol dis w/o 

CC/MCC 617 

620 O.R. procedures for obesity w CC 619 

621 O.R. procedures for obesity w/o CC/MCC 619 

626 Thyroid, parathyroid & thyroglossal procedures w CC 625 

627 Thyroid, parathyroid & thyroglossal procedures w/o CC/MCC 625 

654 Major bladder procedures w CC 660 

655 Major bladder procedures w/o CC/MCC 660 

657 Kidney & ureter procedures forneoplasm w CC 656 

658 Kidney & ureter procedures for neoplasm w/o CC/MCC 656 
CMS-1498-P 618 

Proposed 

MSLTCDRG Proposed MS-LTC-DRG Description 

Proposed 

CrossWalked 

MS-LTCDRG 

661 Kidney & ureter procedures for non-neoplasm w/o CC/MCC 660 

662 Minor bladder procedures w MCC 663 

664 Minor bladder procedures w/o CC/MCC 663 

666 Prostatectomy w CC 665 

667 Prostatectomy w/o CC/MCC 665 

670 Transurethral procedures w/o CC/MCC 669 

672 Urethral procedures w/o CC/MCC 671 

688 Kidney & urinary tract neoplasms w/o CC/MCC 687 

691 Urinary stones w esw lithotripsy w CC/MCC 693 

692 Urinary stones w esw lithotripsy w/o CC/MCC 694 

707 Major male pelvic procedures w CC/MCC 659 

708 Major male pelvic procedures w/o CC/MCC 660 

712 Testes procedures w/o CC/MCC 711 

714 Transurethral prostatectomy w/o CC/MCC 669 

715 Other male reproductive system O.R. proc for malignancy w CC/MCC 717 

716 

Other male reproductive system O.R. proc for malignancy w/o 

CC/MCC 718 

724 Malignancy, male reproductive system w/o CC/MCC 723 

734 Pelvic evisceration, rad hysterectomy & rad vulvectomy w CC/MCC 749 

735 Pelvic evisceration, rad hysterectomy & rad vulvectomy w/o CC/MCC 749 

736 Uterine & adnexa proc for ovarian or adnexal malignancy w MCC 749 

737 Uterine & adnexa proc for ovarian or adnexal malignancy w CC 755 

738 

Uterine & adnexa proc for ovarian or adnexal malignancy w/o 

CC/MCC 755 

739 Uterine,adnexa proc for non-ovarian/adnexal malig w MCC 628 

740 Uterine,adnexa proc for non-ovarian/adnexal malig w CC 629 

741 Uterine,adnexa proc for non-ovarian/adnexal malig w/o CC/MCC 630 

742 Uterine & adnexa proc for non-malignancy w CC/MCC 629 

743 Uterine & adnexa proc for non-malignancy w/o CC/MCC 630 

744 D&C, conization, laparascopy & tubal interruption w CC/MCC 749 

745 D&C, conization, laparascopy & tubal interruption w/o CC/MCC 749 

747 Vagina, cervix & vulva procedures w/o CC/MCC 749 

748 Female reproductive system reconstructive procedures 749 

750 Other female reproductive system O.R. procedures w/o CC/MCC 749 

756 Malignancy, female reproductive system w/o CC/MCC 755 

765 Cesarean section w CC/MCC 749 

766 Cesarean section w/o CC/MCC 749 

767 Vaginal delivery w sterilization &/or D&C 749 
CMS-1498-P 619 

Proposed 

MSLTCDRG Proposed MS-LTC-DRG Description 

Proposed 

CrossWalked 

MS-LTCDRG 

768 Vaginal delivery w O.R. proc except steril &/or D&C 749 

770 Abortion w D&C, aspiration curettage or hysterotomy 749 

774 Vaginal delivery w complicating diagnoses 749 

775 Vaginal delivery w/o complicating diagnoses 749 

777 Ectopic pregnancy 776 

778 Threatened abortion 776 

779 Abortion w/o D&C 776 

780 False labor 776 

782 Other antepartum diagnoses w/o medical complications 781 

789 Neonates, died or transferred to another acute care facility 781 

790 Extreme immaturity or respiratory distress syndrome, neonate 781 

791 Prematurity w major problems 781 

792 Prematurity w/o major problems 781 

793 Full term neonate w major problems 781 

794 Neonate w other significant problems 781 

795 Normal newborn 781 

799 Splenectomy w MCC 802 

800 Splenectomy w CC 802 

801 Splenectomy w/o CC/MCC 802 

803 Other O.R. proc of the blood & blood forming organs w CC 802 

804 Other O.R. proc of the blood & blood forming organs w/o CC/MCC 802 

810 

Major hematol/immun diag exc sickle cell crisis & coagul w/o 

CC/MCC 812 

816 Reticuloendothelial & immunity disorders w/o CC/MCC 815 

820 Lymphoma & leukemia w major O.R. procedure w MCC 821 

822 Lymphoma & leukemia w major O.R. procedure w/o CC/MCC 821 

825 Lymphoma & non-acute leukemia w other O.R. proc w/o CC/MCC 824 

826 Myeloprolif disord or poorly diff neopl w maj O.R. proc w MCC 827 

828 Myeloprolif disord or poorly diff neopl w maj O.R. proc w/o CC/MCC 827 

830 

Myeloprolif disord or poorly diff neopl w other O.R. proc w/o 

CC/MCC 829 

837 Chemo w acute leukemia as sdx or w high dose chemo agent w MCC 846 

838 Chemo w acute leukemia as sdx or w high dose chemo agent w CC 847 

839 

Chemo w acute leukemia as sdx or w high dose chemo agent w/o 

CC/MCC 847 

848 

Chemotherapy w/o acute leukemia as secondary diagnosis w/o 

CC/MCC 847 

894 Alcohol/drug abuse or dependence, left ama 897 
CMS-1498-P 620 

Proposed 

MSLTCDRG Proposed MS-LTC-DRG Description 

Proposed 

CrossWalked 

MS-LTCDRG 

895 Alcohol/drug abuse or dependence w rehabilitation therapy 897 

916 Allergic reactions w/o MCC 915 

927 Extensive burns or full thickness burns w MV 96+ hrs w skin graft 928 

955 Craniotomy for multiple significant trauma 25 

956 Limb reattachment, hip & femur proc for multiple significant trauma 480 

958 Other O.R. procedures for multiple significant trauma w CC 957 

959 Other O.R. procedures for multiple significant trauma w/o CC/MCC 957 

986 Prostatic O.R. procedure unrelated to principal diagnosis w/o CC/MCC 985 

 To illustrate this methodology for determining the proposed relative weights for 

the proposed FY 2011 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 2011 provided in the chart above. 

 Example: There were no cases in the FY 2009 MedPAR file used for this 

proposed rule for MS-LTC-DRG 61 (Acute Ischemic Stroke with Use of Thrombolytic 

Agent with MCC). We determined that proposed MS-LTC-DRG 70 (Nonspecific 

Cebrovascular Disorders with MCC) was similar clinically and based on resource use to 

MS-LTC-DRG 61. Therefore, we assigned the same proposed relative weight of 

MS-LTC-DRG 70 of 0.9204 for FY 2011 to MS-LTC-DRG 61 (Table 11 of the 

Addendum to this proposed rule). 

 Furthermore, for FY 2011, consistent with our historical relative weight 

methodology, we are proposing to establish MS-LTC-DRG relative weights of 0.0000 for 

the following transplant proposed MS-LTC-DRGs: Heart Transplant or Implant of Heart 

Assist System with MCC (proposed MS-LTC-DRG 1); Heart Transplant or Implant of 
CMS-1498-P 621 

Heart Assist System without MCC (proposed MS-LTC-DRG 2); Liver Transplant with 

MCC or Intestinal Transplant (proposed MS-LTC-DRG 5); Liver Transplant without 

MCC (proposed MS-LTC-DRG 6); Lung Transplant (proposed MS-LTC-DRG 7); 

Simultaneous Pancreas/Kidney Transplant (proposed MS-LTC-DRG 8); Pancreas 

Transplant (proposed MS-LTC-DRG 10); and Kidney Transplant (proposed MS-LTCDRG 652). 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. At the present time, we only include these 

eight 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 MS-LTC-DRGs would be administratively burdensome. (For 

additional information regarding our treatment of transplant MS-LTC-DRGs, we refer 

readers to the RY 2010 LTCH PPS final rule (74 FR 43964).) Again, we note that, as 

this system is dynamic, it is entirely possible that the number of 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 MS-LTC-DRGs 

and to determine the proposed relative weights in this proposed rule. 

 Step 6--Adjust the proposed FY 2011 MS-LTC-DRG relative weights to account 

for nonmonotonically increasing relative weights. 

As discussed earlier in this section, the MS-DRGs contain base DRGs that have 

been subdivided into one, two, or three severity of illness levels. Where there are three 

severity levels, the most severe level has at least one code that is referred to as an MCC 
CMS-1498-P 622 

(that is, major complication or comorbidity). The next lower severity level contains cases 

with at least one code that is a CC (that is, complication or comorbidity). Those cases 

without an MCC or a CC are referred to as “without CC/MCC.” When data do not 

support the creation of three severity levels, the base DRG is subdivided into either two 

levels or the base DRG is not subdivided. The two-level subdivisions could consist of the 

with CC/MCC and the without CC/MCC. Alternatively, the other type of two-level 

subdivision may consist of the MCC and without MCC. 

 In those base MS-LTC-DRGs that are split into either two or three severity levels, 

cases classified into the “without CC/MCC” MS-LTC-DRG are expected to have a lower 

resource use (and lower costs) than the “with CC/MCC” MS-LTC-DRG (in the case of a 

two-level split) or both the “with CC” and the “with MCC” MS-LTC-DRGs (in the case 

of a three-level split). 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 relative weights decrease as severity decreased (that is, if within 

a base MS-LTC-DRG, an MS-LTC-DRG with CC has a higher relative weight than one 

with MCC, or the 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 because the payment for the cases in the higher severity level in a base 

MS-LTC-DRG (which are generally expected to have higher resource use and costs) 

would be lower than the payment for cases in a lower severity level within the same base 
CMS-1498-P 623 

MS-LTC-DRG (which are generally expected to have lower resource use and costs). 

Consequently, in determining the proposed FY 2011 MS-LTC-DRG relative weights in 

this proposed rule, consistent with our historical methodology, we are proposing to 

combine MS-LTC-DRG severity levels within a base MS-LTC-DRG for the purpose of 

computing a relative weight when necessary to ensure that monotonicity is maintained. 

For a comprehensive description of our existing methodology to adjust for 

nonmonotonicity, we refer readers to the FY 2010 IPPS/RY 2010 LTCH PPS final rule 

(74 FR 43964 through 43966). Any adjustments for nonmonotonicity that were made in 

determining the proposed FY 2011 MS-LTC-DRG relative weights in this proposed rule 

by applying this methodology are denoted in Table 11 of the Addendum to this proposed 

rule. 

Step 7-- Calculate the proposed FY 2011 budget neutrality factor. 

 As we established in the RY 2008 LTCH PPS final rule (72 FR 26882), under the 

broad authority conferred upon the Secretary to develop the LTCH PPS under section 

123 of Pub. L. 106-113, as amended by section 307(b) of Pub. L. 106-554, beginning 

with the MS-LTC-DRG update for FY 2008, the annual update to the MS-LTC-DRG 

classifications and relative weights is 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 MS-LTC-DRG classification and relative weight changes (§412.517(b) 

in conjunction with §412.503). (For a detailed discussion on the establishment of the 
CMS-1498-P 624 

budget neutrality requirement to update the MS-LTC-DRG classifications and relative 

weights, we refer readers to the RY 2008 LTCH PPS final rule (72 FR 26881).) 

 The MS-LTC-DRG classifications and relative weights are updated annually 

based on the most recent available LTCH claims data to reflect changes in relative LTCH 

resource use (§412.517(a) in accordance with §412.503). Under the budget neutrality 

requirement at §412.517(b), for each annual update, the MS-LTC-DRG relative weights 

are uniformly adjusted to ensure that estimated aggregate payments under the LTCH PPS 

would not be affected (that is, decreased or increased). Consistent with that provision, 

we are proposing to update the proposed MS-LTC-DRG classifications and relative 

weights for FY 2011 based on the most recent available LTCH data, and to apply a 

budget neutrality adjustment in determining the proposed FY 2011 MS-LTC-DRG 

relative weights. 

 To ensure budget neutrality in the proposed update to the MS-LTC-DRG 

classifications and relative weights under §412.517(b), we are proposing to continue to 

use our established two-step budget neutrality methodology. Specifically, in the first step 

of our MS-LTC-DRG budget neutrality methodology, we calculate and apply a 

normalization factor to the proposed recalibrated relative weights (the result of Steps 1 

through 6 above) to ensure that estimated payments are not influenced by changes in the 

composition of case types or the changes 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 

the average CMI. 
CMS-1498-P 625 

 To calculate the proposed normalization factor for FY 2011 (the first step of our 

budget neutrality methodology), we are proposing to use the following three steps: 

(1.a.) we use the most recent available LTCH claims data (FY 2009) and group them 

using the proposed FY 2011 GROUPER (Version 28.0) and the proposed recalibrated 

FY 2011 MS-LTC-DRG relative weights (determined in steps 1 through 6 of the Steps 

for Determining the Proposed FY 2011 MS-LTC-DRG Relative Weights above) to 

calculate the average CMI; (1.b.) we group the same LTCH claims data (FY 2009) using 

the FY 2010 GROUPER (Version 27.0) and FY 2010 MS-LTC-DRG relative weights 

and calculate the average CMI; and (1.c) we compute the ratio of these average CMIs by 

dividing the average CMI for FY 2010 (determined in Step 1.b.) by the average CMI for 

FY 2011 (determined in step 1.a.). In determining the proposed MS-LTC-DRG relative 

weights for FY 2011, each recalibrated MS-LTC-DRG relative weight is multiplied by 

1.10362 in the first step of the budget neutrality methodology, which produces 

"normalized relative weights." 

 In the second step of our MS-LTC-DRG budget neutrality methodology, we 

determine a budget neutrality factor to ensure that estimated aggregate LTCH PPS 

payments (based on the most recent available LTCH claims data) after reclassification 

and recalibration (that is, the proposed FY 2011 MS-LTC-DRG classifications and 

relative weights) are equal to estimated aggregate LTCH PPS payments before 

reclassification and recalibration (that is, the FY 2010 MS-LTC-DRG classifications and 

relative weights). Accordingly, consistent with our existing methodology, we are 

proposing to use FY 2009 discharge data to simulate payments and compare estimated 
CMS-1498-P 626 

aggregate LTCH PPS payments using the FY 2010 MS-LTC-DRGs and relative weights 

to estimate aggregate LTCH PPS payments using the proposed FY 2011 MS-LTC-DRGs 

and relative weights. As noted above, the most recent available LTCH claims data for 

this proposed rule are from the December 2009 update of the FY 2009 MedPAR file. 

Consistent with our historical policy of using the best available data, we are proposing to 

use the most recently available claims data for determining the budget neutrality 

adjustment factor in the final rule. 

 For this proposed rule, we determined the proposed FY 2011 budget neutrality 

adjustment factor rule using the following three steps: (2.a.) we simulate estimated total 

LTCH PPS payments using the normalized proposed relative weights for FY 2011 and 

GROUPER Version 28.0 (as described above); (2.b.) we simulate estimated total LTCH 

PPS payments using the FY 2010 GROUPER (Version 27.0) and the FY 2010 

MS-LTC-DRG relative weights shown in Table 11 of the FY 2010 IPPS/RY 2010 LTCH 

PPS final rule (74 FR 44183 through 44192); and (2.c.) we calculate the ratio of these 

estimated total LTCH PPS payments by dividing the estimated total LTCH PPS payments 

using the FY 2010 GROUPER (Version 27.0) and the FY 2010 MS-LTC-DRG relative 

weights (determined in step 2.b.) by the estimated total LTCH PPS payments using the 

proposed FY 2011 GROUPER (Version 28.0) and the normalized proposed 

MS-LTC-DRG relative weights for FY 2011 (determined in Step 2.a.). In determining 

the proposed FY 2011 MS-LTC-DRG relative weights, each normalized proposed 

relative weight is multiplied by a budget neutrality factor of 0.987575 in the second step 
CMS-1498-P 627 

of the budget neutrality methodology to determine the proposed budget neutral FY 2011 

relative weight for each MS-LTC-DRG. 

 Accordingly, in determining the proposed FY 2011 MS-LTC-DRG relative 

weights in this proposed rule, consistent with our existing methodology, we are proposing 

to apply a normalization factor of 1.10362 and a budget neutrality factor of 0.987575 

(computed as described above). 

 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 (used in determining SSO 

payments under §412.529) for FY 2011. The proposed FY 2011 MS-LTC-DRG relative 

weights in Table 11 in the Addendum to this proposed rule reflect both the proposed 

normalization factor of 1.10362 and the proposed budget neutrality factor of 0. 987575. 

C. Proposed Changes to the LTCH Payment Rates and Other Changes to the FY 2011

LTCH PPS

1. Overview of Development of the LTCH Payment Rates 

 The LTCH PPS was effective beginning with a LTCH's first cost reporting period 

beginning on or after October 1, 2002. Effective beginning with that cost reporting 

period, LTCHs were paid, during a 5-year transition period, a total LTCH prospective 

payment that was comprised of an increasing proportion of the LTCH PPS Federal rate 

and a decreasing proportion based on reasonable cost-based principles, unless the hospital 

made a one-time election to receive payment based on 100 percent of the Federal rate, as 
CMS-1498-P 628 

specified in §412.533. New LTCHs (as defined at §412.23(e)(4)) are paid based on 

100 percent of the Federal rate, with no phase-in transition payments. 

 The basic methodology for determining LTCH PPS Federal prospective payment 

rates is set forth at §412.515 through §412.536. In this section, we discuss the factors 

that would be used to update the LTCH PPS standard Federal rate for the FY 2011 that 

would be effective for LTCH discharges occurring on or after October 1, 2010 through 

September 30, 2011. 

 For further details on the development of the FY 2003 standard Federal rate, we 

refer readers to the August 30, 2002 LTCH PPS final rule (67 FR 56027 through 56037), 

and for subsequent updates to the LTCH PPS Federal rate, we refer readers to the 

following final rules: RY 2004 LTCH PPS final rule (68 FR 34134 through 34140), 

RY 2005 LTCH PPS final rule (69 FR 25682 through 25684), RY 2006 LTCH PPS final 

rule (70 FR 24179 through 24180), RY 2007 LTCH PPS final rule (71 FR 27819 through 

27827), RY 2008 LTCH PPS final rule (72 FR 26870 through 27029), RY 2009 LTCH 

PPS final rule (73 FR 26800 through 26804), and RY 2010 LTCH PPS final rule (74 FR 

44021 through 44030). The proposed update to the LTCH PPS standard Federal rate for 

FY 2011 is presented in section V.A. of the Addendum to this proposed rule. The two 

components of the proposed update to the LTCH PPS standard Federal rate for FY 2011 

are discussed below. 

2. Market Basket for LTCHs Reimbursed under the LTCH PPS 

a. Overview 
CMS-1498-P 629 

Historically, the Medicare program has used a market basket to account for price 

increases in the services furnished by providers. The market basket used for the LTCH 

PPS includes both operating and capital-related costs of LTCHs because the LTCH PPS 

uses a single payment rate for both operating and capital-related costs. With the initial 

implementation of the LTCH PPS for FY 2003, we established the use of the excluded 

hospital with capital market basket as the LTCH PPS market basket (67 FR 56016 

through 56017). The development of the initial LTCH PPS standard Federal rate for 

FY 2003, using the excluded hospital with capital market basket, is discussed in further 

detail in the August 30, 2002 LTCH PPS final rule (67 FR 56027 through 56033). For 

further details on the development of the excluded hospital with capital market basket, we 

refer readers to the RY 2004 LTCH PPS final rule (68 FR 34134 through 34137). 

Beginning in RY 2007, we adopted the rehabilitation, psychiatric, long-term care 

(RPL) hospital market basket based on FY 2002 data as the appropriate market basket of 

goods and services under the LTCH PPS for discharges occurring on or after 

July 1, 2006. As discussed in the RY 2007 LTCH PPS final rule (71 FR 27810), based 

on our research, we did not develop a market basket specific to LTCH services. We were 

unable to create a separate market basket specifically for LTCHs at that time due to the 

small number of facilities and the limited amount of data that was reported. 

For further details on the development of the FY 2002-based RPL market basket, 

we refer readers to the RY 2007 LTCH PPS final rule (71 FR 27810 through 27817). 

b. Market Basket under the LTCH PPS for FY 2011 
CMS-1498-P 630 

 When we initially created the FY 2002-based RPL market basket, we were unable 

to create a separate market basket specifically for LTCHs due, in part, to the small 

number of facilities and the limited data that were provided in the Medicare cost reports. 

Over the last several years, however, the number of LTCH facilities submitting valid 

Medicare cost report data has increased. Based on this development, as well as our desire 

to move from one RPL market basket to three stand-alone and provider-specific market 

baskets (for IRFs, IPFs, and LTCHs, respectively), we plan to begin exploring the 

viability of creating these market baskets for future use. However, as we discussed in the 

RY 2010 LTCH PPS final rule (74 FR 43967 through 43968), we are conducting further 

research to assist us in understanding the reasons for the variations in costs and cost 

structure between freestanding IRFs and hospital-based IRFs. We also are researching 

the reasons for similar variations in costs and cost structure between freestanding IPFs 

and hospital-based IPFs. Therefore, as we continue to explore the development of 

stand-alone market baskets for LTCHs, IRFs and IPFs, respectively, we believe that it is 

appropriate to continue to use the FY 2002-based RPL market basket for LTCHs, IRFs 

and IPFs under their respective PPSs. 

 In addition, for the reasons discussed when we adopted the RPL market basket for 

use under the LTCH PPS in the RY 2007 LTCH PPS final rule (71 FR 27810 through 

27817), we continue to believe that the RPL market basket appropriately reflect the cost 

structure of LTCHs. For the reasons explained above, in this proposed rule, we are 

proposing to continue to use the FY 2002-based RPL market basket under the LTCH PPS 

for FY 2011. We are hopeful that progress can be made in the near future with respect to 
CMS-1498-P 631 

creating stand-alone market baskets for LTCHs, IRFs, and IPFs and, as a result, may 

propose to rebase the appropriate market basket(s) for subsequent updates in the future. 

c. Proposed Market Basket Update for LTCHs for FY 2011 

 Consistent with our historical practice, we estimate the RPL market basket update 

based on IHS Global Insight, Inc.’s forecast using the most recent available data. IHS 

Global Insight, Inc. is a nationally recognized economic and financial forecasting firm 

that contracts with CMS to forecast the components of the hospital market baskets. 

Based on IHS Global Insight Inc.’s first quarter 2010 forecast, the proposed FY 2011 

market basket estimate for the LTCH PPS using the FY 2002-based RPL market basket is 

2.4 percent. Consistent with our historical practice of using market basket estimates 

based on the most recent available data, we are proposing that if more recent data are 

available when we develop the final rule, we would use such data, if appropriate. (We 

note that in section V. of the Addendum to this proposed rule, for FY 2011, we are 

proposing to update the LTCH PPS standard Federal rate by -0.1 percent. This proposed 

update reflects an adjustment based on the most recent market basket estimate (currently 

2.4 percent, as discussed above) and a proposed adjustment to account for the increase in 

case-mix in the prior periods (FYs 2008 through 2009) that resulted from changes in 

documentation and coding practices rather than increases in patients’ severity of illness.) 

d. Proposed Labor-Related Share under the LTCH PPS for FY 2011 

 As discussed in section V.B. of the Addendum to this proposed rule, under the 

authority of section 123 of the BBRA as amended by section 307(b) of the BIPA, we 

established an adjustment to the LTCH PPS payments to account for differences in 
CMS-1498-P 632 

LTCH area wage levels at §412.525(c). The labor-related portion of the LTCH PPS 

Federal rate, hereafter referred to as the labor-related share, is adjusted to account for 

geographic differences in area wage levels by applying the applicable LTCH PPS wage 

index. 

 The labor-related share is determined by identifying the national average 

proportion of operating and capital costs that are related to, influenced by, or vary with 

the local labor market. We continue to classify a cost category as labor-related if the 

costs are labor-intensive and vary with the local labor market. Consistent with our 

proposal to continue to use the FY 2002-based RPL market basket under the LTCH PPS 

for FY 2011 discussed above, we are proposing to continue to define the labor-related 

share as the national average proportion of operating costs that are attributable to wages 

and salaries, employee benefits, contract labor, professional fees, labor-intensive services, 

and a labor-related portion of capital based on the FY 2002-based RPL market basket. 

(Additional information on the development of the FY 2002-based RPL market basket 

used under the LTCH PPS can be found in the RY 2007 LTCH PPS final rule 

(71 FR 27809 through 27818).) 

 Furthermore, for FY 2011, we are proposing to continue to define the LTCH PPS 

labor-related share as the national average proportion of operating costs (wages and 

salaries, employee benefits, professional fees, and all other labor-intensive services) and a 

labor-related portion of capital costs based on the FY 2002-based RPL market basket. 

Consistent with our historical practice of using the best available data, we are proposing 

to use IHS Global Insight, Inc.’s first quarter 2010 forecast of the FY 2002-based RPL 
CMS-1498-P 633 

market basket for FY 2011 to determine the proposed labor-related share for the LTCH 

PPS for FY 2011 that would be effective for discharges occurring on or after 

October 1, 2010, and through September 30, 2011, as these are the most recent available 

data. 

 The proposed labor-related share for FY 2011 would be the sum of the proposed 

FY 2011 relative importance of each labor-related cost category, and would reflect the 

different rates of price change for these cost categories between the base year (FY 2002) 

and FY 2011. The sum of the proposed relative importance for FY 2011 for operating 

costs (wages and salaries, employee benefits, professional fees, and all-other 

labor-intensive services) would be 71.537 percent, as shown in the chart below. The 

portion of capital that is influenced by the local labor market is estimated to be 

46 percent. Because the relative importance for capital in FY 2011 would be 8.414 

percent of the FY 2002-based RPL market basket, we are proposing to take 46 percent of 

8.414 percent to determine the proposed labor-related share of capital for FY 2011. The 

result would be 3.870 percent, which we are proposing to add to 71.537 percent for the 

operating cost amount to determine the total proposed labor-related share for FY 2011. 

Thus, the labor-related share that we are proposing to use for LTCH PPS in FY 2011 

would be 75.407 percent. 

 The chart below shows the proposed FY 2011 relative importance labor-related 

share using the FY 2002-based RPL market basket. 

Proposed FY 2011 Labor-Related Share 

Based on the FY 2002-Based RPL Market Basket 
CMS-1498-P 634 

Cost Category FY 2011 Relative 

Importance (Percent) 

Wages and Salaries 52.590 

Employee Benefits 13.987 

Professional Fees: 2.848 

All Other Labor-Intensive 

Services 2.112 

Subtotal 71.537 

Labor-Related Share of 

Capital Costs (46 percent x 

8.414) 3.870 

Total Labor-Related 

Share 

75.407 

 Accordingly, under the authority set forth in section 123 of the BBRA as amended 

by section 307(b) of the BIPA, we are proposing to establish a labor-related share of 

75.407 percent under the LTCH PPS for the FY 2011. Furthermore, consistent with our 

historical practice of using the best data available, we also are proposing that if more 

recent data are available to determine the labor-related share used under the LTCH PPS 

for FY 2011, we would use these data for determining the FY 2011 LTCH PPS 

labor-related share in the final rule. 

3. Proposed Adjustment for Changes in LTCHs’ Case-Mix Due to Changes in 

Documentation and Coding Practices That Occurred in a Prior Period 

a. Background 

Beginning in RY 2007, in updating the standard Federal rate for the LTCH PPS, 

we have accounted for increases in payments from a past period that were due to changes 

in case-mix due to changes in documentation and coding practices. For additional 

information on the adjustments established for changes in LTCHs’ case-mix due to 

changes in documentation and coding practices that occurred in a prior period, we refer 
CMS-1498-P 635 

readers to the following final rules published in the Federal Register: the RY 2007 

LTCH PPS final rule (71 FR 27820); the RY 2008 LTCH PPS final rule (72 FR 26880 

through 26890); the RY 2009 LTCH PPS final rule (73 FR 26805 through 26812); and 

the FY 2010IPPS/RY 2010 LTCH PPS final rule (74 FR 43969 through 43970). 

For RY 2010, we performed an analysis of LTCHs’ case-mix index (CMI) 

changes in the prior periods (FY 2007 and FY 2008) and established a methodology to 

determine if an adjustment to account for changes in documentation and coding practices 

was applicable (74 FR 43969 through 43970). This methodology is consistent with the 

methodology established for case-mix analysis under the IPPS. In general, under our 

established methodology, in order to isolate the documentation and coding effect, we 

divided the combined effect of the changes in documentation and coding and 

measurement by the measurement effect (74 FR 43970). 

For the RY 2010 LTCH PPS proposed rule, we performed a retrospective 

evaluation of the FY 2007 and FY 2008 data for LTCH claims paid through December 

2008. Based on this evaluation, our actuaries determined that case-mix increased 

0.5 percent in FY 2007 and 1.3 percent in FY 2008 due to documentation and coding that 

did not reflect real changes in case-mix. In light of this analysis, in the RY 2010 LTCH 

PPS proposed rule, we proposed to apply a cumulative adjustment for changes in 

documentation and coding that do not reflect an increase in patients’ severity of illness of 

-1.8 percent (that is, -0.5 percent for FY 2007 plus -1.3 percent for FY 2008). We also 

invited public comment on our proposed methodology and analysis. (For additional 

information on our methodology and the results of the retrospective evaluation, we refer 
CMS-1498-P 636 

reader to sections VIII.C.3. of the preamble of the FY 2010 IPPS/RY 2010 LTCH PPS 

proposed and final rules (74 FR 24229 through 24230 and 74 FR 43970 through 43972, 

respectively).) 

In the FY 2010 IPPS/LTCH PPS final rule, we responded to comments on our 

methodology for the retrospective evaluation of FY 2007 and FY 2008 claims data, as 

well as our proposed -1.8 percent documentation and coding adjustment for RY 2010. In 

that same final rule, we finalized our proposal and established an adjustment of 

-0.5 percent to account for the documentation and coding increase that occurred in 

FY 2007. However, after consideration of public comments, and consistent with the 

decision to postpone the application of the prospective adjustment for estimated FY 2008 

documentation and coding increases under the IPPS, we delayed the application of the 

FY 2008 documentation and coding adjustment of -1.3 percent that was proposed under 

the LTCH PPS for RY 2010. We also stated our intent to address any future 

documentation and coding adjustment to the LTCH PPS standard Federal rate based on 

our analysis of the FY 2008 LTCH claims data in the FY 2011 rulemaking cycle through 

the notice-and-comment rulemaking process. (74 FR 43970 through 43972) 

b. Evaluation of FY 2009 Claims Data 

 For this proposed rule, we have performed a thorough retrospective evaluation of 

the most recent available claims data (that is, FY 2009 claims updated through December 

2009) using the methodology that was adopted in the FY 2010 IPPS/RY 2010 LTCH PPS 

final rule and that was used to assess whether an adjustment for RY 2010 to account for 

changes in documentation and coding practices that occurred in a prior period was 
CMS-1498-P 637 

appropriate. (We refer readers to the explanation of our rationale for adopting this 

methodology as well as its intended purpose in the FY 2010 IPPS/RY 2010 LTCH PPS 

final rule (74 FR 43970 through 43972).) 

We performed this analysis by first dividing the CMI obtained by grouping the 

FY 2009 LTCH claims through the FY 2009 GROUPER (Version 26.0) by the CMI 

obtained by grouping these same FY 2009 LTCH claims through the FY 2007 

GROUPER (Version 24.0). This resulted in a value of 1.0248. Because this CMI 

analysis is based on the same FY 2009 cases grouped using the Versions 24.0 and 26.0 of 

the GROUPER, we attribute this increase in average CMI primarily to two factors: 

(1) the effect of changes in documentation and coding under the MS-DRG system; and 

(2) the measurement effect from the calibration of the GROUPER. Next, we estimated 

the measurement effect from the calibration of the GROUPER by dividing the CMI 

obtained by grouping the FY 2007 LTCH claims through the FY 2009 GROUPER 

(Version 26.0) by the CMI obtained by grouping these same LTCH claims through the 

FY 2007 GROUPER (Version 24.0). This resulted in a value of 0.9999. In order to 

isolate the documentation and coding effect, we then divided the combined effect of the 

changes in documentation and coding measurement (1.0248) by the measurement effect 

(0.9999) to yield 1.025. Therefore, based on the results of this analysis, we estimate that 

the cumulative effect of documentation and coding changes that occurred in FYs 2008 

and 2009 was 2.5 percent. We note that, in applying the methodology we established for 

determining the effects of documentation and coding in the FY 2010 IPPS/RY 2010 

LTCH PPS proposed and final rules, we applied such methodology separately to FY 2007 
CMS-1498-P 638 

and FY 2008 LTCH claims data because those data were generated under different 

patient classification systems (that is, FY 2007 was the last year under the CMS LTCDRGs and FY 2008 was the first year under the MS-LTC-DRGs). Because the same 

patient classification system was in effect for both FY 2008 and FY 2009 (that is, the 

MS-LTC-DRGs), consistent with the application of this methodology under the IPPS 

(discussed in section II.D.5. of this preamble), we believe it is appropriate to propose to 

apply our established methodology for determining the cumulative effects of 

documentation and coding for FYs 2008 and 2009, rather than proposing to applying the 

methodology separately to FY 2008 and FY 2009 LTCH claims data. We seek public 

comment on our proposal to determine the cumulative effects of documentation and 

coding in FYs 2008 and 2009. (We note that the FY 2007 and FY 2009 (as well as 

FY 2008) MedPAR files are available to the public to allow independent analysis of the 

documentation and coding effect in FYs 2008 and 2009.) 

c. Proposed FY 2011 Documentation and Coding Adjustment 

Based on analysis of the most recent available LTCH claims data as described 

above, we are proposing to apply a cumulative adjustment for changes in documentation 

and coding in a prior period (FYs 2008 and 2009) that do not reflect an increase in 

patients’ severity of illness of -2.5 percent. Accordingly, as discussed in section V.A.2. 

of the Addendum to this proposed rule, we are proposing to update the proposed FY 2011 

LTCH PPS standard Federal rate by -0.1 percent, which is based on the most recent 

estimate of the market basket increase (2.4 percent) and a proposed adjustment to account 

for changes in documentation and coding practices (-2.5 percent). We also are proposing 
CMS-1498-P 639 

that if more recent data are available for the final rule, we would use those data to 

establish a final update to the FY 2011 LTCH PPS standard Federal rate, if applicable. 

D. Proposed Change in Terminology from “Rate Year” to “Fiscal Year” and Other 

Proposed Changes

Beginning with the annual update to the LTCH PPS that took effect on 

October 1, 2009, we consolidated the rulemaking cycle for the annual update of the 

LTCH PPS Federal payment rates with the annual update of the MS-LTC-DRG 

classifications and associated weighting factors for LTCHs so that the updates to the rates 

and the weights now occur on the same schedule and appear in the same Federal 

Register document. As a result, the updates to the LTCH standard Federal rates and the 

MS-LTC-DRG relative weights are now effective on October 1 (on a Federal fiscal year 

schedule), and the annual updates to the LTCH standard Federal rates are no longer 

published with a July 1 effective date. To reflect this change to the annual payment rate 

update cycle, we revised the regulations at §412.503 to specify that, beginning on or 

after October 1, 2009, the LTCH PPS rate year is defined as October 1 through 

September 30 (73 FR 26797 through 26798 and 26838). 

In this proposed rule, we are proposing to change the terminology used under the 

LTCH PPS to designate the annual payment update and MS-DRG relative weight 

recalibration cycle from “rate year” to “fiscal year,” in order to conform with the standard 

definition of the Federal fiscal year (October 1 through September 30) used by the IPPS. 

We believe that this proposed change is appropriate because both the yearly update cycle 

of the LTCH standard Federal rates (and associated factors) and the annual 
CMS-1498-P 640 

reclassification and recalibration of the MS-LTC-DRG relative weights (which were 

always updated on October 1, consistent with the IPPS) are now concurrent with the IPPS 

update and implementation schedule of October 1 through September 30. Because the 

annual updates to both the LTCH standard Federal rates (and associated factors) and the 

MS-LTC-DRG relative weights now occur at the same time as the annual updates under 

the IPPS, we believe we would eliminate any possible confusion that may be caused by 

continuing to identify the LTCH PPS update cycle as a “rate year.” We believe that 

changing the “fiscal year” terminology would provide important clarity for the LTCH 

provider community, particularly because both the proposed and final rules for the IPPS 

and the LTCH PPS are generally published in the same Federal Register document. 

Consequently, we are proposing to use the term “fiscal year” when referring to the annual 

updates for the LTCH standard Federal payment rates and MS-LTC-DRG relative 

weights as well as to the publication cycle for rulemaking for the LTCH PPS, consistent 

with the IPPS. We are proposing to revise our definition of “rate year” in the regulations 

at §412.503 to reflect this proposed terminology change. 

This proposed terminology revision from “rate year” to “fiscal year” would 

clarify the fact that since October 1, 2003, when we implemented the LTCH PPS, at 

different times, we have used the terms "rate year" and "fiscal year" when referring to the 

payment year under the LTCH PPS. In existing regulations at §412.503, we specify the 

time periods during which each term was used. We also are proposing to add a definition 

of "long-term care hospital prospective payment system payment year" to §412.503 in 

order to encompass both the long-term care hospital prospective payment system rate 
CMS-1498-P 641 

year and the long-term care hospital prospective payment system fiscal year. This 

proposed term would be used when describing ongoing policy features of the LTCH PPS 

for which, depending upon the time period, either the term “long-term care hospital 

prospective payment system rate year” or “long-term care hospital prospective payment 

system fiscal year” would be applicable. We believe that creating this term would 

minimize confusion by keeping the regulation text as simple as possible because this term 

would apply to the “long-term care hospital prospective payment system rate year” or to 

the “long-term care hospital prospective payment system fiscal year.” In this respect, 

existing regulation text (for example, §412.525(a)) would not need to be revised to 

address the specific time periods during which the terms “long-term care hospital 

prospective payment system rate year” and “long-term care hospital prospective payment 

system fiscal year” are used. 

In addition, as a conforming change, we are proposing to change the terminology 

in §412.525(a)(1) and (a)(2), which describes the high-cost outlier policy (an ongoing 

feature of the LTCH PPS from its inception), from "long-term care hospital prospective 

payment system rate year" to "long-term care hospital prospective payment system 

payment year". We believe that this proposed change, which would reference the 

proposed new definition of the long-term care hospital prospective payment system 

payment year period at §412.503, clearly reflects the application of the high-cost outlier 

policy for the period encompassed by both the current "rate year" terminology and the 

proposed change to "fiscal year" terminology, described above. We believe that these 

proposed changes present a straightforward way to provide additional clarity to our 
CMS-1498-P 642 

regulations in a circumstance that reflects changes in terminology but do not entail any 

change to the high-cost outlier policy. Furthermore, consistent with this proposal, for 

purposes of clarity, in this proposed rule, when discussing the annual update for the 

LTCH PPS, we employ "FY" rather than RY" because it is our intent that "FY" be used 

prospectively in all circumstances dealing with the LTCH PPS. 

VIII. Effective Date of Provider Agreements and Supplier Approvals 

A. Background

Section 1866 of the Act states that any provider of services as defined under 

section 1861(u) of the Act (except a fund designated for purposes of sections 1814(g) and 

1835(e) of the Act) shall be qualified to participate in the Medicare program and shall be 

eligible for Medicare payments if it files with the Secretary 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. Section 1866(b)(2) of the Act provides that the Secretary may refuse to enter into, 

or may terminate, an agreement with a provider for various reasons, including the 

provider’s failure to comply with the provisions of the agreement and if it has been 

determined that the provider fails to meet the applicable provisions of section 1861 of the 

Act, including health and safety standards. Certain suppliers are also required under the 

Act to meet health and safety standards specified by the Secretary: section 

1861(aa)(2)(K), with respect to rural health clinics; section 1832(a)(2)(F)(i), with respect 

to ambulatory surgical centers; and section 1881(b)(1)(A), with respect to providers of 

renal dialysis services. 
CMS-1498-P 643 

Under section 1864(a) of the Act, the Secretary enters into agreements with State 

agencies to determine if providers and suppliers meet the requisite Medicare 

requirements. Section 1865 of the Act permits CMS to “deem” facilities that have been 

accredited by a national accreditation organization under a CMS-approved accreditation 

program as having met the Medicare health and safety standards. Section 1871 of the Act 

authorizes the Secretary to adopt such regulations as may be necessary to carry out the 

requirements of Title XVIII of the Act. 

On August 18, 1997, we adopted regulations, effective September 17, 1997 

(1997 final rule), establishing uniform criteria for determining the effective dates of 

provider agreements and supplier approvals in the Medicare and Medicaid programs 

(62 FR 43931). Included in these regulations was 42 CFR 489.13, governing the 

determination of the effective date of a Medicare provider agreement or supplier approval 

for health care facilities that are subject to survey and certification. Facilities subject to 

survey and certification are those that must comply with Medicare health and safety 

standards, that is, the conditions of participation (CoPs), long-term care requirements, 

conditions for coverage (CfC), or conditions for certification, depending on the type of 

facility. (The regulations exempt clinical laboratories, community mental health centers, 

and federally qualified health centers from its general provisions, establishing alternative 

requirements for these entities.) Compliance with the applicable health and safety 

standards is determined through an onsite survey by a State survey agency, CMS staff, or 

a CMS contractor, or, in accordance with section 1865 of the Act, CMS may “deem” an 

entity to have satisfied these requirements if it has been accredited by a national 
CMS-1498-P 644 

accreditation program approved by CMS. Currently, we have approved 15 accreditation 

programs offered by 7 national accreditation organizations for the following types of 

providers or suppliers: hospitals, CAHs, HHAs, hospices, and ambulatory surgical 

centers. 

Under §489.13(b) of the regulations, the date the survey is completed is the 

effective date of the provider agreement or supplier approval, if all applicable Federal 

requirements have been met on that date. Similarly, §489.13(d) provides that the 

effective date for a provider or supplier accredited by a national accreditation 

organization under a CMS-approved program, and which is subject to additional 

requirements not contained in the approved program, is the date on which all Federal 

requirements have been met, including the additional requirements. We have interpreted 

these provisions to mean not only that the survey/accreditation decision must show that 

the prospective provider or supplier is in compliance with all of the applicable health and 

safety standards, but also that all other Federal requirements related to the prospective 

provider’s or supplier’s participation in the Medicare program have been met. 

Other Federal requirements include, but are not limited to, the submission of an 

application to enroll in the Medicare program that has been reviewed by our legacy fiscal 

intermediaries, legacy carriers, or MACs, as applicable, and has been found to meet the 

enrollment requirements established in 42 CFR Part 424, Subpart P. Other Federal 

requirements also include, for providers, compliance with Office for Civil Rights 

requirements. There also are additional Federal requirements specific to certain provider 
CMS-1498-P 645 

types, such as IPPS exclusion requirements for certain types of hospitals, capitalization 

and surety bond requirements for home health agencies, among others. 

Under our current process, section 2003B of the State Operations Manual (SOM) 

(Publication No. 100-07) states that: “The SA [State Survey agency] should not perform a 

survey of a new facility until it has received notice from the FI [fiscal intermediary] or carrier 

that the information provided on the enrollment application has been verified.” Section 2005 

of the SOM further states: “The MAC/legacy FI will process the Form CMS-855A and the 

MAC/legacy Carrier will process the Form CMS-855B, depending on which contractor is 

responsible for processing bills or claims for the provider/supplier. . . . The State Survey 

Agency will be responsible for surveying initial applicants following the contractor’s 

recommendation for approval, and providing the initial certification package.” (Emphasis 

added.) 

In accordance with §488.8(a)(2) of the regulations, one of the requirements for our 

approval of a national accreditation program is the comparability of its survey process to that 

of State survey agencies. Consistent with this requirement, in Survey and Certification 

Policy Memorandum S&C-09-08, dated October 17, 2008, we indicated that a 

CMS-approved national accreditation organization also must not conduct a survey of a 

facility seeking a Medicare provider agreement or supplier approval until after the MAC, the 

legacy fiscal intermediary, or the legacy carrier has completed its review of the enrollment 

application and notified the applicant that its review has been completed and a 

recommendation has been made to CMS. 

Therefore, historically, in the normal course of events, the health and safety survey 

(including the Life Safety Code survey, if applicable) of a prospective provider or supplier 
CMS-1498-P 646 

has usually occurred after it has demonstrated that it meets the Medicare enrollment 

requirements, and, as a result, the effective date of a provider agreement or supplier approval 

is generally later than the date when the contractor has verified that all enrollment 

requirements have been met. However, on occasion, a survey can take place before the CMS 

contractor has verified that enrollment requirements have been met. This has tended to 

happen more frequently in the case of facilities that seek to satisfy Medicare participation 

requirements through accreditation by a CMS-approved accreditation program, because the 

accreditation organization relies upon the facility to advise it when it has received notice of 

completion of the review of its enrollment application. This can result in the date of an 

accreditation decision preceding the date when the CMS contractor determination has 

occurred. In addition, in order to prevent fraud and abuse, there may be other situations in 

which the CMS contractor performs additional enrollment verification activities even after a 

health and safety survey has been performed. 

In cases where the CMS contractor determines that the prospective provider’s or 

supplier’s compliance with enrollment requirements did not occur until after a survey by the 

State survey agency or after the accreditation survey and accreditation decision take place, it 

is our policy, consistent with our interpretation of §489.13(b), to make the effective date of 

the provider agreement or supplier approval the date when the enrollment requirements are 

considered to have been met, that is, the date determined by the CMS contractor, pursuant to 

its review and verification activities, to be the date when the applicant is in compliance with 

all enrollment requirements and the CMS contractor is prepared to convey Medicare billing 

privileges to the provider or supplier, unless there are still other Federal requirements that 

remain to be satisfied, such as submission of required civil rights compliance documentation 
CMS-1498-P 647 

or satisfaction of the specialized requirements governing IPPS-excluded hospitals. If there 

are other unsatisfied requirements, the effective date would be the date when the last 

requirement has been satisfied, as determined by CMS. 
CMS-1498-P 648 

B. Departmental Appeals Board Decision

In a decision dated September 28, 2009, the Appellate Division of the Departmental 

Appeals Board (DAB), in the case of Renal CarePartners of Delray Beach, LLC v. Centers 

for Medicare and Medicaid Services (DAB Decision No. 2271), rejected our longstanding 

interpretation of §489.13(b). In this case, a State survey agency completed an initial 

certification survey on July 6, 2007, of an end-stage renal disease supplier, Renal 

CarePartners, prior to the CMS contractor’s November 21, 2007 recommendation of approval 

of the supplier’s enrollment application. The DAB concluded that there was no basis in 

regulation or policy issuances for our position that CMS contractor approval is a requirement 

a supplier must satisfy “before it may furnish services for which it will be reimbursed under 

Medicare once it is enrolled and obtains billing privileges” (DAB Decision No. 2271, 

page 2). The DAB further characterized the issue as “. . . not whether the effective date may 

be earlier than the date Renal CarePartners complied with a prerequisite it was required to 

meet in order to enroll, but whether the effective date must be delayed until the date the 

Medicare contractor notified CMS that the requirements were met” (DAB Decision No. 

2271, page 5) (emphasis in original). The DAB agreed with Renal CarePartners that the 

requirement for the Medicare contractor to verify and determine whether an application 

should be approved is not a requirement for the supplier to meet, but a requirement for 

Medicare contractor action (DAB Decision No. 2271, page 5). The DAB further cited the 

provisions of §489.13(d), concerning accredited facilities, as an example to bolster its 

contention that there is precedent for providers or suppliers to be retroactively reimbursed for 

services provided before the date of approval of the supplier or provider agreement (DAB 

Decision No. 2271, page 7). 
CMS-1498-P 649 

We disagree with the DAB’s reading of our existing regulations. We believe that the 

intent of the existing regulations is to require that all applicable Federal requirements, 

including a determination of whether the enrollment requirements have been satisfied, must 

be met before a provider agreement or supplier approval may be effective. Any other reading 

of the regulations could result in a provider or supplier being permitted to bill the Medicare 

program for services provided at a time when its compliance with Medicare’s requirements is 

unknown and possibly deficient. For example, in the event a State survey precedes the CMS 

contractor’s review of the enrollment application of a prospective provider or supplier, it 

might be possible that the application originally submitted to the CMS contractor is 

incomplete or incorrect, or both, and the applicant must provide additional information to the 

CMS contractor to demonstrate compliance with the enrollment requirements. It would not 

be consistent with our duty to protect the Medicare Trust Funds from unsupported claims 

against it to permit payment for services furnished by a health care facility after it has passed 

a State survey or been accredited, but before it has satisfied all other Medicare participation 

requirements, including enrollment requirements. 

Such a reading also might undermine the incentives inherent in our longstanding 

policy, affirmed in the June 1, 1994 decision of the U.S. Court of Appeals for the Fifth 

Circuit in U.S. v. Vernon Home Health, Inc. (21 F.3d 693 (5th Cir. 1994), cert. denied, 

115 S.Ct. 575 (1994)). Under that policy, a buyer of a Medicare-participating facility that 

chooses not to assume the provider agreement or supplier approval of the seller must be 

treated as an initial applicant to the Medicare program, with a necessary break in 

Medicare payments for services furnished to beneficiaries during the period between the 

effective date of the change of ownership, and the effective date of the new owner’s 
CMS-1498-P 650 

provider agreement or supplier approval. Assumption of the seller’s provider agreement 

or supplier approval includes assumption of the assets and liabilities associated with that 

agreement or approval, which has proven to be an important tool in protecting the 

Medicare Trust Funds through continuity in the ability to recover outstanding 

overpayments. Any requirement to make payments retroactive to the date of a State 

survey or accreditation decision, despite the fact that all other Federal requirements may 

not yet have been met, could provide an incentive for more buyers to refuse assumption 

of the seller’s provider agreement or supplier approval, because there would potentially 

be no break in payments. Therefore, effectively, a buyer who does not assume the 

seller’s active provider agreement could begin receiving Medicare payments (assuming it 

meets all the requirements), but not be responsible for any existing liabilities of the 

provider agreement. This would also be an incentive for existing providers or suppliers 

with civil money penalties or overpayments to sell their facilities in order to escape any 

financial responsibility to the Medicare program. 

C. Proposed Revisions to Regulations

We are proposing to amend §489.13 and make a technical amendment to §489.1 in 

order to clarify our policy. Specifically, we are proposing to revise §489.13(a) to make it 

clearer that it is only CMS that determines whether health care facilities have satisfied the 

requirements for participation in the Medicare program, not State survey agencies or 

national accreditation organizations. We note that, although this CMS determination is 

sometimes referred to as a “certification,” or “certification decision,” §488.1 defines 

“certification” as “a recommendation made by the State survey agency on the compliance 

of providers and suppliers with the conditions of participation, requirements (for SNFs 
CMS-1498-P 651 

and NFs), and conditions of coverage.” Further, §488.12 provides that CMS makes the 

determination on whether a provider or supplier is eligible to participate in or be covered by 

the Medicare program, based on the State survey agency’s recommendation, or on the 

facility’s accreditation. 

We also are proposing to add language to §489.13(a) in order to clarify that surveys 

of nonaccredited facilities may be conducted not only by State survey agencies, but also by 

CMS staff or contractors, as appropriate. We have used contractors to conduct certain types 

of surveys, such as life safety code, transplant program and psychiatric hospital special 

conditions surveys, and may continue to do so in the future. In addition, certain types of 

facilities, such as Indian Health Services (IHS) facilities and RNHCIs, have traditionally been 

surveyed by CMS employees rather than State survey agencies. 

We are proposing to revise §489.13(b) to make explicit that the effective date of a 

provider agreement or supplier approval may not be earlier than the latest of the dates on 

which each applicable Federal requirement is determined to be met. We also are 

proposing to state explicitly that “Federal requirements” include, but are not limited to, 

the enrollment requirements established in 42 CFR Part 424, Subpart P, that have been 

determined by CMS to have been met. In addition, we are proposing to revise §489.13(b) 

to include language concerning accredited facilities, to assure that accredited and 

nonaccredited facilities are treated in the same manner. 

We wish to further explain the rationale behind the proposed change to 

§489.13(b), particularly with respect to the requirements in the provider/supplier 

enrollment process. 
CMS-1498-P 652 

A CMS contractor will review and conduct an initial assessment of a prospective 

provider’s or supplier’s enrollment. If the contractor finds that a prospective provider or 

supplier meets the basic enrollment requirements to participate in the Medicare program 

for its identified certified provider or supplier type, the contractor will notify the 

appropriate CMS Regional Office. Essentially, the contractor's initial assessment means 

that it has concluded its preliminary review of the application and has concluded that the 

survey and certification process can be initiated, and, consequently, it issues a 

recommendation of approval. In order to help ensure compliance with enrollment 

requirements throughout this process, the contractor may continue to perform a number 

of enrollment verification tasks even after it has issued a recommendation for approval. 

These include, but are not limited to, conducting onsite visits of the prospective provider 

or supplier to ensure that it is still operational; verifying an HHA applicant’s compliance 

with the capitalization provisions in 42 CFR 489.28; and requesting the provider or 

supplier applicant to reaffirm the accuracy of the information it furnished on its initial 

enrollment application. Given the potentially significant length of time between when 

the contractor issues its recommendation of approval after its initial assessment and when 

the health and safety survey (or accreditation) and certification process is completed, we 

believe that it is essential for the contractor to verify that a provider or supplier applicant 

continues to meet enrollment requirements prior to the issuance of a Medicare provider 

agreement or supplier approval and the issuance of Medicare billing privileges. 

To that end, we believe that the CMS contractor should verify that a provider or 

supplier is in compliance with all enrollment requirements when an enrollment 
CMS-1498-P 653 

application is submitted, during the period in which a provider or supplier is undergoing 

the health and safety survey and certification process and before the issuance of a 

Medicare provider agreement or supplier approval and billing privileges. If a provider or 

supplier is determined to be in compliance with all Medicare requirements, including the 

enrollment requirements, the enrollment process will be completed, and the Medicare 

provider agreement or supplier approval and billing privileges will be issued to the 

applicant. However, if a provider or supplier is determined to be out of compliance with 

Medicare enrollment requirements prior to the issuance of a Medicare provider 

agreement or supplier approval and billing privileges to the applicant, we believe that 

CMS must deny Medicare billing privileges using the applicable denial reason found in 

42 CFR 424.530 and afford the applicant with the applicable Medicare appeal rights. 

We are proposing to revise §489.13(c) to make clear that this paragraph addresses 

those situations in which a facility has met all other Federal requirements but, upon survey, 

has been found to not meet all applicable CoPs, long-term care requirements, CfCs, or 

conditions for certification. We also are proposing to revise this paragraph to include 

language concerning accredited facilities, to assure that accredited and nonaccredited 

facilities are treated in the same manner.

We are proposing to remove §489.13(d), concerning the determination of the 

effective date for accredited facilities. We see no reason for differential treatment of 

accredited and nonaccredited facilities with respect to the determination of their effective 

date, and, in practice, we have not treated them differentially. In particular, as a matter of 

policy, we have not exercised the discretion permitted under §489.13(d)(2) to grant 

accredited facilities an effective date retroactive up to 1 year prior to what otherwise would 
CMS-1498-P 654 

be their effective date. Permitting such retroactive payment would provide accredited 

facilities an unwarranted advantage when compared to nonaccredited facilities. It would also 

seriously undermine our policy concerning change of ownership without assumption of the 

seller’s provider agreement or supplier approval. However, the existence of this 

discretionary provision appears to cause confusion among accredited providers and suppliers 

who incorrectly believe they are entitled to a retroactive effective date. 

This discretionary provision was included in the 1997 final rule as a result of public 

comments that concerned the Medicaid program. The commenters were concerned that the 

proposed rule would not have allowed for a retroactive agreement for a facility that was 

already accredited and cited two Medicaid program scenarios to illustrate their concern. 

In one scenario, a facility participates in its own State’s Medicaid program and provides 

services to a Medicaid recipient from another State. In the other scenario, a facility does 

not participate in Medicaid but provides services to a Medicaid recipient before learning 

of the individual’s Medicaid status. Neither of these scenarios is pertinent to the 

Medicare program because Medicare enrollment is managed nationally. However, the 

stated intent of the 1997 final rule was to use a standard approach for both Medicare and 

Medicaid to determine the effective date of a provider agreement and a supplier approval, 

and, as a result, the provisions of §489.13(d)(2) are identical to those at §431.108(d)(2) 

for the Medicaid program. 

Upon further consideration, we believe it is important to recognize the significant 

differences resulting from a State-based versus national system of beneficiary enrollment, 

and to ensure that the provisions of §489.13 are tailored to the requirements of the 

Medicare program. As stated, as a matter of longstanding policy, reflected in issuances 
CMS-1498-P 655 

dating back at least as far as 1994, we have required new owners who do not accept the 

seller’s Medicare provider agreement or supplier approval to be treated as initial 

applicants to the Medicare program. In a 1999 issuance, reaffirmed in several subsequent 

issuances, including the 2004 publication of the online version of the SOM and in Survey 

and Certification Memorandum S&C-09-08 issued on October 17, 2008, we explicitly 

state that this policy applies to accredited facilities as well. Therefore, we believe it is 

appropriate to remove §489.13(d), and to instead make appropriate reference to the 

situation of accredited facilities in §§489.13(b) and (c). 

Finally, we are proposing to make several technical amendments to §489.1. 

Specifically, we are proposing to revise that section to add a reference to section 1865 of 

the Act, which permits CMS to “deem” facilities that have been accredited by a national 

accreditation organization under a CMS-approved accreditation program as having met 

the Medicare health and safety standards. We also are proposing to revise and renumber 

the existing provision of §489.1 and to add references to “the Act” where the section 

refers to a provision of the Social Security Act. 

IX. Proposed Changes to Medicare Conditions of Participation Affecting Hospital 

Rehabilitation Services and Respiratory Care Services 

Recently, CMS received several public requests for clarification of the Medicare 

conditions of participation (CoPs) for hospitals relating to rehabilitation services at 

§482.56 and respiratory care services at §482.57. The questions concerning these 

conditions have been in the context of apparent inconsistencies between the two COPs 

themselves, and between the two CoPs and many State laws, regarding which 
CMS-1498-P 656 

practitioners are allowed to order rehabilitation and respiratory care services in the 

hospital setting. 

 Many States, under their scope-of-practice laws and other regulations, allow 

qualified, licensed practitioners (including nurse practitioners (NPs) and physician 

assistants (PAs)) to order rehabilitation services and respiratory care services, in addition 

to other common hospital services such as dietary and social work services. We also 

found that most States limit the types of practitioners allowed to order rehabilitation 

services, respiratory care services, and other hospital services to physicians and other 

qualified, licensed practitioners such as NPs and PAs. 

However, the current standard at §482.56(b) (Delivery of services) requires only 

that hospital rehabilitation services (for example, physical therapy, occupational therapy, 

audiology, and speech-pathology services) be ordered by “practitioners who are 

authorized by the medical staff to order the services.” We believe that this requirement 

may be too open for interpretation and is not consistent with various State laws that limit 

the ordering of hospital services (including diagnostic tests, drugs and biologicals, and 

inpatient treatment modalities) to qualified, licensed practitioners who are responsible for 

the care of the patient and who are, most importantly, working within a State’s delineated 

scope of practice for these types of practitioners. As this requirement is currently written, 

it would be conceivable for a hospital’s medical staff to grant ordering privileges for 

rehabilitation services to personnel who are responsible for providing such services, that 

is, physical therapists, occupational therapists, audiologists, and speech-language 

pathologists. Such a situation would not only constitute a conflict of interest (for 
CMS-1498-P 657 

example, a physical therapists ordering physical therapy services for a patient for which 

medical necessity has not been established), but it would also potentially compromise 

coordination of care and patient safety if the practitioners who are responsible for the care 

of patients (that is, doctors of medicine, doctors of osteopathy, NPs, and PAs) are 

unaware of which services have been ordered for their patients. 

Conversely, the current requirement for respiratory care services at §482.57(b)(3) 

explicitly states that these services “must be provided only on, and in accordance with, 

the orders of a doctor of medicine or osteopathy.” Similar to our finding that the 

requirement for the ordering of rehabilitation services is too broad in its parameters for 

determining which practitioners should be allowed to order those services, we find the 

parameters for the ordering of respiratory care services to be too narrow. While doctors 

of medicine or doctors of osteopathy have the option of delegating this task to NPs and 

PAs, this delegation requires physicians to countersign all orders by NPs or PAs for 

respiratory care services. We have not found any evidence that indicates that the 

ordering of respiratory care services should be kept to a different, and possibly higher, 

standard than rehabilitation and other hospital services. Nor have we found any 

documented studies indicating that qualified, licensed practitioners such as NPs and PAs 

should be restricted from ordering these necessary services for their patients. Further, we 

believe that the process of physician countersignature of orders written by qualified, 

licensed NPs and PAs, specifically for common hospital services such as rehabilitation 

and respiratory care services, is burdensome to practitioners (physicians as well as NPs 

and PAs) and the hospitals that they serve. In addition, we believe that this process also 
CMS-1498-P 658 

runs counter to what many States have already decided for NPs and PAs in their 

individual State regulations and scope-of-practice laws. 

As a result of our analysis of the issues surrounding conflict of the Medicare CoPs 

with State laws, and conflict of the Medicare CoP with each other, we are proposing 

several revisions to the existing regulations. We are proposing to revise §482.56 to 

clarify the types of practitioners who are allowed to order rehabilitation services. 

Further, we are proposing to limit those types of individuals to qualified, licensed 

practitioners who are responsible for the care of the patient and who are acting within the 

scope of practice under State law. We also are proposing that these practitioners would 

need to be authorized to order rehabilitation services by the hospital’s medical staff, in 

accordance with both hospital policies and procedures and State laws. 

In addition, we are proposing changes to the existing requirements for the 

ordering of respiratory care services at §482.57. Existing requirements only allow for 

services to be provided on the orders of a doctor of medicine or osteopathy. As stated 

above, we recently received several public requests (including requests from various 

hospitals as well as from The Joint Commission) for clarification of this requirement in 

the context of what is currently allowed under many State laws. Many States, under their 

scope-of-practice laws and other regulations, allow qualified, licensed practitioners 

(including NPs and PAs) to order respiratory care services. We are proposing to revise 

the existing requirements at §482.57 to allow these practitioners, in addition to physicians 

as currently allowed, to order these services as long as such privileges are authorized by 

the medical staff and are in accordance with both hospital policies and procedures and 
CMS-1498-P 659 

State laws. As is required under the CoPs for all patient orders, the ordering practitioner 

must also be an individual who is responsible for the care of the patient. 

In both of the CoPs for rehabilitation services and respiratory care services, we 

also are proposing that all orders for these services be documented in accordance with the 

requirements at §482.24, Medical records. 

X. Proposed Changes to the Accreditation Requirements for Medicaid Providers of 

Inpatient Psychiatric Services for Individuals under Age 21 

A. Background

 Inpatient psychiatric services provided to individuals under the age of 21 were 

authorized as part of the Medicaid program by the Social Security Amendments of 1972 

(Pub. L. 92-603). At that time, these services were only permitted to be provided by 

psychiatric hospitals accredited by the Joint Commission on Accreditation of Hospitals 

(later renamed as the Joint Commission on Accreditation of Healthcare Organizations 

and now named The Joint Commission). In 1984, Congress eliminated the requirement 

that such hospitals be accredited exclusively by The Joint Commission (section 2340(b) 

of Pub. L. 98-369). 

 Through statutory and regulatory amendments, inpatient psychiatric services 

provided to individuals under the age of 21 were also authorized to be provided in 

inpatient psychiatric programs within hospitals and in psychiatric facilities other than 

hospitals, called psychiatric residential treatment facilities (PRTFs). While PRTFs were 

given flexibility through rulemaking in 1998 to obtain accreditation from several specific 

accrediting organizations, or any other accrediting body with comparable standards 
CMS-1498-P 660 

recognized by the State, accreditation by The Joint Commission has remained a 

requirement for psychiatric hospitals and inpatient psychiatric programs within hospitals. 

 We have been contacted by several psychiatric hospitals and hospitals with 

inpatient psychiatric programs asking for relief of The Joint Commission accreditation 

requirement. In addition, The Joint Commission has previously expressed concern with 

the mandate for Joint Commission accreditation contained in existing regulation, as its 

policy is for facilities to seek accreditation voluntarily. 

B. Proposed Revision of Policy and Regulations

 In response to the concerns described above, we are proposing to remove the 

requirement that psychiatric hospitals and hospitals with inpatient psychiatric programs 

providing inpatient psychiatric services to individuals under age 21 must obtain 

accreditation from The Joint Commission in order to provide these services under the 

Medicaid program. Under our proposed policy change, psychiatric hospitals would have 

the choice of meeting the requirements to participate in Medicare as a psychiatric hospital 

under 42 CFR 482.60 or obtaining accreditation from a national accrediting organization 

whose psychiatric hospital accrediting program has been approved by CMS. Hospitals 

with inpatient psychiatric programs would have the choice of meeting the requirements 

for participation in Medicare as a hospital as specified in 42 CFR Part 482 or obtaining 

accreditation from a national accrediting organization whose hospital accreditation 

program has been approved by CMS. These national accreditation bodies must provide 

reasonable assurance to CMS that their hospital accrediting programs require adherence 

to requirements that are at least as stringent as the Medicare requirements. 
CMS-1498-P 661 

 In addition, we are proposing to revise the accreditation requirements for PRTFs 

by removing any specific references to accreditation organizations to afford them 

flexibility in obtaining accreditation by a national accrediting organization whose 

program has been approved by CMS, or by any other accrediting organization with 

comparable standards that is recognized by the State. This proposed revision would 

remove specific reference to national accrediting bodies to provide appropriate 

administrative flexibility to account for any changes in qualifying accrediting 

organizations. Accrediting bodies approved by CMS must have accrediting requirements 

for an entity comparable to the CMS requirements for the same entity, and must have 

survey procedures comparable to those of State survey agencies. 

 The regulations at 42 CFR 488.4 describe the procedures to be followed by 

accrediting organizations applying or reapplying for approval of deeming authority for 

Medicare requirements. The regulations at 42 CFR 488.5(b) and 488.6(b) allow 

providers and suppliers deemed eligible for Medicare by these accrediting organizations 

to be also deemed eligible for Medicaid participation in the absence of Medicaid 

regulations requiring adherence to a different standard. In addition, the regulations at 

42 CFR 488.8 detail the procedures that CMS will follow in reviewing and approving 

national accreditation organizations. Nothing in this proposed rule would alter the 

implementation of these regulatory provisions. 

 We believe this flexibility in obtaining accreditation would facilitate the provision 

of medically necessary, Medicaid-reimbursable psychiatric services to vulnerable 

children, while maintaining the high quality of care demanded by the Medicaid program. 
CMS-1498-P 662 

While services may be provided in different settings, the requirements of 42 CFR 

441.150 through 441.182 must be adhered to by any provider of services. We are 

inviting public comments on our suggestions for improving current protections for 

children. 

 To incorporate the proposed changes described above in our regulations, we are 

proposing to revise §440.160(b)(1) and §441.151(a)(2)(i) by removing the requirement 

for accreditation by The Joint Commission of psychiatric hospitals and hospitals with 

inpatient psychiatric programs. Psychiatric hospitals would have the choice of meeting 

the requirements to participate in Medicare as a psychiatric hospital under 42 CFR 482.60 

or obtaining accreditation from a national accrediting organization whose psychiatric 

hospital accrediting program has been approved by CMS. Hospitals with inpatient 

psychiatric programs would have the choice of meeting the requirements for participation 

in Medicare as a hospital as specified in 42 CFR Part 482 or obtaining accreditation by a 

national accrediting organization whose hospital accrediting program has been approved 

by CMS. We are proposing to revise §440.160 (b)(2) and §441.151(a)(2)(ii) by removing 

an specific references to accreditation organizations to afford PRTFs the flexibility in 

obtaining accreditation by a national accrediting organization whose program has been 

approved by CMS, or by any other accrediting organization with comparable standards 

that is recognized by the State. 
CMS-1498-P 663 

XI. MedPAC Recommendations 

 Under section 1886(e)(4)(B) of the Act, the Secretary must consider MedPAC's 

recommendations regarding hospital inpatient payments. Under section 1886(e)(5) of the 

Act, the Secretary must publish in the annual proposed and final IPPS rules the 

Secretary's recommendations regarding MedPAC's recommendations. We have reviewed 

MedPAC’s March 2010 “Report to the Congress: Medicare Payment Policy” and have 

given the recommendations in the report careful consideration in conjunction with the 

policies set forth in this proposed rule. 

 MedPAC’s Recommendation 2A-1 states that “The Congress should increase 

payment rates for the acute inpatient and outpatient prospective payment systems in 2011 

by the projected rate of increase in the hospital market basket index, concurrent with 

implementation of a quality incentive payment program.” This recommendation for the 

IPPS is discussed in Appendix B to this proposed rule. 

 MedPAC’s Recommendation 2A-2 states that “To restore budget neutrality, the 

Congress should require the Secretary to fully offset increases in inpatient payments due 

to hospitals’ documentation and coding improvements. To accomplish this goal, the 

Secretary must reduce payment rates in the inpatient prospective payment system by the 

same percentage (not to exceed 2 percentage points) each year in 2011, 2012, and 2013. 

The lower rates would remain in place until overpayments are fully recovered.” 

Response to Recommendation 2A-2: Beginning in FY 2008, CMS adopted the 

new MS-DRG patient classification system for the IPPS to better recognize severity of 

illness in Medicare payment rates. Adoption of the MS-DRGs resulted in the expansion 
CMS-1498-P 664 

of the number of DRGs from 538 in FY 2007 to 745 in FY 2008. The increase in the 

number of DRGs provides incentives for hospitals to change documentation and coding 

that can increase Medicare expenditures without any corresponding increase in 

underlying patient severity. Consistent with the statutory requirement to maintain budget 

neutrality, we established prospective documentation and coding adjustments of -

1.2 percent for FY 2008, -1.8 percent for FY 2009, and -1.8 percent for FY 2010 when 

the new MS-DRG system was implemented in FY 2008. Subsequent to issuance of the 

FY 2008 IPPS final rule, section 7 of the TMA of 2007 (Pub. L. 110-90) divided in half 

the documentation and coding adjustments for the MS-DRG system that we adopted in 

the FY 2008 IPPS final rule to -0.6 percent for FY 2008 and -0.9 percent for FY 2009. 

Section 7 requires that, if the implementation of the new MS-DRG payment system 

resulted in actual changes in documentation and coding in FY 2008 or FY 2009, or both 

years, that are different from those reflected in the -0.6 percent and -0.9 percent 

documentation and coding adjustments applied to payment rates in FY 2008 and 

FY 2009, respectively, the Secretary further adjust operating IPPS rates. This further 

adjustment must offset the estimated amount of the increase or decrease in aggregate 

payments for discharges occurring during FY 2008 and FY 2009, and must be made 

during FY 2010, FY 2011, and/or FY 2012. These adjustments are referred to as the 

recoupment adjustments and apply only to acute IPPS operating payments. In addition, 

the law requires that the Secretary eliminate the effect of all actual documentation and 

coding changes occurring in FY 2008 and FY 2009 incorporated into FY 2010 IPPS 

operating rates not already accounted for beyond the -0.6 and -0.9 percent adjustments. 
CMS-1498-P 665 

These adjustments are referred to as the prospective adjustments. As discussed in section 

II.D. of the preamble of this proposed rule, our current estimate is that an aggregate 

adjustment of 9.7 percent would be necessary to satisfy these requirements. 

We discuss our proposed adjustments to correct for the effects of improved 

documentation and coding on Medicare payments to hospitals in section II.D. of the 

preamble of this proposed rule for IPPS operating payments, in section V.E. of the 

preamble of this proposed rule for IPPS capital payments, and in section VII.C.3. of the 

preamble of this proposed rule for LTCH PPS payments. In this context, we note that, in 

considering whether to adopt MedPAC’s recommendation, we took into consideration the 

statutory requirement that the adjustment must offset the estimated amount of the 

increase or decrease in aggregate payments for discharges occurring during FY 2008 and 

FY 2009 must be made during FY 2010, FY 2011, and/or FY 2012. 

 For further information relating specifically to the MedPAC reports or to obtain a 

copy of the reports, contact MedPAC at (202) 653-7226, or visit MedPAC's Web site at: 

http://www.medpac.gov. 

XII. 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 now available on compact disc 

(CD) format. However, many of the files are available on the Internet at: 

http://www.cms.hhs.gov/AcuteInpatientPPS. Data files and the cost for each file, if 
CMS-1498-P 666 

applicable, are listed below. Anyone wishing to purchase data tapes, cartridges, or 

diskettes should submit a written request along with a company check or money order 

(payable to CMS-PUF) to cover the cost of 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 

III from FY 2007 Medicare cost reports used to create the proposed FY 2011 prospective 

payment system wage index. Multiple versions of this file are created each year. For a 

complete schedule on the release of different versions of this file, we refer readers to the 

wage index schedule in section III.K. of the preamble of this proposed rule. 

Processing Year Wage Data Year PPS Fiscal Year 

2010 2007 2011 

2009 2006 2010 

2008 2005 2009 

2007 2004 2008 

 Media: Internet at: 

http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage. 

Periods Available: FY 2007 through FY 2011 IPPS Update. 

2. CMS Occupational Mix Data Public Use File 

 This file contains the 2007-2008 occupational mix survey data to be used to 

compute the occupational mix adjustment wage indexes. Multiple versions of this file are 

created each year. For a complete schedule on the release of different versions of this 
CMS-1498-P 667 

file, we refer readers to the wage index schedule in section III.K. of the preamble of this 

proposed rule. 

 Media: Internet at: 

http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage. 

 Period Available: FY 2011 IPPS Update. 

3. Provider Occupational Mix Adjustment Factors for Each Occupational Category 

Public Use File 

 This file contains each hospital’s occupational mix adjustment factors by 

occupational category. Two versions of these files are created each year. They support 

the following: 

● Notice of proposed rulemaking 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. 

 Period Available: FY 2011 IPPS Update. 

4. Other Wage Index Files 

 CMS releases other wage index analysis files after each proposed and final rule. 

 Media: Internet at: 

http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage. 

 Periods Available: FY 2007 through FY 2011 IPPS Update. 

5. FY 2011 IPPS SSA/FIPS CBSA State and County Crosswalk 

 This file contains a crosswalk of State and county codes used by the Social 
CMS-1498-P 668 

Security Administration (SSA) and the Federal Information Processing Standards (FIPS), 

county name, and a historical list of Metropolitan Statistical Areas (MSAs). 

 Media: Internet at: 

http://www.cms.hhs.gov/AcuteInpatientPPS/FFD/list.asp#TopOfPage. 

 Period Available: FY 2011 IPPS Update. 

6. HCRIS Cost Report Data 

 The data included in this file contain cost reports with fiscal years ending on or 

after September 30, 1996. These data files contain the highest level of cost report status. 

 Media: Internet at: 

http://www.cms.hhs.gov/CostReports/02_HospitalCostReport.asp and Compact Disc 

(CD). 

 File Cost: $100.00 per year.7. Provider-Specific File 

 This file is a component of the PRICER program used in the fiscal intermediary’s 

or the MAC’s system to compute DRG/MS-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/03_psf_text.asp 

 Period Available: FY 2011 IPPS Update. 

8. CMS Medicare Case-Mix Index File 
CMS-1498-P 669 

 This file contains the Medicare case-mix index by provider number as published 

in each year’s update of the Medicare hospital inpatient prospective payment system. 

The case-mix index is a measure of the costliness of cases treated by a hospital relative to 

the cost of the national average of all Medicare hospital cases, using DRG/MS-DRG 

weights as a measure of relative costliness of cases. Two versions of this file are created 

each year. They support the following: 

● Notice of proposed rulemaking 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 1985 through FY 2011. 

9. MS-DRG Relative Weights (Also Table 5 - MS-DRGs) 

 This file contains a listing of MS-DRGs, MS-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. 

● Notice of proposed rulemaking. 

● Final rule. 

 Media: Internet at: 

http://www.cms.hhs.gov/AcuteInpatientPPS/FFD/list.asp#TopOfPage 

 Periods Available: FY 2006 through 2011 IPPS Update 

10. IPPS Payment Impact File 

 This file contains data used to estimate payments under Medicare’s hospital 

impatient prospective payment systems for operating and capital-related costs. The data 
CMS-1498-P 670 

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 2011 IPPS Update. 

11. AOR/BOR Tables 

 This file contains data used to develop the MS-DRG relative weights. It contains 

mean, maximum, minimum, standard deviation, and coefficient of variation statistics by 

MS-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: 

● Notice of proposed rulemaking 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 2006 through FY 2011 IPPS Update. 

12. Prospective Payment System (PPS) Standardizing File 

 This file contains information that standardizes the charges used to calculate 

relative weights to determine payments under the hospital inpatient operating and capital 
CMS-1498-P 671 

prospective payment systems. Variables include wage index, cost-of-living adjustment 

(COLA), case-mix index, indirect medical education (IME) adjustment, disproportionate 

share, and the Core-based Statistical Area (CBSA). The file supports the following: 

 ● Notice of proposed rulemaking 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. 

 Period Available: FY 2011 IPPS Update. 

 For further information concerning these data tapes, contact the CMS Public Use 

Files Hotline at (410) 786-3691. 

Commenters interested in discussing any data used in constructing this proposed 

rule should contact Nisha Bhat at (410) 786-5320. 

B. Collection of Information Requirements

1. Legislative Requirement for Solicitation of Comments 

 Under the Paperwork Reduction Act of 1995, we are required to provide 60-day 

notice in the Federal Register and solicit public comment before a collection of 

information requirement is submitted to the Office of Management and Budget (OMB) 

for review and approval. In order to fairly evaluate whether an information collection 

should be approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act of 

1995 requires that we solicit comment on the following issues: 

● The need for the information collection and its usefulness in carrying out the 

proper functions of our agency. 
CMS-1498-P 672 

● 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 (ICRs). 

2. Requirements in Regulation Text 

a. ICRs Regarding Withdrawing an Application, Terminating an Approved 3-Year 

Reclassification, or Canceling a Previous Withdrawal or Termination (Proposed Revised 

§412.273)

Proposed revised §412.273(b) states that the MGCRB allows a hospital, or group 

of hospitals, to withdraw its application or to terminate an already existing 3-year 

reclassification. Proposed revised §412.273(c) further specifies the timing requirements 

for the withdrawal or termination requirements. Proposed §412.273(c)(1) provides that a 

request for withdrawal must be received by the MGCRB at any time before the MGCRB 

issues a decision on the application; or after the MGCRB issues a decision, provided that 

the request for withdrawal is received by the MGCRB within 45 days of publication of 

CMS' annual notice of proposed rulemaking concerning changes to the IPPS and 

proposed payment rates for the fiscal year for which the application has been filed. 

The burden associated with this requirement is the time and effort necessary for a 

hospital to submit a written withdrawal request to the MGCRB. While this requirement 

is subject to the PRA, we cannot accurately quantify the burden associated with this 
CMS-1498-P 673 

requirement. We currently review each request on a case-by case basis. We believe the 

associated burden is thereby exempt from the PRA as stipulated under 

5 CFR 1320.3(h)(6). 

Proposed revised §412.273(c)(2) provides that a request for termination must be 

received by the MGCRB within 45 days of the publication of CMS’ annual notice of 

proposed rulemaking concerning changes to the IPPS and proposed payment rates for the 

fiscal year for which the termination is to apply. The burden associated with this 

requirement is the time and effort necessary for a hospital to submit a written termination 

request to the MGCRB. While this requirement is subject to the PRA, we cannot 

accurately quantify the burden associated with this requirement. We currently review 

each request on a case-by case basis. We believe the associated burden is thereby exempt 

from the PRA as stipulated under 5 CFR 1320.3(h)(6). 

Proposed revised §412.273(d)(1) states that a hospital (or group of hospitals) may 

cancel a withdrawal or termination in a subsequent year and request the MGCRB to 

reinstate the wage index reclassification for the remaining fiscal year(s) of the 3-year 

period. Proposed revised §412.273(d)(2) would require that cancellation requests be 

received in writing by the MGCRB no later than the deadline for submitting 

reclassification applications for the following fiscal year, as specified in §412.256(a)(2). 

The burden associated with this requirement is the time and effort necessary for a hospital 

to submit a written request to the MGCRB, requesting that the current withdrawal or 

termination request be cancelled. While this requirement is subject to the PRA, we 

cannot accurately quantify the burden associated with this requirement. We currently 
CMS-1498-P 674 

review each request on a case-by case basis. We believe the associated burden is thereby 

exempt from the PRA as stipulated under 5 CFR 1320.3(h)(6). 

Proposed §412.273(d)(3) states that a hospital would be able to apply for 

reclassification to a different area (that is, an area different from the one to which it was 

originally reclassified for the 3-year period). If the application is approved, the 

reclassification will be effective for 3 years. Once a 3-year reclassification becomes 

effective, a hospital may no longer cancel a withdrawal or termination of another 3-year 

reclassification, regardless of whether the withdrawal or termination request is made 

within 3 years from the date of the withdrawal or termination. The burden associated 

with the reapplication requirement is the time and effort necessary for a hospital to 

submit a reclassification request to the MGCRB. While this requirement is subject to the 

PRA, the associated burden is approved under OMB control number 0938-0573, with an 

expiration date of December 31, 2011. 

Proposed §412.273(f)(1) states that a hospital may file an appeal of the MGCRB's 

denial of its request for withdrawal or termination, or of the MGCRB’s denial of its 

request for a cancellation of such withdrawal or termination, to the Administrator. The 

appeal must be received within 15 days of the date of the notice of the denial. The 

burden associated with this requirement is the time and effort necessary for a hospital to 

file a written appeal of the MGCRB’s denial. While this requirement is subject the PRA, 

the associated burden is exempt under 5 CFR 1320.4. The burden associated with 

collection information as part of or subsequent to an administrative action is not subject 

to the PRA. 
CMS-1498-P 675 

b. ICRs Regarding Condition of Participation: Respiratory Care Services (§482.57) 

 Proposed §482.57(b)(4) imposes a recordkeeping requirement. This section 

would require all respiratory care services orders to be documented in the patient's 

medical record according to the requirements at §482.24. The burden associated with 

this requirement is the time and effort necessary for hospital staff to document and 

maintain the respiratory care services orders in a patient’s medical record. While these 

requirements are subject to the PRA, the associated burden is exempt from the PRA 

under 5 CFR 1320.3(b)(2). We believe hospitals will not incur any burden above and 

beyond that associated with the usual and customary business practice of maintaining 

detailed patient medical records. 

3. Additional Information Collection Requirements 

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 contained in this document. The following is a discussion of these 

information collections, some of which have already received OMB approval. 

a. Present on Admission (POA) Indicator Reporting 

Section II.F.6. of the preamble of this proposed rule discusses the POA indicator 

reporting program. As stated earlier, collection of POA indicator data is necessary to 

identify which conditions were acquired during hospitalization for the HAC payment 

provision and for broader public health uses of Medicare data. Through Change Request 
CMS-1498-P 676 

5499 dated May 11, 2007, CMS issued instructions that require IPPS hospitals to submit 

POA indicator data for all diagnosis codes on Medicare claims. 

The burden associated with this requirement is the time and effort necessary to 

place the appropriate POA indicator codes on Medicare claims. This requirement is 

subject to the PRA; however, the associated burden is currently approved under OMB 

control number 0938–0997, with an expiration date of October 31, 2012. 

b. Add-On Payments for New Services and Technologies 

Section II.I.1. of the preamble of this proposed rule discusses 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 2011 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 

detailed the burden associated with this requirement in the September 7, 2001, IPPS final 

rule (66 FR 46902). As stated in that final rule, collection of the information for this 

requirement is conducted on an individual case-by-case basis. We believe the associated 

burden is thereby exempt from the PRA as stipulated under 5 CFR 1320.3(h)(6). 

Similarly, we also believe the burden associated with this requirement is exempt from the 

PRA under 5 CFR 1320.3(c), which defines the agency collection of information subject 

to the requirements of the PRA as information collection imposed on 10 or more persons 
CMS-1498-P 677 

within any 12-month period. This information collection does not impact 10 or more 

entities in a 12-month period. In FYs 2008, 2009, 2010, and 2011 we received 1, 4, 5, 

and 3 applications, respectively. 

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

 As discussed in section V.A. of this proposed rule, the RHQDAPU program was 

originally established to implement section 501(b) of Pub. L. 108–173. The RHQDAPU 

program originally consisted of a "starter set" of 10 quality measures. OMB approved 

the collection of data associated with the original starter set of quality measures under 

OMB control number 0938–0918, with a current expiration date of January 31, 2011. 

 As part of our implementation of section 5001(a) of the DRA, we expanded the 

number of quality measures reported in the RHQDAPU program. Specifically, 

section 1886(b)(3)(B)(viii)(III) of the Act, added by section 5001(a) of the DRA, requires 

that the Secretary expand the "starter set" of 10 quality measures that were established by 

the Secretary as of November 1, 2003, to include measures "that the Secretary determines 

to be appropriate for the measurement of the quality of care (including medication errors) 

furnished by hospitals in inpatient settings." Under this provision, we established 

additional program measures to bring the total number of measures to 30. The burden 

associated with these reporting requirements is currently approved under OMB control 

number 0938–1022, with a current expiration date of June 30, 2011. 

 In the FY 2010 IPPS proposed rule (74 FR 24168), we solicited public comments 

on several considerations for expanding and updating quality measures. We responded to 

the public comments received in the FY 2010 IPPS/RY 2010 LTCH PPS final rule 
CMS-1498-P 678 

(74 FR 43866 through 43868). We also expanded and finalized the RHQDAPU program 

measure set for the FY 2011 payment determination. As part of the expansion effort, we 

finalized 46 measures in the FY 2010 IPPS/RY 2010 LTCH PPS final rule 

(74 FR 43872). 

 In this FY 2011 IPPS/LTCH PPS proposed rule, we are proposing to retire one 

measure for the FY 2011 payment determination. For the FY 2012 through FY 2014 

payment determinations, we are proposing to retain the remaining 45 of the 46 current 

measures; and for FY 2012, to add 10 new measures and to require all-patient volume 

data for selected MS-DRGs that relate to RHQDAPU program measures; for FY 2013, to 

retain the FY 2012 measures and add 35 new measures; and for FY 2014, to retain the 

FY 2013 measures and to add 4 new measures. In addition, we have listed 28 new 

measures that are under consideration for adoption in future years. We are proposing that 

beginning with CY 2011 discharges, hospitals submit some of the new measure data to a 

qualified registry. We are also soliciting public comments on retiring one or more of the 

11 additional measures suggested by commenters in the FY 2010 IPPS/RY 2010 LTCH 

PPS final rule based on topped out performance and other rationales. 

 In summary, we are proposing to retire one measure for the FY 2011 annual 

payment update and seeking comments on whether to retire 11 additional measures 

suggested by commenters in the FY 2010 IPPS/RY 2010 LTCH PPS final rule. In 

addition, we are proposing to expand the RHQDAPU program measure set to: 

55 measures for the FY 2012 annual payment update (taking into account our proposal to 

retire one measure for the FY 2011 annual payment update); 90 measures for the 
CMS-1498-P 679 

FY 2013 annual payment update, and 94 measures for the FY 2014 annual payment 

update. We also list are 28 additional measures under consideration for adoption in 

future years which may increase these numbers if we propose and adopt them in future 

IPPS rulemaking. Finally, we are proposing that, beginning with the FY 2012 annual 

payment update, hospitals that participate in the RHQDAPU program submit all-patient 

volume data for selected MS-DRGs that relate to RHQDAPU program measures. This 

proposal would require hospitals to report these data beginning with CY 2011 discharges. 

 We submitted a revised version of the information collection request approved 

under OMB control number 0938–1022, to obtain approval for the proposed new 

measures. 

 Section V.A.10. 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 CMS to reconsider our decision. The hospital’s request for reconsideration 

must explain the reasons why it believes it satisfied 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. 

d. Proposed Occupational Mix Adjustment to the FY 2011 Index (Hospital Wage Index 

Occupational Mix Survey) 
CMS-1498-P 680 

Section II.D. of the preamble of this proposed rule discusses the proposed 

occupational mix adjustment to the FY 2011 wage index. While the preamble does not 

contain any new ICRs, it is important to note that there is an OMB approved information 

collection request associated with the hospital wage index. 

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 requirement is the time 

and effort required to collect and submit the data in the Hospital Wage Index 

Occupational Mix Survey to CMS. The aforementioned burden is subject to the PRA; 

however, it is currently approved under OMB control number 0938-0907, with an 

expiration date of February 28, 2013. 

e. Hospital Applications for Geographic Reclassifications by the MGCRB 

Section III.I.3. of the preamble of this proposed rule discusses revisions to the 

wage index based on hospital redesignations. As stated in that section, under section 

1886(d)(10) of the Act, the MGCRB has the authority to accept short-term IPPS hospital 

applications requesting geographic reclassification for wage index or standardized 

payment amounts and to issue decisions on these requests by hospitals for geographic 

reclassification for purposes of payment under the IPPS. 
CMS-1498-P 681 

The burden associated with this application process is the time and effort 

necessary for an IPPS hospital to complete and submit an application for reclassification 

to the MGCRB. While this requirement is subject to the PRA, the associated burden is 

currently approved under OMB control number 0938–0573, with an expiration date of 

December 31, 2011. 

f. Direct GME Payments: General Requirements 

Existing regulations at §413.75(b) permit hospitals that share residents to elect to 

form a Medicare GME affiliated group if they are in the same or contiguous urban or 

rural areas, if they are under common ownership, or if they are jointly listed as program 

sponsors or major participating institutions in the same program. The purpose of a 

Medicare GME affiliated group is to provide flexibility to hospitals in structuring 

rotations under an aggregate FTE resident cap when they share residents. The existing 

regulations at §413.79(f)(1) specify that each hospital in a Medicare GME affiliated 

group must submit a Medicare GME affiliation agreement (as defined under §413.75(b)) 

to the Medicare fiscal intermediary or MAC servicing the hospital and send a copy to 

CMS’ Central Office no later than July 1 of the residency program year during which the 

Medicare GME affiliation agreement will be in effect. 

In section V.H.3. of the preamble of this proposed rule, we are proposing to allow 

hospitals to electronically submit the copy of the affiliation agreement that is required to 

be sent to the CMS Central Office. As stated earlier in the preamble, the proposed 

electronic submission process would consist of either an e-mail mailbox or a Web site 

where hospitals would submit their Medicare GME affiliation agreements to the CMS 
CMS-1498-P 682 

Central Office to a designated online mailbox. We are proposing that a copy of the 

Medicare GME affiliation agreement would need to be received through the electronic 

system no later than 11:59 p.m. on July 1 of each academic year. We are proposing that 

the electronic affiliation agreement would need to be submitted either as a scanned copy 

or a Printer-Friendly Display (PDF) version of that hard copy agreement; we are 

proposing not to accept an agreement in any electronic format that could be subject to 

manipulation. The scanned and/or PDF format will enable CMS to ensure that the 

agreements are signed and dated as required in the regulations at §413.75. Under this 

proposal, hospitals would have the option to continue to submit a hard copy of its 

affiliation agreement to the CMS Central Office. In addition, each fiscal intermediary or 

MAC would continue to have the authority to specify its requirements for submittal of the 

Medicare GME affiliation agreement by hospitals that are part of the affiliation. 

The burden associated with this requirement is the time and effort it would take 

for the new hospital to develop and submit the Medicare GME affiliation agreement, to 

submit it the agreement to its fiscal intermediary or MAC, and to submit a copy to CMS. 

In the proposed and final rules that published on May 22, 2009 (74 FR 24080) and 

August 27, 2009 (74 FR 43754), we stated that it was difficult for us to estimate the 

annual burden associated with this requirement because we cannot estimate the additional 

number of hospitals that will be permitted to submit Medicare GME affiliation 

agreements in any given year as a result of the change. However, we now have better 

data available to quantify the burden associated with the existing requirement for 

hospitals to submit GME affiliation agreements to the fiscal intermediary or MAC 
CMS-1498-P 683 

servicing the hospital and new requirement for the electronic submission of a copy of the 

affiliation agreement to CMS. We are submitting a new information collection request to 

OMB for review and approval of the associated burden. 

We anticipate receiving between 100 and 150 GME affiliation agreements 

annually. For the purposes of our information collection request, we estimate that we 

will receive 125 agreements annually. CMS provides a two-page sample agreement for 

hospitals; however, some facilities may submit additional information that is not 

required. We estimate that it will take 1 hour for a hospital to develop a GME affiliation 

agreement or to follow the format provided by CMS. Similarly, we estimate that it will 

take each hospital 15 minutes to submit a hard copy of the affiliation agreement to its 

fiscal intermediary or MAC. Finally, we estimate that it will take each hospital 5 minutes 

to submit an electronic copy of its GME affiliation agreement to CMS. The total annual 

burden associated with developing the affiliation agreement is 125 hours. The total 

annual burden associated with submitting a hard copy of the affiliation agreement is 31 

hours. The total annual burden associated with submitting the agreement electronically is 

10 hours. The total annual burden associated with all of the requirements in this section 

is 166 hours. The total cost associated with this requirement is $5,000 ($40.00 x 125 

agreements).

If you comment on these information collection and recordkeeping requirements, 

please do either of the following: 

 1. Submit your comments electronically as specified in the ADDRESSES section 

of this proposed rule; or 
CMS-1498-P 684 

 2. Submit your comments to the Office of Information and Regulatory Affairs, 

Office of Management and Budget, 

 Attention: CMS Desk Officer, CMS-1498-P 

 Fax: (202) 395-6974; or 

 Email: OIRA_submission@omb.eop.gov 

C. Response to Comments

 Because of the large number of public comments we normally receive on Federal 

Register documents, we are not able to acknowledge or respond to them individually. 

We will consider all comments we receive by the date and time specified in the 

“DATES” section of this preamble, and, when we proceed with a subsequent document, 

we will respond to the comments in the preamble to that document. 
CMS-1498-P 685 

List of Subjects 

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 440 

 Grant program-health, Medicaid. 

42 CFR Part 441 

 Family planning, Grant program-health, Infants and children, Medicaid, Penalties, 

Prescription drugs, Reporting and recordkeeping requirements. 

42 CFR Part 482 

 Grant program-health, Hospitals, Medicaid, Medicare, Reporting and 

rcordkeeping requirements. 

42 CFR Part 485 

Grant programs-health, Health facilities, Medicaid, Medicare, Reporting and 

recordkeeping requirements. 

42 CFR Part 489 

 Health facilities, Medicare, Reporting and recordkeeping requirements. 

For the reasons stated in the preamble of this proposed rule, the Centers for 

Medicare & Medicaid Services is proposing to amend 42 CFR Chapter IV as follows:
CMS-1498-P 686 

PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT 

HOSPITAL SERVICES 

 1. The authority citation for Part 412 continues to read as follows: 

 Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 

1395hh), and sec. 124 of Pub. L. 106-113 (113 Stat. 1501A-332). 

 2. Section 412.4 is amended by— 

a. Republishing the introductory language of paragraph (b). 

b. Removing the word “or” at the end of paragraph (b)(1). 

c. Removing the period at the end of paragraph (b)(2) and adding in its place a 

semicolon. 

d. Adding new paragraphs (b)(3) and (b)(4). 

The additions read as follows: 

§412.4 Discharges and transfers. 

* * * * * 

 (b) Acute care transfers. A discharge of a hospital inpatient is considered to be a 

transfer for purposes of payment under this part if the patient is readmitted the same day 

(unless the readmission is unrelated to the initial discharge) to another hospital that is— 

* * * * * 

 (3) An acute care hospital that would otherwise be eligible to be paid under the 

IPPS, but does not have an agreement to participate in the Medicare program; or 

 (4) A critical access hospital. 

* * * * * 
CMS-1498-P 687 

§412.106 [Amended] 

 3. Section 412.106 is amended by— 

 a. In paragraph (b)(2)(i)(B), removing the word “or” and adding in its place the 

word “including”. 

 b. In paragraph (b)(2)(iii)(B), removing the word “or” and adding in its place the 

word “including”. 

§412.108 [Amended] 

4. Amend §412.108 (a)(1)(iii) introductory text by removing the word 

“receiving” and adding in its place the words “entitled to”.

5. Section 412.113 is amended by revising paragraph (c)(2)(i)(A) to read as 

follows: 

§412.113 Other payments. 

* * * * * 

 (c) * * * 

 (2)(i) * * * 

 (A) The hospital or CAH is located in a rural area as defined in §412.62(f) and is 

not deemed to be located in an urban area under the provisions of §412.64(b)(3). For cost 

reporting periods beginning on or after October 1, 2010, the hospital or CAH is either 

located in a rural area as defined in §412.62(f) and is not deemed to be located in an 

urban area under the provisions of §412.64(b)(3) or the hospital or CAH has reclassified 

as rural under the provisions at §412.103. 

* * * * * 
CMS-1498-P 688 

6. Section 412.273 is revised to read as follows: 

§412.273 Withdrawing an application, terminating an approved 3-year 

reclassification, or canceling a previous withdrawal or termination. 

(a) Definitions. For purposes of this section, the following definitions apply. 

Termination refers to the termination of an already existing 3-year MGCRB 

reclassification where such reclassification has already been in effect for 1 or 2 years, and 

there are 1 or 2 years remaining on the 3-year reclassification. A termination is effective 

only for the full fiscal year(s) remaining in the 3-year period at the time the request is 

received. Requests for terminations for part of a fiscal year are not considered. 

Withdrawal refers to the withdrawal of a 3-year MGCRB reclassification that has 

not yet gone into effect or where the MGCRB has not yet issued a decision on the 

application. 

(b) General rule. The MGCRB allows a hospital, or group of hospitals, to 

withdraw its application or to terminate an already existing 3-year reclassification, in 

accordance with this section. 

(c) Timing. (1) A request for withdrawal must be received by the MGCRB-- 

(i) At any time before the MGCRB issues a decision on the application; or 

(ii) After the MGCRB issues a decision, provided that the request for withdrawal 

is received by the MGCRB within 45 days of publication of CMS' annual notice of 

proposed rulemaking concerning changes to the inpatient hospital prospective payment 

system and proposed payment rates for the fiscal year for which the application has been 

filed. 
CMS-1498-P 689 

(2) A request for termination must be received by the MGCRB within 45 days of 

the publication of CMS’ annual notice of proposed rulemaking concerning changes to the 

inpatient hospital prospective payment system and proposed payment rates for the fiscal 

year for which the termination is to apply. 

(d) Reapplication within the approved 3-year period, cancellations of 

terminations and withdrawals, and prohibition on overlapping reclassification approvals. 

(1) Cancellation of terminations or withdrawals. Subject to the provisions of this 

section, a hospital (or group of hospitals) may cancel a withdrawal or termination in a 

subsequent year and request the MGCRB to reinstate the wage index reclassification for 

the remaining fiscal year(s) of the 3-year period. (Withdrawals may be cancelled only in 

cases where the MGCRB issued a decision on the geographic reclassification request.) 

(2) Timing and process of cancellation request. Cancellation requests must be 

received in writing by the MGCRB no later than the deadline for submitting 

reclassification applications for the following fiscal year, as specified in §412.256(a)(2). 

(3) Reapplications. A hospital may apply for reclassification to a different area 

(that is, an area different from the one to which it was originally reclassified for the 

3-year period). If the application is approved, the reclassification will be effective for 

3 years. Once a 3-year reclassification becomes effective, a hospital may no longer 

cancel a withdrawal or termination of another 3-year reclassification, regardless of 

whether the withdrawal or termination request is made within 3 years from the date of the 

withdrawal or termination. 
CMS-1498-P 690 

(4) Termination of existing 3-year reclassification. In a case in which a hospital 

with an existing 3-year wage index reclassification applies to be reclassified to another 

area, its existing 3-year reclassification will be terminated when a second 3-year wage 

index reclassification goes into effect for payments for discharges on or after the 

following October 1. 

(e) Written request only. A request to withdraw an application must be made in 

writing to the MGCRB by all hospitals that are party to the application. A request to 

terminate an approved reclassification may be made in writing to the MGCRB by an 

individual hospital or by an individual hospital that is party to a group classification. 

(f) Appeal of the MGCRB's denial of a hospital's request for withdrawal or 

termination, or for cancellation of a withdrawal or termination. 

(1) A hospital may file an appeal of the MGCRB's denial of its request for 

withdrawal or termination, or of the MGCRB’s denial of its request for a cancellation of 

such withdrawal or termination, to the Administrator. The appeal must be received 

within 15 days of the date of the notice of the denial. 

(2) Within 20 days of receipt of the hospital's request for appeal, the 

Administrator affirms or reverses the denial. 

7. Section 412.503 is amended by— 

a. Adding a definition of “long-term care hospital prospective payment system 

fiscal year”. 

b. Adding a definition of "long-term care hospital prospective payment system 

payment year". 
CMS-1498-P 691 

c. Revising paragraph (3) of the definition of "long-term care hospital prospective 

payment system rate year". 

The additions and revision read as follows: 

§412.503 Definitions. 

* * * * * 

 Long-term care hospital prospective payment system fiscal year means, beginning 

October 1, 2010, the 12-month period of October 1 through September 30. 

 Long-term care hospital prospective payment system payment year means the 

general term that encompasses both the definition of "long-term care hospital prospective 

payment system rate year" and "long-term care hospital prospective payment system 

fiscal year" specified in this section. 

 Long-term care hospital prospective payment system rate year means— 

* * * * * 

 (3) From October 1, 2009 through September 30, 2010, the 12-month period of 

October 1 through September 30. 

* * * * * 

 8. Section 412.523 is amended by adding a new paragraph (c)(3)(vii) to read as 

follows: 

§412.523 Methodology for calculating the Federal prospective payment rate.

* * * * * 

 (c) * * * 

 (3) * * * 
CMS-1498-P 692 

 (vii) For long-term care hospital prospective payment system fiscal year 

beginning October 1, 2010, and ending September 30, 2011. The standard Federal rate 

for the long-term care hospital prospective payment system fiscal year beginning 

October 1, 2010, and ending September 30, 2011, is the standard Federal rate for the 

previous long-term care hospital prospective payment system rate year updated by -0.1 

percent. The standard Federal rate is adjusted, as appropriate, as described in paragraph 

(d) of this section. 

* * * * * 

 9. Section 412.525 is amended by revising paragraphs (a)(1) and (a)(2) to read as 

follows: 

§412.525 Adjustments to the Federal prospective payment.

 (a) Adjustments for high-cost outliers. (1) CMS provides for an additional 

payment to a long-term care hospital if its estimated costs for a patient exceed the 

adjusted LTC-MS-DRG payment plus a fixed-loss amount. For each long-term care 

hospital prospective payment system payment year, as described in §412.503, CMS 

determines a fixed-loss amount that is the maximum loss that a hospital can incur under 

the prospective payment system for a case with unusually high costs. 

 (2) The fixed-loss amount is determined for the long-term care hospital 

prospective payment system payment year, as defined in §412.503, using the 

LTC-MS-DRG relative weights that are in effect at the start of the applicable long-term 

care hospital prospective payment system payment year, as defined in §412.503. 
CMS-1498-P 693 

* * * * * 

PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; 

PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; OPTIONAL 

PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED 

NURSING FACILITIES

10. The authority citation for Part 413 continues 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). 

 11. Section 413.70 is amended by— 

 a. Revising paragraph (b)(3)(i)(A). 

 b. Revising paragraph (b)(3)(i)(B). 

 c. Revising paragraph (b)(3)(i)(D). 

 The revisions read as follows: 

§413.70 Payment for services of a CAH. 

* * * * * 

 (b) * * * 

 (3) * * * 

 (i) * * * 

 (A)(1) For cost reporting periods beginning before October 1, 2010. The election 

must be made in writing, made on an annual basis, and delivered to the fiscal 
CMS-1498-P 694 

intermediary or MAC servicing the CAH at least 30 days before the start of the cost 

reporting period for which the election is made. An election, once made for a cost 

reporting period, remains in effect for all of that period. 

 (2) For cost reporting periods beginning on or after October 1, 2010. If a CAH 

had elected the method specified in paragraph (b)(3)(i) of this section in its most recent 

cost reporting period beginning prior to October 1, 2010, that election remains in effect 

for all of that period and for all subsequent cost reporting periods, unless the CAH 

submits a termination request to the fiscal intermediary or MAC servicing the CAH at 

least 30 days before the start of the next cost reporting period. If a CAH had not, in its 

most recent cost reporting period, elected the method described in paragraphs (b)(3)(ii) 

and (b)(3)(iii) of this section and chooses to elect this method on or after October 1, 2010, 

the election must be made in writing and delivered to the fiscal intermediary or MAC 

servicing the CAH at least 30 days before the start of the first cost reporting period for 

which the election is made. Once the election is made, it remains in effect for all of that 

period and for all subsequent cost reporting periods unless the CAH submits a 

termination request to the fiscal intermediary or MAC servicing the CAH at least 30 days 

before the start of the next cost reporting period. For cost reporting periods beginning in 

October 2010 and November 2010, if a CAH wishes to terminate its election, the CAH 

must submit a termination request to the fiscal intermediary or MAC servicing the CAH 

prior to December 1, 2010. 

 (B) An election of the payment method specified under paragraph (b)(3)(i) of this 

section applies to all services furnished to outpatients by a physician or other practitioner 
CMS-1498-P 695 

who has reassigned his or her rights to bill for those services to the CAH in accordance 

with subpart F of Part 424 of this chapter. If a physician or other practitioner does not 

reassign his or her billing rights to the CAH in accordance with subpart F of Part 424 of 

this chapter, payment for the physician’s or practitioner’s services furnished to CAH 

outpatients will be made on a fee schedule or other applicable basis as specified in 

subpart B of Part 414 of this subchapter. 

* * * * * 

 (D) An election made under paragraph (b)(3)(i) of this section is effective as 

provided for under paragraph (b)(3)(i)(A) or paragraph (b)(3)(i)(C) of this section and 

does not apply to an election that was terminated prior to the start of the cost reporting 

period for which it would otherwise apply. 

* * * * * 

 12. Section 413.75 is amended by revising the definitions of “Primary care 

resident” and “Resident” under paragraph (b) to read as follows: 

§413.75 Direct GME payments: General requirements. 

* * * * * 

 (b) * * * 

Primary care resident is a resident who is enrolled in an approved medical 

residency training program in family medicine, general internal medicine, general 

pediatrics, preventive medicine, geriatric medicine or osteopathic general practice. 

Effective for cost reporting periods beginning on or after October 1, 2010, primary care 

resident is a resident who is formally accepted, enrolled, and participating in an approved 
CMS-1498-P 696 

medical residency training program in family medicine, general internal medicine, 

general pediatrics, preventive medicine, geriatric medicine or osteopathic general 

practice. 

* * * * * 

 Resident means an intern, resident, or fellow who participates in an approved 

medical residency program, including programs in osteopathy, dentistry, and podiatry, as 

required in order to become certified by the appropriate specialty board. Effective for 

cost reporting periods beginning on or after October 1, 2010, resident means an intern, 

resident, or fellow who is formally accepted, enrolled, and participating in an approved 

medical residency program, including programs in osteopathy, dentistry, and podiatry, as 

required in order to become certified by the appropriate specialty board. 

* * * * * 

PART 440—SERVICES: GENERAL PROVISIONS 

13. The authority citation for Part 440 continues to read as follows:

Authority: Sec. 1102 of the Social Security Act (42 U.S.C. 1302). 

18. Section 440.160 is amended by revising paragraphs (b)(1) and (b)(2) to read 

as follows: 

§440.160 Inpatient psychiatric services for individuals under age 21.

* * * * * 

(b) * * * 

(1) A psychiatric hospital that meets the requirements for participation in 

Medicare as a psychiatric hospital as specified in §482.60 of this chapter, or is accredited 
CMS-1498-P 697 

by a national organization whose psychiatric hospital accrediting program has been 

approved by CMS, or a hospital with an inpatient psychiatric program that meets the 

requirements for participation in Medicare as a hospital as specified in Part 482 of this 

chapter or is accredited by a national accrediting organization whose hospital accrediting 

program has been approved by CMS. 

(2) A psychiatric facility that is not a hospital and is accredited by a national 

accrediting organization whose program has been approved by CMS, or by any other 

accrediting organization with comparable standards that is recognized by the State. 

* * * * * 

PART 441—SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO 

SPECIFIC SERVICES 

 14. The authority citation for Part 441 continues to read as follows: 

Authority: Sec. 1102 of the Social Security Act (42 U.S.C. 1302). 

15. Section 441.151 is amended by revising paragraphs (a)(2)(i) and (a)(2)(ii) to 

read as follows: 

§441.151 General requirements. 

 (a) * * * 

 (2) * * * 

 (i) A psychiatric hospital that meets the requirements for participation in 

Medicare as a psychiatric hospital as specified in §482.60 of this chapter, or is accredited 

by a national organization whose psychiatric hospital accrediting program has been 

approved by CMS, or a hospital with an inpatient psychiatric program that meets the 
CMS-1498-P 698 

requirements for participation in Medicare as a hospital as specified in Part 482 of this 

chapter or is accredited by a national accrediting organization whose hospital accrediting 

program has been approved by CMS. 

 (ii) A psychiatric facility that is not a hospital and is accredited by a national 

accrediting organization whose program has been approved by CMS, or by any other 

accrediting organization with comparable standards that is recognized by the State. 

* * * * * 

PART 482—CONDITIONS OF PARTICIPATION FOR HOSPITALS 

 16. The authority citation for Part 482 continues to read as follows: 

 Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 

1395(hh)). 

 17. Section 482.56 is amended by revising paragraph (b) to read as follows: 

§482.56 Condition of participation: Rehabilitation services.

* * * * * 

(b) Standard: Delivery of services. Services must only be provided under the 

orders of a qualified and licensed practitioner who is responsible for the care of the 

patient, acting within his or her scope of practice under State law, and who is authorized 

by the hospital’s medical staff to order the services in accordance with hospital policies 

and procedures and State laws. 

 (1) All rehabilitation services orders must be documented in the patient's 

medical record according to the requirements at §482.24. 
CMS-1498-P 699 

 (2) The provision of care and the personnel qualifications must be in 

accordance with national acceptable standards of practice and must also meet the 

requirements of §409.17 of this chapter. 

 18. Section 482.57 is amended by revising paragraph (b)(3) and adding paragraph 

(b)(4) to read as follows: 

§482.57 Condition of participation: Respiratory care services. 

* * * * * 

(b) * * * 

(3) Services must only be provided under the orders of a qualified and licensed 

practitioner who is responsible for the care of the patient, acting within his or her scope 

of practice under State law, and who is authorized by the hospital’s medical staff to order 

the services in accordance with hospital policies and procedures and State laws. 

 (4) All respiratory care services orders must be documented in the patient's 

medical record according to the requirements at §482.24. 

PART 485—CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS 

 19. The authority citation for Part 485 continues to read as follows: 

 Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 

1395(hh)). 

 20. Section 485.610 is amended by revising the introductory text of paragraph (b) 

to read as follows: 

§485.610 Condition of participation: Status and location.

* * * * * 
CMS-1498-P 700 

 (b) Standard: Location in a rural area or treatment as rural. The CAH meets the 

requirements of either paragraph (b)(1) or (b)(2) of this section or the requirements of 

either (b)(3) or (b)(4) of this section. 

* * * * * 

PART 489--PROVIDER AGREEMENTS AND SUPPLIER APPROVAL 

21. The authority citation for Part 489 continues to read as follows:

 Authority: Secs. 1102, 1819, 1820(e), 1861, 1864(m), 1866, 1869, and 1871 of 

the Social Security Act (42 U.S.C. 1302, 1395i-3, 1395x, 1395aa(m), 1395cc, 1395ff, and 

1395hh). 

 22. Section 489.1 is revised to read as follows: 

§489.1 Statutory basis.

(a) This part implements section 1866 of the Social Security Act (the Act). 

Section 1866 of the Act specifies the terms of provider agreements, the grounds for 

terminating a provider agreement, the circumstances under which payment for new 

admissions may be denied, and the circumstances under which payment may be withheld 

for failure to make timely utilization review. The sections of the Act specified in 

paragraphs (a)(1) through (a)(4) of this section are also pertinent. 

(1) Section 1861 of the Act defines the services covered under Medicare and the 

providers that may be reimbursed for furnishing those services. 

(2) Section 1864 of the Act provides for the use of State survey agencies to 

ascertain whether certain entities meet the conditions of participation. 
CMS-1498-P 701 

(3) Section 1865(a)(1) of the Act provides that an entity accredited by a national 

accreditation body found by the Secretary to satisfy the Medicare conditions of 

participation, conditions for coverage, or conditions of certification or requirements for 

participation shall be treated as meeting those requirements. Section 1865(a)(2) of the 

Act requires the Secretary to consider when making such a finding, among other things, 

the national accreditation body’s accreditation requirements and survey procedures. 

(4) Section 1871 of the Act authorizes the Secretary to prescribe regulations for 

the administration of the Medicare program. 

(b) Although section 1866 of the Act speaks only to providers and provider 

agreements, the effective date rules in this part are made applicable also to the approval 

of suppliers that meet the requirements specified in §489.13. 

(c) Section 1861(o)(7) of the Act requires each HHA to provide CMS with a 

surety bond. 

23. Section 489.13 is revised to read as follows: 

§489.13 Effective date of agreement or approval. 

(a) Applicability—(1) General rule. Except as provided in paragraph (a)(2) of 

this section, this section applies to Medicare provider agreements with, and supplier 

approval of, entities that, as a basis for participation in Medicare are subject to a 

determination by CMS on the basis of-- 

(i) A survey conducted by the State survey agency or CMS staff surveyors; or 

(ii) Accreditation by an accreditation organization whose program has CMS 

approval at the time of the accreditation survey and accreditation decision. 
CMS-1498-P 702 

(2) Exceptions. (i) For an agreement with a community mental health center 

(CMHC) or a federally qualified health center (FQHC), the effective date is the date on 

which CMS accepts a signed agreement which assures that the CMHC or FQHC meets 

all Federal requirements. 

(ii) A Medicare supplier approval of a laboratory is effective only while the 

laboratory has in effect a valid CLIA certificate issued under Part 493 of this chapter, and 

only for the specialty and subspecialty tests it is authorized to perform. 

(b) All health and safety standards are met on the date of survey. The agreement 

or approval is effective on the date the State agency, CMS staff, or the CMS contractor 

survey (including the Life Safety Code survey, if applicable) is completed, or on the date 

of the accreditation decision, as applicable, if on that date the provider or supplier meets 

all applicable Federal requirements as set forth in this chapter. (If the agreement or 

approval is time-limited, the new agreement or approval is effective on the day following 

the expiration of the current agreement or approval.) However, the effective date of the 

agreement or approval may not be earlier than the latest of the dates on which CMS 

determines that each applicable Federal requirement is met. Federal requirements 

include, but are not limited to-- 

(1) Enrollment requirements established in Part 424, Subpart P, of this chapter. 

CMS determines, based upon its review and verification of the prospective provider’s or 

supplier’s enrollment application, the date on which enrollment requirements have been 

met; 

(2) The requirements identified in §§489.10 and 489.12; and 
CMS-1498-P 703 

(3) The applicable Medicare health and safety standards, such as the applicable 

conditions of participation, the requirements for participation, the conditions for 

coverage, or the conditions for certification. 

(c) All health and safety standards are not met on the date of survey. If, on the 

date the survey is completed, the provider or supplier has failed to meet any one of the 

applicable health and safety standards, the following rules apply for determining the 

effective date of the provider agreement or supplier approval, assuming that no other 

Federal requirements remain to be satisfied. The effective date of the agreement or 

approval may not be earlier than the latest of the dates on which each applicable Federal 

requirement is met. 

(1) For an agreement with an SNF, the effective date is the date on which— 

(i) The SNF is in substantial compliance (as defined in §488.301 of this chapter) 

with the requirements for participation; and 

(ii) CMS or the State survey agency receives from the SNF, if applicable, an 

approvable waiver request. 

(2) For an agreement with, or an approval of, any other provider or supplier, 

(except those specified in paragraph (a)(2) of this section), the effective date is the earlier 

of the following: 

(i) The date on which the provider or supplier meets all applicable conditions of 

participation, conditions for coverage, or conditions for certification; or, if applicable, the 

date of a CMS-approved accreditation organization program’s positive accreditation 
CMS-1498-P 704 

decision, issued after the accreditation organization has determined that the provider or 

supplier meets all applicable conditions. 

(ii) The date on which a provider or supplier is found to meet all conditions of 

participation, conditions for coverage, or conditions for certification, but has lower-level 

deficiencies, and-- 

(A) CMS or the State survey agency receives an acceptable plan of correction for 

the lower-level deficiencies (the date of receipt is the effective date regardless of when 

the plan of correction is approved); or, if applicable, a CMS-approved accreditation 

organization program issues a positive accreditation decision after it receives an 

acceptable plan of correction for the lower-level deficiencies; or 

(B) CMS receives an approvable waiver request (the date of receipt is the 

effective date regardless of when CMS approves the waiver request). 

(C) For an agreement with any other provider or an approval of any other 

supplier (except those specified in paragraph (a)(2) of this section) that is found to meet 

all conditions of participation, conditions for coverage, or conditions for certification, but 

has lower-level deficiencies and has submitted both an approvable plan of 

correction/positive accreditation decision and an approvable waiver request, the effective 

date is the later of the dates that result when calculated in accordance with paragraph 

(c)(2)(ii)(A) or (c)(2)(ii)(B) of this section. 
CMS-1498-P 

(Catalog of Federal Domestic Assistance Program No. 93.773, Medicare--Hospital Insurance; 

Program No. 93.774, Medicare--Supplementary Medical Insurance Program; and Program No. 

93.778, Medical Assistance) 

Dated: April 6, 2010. 

 

 ______________________________ 

 Charlene Frizzera,

 Acting Administrator, Centers for 

 Medicare & Medicaid Services

Dated: April 16, 2010. 

 ___________________________ 

 Kathleen Sebelius,

 Secretary. 

BILLING CODE 4120-01-P
CMS-1498-P 706 

[Editorial Note: The following Addendum and appendixes 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, 2010 

I. Summary and Background 

 In this Addendum, we are setting forth a description of the methods and data we used to 

determine the proposed prospective payment rates for Medicare hospital inpatient operating costs 

and Medicare hospital inpatient capital-related costs for FY 2011 for acute care hospitals. We 

note that on March 23, 2010, the Patient Protection and Affordable Care Act (PPACA), Pub. L. 

111-148 was enacted. Following the enactment of Pub. L. 111-148, the Health Care and 

Education Reconciliation Act of 2010, Public L. 111-152 (enacted on March 30, 2010), amended 

certain provisions of Pub. L. 111-148. A number of the provisions of Pub. L. 111-148, as 

amended by Pub. L. 111-152, affect the IPPS and the LTCH PPS and the providers and suppliers 

addressed in this proposed rule. However, due to the timing of the passage of the legislation, we 

are unable to address those provisions in this proposed rule. Therefore, the proposed policies 

and payment rates in this proposed rule do not reflect the new legislation. We plan to issue 

separate documents in the Federal Register addressing the provisions of Pub. L. 111-148, as 

amended, that affect our proposed policies and payment rates for FY 2011 under the IPPS and 

the LTCH PPS. In addition, we plan to issue further instructions implementing the provisions of 

Pub. L. 111-148, as amended, that affect the policies and payment rates for FY 2010 under the 

IPPS and for RY 2010 under the LTCH PPS. 
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We also are setting forth the proposed rate-of-increase percentages for updating the target 

amounts for certain hospitals excluded from the IPPS for FY 2011. We note that, because 

certain hospitals excluded from the IPPS are paid on a reasonable cost basis subject to a rate-ofincrease ceiling (and not by the IPPS), these hospitals are not affected by the figures for the 

standardized amounts, offsets, and budget neutrality factors. Therefore, in this proposed rule, we 

are proposing to establish the rate-of-increase percentages for updating the target amounts for 

certain hospitals excluded from the IPPS that are effective for cost reporting periods beginning 

on or after October 1, 2010. 

 In addition, we are setting forth a description of the methods and data we used to 

determine the proposed standard Federal rate that will be applicable to Medicare LTCHs for 

FY 2011. 

 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. 

 Currently, 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; the updated hospital-specific rate based on FY 1996 costs per discharge; or the 

updated hospital-specific rate based on the FY 2006 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 
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FY 1987 costs per discharge, whichever was higher. However, section 5003(a)(1) of 

Pub. L. 109-171 extended and modified the MDH special payment provision that was previously 

set to expire on October 1, 2006, to include 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 an MDH’s target amount, we must rebase an MDH's hospital-specific rates based on 

its FY 2002 cost report. Section 5003(c) of Pub. L. 109-171 further required that MDHs be paid 

based on the Federal national rate or, if higher, the Federal national rate plus 75 percent of the 

difference between the Federal national rate and the updated hospital-specific rate. Further, 

based on the provisions of 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 located in Puerto Rico, the payment per discharge is based on the sum of 

25 percent of an updated Puerto Rico-specific rate based on average costs per case of 

Puerto Rico hospitals for the base year and 75 percent of the Federal national rate. (We refer 

readers to 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 

acute care hospitals for FY 2011. In section III. of this Addendum, we discuss our proposed 

policy changes for determining the prospective payment rates for Medicare inpatient 

capital-related costs for FY 2011. In section IV. of this Addendum, we are setting forth our 

proposed changes for determining the rate-of-increase limits for certain hospitals excluded from 

the IPPS for FY 2011. In section V. of this Addendum, we are proposing to make changes in the 

determination of the standard Federal rate for LTCHs under the LTCH PPS for FY 2011. The 
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tables to which we refer in the preamble of this proposed rule are presented in section VI. of this 

Addendum.

II. Proposed Changes to Prospective Payment Rates for Hospital Inpatient Operating 

Costs for Acute Care Hospitals for FY 2011 

 The basic methodology for determining prospective payment rates for hospital inpatient 

operating costs for acute care hospitals 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 proposed prospective payment rates for FY 2011. 

 In summary, the proposed standardized amounts set forth in Tables 1A, 1B, and 1C 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)(II) 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 Ricospecific 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 2.4 percent for all areas (that is, the estimated full market basket 

percentage increase of 2.4 percent), as required by section 1886(b)(3)(B)(i)(XX) of the Act, as 

amended by section 5001(a)(1) of Pub. L. 109-171, and reflecting the requirements of section 

1886(b)(3)(B)(viii) of the Act, as added by section 5001(a)(3) of Pub. L. 109-171, to reduce the 
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applicable percentage increase by 2.0 percentage points for a hospital that fails to submit data, in 

a form and manner, and at the time specified by the Secretary, relating to the quality of inpatient 

care furnished by the hospital. 

● A proposed update of 2.4 percent to the Puerto Rico-specific standardized amount 

(that is, the full estimated rate-of-increase in the hospital market basket for IPPS hospitals), as 

provided for under §412.211(c), which states that we update the Puerto Rico-specific 

standardized amount using the percentage increase specified in §412.64(d)(1), or the percentage 

increase in the market basket index for prospective payment hospitals for all areas. 

● 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 changes are budget neutral, as provided for 

under section 1886(d)(3)(E)(i) of the Act. We note that section 1886(d)(3)(E)(i) of the Act 

requires that we do not consider the labor-related share of 62 percent to compute wage index 

budget neutrality. 

● 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 2010 budget neutrality 

factor and applying a revised factor. 

● An adjustment to remove the FY 2010 outlier offset and apply an offset for FY 2011, 

as provided for in section 1886(d)(3)(B) of the Act. 

● As discussed below and in section II.D. of the preamble to this proposed rule, an 

adjustment to meet the requirements of section 7(b)(1)(B) of Pub. L. 110-90 to adjust the 

standardized amounts to offset the estimated amount of the increase in aggregate payments 
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(including interest) due to documentation and coding that did not reflect real changes in case-mix 

for discharges occurring during FY 2008 and FY 2009. 

For FY 2011 (in the absence of the provisions of Pub. L. 111-148 as amended by Pub. L. 

111-152), the requirement under section 410A of Pub. L. 108-173 to conduct a rural community 

hospital demonstration program and under section 410A(c)(2) of Pub. L. 108-173 to adjust the 

standardized amount to ensure the effects of the rural community hospital demonstration are 

budget neutral has expired. Therefore, for this proposed rule, there is no adjustment applied the 

standardized amount to ensure the effects of the rural community hospital demonstration are 

budget neutral. 

 We note that, beginning in FY 2008, we applied the budget neutrality adjustment for the 

rural floor to the hospital wage indices rather than the standardized amount. As we did for FY 

2010, for FY 2011, we are proposing to continue to apply the rural floor budget neutrality 

adjustment to hospital wage indices rather than the standardized amount. In addition, instead of 

applying the budget neutrality adjustment for the imputed floor adopted under section 

1886(d)(3)(E) of the Act to the standardized amount, for FY 2011, we are proposing to continue 

to apply the imputed floor budget neutrality adjustment to the wage indices. Consistent with the 

policy we established in the FY 2009 IPPS final rule (in absence of the provisions of Pub. L. 

111-148, as amended by Pub. L. 111-152), we also are proposing to continue to apply the budget 

neutrality adjustments for the rural floor and imputed rural floor at the State level rather than the 

national level. For a complete discussion of the budget neutrality changes concerning the rural 

floor and the imputed floor, including the within-State budget neutrality adjustment, we refer 

readers to section III.B.2. of the preamble of the FY 2009 IPPS final rule and this proposed rule. 
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A. Calculation of the 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), updated and 

otherwise adjusted in accordance with the provisions of section 1886(d) of the Act. For Puerto 

Rico hospitals, the Puerto Rico-specific standardized amount is based on per discharge averages 

of 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)(9) 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 for 

urban and rural hospitals 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 1886(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, IME 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 to be 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 
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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 2011, we are proposing to continue to use a labor-related share of 68.8 percent for 

discharges occurring on or after October 1, 2010 for the national standardized amounts and 62.1 

percent for the Puerto Rico-specific standardized amount. Consistent with section 1886(d)(3)(E) 

of the Act, we are applying the wage index to a labor-related share of 62 percent for all IPPS 

hospitals whose wage index values are less than or equal to 1.0000. For all IPPS hospitals whose 

wage indices are greater than 1.0000, we are applying the wage index to a labor-related share of 

68.8 percent of the national standardized amount. For FY 2011, all Puerto Rico hospitals have a 

wage index less than 1.0. Therefore, the national labor-related share will always be 62 percent 

because the wage index for all Puerto Rico hospitals is less than 1.0. 

For hospitals located in Puerto Rico, we are applying a labor-related share of 62.1 percent 

if its Puerto Rico-specific wage index is greater than 1.0000. For hospitals located in Puerto 

Rico whose Puerto-Rico specific wage index values are less than or equal to 1.0000, we are 

applying a labor share of 62 percent.

 The proposed 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)(II) of the Act requires that, beginning with FY 2004 and 

thereafter, an equal standardized amount 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)(ii)(II) of the Act equalizes the Puerto Rico-specific urban and rural area rates. 
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Accordingly, we are proposing to calculate the FY 2011 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 proposing to update 

the equalized standardized amount for FY 2011 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 increase in the market 

basket reflects the average change in the price of goods and services comprising routine, 

ancillary, and special care unit hospital inpatient services. The most recent forecast of the 

hospital market basket increase for FY 2011 is 2.4 percent. Thus, for FY 2011, the proposed 

update to the average standardized amount is 2.4 percent for hospitals in all areas. The estimated 

market basket increase of 2.4 percent is based on IHS Global Insight, Inc.’s 2010 first quarter 

forecast of the hospital market basket increase (as discussed in Appendix B of this proposed 

rule). 

 Section 1886(b)(3)(B) of the Act specifies the mechanism to be 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 from 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 V.A. of the preamble of this 

final rule. The proposed standardized amounts in Tables 1A through 1C of section VI. of this 

Addendum reflect these differential amounts. 
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 Section 412.211(c) states that we update the Puerto Rico-specific standardized amount 

using the percentage increase specified in §412.64(d)(1), or the percentage increase in the market 

basket index for prospective payment hospitals for all areas. We are proposing to apply the full 

rate-of-increase in the hospital market basket for IPPS hospitals to the Puerto Rico-specific 

standardized amount. Therefore, the proposed update to the Puerto Rico-specific standardized 

amount is 2.4 percent. 

 Although the update factors for FY 2011 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 2011 for both IPPS hospitals and hospitals and hospital units 

excluded from the IPPS. Section 1886(e)(5)(A) of the Act requires that we publish our proposed 

recommendations in the Federal Register for public comment. Our recommendation on the 

update factors is set forth in Appendix B of this proposed rule. 

4. Other Adjustments to the Average Standardized Amount 

 As in the past, we are proposing to adjust the FY 2011 standardized amount to remove 

the effects of the FY 2010 geographic reclassifications and outlier payments before applying the 

FY 2011 updates. We then apply budget neutrality offsets for outliers and geographic 

reclassifications to the standardized amount based on FY 2011 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 

updates in the DRG relative weights and wage index should equal estimated aggregate payments 

prior to the changes. If we removed the prior year’s adjustment, we would not satisfy these 

conditions. 
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Budget neutrality is determined by comparing aggregate IPPS payments before and 

after making 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.

 Similar to last year, because IME Medicare Advantage payments are made to IPPS 

hospitals under section 1886(d) of the Act, we believe these payments must be part of these 

budget neutrality calculations. However, we note that it is not necessary to include Medicare 

Advantage IME payments in the outlier threshold calculation or the outlier offset to the 

standardized amount because the statute requires that outlier payments be not less than 5 percent 

nor more than 6 percent of total “operating DRG payments,” which does not include IME and 

DSH payments. In order to account for these Medicare Advantage IME payments in 

determining the budget neutrality adjustments for this proposed rule, we identified Medicare 

Advantage claims from IPPS teaching hospitals in the MedPAR data. The GHO Paid indicator 

with a value of "1" on the MedPAR file indicates that the claim was paid by a Medicare 

Advantage plan (other than the IPPS IME payment specified at §412.105(g)). For these 

Medicare Advantage claims from IPPS teaching hospitals, we computed a transfer-adjusted CMI 

by provider based on the FY 2009 MS-DRG GROUPER Version 27.0 assignment and relative 

weights. We also computed a transfer- adjusted CMI for these Medicare Advantage claims from 

IPPS teaching hospitals based on the FY 2010 MS-DRG GROUPER Version 28.0 assignments 

and relative weights. These transfer-adjusted CMIs (and corresponding case counts) were used 

to calculate an IME teaching add-on payment in accordance with §412.105(g). The total 

Medicare Advantage IME payment amount was then added to the total Federal payment amount 
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for each provider (where applicable) in order to account for the Medicare Advantage IME 

payment in determining the budget neutrality adjustments. We note that we did not include 

Medicare Advantage IME claims when estimating outlier payments for providers because 

Medicare Advantage claims are not eligible for outlier payments under the IPPS. 

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 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)(i) 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. Section 1886(d)(3)(E)(i) of the Act requires that 

we implement the wage index adjustment in a budget neutral manner. However, section 

1886(d)(3)(E)(ii) of the Act sets the labor-related share at 62 percent for hospitals with a wage 
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index less than or equal to 1.0, and section 1886(d)(3)(E)(i) of the Act provides that the Secretary 

shall calculate the budget neutrality adjustment for the adjustments or updates made under that 

provision as if section 1886(d)(3)(E)(ii) of the Act had not been enacted. In other words, this 

section of the statute requires that we implement the updates to the wage index in a budget 

neutral manner, but that our budget neutrality adjustment should not take into account the 

requirement that we set the labor-related share for hospitals with indices less than or equal to 1.0 

at the more advantageous level of 62 percent. Therefore, for purposes of this budget neutrality 

adjustment, section 1886(d)(3)(E)(i) of the Act prohibits us from taking into account the fact that 

hospitals with a wage index less than or equal to 1.0 are paid using a labor-related share of 62 

percent. Consistent with current policy, for FY 2011, we are proposing to adjust 100 percent of 

the wage index factor for occupational mix. We describe the proposed occupational mix 

adjustment in section III.D. of the preamble of this proposed rule. 

 For FY 2011, to comply with the requirement that DRG reclassification and recalibration 

of the relative weights be budget neutral for the Puerto Rico standardized amount and the 

hospital-specific rates, we used FY 2009 discharge data to simulate payments and compared 

aggregate payments using the FY 2010 labor-related share percentages, the FY 2010 relative 

weights, and the FY 2010 pre-reclassified wage data to aggregate payments using the FY 2010 

labor-related share percentages, the proposed FY 2011 relative weights, and the FY 2010 prereclassified wage data. Based on this comparison, we computed a proposed budget neutrality 

adjustment factor equal to 0.996963. As discussed in section IV. of this Addendum, we would 

also apply the proposed DRG reclassification and recalibration budget neutrality factor of 

0.996856 to the hospital-specific rates that are to be effective for cost reporting periods 

beginning on or after October 1, 2010. 
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 In order to meet the statutory requirements that we do not take into account the laborrelated share of 62 percent when computing wage index budget, it was necessary to use a 

three-step process to comply with the requirements that DRG reclassification and recalibration of 

the relative weights and the updated wage index and labor-related share have no effect on 

aggregate payments for IPPS hospitals. We first determined a proposed DRG reclassification 

and recalibration budget neutrality factor of 0.996856 by using the same methodology described 

above to determine the proposed DRG reclassification and recalibration budget neutrality factor 

for the Puerto Rico standardized amount and hospital-specific rates. Secondly, to compute a 

budget neutrality factor for wage index and labor-related share changes, we used FY 2009 

discharge data to simulate payments and compared aggregate payments using proposed FY 2011 

relative weights and FY 2010 pre-reclassified wage indices, and applied the FY 2010 laborrelated share of 68.8 percent to all hospitals (regardless of whether the hospital’s wage index was 

above or below 1.0) to aggregate payments using the proposed FY 2011 relative weights and the 

proposed FY 2011 pre-reclassified wage indices, and applied the labor-related share for FY 2011 

of 68.8 percent to all hospitals (regardless of whether the hospital’s wage index was above or 

below 1.0). In addition, we applied the proposed DRG reclassification and recalibration budget 

neutrality factor (derived in the first step) to the rates that were used to simulate payments for 

this comparison of aggregate payments from FY 2010 to FY 2011. By applying this 

methodology, we determined a proposed budget neutrality factor of 1.000107 for changes to the 

wage index. Finally, we multiplied the proposed DRG reclassification and recalibration budget 

neutrality factor of 0.996856 (derived in the first step) by the proposed budget neutrality factor of 

1.000107 for changes to the wage index (derived in the second step) to determine the proposed 
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DRG reclassification and recalibration and updated wage index budget neutrality factor of 

0.996963. 

b. Reclassified Hospitals—Proposed 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 proposed 

budget neutrality factor for FY 2011, we used FY 2009 discharge data to simulate payments and 

compared total IPPS payments with proposed FY 2011 relative weights, FY 2011 labor share 

percentages, and proposed FY 2011 wage data prior to any reclassifications under sections 

1886(d)(8)(B) and (C) and 1886(d)(10) of the Act to total IPPS payments with proposed FY 

2011 relative weights, FY 2011 labor share percentages, and proposed FY 2011 wage data after 

such reclassifications. Based on these simulations, we calculated a proposed adjustment factor 
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of 0.991756 to ensure that the effects of these provisions are budget neutral, consistent with the 

statute. 

 The proposed FY 2011 budget neutrality adjustment factor is applied to the standardized 

amount after removing the effects of the FY 2010 budget neutrality adjustment factor. We note 

that the proposed FY 2011 budget neutrality adjustment reflects proposed FY 2011 wage index 

reclassifications approved by the MGCRB or the Administrator. Furthermore, for this proposed 

rule, we note that the proposed FY 2011 wage index reclassifications approved by the MGCRB 

or the Administrator are in the absence of the provisions of Pub. L. 111-148, as amended by Pub. 

L. 111-152. 

c. Proposed Rural Floor and Imputed Floor Budget Neutrality Adjustment 

CMS makes an adjustment to the wage index to ensure that aggregate payments after 

implementation of the rural floor under section 4410 of the BBA (Pub. L. 105-33) and the 

imputed floor under §412.64(h)(4) of the regulations are made in a manner that ensures that 

aggregate payments to hospitals are not affected. As discussed in section III.B. of the preamble 

of the FY 2009 IPPS final rule (73 FR 48570 through 48574), we adopted as final State-level 

budget neutrality for the rural and imputed floors, effective beginning with the FY 2009 wage 

index. In response to the public’s concerns and taking into account the potentially significant 

payment cuts that could occur to hospitals in some States if we implemented this change with no 

transition, we decided to phase in, over a 3-year period, the transition from the national rural 

floor budget neutrality adjustment on the wage index to the State-level rural floor budget 

neutrality adjustment on the wage index. In FY 2009, hospitals received a blended wage index 

that was comprised of 20 percent of the wage index adjusted by applying the State-level rural 

and imputed floor budget neutrality adjustment and 80 percent of the wage index adjusted by 
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applying the national budget neutrality adjustment. For FY 2010, the blended wage index was 

determined by adding 50 percent of the wage index adjusted by applying the State-level rural and 

imputed floor budget neutrality adjustment and 50 percent of the wage index adjusted by 

applying the national budget neutrality adjustment. In FY 2011 (in the absence of provisions of 

Pub. L. 111-148, as amended by Pub. L. 111-152), the proposed adjustment will be completely 

transitioned to the State-level methodology, such that the wage index will be determined by 

applying 100 percent of the State-level budget neutrality adjustment. As stated earlier, we note 

that the rural floor budget neutrality adjustment is applied to the wage index and not the 

standardized amount. However, because the 100 percent State-level rural and imputed floor 

budget neutrality adjustment is used in calculating the proposed FY 2011 outlier threshold (as 

discussed below), we are explaining our calculation of the proposed rural floor budget neutrality 

adjustments (in this section) below. 

 In order to compute a budget neutral wage index that is 100 percent of the wage index 

adjusted by the State-level rural and imputed floor budget neutrality adjustment, we used FY 

2009 discharge data with proposed FY 2011 relative weights, proposed FY 2011 labor share 

percentages, and proposed FY 2011 post reclassified wage indices to simulate IPPS payments. 

To determine each State's rural or imputed floor budget neutrality adjustment, we compared each 

State's total simulated payments with and without the rural or imputed floor applied. These 

State-level rural and imputed floor budget neutrality factors were then applied to the wage 

indices to produce a State-level rural and imputed floor budget neutral wage index, which was 

used in determining the FY 2011 wage indices. 
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d. Proposed Case-Mix Budget Neutrality Adjustment 

(1) Adjustment to the FY 2011 IPPS Standardized Amount 

 As stated earlier, beginning in FY 2008, we adopted the MS–DRG patient classification 

system for the IPPS to better recognize patients’ severity of illness in Medicare payment rates. 

In the FY 2008 IPPS final rule with comment period (73 FR 47175 through 47186), we indicated 

that we believe the adoption of the MS-DRGs had the potential to lead to increases in aggregate 

payments without a corresponding increase in actual patient severity of illness due to the 

incentives for changes in documentation and coding. In that final rule, using the Secretary’s 

authority under section 1886(d)(3)(A)(vi) of the Act to maintain budget neutrality by adjusting 

the national standardized amounts to eliminate the effect of changes in documentation and 

coding that do not reflect real change in case-mix, we established prospective documentation and 

coding adjustments of -1.2 percent for FY 2008, -1.8 percent for FY 2009, and -1.8 percent for 

FY 2010 (for a total adjustment of -4.8 percent). On September 29, 2007, Pub. L. 110–90 was 

enacted. Section 7 of Pub. L. 110-90 included a provision that reduces the documentation and 

coding adjustment for the MS–DRG system that we adopted in the FY 2008 IPPS final rule with 

comment period to -0.6 percent for FY 2008 and -0.9 percent for FY 2009. To comply with the 

provision of section 7(a) of Pub. L. 110-90, in a final rule that appeared in the Federal Register

on November 27, 2007 (72 FR 66886), we changed the IPPS documentation and coding 

adjustment for FY 2008 to -0.6 percent, and revised the FY 2008 national standardized amounts 

(as well as other payment factors and thresholds) accordingly, with these revisions being 

effective as of October 1, 2007. For FY 2009, section 7(a) of Pub. L. 110-90 required a 

documentation and coding adjustment of -0.9 percent instead of the -1.8 percent adjustment 

specified in the FY 2008 IPPS final rule with comment period. As required by statute, we 
CMS-1498-P 724 

applied a documentation and coding adjustment of -0.9 percent to the FY 2009 IPPS national 

standardized amounts. The documentation and coding adjustments established in the FY 2008 

IPPS final rule with comment period are cumulative. As a result, the -0.9 percent documentation 

and coding adjustment in FY 2009 was in addition to the -0.6 percent adjustment in FY 2008, 

yielding a combined effect of -1.5 percent. 

 In the FY 2010 IPPS proposed and final rules, we discussed our analysis of FY 2008 

claims data which showed an increase in case-mix of 2.5 percent due to changes in 

documentation and coding that do not reflect real changes in case-mix for discharges occurring 

during FY 2008. For FY 2010, we proposed to reduce the average standardized amounts under 

section 1886(d) of the Act in FY 2010 by -1.9 percent, which represents the difference between 

changes in documentation and coding that do not reflect real changes in case-mix for discharges 

occurring during FY 2008 and the prospective adjustment applied under Pub. L. 110-90. As 

discussed in section II.D. of the preamble of the FY 2010 IPPS final rule, after consideration of 

the public comments we received on our analysis and proposals presented in the proposed rule, 

we decided to postpone adopting documentation and coding adjustments as authorized under 

section 7(a) of Pub. L. 110-90 and section 1886(d)(3)(A)(vi) of the Act until a full analysis of 

FY 2009 case-mix changes could be completed. Accordingly, in the FY 2010 IPPS final rule, 

for FY 2010, we did not apply any additional documentation and coding adjustments to the 

average standardized amounts under section 1886(d) of the Act. 

 As indicated in section II.D.in the preamble to this proposed rule, the change due to 

documentation and coding that did not reflect real changes in case mix for discharges occurring 

during FY 2008 and FY 2009 exceeded the -0.6 and -0.9 percent prospective documentation and 

coding adjustment applied under section 7(a) of Pub. L. 110-90 for those 2 years respectively by 
CMS-1498-P 725 

1.9 percentage points in FY 2008 and 3.9 percentage points in FY 2009. In total, this change 

exceeded the cumulative prospective adjustments by 5.8 percentage points. Our actuaries 

currently estimate that this 5.8 percentage point increase resulted in an increase in aggregate 

payments of approximately $6.9 billion. Therefore, an aggregate adjustment of -5.8 percent in 

FYs 2011 and 2012, subject to actuarial adjustment to reflect accumulated interest, is necessary 

in order to meet the requirements of section 7(b)(1)(B) of Pub. L. 110-90 to adjust the 

standardized amounts for discharges occurring in FYs 2010, 2011, and/or 2012 to offset the 

estimated amount of the cumulative increase in aggregate payments (including interest) in FYs 

2008 and 2009. We refer the reader to section II.D. of the preamble to this proposed rule for 

more discussion. 

 It is often our practice to phase in rate adjustments over more than one year in order to 

moderate the effect on rates in any one year. Therefore, we are proposing to make an adjustment 

to the standardized amount of -2.9 percent, representing half of the aggregate adjustment 

required under section 7(b)(1)(B) of Pub. L. 110-90, for FY 2011. As we have previously noted, 

unlike the prospective adjustment to the standardized amounts under section 7(b)(1)(A) of Pub. 

L. 110-90 described earlier, the recoupment or repayment adjustment to the standardized 

amounts under section 7(b)(1)(B) of Pub. L. 110-90 is not cumulative, but would be removed for 

subsequent fiscal years once we have offset the increase in aggregate payments for discharges for 

FY 2008 expenditures and FY 2009 expenditures. We note that we are not making a formal 

proposal for the further implementation of section 7(b)(1)(B) of Pub. L. 110-90 in FY 2012 in 

this proposed rule. 
CMS-1498-P 726 

(2) Proposed Adjustment to the FY 2011 Hospital-Specific Rates for SCHs and MDHs 

 As discussed in section II.D. of the preamble of this proposed rule, because hospitals 

(SCHs and MDHs) paid based in whole or in part on the hospital-specific rate use the same 

MS-DRG system as other hospitals, we believe they have the potential to realize increased 

payments from documentation and coding changes that do not reflect real increases in patients' 

severity of illness. Under section 1886(d)(3)(A)(vi) of the Act, Congress stipulated that hospitals 

paid based on the standardized amount should not receive additional payments based on the 

effect of documentation and coding changes that do not reflect real changes in case-mix. 

Similarly, we believe that hospitals paid based on the hospital-specific rate should not have the 

potential to realize increased payments due to documentation and coding changes that do not 

reflect real increases in patients' severity of illness. While we continue to believe that section 

1886(d)(3)(A)(vi) of the Act does not provide explicit authority for application of the 

documentation and coding adjustment to the hospital-specific rates, we believe that we have the 

authority to apply the documentation and coding adjustment to the hospital-specific rates using 

our special exceptions and adjustment authority under section 1886(d)(5)(I)(i) of the Act. 

 As discussed in the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule, based on our 

analysis of FY 2008 claims data, we found that, independently for both SCHs and MDHs, the 

change due to documentation and coding that did not reflect real changes in case-mix for 

discharges occurring during FY 2008 slightly exceeded the 2.5 percent result discussed earlier, 

but did not significantly differ from that result. 

 Therefore, in FY 2010, we proposed to use our authority under section 1886(d)(5)(I)(i) of 

the Act to prospectively adjust the hospital-specific rates by -2.5 percent in FY 2011 for our 

estimated documentation and coding effect in FY 2008 that does not reflect real changes in case-
CMS-1498-P 727 

mix. We also noted that, unlike the national standardized rates, the FY 2010 hospital-specific 

rates were not previously reduced in order to account for anticipated changes in documentation 

and coding that do not reflect real changes in case-mix resulting from the adoption of the 

MS-DRGs. 

 Consistent with our approach for determining the national average standardized amounts 

discussed earlier, after consideration of the public comments we received on our analysis and 

proposals presented in the FY 2010 IPPS proposed rule, for FY 2010, we also postponed 

adoption of a documentation and coding adjustment to the hospital-specific rate until a full 

analysis of FY 2009 case-mix changes could be completed. Accordingly, for FY 2010, we did 

not apply a documentation and coding adjustment to the hospital-specific rates. 

As we discuss in section II.D. of the preamble of this proposed rule, because SCHs and 

MDHs use the same DRG system as all other hospitals, we believe they have the potential to 

realize increased payments from documentation and coding changes that do not reflect real 

increases in patients' severity of illness. Therefore, we believe they should be equally subject to 

a prospective budget neutrality adjustment that we are applying for adoption of the MS-DRGs to 

all other hospitals. While the findings of the effects documentation and coding are different for 

SCHs/MDHs and other IPPS hospitals, we continue to believe that the documentation and coding 

adjustments for all subsection (d) hospitals should be the same. We continue to believe that this 

is the appropriate policy so as to neither advantage nor disadvantage different types of providers. 

As we have also discussed in section II.D of the preamble to this proposed rule, our best 

estimate, based on the most recently available data, is that a cumulative adjustment of -5.4

percent is required to eliminate the full effect of the documentation and coding changes on future 

payments. Unlike the case of standardized amounts paid to IPPS hospitals, we have not made 
CMS-1498-P 728 

any previous adjustments to the hospital specific rates paid to SCHs and MDHs to account for 

documentation and coding changes. Therefore, the entire -5.4 percent adjustment remains to be 

implemented. Therefore, in order to maintain consistency as far as possible with the adjustments 

applied to IPPS hospitals, we are proposing an adjustment of -2.9 percent in FY 2011 to the 

hospital-specific rates paid to SCHs and MDHs. We believe that this proposed adjustment is the 

most appropriate means to take into full account the effect of documentation and coding changes 

on payments, and to maintain equity between hospitals paid on the basis of different prospective 

rates. 

(3) Proposed Adjustment to the FY 2011 Puerto Rico Standardized Amount 

 As stated in section II.D. of the preamble of this proposed rule, we believe that we have 

the authority to apply the documentation and coding adjustment to the Puerto Rico-specific 

standardized amount using our special exceptions and adjustment authority under section 

1886(d)(5)(I)(i) of the Act. Similar to SCHs and MDHs that are paid based on the hospitalspecific rate, we believe that Puerto Rico hospitals that are paid based on the Puerto Ricospecific standardized amount should not have the potential to realize increased payments due to 

documentation and coding changes that do not reflect real increases in patients' severity of 

illness. In the FY 2010 IPPS proposed rule, we discussed our analysis of FY 2008 claims data 

for Puerto Rico hospitals, which showed that, for Puerto Rico hospitals, the increase in payments 

for discharges occurring during FY 2008 due to documentation and coding changes that did not 

reflect real changes in case-mix for discharges occurring during FY 2008 was approximately 1.1 

percent. We noted that, unlike the national standardized rates, the FY 2009 Puerto Rico-specific 

standardized amount was not previously reduced in order to account for anticipated changes in 

documentation and coding that do not reflect real changes in case-mix resulting from the 
CMS-1498-P 729 

adoption of the MS-DRGs. Therefore, for FY 2010, we proposed to use our authority under 

section 1886(d)(5)(I)(i) of the Act to adjust the Puerto Rico-specific standardized amount by 

-1.1 percent in FY 2010 to account for the FY 2008 documentation and coding changes that are 

not due to changes in real case-mix and to leave that adjustment in place for subsequent fiscal 

years. 

 Consistent with our approach for determining the national average standardized amounts 

and hospital-specific rates of SCHs and MDHs discussed above, after consideration of the public 

comments we received on our analysis and proposals presented in the FY 2010 IPPS proposed 

rule, for FY 2010, we also postponed adoption of a documentation and coding adjustment to the 

Puerto Rico-specific rates until a full analysis of FY 2009 case-mix changes can be completed. 

Accordingly, in the FY 2010 IPPS final rule, for FY 2010, we did not apply a documentation and 

coding adjustment to the Puerto Rico-specific rates. 

As we have noted above, similar to SCHs and MDHs, hospitals in Puerto Rico use the 

same DRG system as all other hospitals and we believe they have the potential to realize 

increased payments from documentation and coding changes that do not reflect real increases in 

patients' severity of illness. Therefore, we believe they should be equally subject to a 

prospective budget neutrality adjustment that we are applying for adoption of the MS-DRGs to 

all other hospitals. 

As we have discussed in section II.D. of the preamble of this proposed rule, our best 

estimate, based on the most recently available data, is that a cumulative adjustment of --2.4 

percent is required to eliminate the full effect of the documentation and coding changes on future 

payments from the Puerto Rico-specific rate. Unlike the case of standardized amounts paid to 

IPPS hospitals, we have not made any previous adjustments to the hospital-specific rates paid to 
CMS-1498-P 730 

Puerto Rico hospitals to account for documentation and coding changes. Therefore, the entire 

-2.4 percent adjustment remains to be implemented. In order to maintain consistency as far as 

possible with the adjustments applied to IPPS hospitals but to take into consideration the fact that 

the cumulative impact was smaller in Puerto Rico hospitals, we are therefore proposing an 

adjustment of -2.4 percent in FY 2011 to Puerto Rico-specific rate that accounts for 25 percent of 

payments to Puerto Rico hospitals, with the remaining 75 percent based on the national 

standardized amount, which are proposing to adjust as described above. Consequently, the 

overall reduction to rates for Puerto Rico hospitals to account for the documentation and coding 

changes will be slightly less than the reduction for IPPS hospitals based on 100 percent of the 

national standardized amount. We note that this proposed -2.4 percent prospective adjustment 

would eliminate the full effect of the documentation and coding changes on future payments 

from the Puerto Rico-specific rate. We believe that this proposed adjustment is the most 

appropriate means to take into full account the effect of documentation and coding changes on 

payments, and to maintain equity between hospitals paid on the basis of different prospective 

rates. 

e. Proposed Outlier Payments 

 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, 
CMS-1498-P 731 

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 2011 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. We note that the statute requires outlier payments to be not less 

than 5 percent nor more than 6 percent of total “operating DRG payments” (which does not 

include IME and DSH payments) plus outlier payments. When setting the outlier threshold, we 

compute the 5.1 percent target by dividing the total operating outlier payments by the total 

operating DRG payments plus outlier payments. We do not include any other payments such as 

IME and DSH within the outlier target amount. Therefore, it is not necessary to include 

Medicare Advantage IME payments in the outlier threshold calculation. 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 located 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
CMS-1498-P 732 

(1) Proposed FY 2011 Outlier Fixed-Loss Cost Threshold 

 For FY 2011, we are proposing to continue to use the same methodology used for 

FY 2009 (73 FR 48763 through 48766) to calculate the outlier threshold. Similar to the 

methodology used in the FY 2009 IPPS final rule, for FY 2011, we are proposing to apply 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 2011 outlier threshold, we simulated 

payments by applying the proposed FY 2011 rates and policies using cases from the FY 2009 

MedPAR files. Therefore, in order to determine the proposed FY 2011 outlier threshold, we 

inflated the charges on the MedPAR claims by 2 years, from FY 2009 to FY 2011. 

We are proposing to continue to use a refined methodology that takes into account the 

lower inflation in hospital charges that are occurring as a result of the outlier final rule 

(68 FR 34494), which changed our methodology for determining outlier payments by 

implementing the use of more current 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 2008 in combination with the first 

quarter of FY 2008 (July 1, 2008 through December 31, 2008) to the last quarter of FY 2009 in 

combination with the first quarter of FY 2010 (July 1, 2009 through December 31, 2009). This 

rate of change was 5.16 percent (1.0516) or 10.59 percent (1.1059) over 2 years. 

As we have done in the past, we established the proposed FY 2011 outlier threshold using 

hospital CCRs from the December 2009 update to the Provider-Specific File (PSF)--the most 

recent available data at the time of this proposed rule. This file includes CCRs that reflect 
CMS-1498-P 733 

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 IPPS final rule (71 FR 48150), we worked with the Office 

of Actuary to derive the methodology described below to develop the CCR adjustment factor. 

For FY 2011, we are proposing to continue to use the same methodology to calculate the CCR 

adjustment by using the FY 2009 operating cost per discharge increase in combination with the 

actual FY 2009 operating market basket percentage increase determined by IHS Global Insight, 

Inc., as well as the charge inflation factor described above to estimate the adjustment to the 

CCRs. (We note that the FY 2009 actual (otherwise referred to as "final") operating market 

basket percentage increase reflects historical data, whereas the published FY 2009 operating 

market basket update factor was based on IHS Global Insight, Inc.'s 2008 second quarter forecast 

with historical data through the first quarter of 2008. We also note that while the FY 2009 

published operating market basket update was based on the FY 2002-based IPPS market basket, 

the actual or “final” market basket percentage increase is based on the FY 2006-based IPPS 

market basket. Similarly, the FY 2009 published capital market basket upate factor was based 

on the FY 2002-based capital market basket and the actual or “final” capital market basket 

percentage increase is based on the FY 2006-based capital market basket.) By using the 

operating market basket percentage 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 2011, 

we determined the adjustment by taking the percentage increase in the operating costs per 

discharge from FY 2007 to FY 2008 (1.0513) from the cost report and dividing it by the final 

operating market basket percentage increase from FY 2008 (1.04). This operation removes the 

measure of pure price increase (the market basket) from the percentage increase in operating cost 
CMS-1498-P 734 

per discharge, leaving the nonprice factors in the cost increase (for example, quantity and 

changes in the mix of goods and services). We repeated this calculation for 2 prior years to 

determine the 3-year average of the rate of adjusted change in costs between the operating 

market basket percentage increase and the increase in cost per case from the cost report (the FY 

2005 to FY 2006 percentage increase of operating costs per discharge of 1.0577 divided by the 

FY 2006 final operating market basket percentage increase of 1.04, the FY 2006 to FY 2007 

percentage increase of operating costs per discharge of 1.0466 divided by FY 2007 final 

operating market basket percentage increase of 1.0360). For FY 2011, we averaged the 

differentials calculated for FY 2006, FY 2007, and FY 2008, which resulted in a mean ratio of 

1.0127. We multiplied the 3-year average of 1.0127 by the FY 2009 final operating market 

basket percentage increase of 1.027, which resulted in an operating cost inflation factor of 

4.00 percent or 1.0400. We then divided the operating cost inflation factor by the 1-year average 

change in charges (1.0515) and applied an adjustment factor of 0.989016 to the operating CCRs 

from the PSF (calculation performed on unrounded numbers). 

As stated in the FY 2009 IPPS final rule (73 FR 48763), we continue to believe it is 

appropriate to apply only a 1-year adjustment factor to the CCRs. On average, it takes 

approximately 9 months for a fiscal intermediary or 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 2009 is approximately 1 year. Therefore, as stated above, we believe a 1-year adjustment 

factor to the CCRs is appropriate. 

We used the same methodology for the capital CCRs and determined the adjustment by 

taking the percentage increase in the capital costs per discharge from FY 2007 to FY 2008 
CMS-1498-P 735 

(1.0800) from the cost report and dividing it by the final capital market basket percentage 

increase from FY 2008 (1.015). We repeated this calculation for 2 prior years to determine the 

3-year average of the rate of adjusted change in costs between the capital market basket 

percentage increase and the increase in cost per case from the cost report (the FY 2005 to FY 

2006 percentage increase of capital costs per discharge of 1.0464 divided by the FY 2006 final 

capital market basket percentage increase of 1.011, the FY 2006 to FY 2007 percentage increase 

of capital costs per discharge of 1.0512 divided by the FY 2007 final capital market basket 

percentage increase of 1.012). For FY 2011, we averaged the differentials calculated for 

FY 2006, FY 2007, and FY 2008, which resulted in a mean ratio of 1.0459. We multiplied the 

3-year average of 1.0459 by the FY 2009 final capital market basket percentage increase of 

1.014, which resulted in a capital cost inflation factor of 6.06 percent or 1.0606. We then 

divided the capital cost inflation factor by the 1-year average change in charges (1.0516) and 

applied an adjustment factor of 1.008534 to the capital CCRs from the PSF (calculation 

performed on unrounded numbers). We are proposing to use 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. 

 As stated above, for FY 2011, we applied the proposed FY 2011 rates and policies using 

cases from the FY 2009 MedPAR files in calculating the proposed outlier threshold. In FY 

2010, for purposes of estimating the proposed outlier threshold, we took into account the 

remaining projected case-mix growth when calculating the outlier threshold that results in outlier 

payments being 5.1 percent of total payments for FY 2010. As explained in the FY 2010 

IPPS/RY 2010 LTCH PPS final rule (74 FR 44008), for the FY 2010 analysis, we inflated the 
CMS-1498-P 736 

FY 2008 claims data by an additional 1.6 percent for the additional case-mix growth projected to 

have occurred since FY 2008. If we did not take into account the remaining 1.6 percent 

projected case-mix growth, our estimate of total FY 2010 payments would have been too low, 

and, as a result, the FY 2010 final outlier threshold would have been too high, such that 

estimated outlier payments would be less than our projected 5.1 percent of total payments. For 

this proposed rule, we are using the FY 2009 claims data to calculate the FY 2011 proposed 

outlier threshold. Our estimate of the cumulative effect of changes in documentation and coding 

due to the adoption of the MS-DRGs through FY 2009 is 5.4 percent, which is already included 

within the claims data (FY 2009 MedPAR files) used to calculate the proposed FY 2011 outlier 

threshold. Furthermore, we currently estimate that there will be no continued changes in 

documentation and coding in FYs 2010 and 2011. Therefore, the cumulative effect of 

documentation and coding that has occurred is already reflected within the FY 2009 MedPAR 

claims data, and we do not believe there is any need to inflate FY 2009 claims data for any 

additional case-mix growth projected to have occurred since FY 2009. 

 Using this methodology, we are proposing an outlier fixed-loss cost threshold for 

FY 2011 equal to the prospective payment rate for the DRG, plus any IME and DSH payments, 

and any add-on payments for new technology, plus $23,970. 

 As we did in establishing the FY 2009 outlier threshold (73 FR 57891), in our projection 

of FY 2011 outlier payments, we are not proposing to make 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 June 9, 2003 outlier final rule (68 

FR 34494), 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 
CMS-1498-P 737 

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 proposing not to 

make any assumptions about the effects of reconciliation on the outlier threshold calculation. 

(2) Other Proposed Changes Concerning Outliers 

 As stated in the FY 1994 IPPS final rule (58 FR 46348), we establish an outlier threshold 

that is 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 threshold resulted in a lower percentage of outlier payments for capital-related 

costs than for operating costs. We project that the thresholds for FY 2011 will result in outlier 

payments that will equal 5.1 percent of operating DRG payments and 5.8 percent of capital 

payments based on the Federal rate. 

 In accordance with section 1886(d)(3)(B) of the Act, we are proposing to reduce the 

FY 2011 standardized amount by the same percentage to account for the projected proportion of 

payments paid as outliers. 

 The outlier adjustment factors that would be applied to the standardized amount for the 

proposed FY 2011 outlier threshold are as follows: 

Operating 

Standardized Amounts Capital Federal Rate 

National 0.948999 0.942415

Puerto Rico 0.951686 0.924977
CMS-1498-P 738 

 We are proposing to apply the outlier adjustment factors to the proposed FY 2011 rates 

after removing the effects of the FY 2010 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. 

 Under our current policy at §412.84, for hospitals for which the fiscal intermediary or 

MAC computes operating CCRs greater than 1.176 or capital CCRs greater than 0.154, 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), we still use statewide average CCRs to determine whether a 

hospital qualifies for outlier payments.15 Table 8A in this Addendum contains the proposed 

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, 2010, these statewide average ratios 

would replace the ratios published in the IPPS final rule for FY 2010 (74 FR 44159). Table 8B 

in this Addendum contains the proposed comparable statewide average capital CCRs. Again, the 

proposed CCRs in Tables 8A and 8B would be used during FY 2011 when hospital-specific 

CCRs based on the latest settled cost report are either not available or are outside the range noted 

above. Table 8C contains the proposed statewide average total CCRs used under the LTCH PPS 

as discussed in section V. of this Addendum. 

We finally note that we published a manual update (Change Request 3966) to our outlier 

policy 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, 

 

15 These figures represent 3.0 standard deviations from the mean of the log distribution of CCRs for all hospitals.
CMS-1498-P 739 

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 intermediary 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 that 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 CCRs, we refer readers to CMS Web site: 

http://www.cms.hhs.gov/manuals/downloads/clm104c03.pdf.

(3) FY 2009 and FY 2010 Outlier Payments 

 In the FY 2010 IPPS final rule (74 FR 44012), we stated that, based on available data, we 

estimated that actual FY 2009 outlier payments would be approximately 5.4 percent of actual 

total DRG payments. This estimate was computed based on simulations using the FY 2008 

MedPAR file (discharge data for FY 2008 claims). That is, the estimate of actual outlier 

payments did not reflect actual FY 2009 claims, but instead reflected the application of FY 2009 

rates and policies to available FY 2008 claims. 

 Our current estimate, using available FY 2009 claims data, is that actual outlier payments 

for FY 2009 were approximately 5.3 percent of actual total DRG payments. Thus, the data 

indicate that, for FY 2009, the percentage of actual outlier payments relative to actual total 

payments is higher than we projected before FY 2009. Consistent with the policy and statutory 

interpretation we have maintained since the inception of the IPPS, we do not plan to make 
CMS-1498-P 740 

retroactive adjustments to outlier payments to ensure that total outlier payments for FY 2009 are 

equal to 5.1 percent of total DRG payments. 

We currently estimate that actual outlier payments for FY 2010 will be approximately 4.7 

percent of actual total DRG payments, approximately 0.4 percentage points lower than the 

5.1 percent we projected in setting the outlier policies for FY 2010. This estimate is based on 

simulations using the FY 2009 MedPAR file (discharge data for FY 2009 claims). We used 

these data to calculate an estimate of the actual outlier percentage for FY 2010 by applying 

FY 2010 rates and policies, including an outlier threshold of $23,140 to available FY 2009 

claims. 

5. Proposed FY 2011 Standardized Amount 

 The proposed adjusted standardized amount is divided into labor-related and 

nonlabor-related portions. Tables 1A and 1B of this Addendum contain the national 

standardized amounts that we are proposing to apply to all hospitals, except hospitals located in 

Puerto Rico, for FY 2011. The proposed Puerto Rico-specific amounts are shown in Table 1C of 

this Addendum. The proposed amounts shown in Tables 1A and 1B differ only in that the laborrelated share applied to the standardized amounts in Table 1A is the labor-related share of 68.8 

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 

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 indices are less than or 

equal to 1.0000. 
CMS-1498-P 741 

 In addition, Tables 1A and 1B include proposed standardized amounts reflecting the 

proposed full 2.4 percent update for FY 2011, and the proposed standardized amounts reflecting 

the 2.0 percentage point reduction to the update (a 0.4 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 2011 are set forth in Table 1C of this Addendum. This table also includes the proposed 

Puerto Rico standardized amounts. The labor-related share applied to the Puerto Rico specific 

standardized amount is the proposed labor-related share of 62.1 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 located in Puerto Rico 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 2010 national 

standardized amount. The second column shows the proposed changes from the FY 2010 

standardized amounts for hospitals that satisfy the quality data submission requirement for 

receiving the full update (2.4 percent). The third column shows the proposed changes for 

hospitals receiving the reduced update (0.4 percent). The first row of the table shows the 

proposed updated (through FY 2010) average standardized amount after restoring the FY 2010 

offsets for outlier payments, demonstration budget neutrality and the geographic reclassification 

budget neutrality. The DRG reclassification and recalibration wage index budget neutrality 
CMS-1498-P 742 

factors are cumulative. Therefore, the FY 2010 factor is not removed from this table. 

Additionally, the documentation and coding adjustments for FY 2008 and FY 2009 are 

cumulative. Therefore, the FY 2008 and FY 2009 adjustment factors are not removed from this 

table. We also have added separate rows to this table to reflect the different labor-related shares 

that apply to hospitals. 

COMPARISON OF FY 2010 STANDARDIZED AMOUNTS TO THE PROPOSED 

FY 2011 STANDARDIZED AMOUNT WITH FULL AND REDUCED UPDATE 

 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 standardized amount (as 

Full Update 

(2.4 percent); Wage 

index is greater than 

1.0000 

Full Update 

(2.4 percent); 

Wage index is less 

than or equal to 

1.0000 

Reduced Update 

(0.4 percent); 

Wage index is 

greater than 1.0000 

Reduced Update 

(0.4 percent); 

Wage index is less 

than or equal to 

1.0000 

FY 2010 Base Rate, after 

removing geographic 

reclassification budget 

neutrality, demonstration 

budget neutrality, 

cumulative FY 2008 and 

FY 2009 documentation 

and coding adjustment and 

outlier offset (based on the 

labor-related share 

percentage for FY 2010) 

Labor: $3,879.09 

Nonlabor: $1,759.12 

Labor: $3,459.69 

Nonlabor: $2,142.52 

Labor: $3,879.09 

Nonlabor: $1,759.12 

Labor: $3,459.69 

Nonlabor: $2,142.52 

Proposed FY 2011 Update 

Factor 1.024 1.024 1.004 1.004 

Proposed FY 2011 DRG 

Recalibration and Wage 

Index Budget Neutrality 

Factor 0.996963 0.996963 0.996963 0.996963 

Proposed FY 2011 

Reclassification Budget 

Neutrality Factor 0.991756 0.991756 0.991756 0.991756 

Proposed FY 2011 Outlier 

Factor 0.948999 0.948999 0.948999 0.948999 

Proposed Cumulative 

Documentation and Coding 

Adjustment 0.957 0.957 0.957 0.957 

Proposed Rate for FY 2011 Labor: $3,566.91 

Nonlabor: $1,617.55 

Labor: $3,214.37 

Nonlabor:$1,970.09 

Labor: $3,497.24 

Nonlabor: $1,585.96 

Labor: $3,151.58 

Nonlabor: $1,931.62 
CMS-1498-P 743 

set forth in Table 1A of this Addendum). The labor-related and nonlabor-related portions of the 

proposed national average standardized amounts for Puerto Rico hospitals are set forth in Table 

1C of this Addendum. This table also includes the proposed Puerto Rico standardized amounts. 

The labor-related share applied to the proposed Puerto Rico standardized amount is 62.1 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 this Addendum, contain the labor-related and 

nonlabor-related shares that we are proposing to use to calculate the prospective payment rates 

for hospitals located in the 50 States, the District of Columbia, and Puerto Rico for FY 2011. 

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 of this proposed rule, we discuss the data and methodology for the proposed FY 2011 

wage index. 
CMS-1498-P 744 

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

 Section 1886(d)(5)(H) of the Act authorizes the Secretary to make 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 2011, 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. These proposed factors were obtained from the 

U.S. Office of Personnel Management (OPM) and are the same as the factors currently in use 

under the IPPS for FY 2010. In addition, we are proposing that if OPM releases revised COLA 

factors after publication of this proposed rule, we would use the revised factors for the 

development of IPPS payments for FY 2011 and publish those revised COLA factors in the final 

rule. 

Table of Cost-of-Living Adjustment Factors: 

Alaska and Hawaii Hospitals 

Area Cost of 

Living 

Adjustment 

Factor 

Alaska: 

City of Anchorage and 80-kilometer (50-mile) radius by road 1.23

City of Fairbanks and 80-kilometer (50-mile) radius by road 1.23

City of Juneau and 80-kilometer (50-mile) radius by road 1.23

Rest of Alaska 1.25

Hawaii: 

City and County of Honolulu 1.25

County of Hawaii 1.18

County of Kauai 1.25

County of Maui and County of Kalawao 1.25

(The above factors are based on data obtained from the U.S. Office of Personnel 

 Management Web site at: http://www.opm.gov/oca/cola/rates.asp.) 
CMS-1498-P 745 

C. Proposed MS-DRG Relative Weights

 As discussed in section II.H. of the preamble of this proposed rule, we have developed 

proposed relative weights for each MS-DRG that reflect the resource utilization of cases in each 

MS-DRG relative to Medicare cases in other MS-DRGs. Table 5 of this Addendum contains the 

proposed relative weights that we would apply to discharges occurring in FY 2011. 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 2011 

 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 2011 equals the Federal rate. 

 Currently, 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; the updated hospital-specific rate based on FY 1996 costs per discharge; or the 

updated hospital-specific rate based on the FY 2006 costs per discharge to determine the rate that 

yields the greatest aggregate payment. 

 The prospective payment rate for SCHs for FY 2011 equals the higher of the applicable 

Federal rate, or the hospital-specific rate as described below. The prospective payment rate for 

MDHs for FY 2011 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. For 

MDHs, the updated hospital-specific rate is based on FY 1982, FY 1987 or FY 2002 costs per 

discharge, whichever yields the greatest aggregate payment. 
CMS-1498-P 746 

The prospective payment rate for hospitals located in Puerto Rico for FY 2011 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 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 nonlabor-related portion of the 

standardized amount by the applicable cost-of-living adjustment factor. 

 Step 4--Add the amount from Step 2 and the nonlabor-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 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 lowvolume payment adjustment under section 1886(d)(12) of the Act and 42 CFR 412.101(b), 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 
CMS-1498-P 747 

 Section 1886(b)(3)(C) of the Act provides that currently 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 hospitalspecific rate based on FY 1987 costs per discharge; the updated hospital-specific rate based on 

FY 1996 costs per discharge; or the updated hospital-specific rate based on the FY 2006 costs 

per discharge to determine the rate that yields the greatest aggregate payment. 

 As discussed previously, currently MDHs are paid based on the Federal national rate or, 

if higher, the Federal national rate plus 75 percent of the difference between the Federal national 

rate and the greater of the updated hospital-specific rates based on either FY 1982, FY 1987 or 

FY 2002 costs per discharge. 

 Hospital-specific rates have been determined for each of these hospitals based on the 

FY 1982 costs per discharge, the FY 1987 costs per discharge, or, for SCHs, the FY 1996 costs 

per discharge or the FY 2006 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 period (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 III. of this Addendum. 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, 2010. 

b. Updating the FY 1982, FY 1987, FY 1996, FY 2002, and FY 2006 Hospital-Specific Rates 

for FY 2011 
CMS-1498-P 748 

 We are proposing to increase the hospital-specific rates by 2.4 percent (the hospital 

market basket percentage increase) for FY 2011 for those SCHs and MDHs that submit 

qualifying quality data and by 0.4 percent for SCHs and MDHs that fail to submit qualifying 

quality data. 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 2011, is the market basket 

percentage increase for hospitals that submit qualifying quality data and the market basket 

percentage increase minus 2 percentage points for hospitals that fail to submit qualifying quality 

data. 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 for under section 

1886(b)(3)(B)(iv) of the Act, which, for FY 2011, is the market basket percentage increase for 

hospitals that submit qualifying quality data and the market basket percentage increase minus 2 

percentage points for hospitals that fail to submit qualifying quality data. 

3. General Formula for Calculation of Prospective Payment Rates for Hospitals Located in 

Puerto Rico Beginning On or After October 1, 2010, and Before October 1, 2011 

 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 (Table 1C of this Addendum). 
CMS-1498-P 749 

 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 

(Table 5 of this 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 

(Table 5 of this 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 would 

then be further adjusted if the hospital qualifies for either the IME or DSH adjustment. 
CMS-1498-P 750 

III. Proposed Changes to Payment Rates for Acute Care Hospital Inpatient CapitalRelated Costs for FY 2011 

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 

the regulations at 42 CFR 412.308 through 412.352. Below we discuss the factors that we are 

proposing to use to determine the capital Federal rate for FY 2011, which would be effective for 

discharges occurring on or after October 1, 2010. 

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 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 be 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 
CMS-1498-P 751 

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 (GAF) 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 capitalrelated costs on a reasonable cost basis during the respective fiscal year. That provision expired 

in FY 1996. Section 412.308(b)(2) describes the 7.4 percent reduction to the capital Federal rate 

that was made in FY 1994, and §412.308(b)(3) describes the 0.28 percent reduction to the capital 

Federal rate made in FY 1996 as a result of the revised policy for 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 as of 

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 to the unadjusted capital 

payment rates 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 
CMS-1498-P 752 

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 made under the regular exception policy effective with cost 

reporting periods beginning in FY 2002, we discontinued use of 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 blended payments to hospitals located in Puerto Rico under 

the IPPS for acute care hospital inpatient capital-related costs. Accordingly, under the capital 

PPS, we compute a separate payment rate specific to hospitals located in Puerto Rico 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 located 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 located 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, the methodology for operating payments made to hospitals located in 
CMS-1498-P 753 

Puerto Rico under the IPPS was revised to make payments 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 located in Puerto Rico to be based on a 

blend of 50 percent of the Puerto Rico capital rate and 50 percent of the national 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 hospitals located in 

Puerto Rico 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 (refer to 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 hospitals located in Puerto Rico is equal to 75 percent 

and the Puerto Rico-specific 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 located 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-specific capital rate and 

75 percent of the national capital Federal rate for discharges occurring on or after 

October 1, 2004. 
CMS-1498-P 754 

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

Rate Update

 In the correction notice to the FY 2010 IPPS/RY 2010 LTCH PPS final rule published on 

October 7, 2009 (74 FR 51499), we established the final capital Federal rate of $429.26 for 

FY 2010. In the discussion that follows, we explain the factors that we are proposing to use to 

determine the capital Federal rate for FY 2011. In particular, we explain why the proposed 

FY 2011 capital Federal rate would decrease approximately 1.9 percent, compared to the 

FY 2010 capital Federal rate. As discussed in the impact analysis, we estimate capital payments 

per discharge would decrease 0.2 percent during that same period. Because capital payments 

constitute about 10 percent of hospital payments, a 1-percent change in the capital Federal rate 

yields only about a 0.1 percent change in actual payments to hospitals. 

 We note that on March 23, 2010, the Patient Protection and Affordable Care Act, 

Pub. L. 111-148, was enacted. Following the enactment of Pub. L. 111-148, the Health Care and 

Education Reconciliation Act of 2010, Pub. L. 111-152 (enacted on March 30, 2010), amended 

certain provisions of Pub. L. 111-148. A number of the provisions of Pub. L. 111-148, as 

amended by Pub. L. 111-152, affect the IPPS and the providers addressed in this proposed rule. 

However, due to the timing of the passage of the legislation, we are unable to implement those 

provisions in this proposed rule. Therefore, the proposed policies and payment rates in this 

section do not reflect the new legislation. We plan to issue separate rulemaking documents in 

the Federal Register addressing the provisions of Pub. L. 111-148, as amended, that affect our 

proposed policies and payment rates for FY 2011 under the IPPS and LTCH PPS, as well as the 

provisions of Pub. L. 111-148, as amended, that affect the policies and payment rates for FY 

2010 under the IPPS. 
CMS-1498-P 755 

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 adjust the projected CIPI rate-ofincrease 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 2011 under that framework is 1.5 

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 0.0 percent adjustment for the FY 2009 DRG 

reclassification and recalibration, and a forecast error correction of 0.3 percent. As discussed 

below in section III.C. of this Addendum, we continue to 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 2011 CIPI projection in that same section of this 

Addendum. We note, as discussed in section VI.E.1. of the preamble of this proposed rule, we 

are proposing to apply a -2.9 percent adjustment to the capital rate in FY 2011 to account for the 

cumulative effect of changes in documentation and coding under the MS-DRGs that do not 

correspond to changes in real increases in patients’ severity of illness. Below we describe the 

policy adjustments that we are proposing to apply in the update framework for FY 2011. 

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. 
CMS-1498-P 756 

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 documentation and 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 documentation and 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 no longer use an update framework to make 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 any increase in case-mix resulting from changes in documentation and coding due 

to the adoption of the MS-DRGs, for FY 2011, we are projecting a 1.0 percent total increase in 

the case-mix index. We estimated that the real case-mix increase will also equal 1.0 percent for 

FY 2011. 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 proposed net 

adjustment for case-mix change in FY 2011 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’s changes to the DRG classifications and relative weights, in order to 
CMS-1498-P 757 

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 have data available to evaluate the effects of the FY 2009 DRG reclassification and 

recalibration as part of our proposed update for FY 2011. To adjust for reclassification and 

recalibration effects, under our historical methodology, we run the FY 2009 cases through the 

FY 2008 GROUPER and through the FY 2009 GROUPER. The resulting ratio of the case-mix 

indices should equate to 1.0. If not, under our historical methodology, in the update framework 

for FY 2011, we would make an adjustment to adjust for the reclassification and recalibration 

effects in FY 2009. As discussed in detail in section II.B. of the preamble of this proposed rule, 

however, when we adopted the MS-DRGs beginning in FY 2008 to better recognize severity of 

illness in Medicare payment rates, we also recognized that changes in documentation and coding 

could potentially lead to increases in aggregate payments without a corresponding increase in 

patients’ severity of illness (that is, increased case-mix index other than real case-mix index 

increase). To maintain budget neutrality for the adoption of the MS-DRGs, as discussed in 

greater detail in section V.E. of the preamble of this proposed rule, we are proposing to make an 

adjustment to the proposed capital Federal rate in FY 2011 based on actuarial estimates of the 

cumulative effects of documentation and coding changes that occurred in FYs 2008 and 2009 

(based on FYs 2008 and 2009 claims data). Therefore, we are not adjusting for reclassification 

and recalibration effects from FY 2009 in the update framework for FY 2011 because it is 

already accounted for in the proposed documentation and coding adjustment to the capital 

Federal rates for FY 2011. Consequently, we are proposing a 0.0 percent adjustment for DRG 

reclassification and recalibration in the proposed FY 2011 update framework. 
CMS-1498-P 758 

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 availability of data to develop a measurement of the forecast 

error. A forecast error of 0.3 percentage point was calculated for the FY 2011 update. That is, 

current historical data indicate that the forecasted FY 2009 CIPI (1.4 percent) used in calculating 

the FY 2009 update factor slightly understated the actual realized price increases (1.7 percent) by 

0.3 percentage point. This is due to the prices associated with both the depreciation and interest 

cost categories growing faster than anticipated. Historically, when the estimation of the change 

in the CIPI is greater than 0.25 percentage points, it is reflected in the update recommended 

under this framework. Therefore, we are proposing to make a 0.3 percent adjustment for forecast 

error in the update for FY 2011. 

Under the capital IPPS update framework, we also make an adjustment for changes in 

intensity. Historically, we have calculated 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 qualityenhancing services, for changes within DRG severity, and for expected modification of practice 
CMS-1498-P 759 

patterns to remove noncost-effective services. Our intensity measure is based on a 5-year 

average. 

Historically, we have calculated case-mix constant intensity as the change in total charges 

per admission, adjusted for price level changes (the CIPI for hospital and related services) and 

changes in real case-mix. Without reliable estimates of the proportions of the overall annual 

intensity increases that are due, respectively, to ineffective practice patterns and the combination 

of quality-enhancing new technologies and complexity within the DRG system, we assume 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 increases within DRG severity 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 increase of 1.0 to 1.5 percent 

per year. However, we used 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. 

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 
CMS-1498-P 760 

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 a result of hospitals attempting to maximize outlier payments, while 

lessening costs, 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. 

For FYs 2006 through 2010, we continued to apply a 0.0 percent adjustment for intensity in the 

capital update framework. 

 In an effort to further refine the intensity adjustment and more accurately reflect 

allowable changes in hospital intensity, we are proposing to use changes in hospital costs per 

discharge over a 5-year average rather than changes in hospital charges, which have been the 

basis of the intensity adjustment in prior years. The unique nature of capital--how and when it is 

purchased, its longevity, and how it is financed--creates a greater degree of variance in capital 

cost among hospitals than does operating cost. We believe that using changes in capital costs per 

discharge as the basis for the intensity adjustment in lieu of changes in charges will decrease 

some of the variability of this adjustment. A case in point is the charge data over much of the 

last decade-- the annual change in hospital charges has fluctuated erratically from as little as 3 

percent to as large as 16 percent. As we have discussed for several years in past rulemaking, we 

believe the effects of hospitals’ charge practices prior to the implementation of the outlier policy 

revisions established in the June 9, 2003 final rule were the main cause of the variability and 

large annual increases in hospital charges for much of the past decade. However, even after the 

outlier policy was implemented, we continued to see evidence of these charge practices in the 
CMS-1498-P 761 

data, as it may have taken hospitals some time to adopt changes in their behavior in response to 

the new outlier policy. Thus, we believe that the charge data for much of the past decade was 

skewed because if hospitals were treating new or different types of cases, which would result in 

an appropriate increase in charges per discharge, we would expect hospitals' case-mix to increase 

proportionally, and it did not. 

Therefore, in this proposed rule, for the reasons discussed above, we believe it would be 

more appropriate to use our intensity adjustment based on the change in capital cost per 

discharge. To determine the proposed intensity adjustment for FY 2011, we have replaced 

charge data with capital cost per discharge data. As expected, there are significantly smaller 

increases in cost per discharge over this time period and less fluctuation from year to year. As 

we did when using charge data, we are basing the intensity measure on a 5-year average. 

Therefore, the proposed intensity measure for FY 2011 is based on an average of cost per 

discharge data from the 5-year period beginning with FY 2004 and extending through FY 2008. 

Based on these data, we estimate that case-mix constant intensity declined during FYs 2004 

through 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. Because we estimate 

intensity declined during that 5-year period, we believe that it is appropriate to continue apply a 

zero intensity adjustment for FY 2011. Therefore, we are proposing to make a 0.0 percent 

adjustment for intensity in the update for FY 2011. 

Above, we described the basis of the components used to develop the proposed 1.5 

percent capital update factor under the capital update framework for FY 2011 as shown in the 

table below. 
CMS-1498-P 762 

CMS FY 2011 Proposed Update Factor to the Capital Federal Rate 

Capital Input Price Index 1.2 

Intensity: 0.0 

Case-Mix Adjustment Factors: 

 Real Across DRG Change -1.0 

 Projected Case-Mix Change 1.0 

Subtotal 1.2 

Effect of FY 2009 Reclassification and Recalibration 0.0 

Forecast Error Correction 0.3 

Total Update 1.5 

b. Comparison of CMS and MedPAC Update Recommendation 

 In its March 2010 Report to Congress, MedPAC did not make a specific update 

recommendation for capital IPPS payments for FY 2011. (MedPAC’s Report to the Congress: 

Medicare Payment Policy, March 2010, Section 2A.) 

2. Proposed Outlier Payment Adjustment Factor 

 Section 412.312(c) establishes a unified outlier payment 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 IPPS DRG payments. 

 For FY 2010, we estimated that outlier payments for capital would equal 5.35 percent of 

inpatient capital-related payments based on the capital Federal rate in FY 2010. Based on the 

thresholds as set forth in section II.A. of this Addendum, we estimate that outlier payments for 

capital-related costs would equal 5.76 percent for inpatient capital-related payments based on the 

proposed capital Federal rate in FY 2011. Therefore, we are proposing to apply an outlier 
CMS-1498-P 763 

adjustment factor of 0.9424 in determining the capital Federal rate. Thus, we estimate that the 

percentage of capital outlier payments to total capital standard payments for FY 2011 would be 

higher than the percentage for FY 2010. This increase in capital outlier payments is primarily 

due to the estimated decrease in capital IPPS payments per discharge. That is, because capital 

payments per discharge are projected to be slightly lower in FY 2011 compared to FY 2010, as 

shown in Table III. in section VIII. of Appendix A to this proposed rule, more cases would 

qualify for outlier payments. 

 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 2011 

outlier adjustment of 0.9424 is a -0.54 percent change from the FY 2010 outlier adjustment of 

0.9475. Therefore, the net change in the outlier adjustment to the proposed capital Federal rate 

for FY 2011 is 0.9946 (0.9424/0.9475). Thus, the proposed outlier adjustment decreases the 

proposed FY 2011 capital Federal rate by 0.54 percent compared with the FY 2010 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 
CMS-1498-P 764 

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. of this Addendum, beginning in FY 2002, an adjustment for regular exception 

payments is no longer necessary. Therefore, we no longer use 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 2011, we compared (separately for the national 

capital rate and the Puerto Rico capital rate) estimated aggregate capital Federal rate payments 

based on the FY 2010 MS-DRG classifications and relative weights and the FY 2010 GAF to 

estimated aggregate capital Federal rate payments based on the FY 2010 MS-DRG 

classifications and relative weights and the proposed FY 2011 GAFs. In making the comparison, 

we set the exceptions reduction factor to 1.00. To achieve budget neutrality for the changes in 

the national GAFs, based on calculations using updated data, we are proposing to apply an 

incremental budget neutrality adjustment of 1.0007 for FY 2011 to the previous cumulative 

FY 2010 adjustment of 0.9907, yielding an adjustment of 0.9915, through FY 2011 (calculated 

with unrounded numbers). For the Puerto Rico GAFs, we are proposing to apply an incremental 
CMS-1498-P 765 

budget neutrality adjustment of 1.0004 for FY 2011 to the previous cumulative FY 2010 

adjustment of 0.9969, yielding a cumulative adjustment of 0.9973 through FY 2011. 

 We then compared estimated aggregate capital Federal rate payments based on the 

FY 2010 DRG relative weights and the proposed FY 2011 GAFs to estimated aggregate capital 

Federal rate payments based on the cumulative effects of the proposed FY 2011 MS-DRG 

classifications and relative weights and the proposed FY 2011 GAFs. The proposed incremental 

adjustment for DRG classifications and proposed changes in relative weights is 0.9992 both 

nationally and for Puerto Rico. The proposed cumulative adjustments for MS-DRG 

classifications and proposed changes in relative weights and for proposed changes in the GAFs 

through FY 2011 are 0.9907 nationally and 0.9965 for Puerto Rico. The following table 

summarizes the adjustment factors for each fiscal year: 
CMS-1498-P 766 

BUDGET NEUTRALITY ADJUSTMENT FOR DRG RECLASSIFICATIONS AND 

RECALIBRATION AND THE GEOGRAPHIC ADJUSTMENT FACTORS 

National Puerto Rico 

Incremental Adjustment Incremental Adjustment 

Fiscal 

Year 

Geographic 

Adjustment 

Factor 

DRG Reclassifications 

and 

Recalibration Combined Cumulative

Geographic 

Adjustment 

Factor 

DRG 

Reclassifications and 

Recalibration Combined

Cumulative 

1992 — — — 1.00000 — — — — 

1993 — — 0.99800 0.99800 — — — — 

1994 — — 1.00531 1.00330 — — — — 

1995 — — 0.99980 1.00310 — — — — 

1996 — — 0.99940 1.00250 — — — — 

1997 — — 0.99873 1.00123 — — — — 

1998 — — 0.99892 1.00015 — — — 1.00000

1999 0.99944 1.00335 1.00279 1.00294 0.99898 1.00335 1.00233 1.00233

2000 0.99857 0.99991 0.99848 1.00142 0.99910 0.99991 0.99901 1.00134

20011 0.99782 1.00009 0.99791 0.99933 1.00365 1.00009 1.00374 1.00508

20012 0.997713 1.000093 0.997803 0.99922 1.003653 1.000093 1.003743 1.00508

2002 0.996664 0.996684 0.993354 0.99268 0.989914 0.996684 0.996624 0.99164

20035 0.99915 0.99662 0.99577 0.98848 1.00809 0.99662 1.00468 0.99628

20036 0.998967 0.996627 0.995587 0.98830 1.00809 0.99662 1.00468 0.99628

20048 1.001759 1.000819 1.002569 0.99083 1.00028 1.00081 1.00109 0.99736

200410 1.001649 1.000819 1.002459 0.99072 1.00028 1.00081 1.00109 0.99736

200511 0.9996712 1.00094 1.0006112 0.99137 0.99115 1.00094 0.99208 0.98946

200513 0.9994612 1.00094 1.0004012 0.99117 0.99115 1.00094 0.99208 0.98946

2006 1.0018514 0.99892 1.0007614 0.99198 1.00762 0.99892 1.00653 0.99592

2007 1.00000 0.99858 0.99858 0.99057 1.00234 0.99858 1.00092 0.99683

2008 1.00172 0.99792 0.99963 0.99021 1.00079 0.99792 0.99870 0.99554

200915 1.00206 0.99945 1.00150 0.99170 1.00097 0.99945 1.00041 0.99595

201016 0.99950 0.99953 0.99902 0.99073 1.00141 0.99953 1.00094 0.99688

201117 1.00074 0.99922 0.99997 0.99070 1.00036 0.99922 0.99959 0.99647

1

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. 

10Factors effective for the second half of FY 2004 (April 2004 through September 2004). 

11Factors effective for the first quarter of FY 2005 (September 2004 through December 2004). 12Incremental 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. 13Factors effective for the last three quarters of FY 2005 (January 2005 through September 2005). 

14Incremental factors are applied to average of the cumulative factors for 2005. 

15Final factors for FY 2009, including the implementation of section 124 of Pub. L. 110-275, which affects wage 

indices and GAFs for FY 2009, 

16 Final factors for FY 2010. 17 Proposed factors for FY 2011 
CMS-1498-P 767 

 The methodology used to determine the recalibration and geographic adjustment factor 

(DRG/GAF) budget neutrality adjustment is similar to the methodology used in establishing 

budget neutrality adjustments under the IPPS for operating costs. One difference is that, under 

the operating IPPS, 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 IPPS, 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 DSH or IME. 

 For FY 2010, we calculated a final GAF/DRG budget neutrality factor of 0.9990 (74 FR 

44019). For FY 2011, we are proposing to establish a GAF/DRG budget neutrality factor of 

1.0000. 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 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 

GAFs. The incremental change in the proposed adjustment from FY 2010 to FY 2011 is 1.0000. 

The cumulative change in the proposed capital Federal rate due to this adjustment is 0.9907 (the 

product of the incremental factors for FYs 1995 though 2010 and the proposed incremental 

factor of 1.0000 for FY 2011). (We note that averages of the incremental factors that were in 

effect during FYs 2005 and 2006, respectively, were used in the calculation of the cumulative 

adjustment of 0.9907 for FY 2011.) 
CMS-1498-P 768 

 The proposed factor accounts for the proposed MS-DRG reclassifications and 

recalibration and for proposed changes in the GAFs. It also incorporates the effects on the 

proposed GAFs of FY 2011 geographic reclassification decisions made by the MGCRB 

compared to FY 2010 decisions. However, it does not account for changes in payments due to 

changes in the DSH and IME adjustment factors. 

4. Exceptions Payment Adjustment Factor 

 Section 412.308(c)(3) of our regulations 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 

proposed FY 2011 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 are 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 proposed exceptions adjustment used in 

calculating the FY 2011 capital Federal rate below. 
CMS-1498-P 769 

 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 the following criteria: (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 and MACs, six hospitals 

have qualified for special exceptions payments under §412.348(g). One of these hospitals closed 

in May 2005. Because we have cost reports ending in FY 2008 for four of these five hospitals, 

we calculated the adjustment based on actual cost experience. (We note that the one hospital for 

which we do not have FY 2008 cost report data has had zero special exception payments for all 

available past cost reports. Consequently, we expect that this hospital would not have any 

special exceptions payments in FY 2008, and the lack of this hospital’s FY 2008 cost report data 

would not distort the calculation of the adjustment.) Using data from cost reports ending in FY 

2008 from the December 2009 update of the HCRIS data, we divided the capital special 

exceptions payment amounts for the four available 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 2008, this ratio is rounded to 0.0003, 

and we are proposing to make an adjustment of 0.0003. Because special exceptions are budget 

neutral, we are proposing to offset the capital Federal rate by 0.03 percent for special exceptions 
CMS-1498-P 770 

payments for FY 2011. Therefore, the proposed exceptions adjustment factor is equal to 0.9997 

(1 - 0.0003) to account for estimated special exceptions payments in FY 2011. 

 In the FY 2010 IPPS final rule (74 FR 44019), we estimated that total (special) 

exceptions payments for FY 2010 would equal 0.02 percent of aggregate payments based on the 

capital Federal rate. Therefore, we applied an exceptions adjustment factor of 0.9998 (1 − 

0.0002) to determine the FY 2010 capital Federal rate. As we stated above, we are proposing to 

apply an exceptions payment adjustment factor of 0.9997 to the proposed capital Federal rate for 

FY 2011 based on our estimate that exceptions payments in FY 2011 would equal 0.03 percent 

of aggregate payments based on the proposed FY 2011 capital Federal rate. The proposed 

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 2011 capital 

Federal rate is 0.9999 (0.9997/0.9998). 

5. Proposed Capital Standard Federal Rate for FY 2011 

For FY 2010, we established a final capital Federal rate of $429.26 (74 FR 51499). We 

are proposing to establish an update of 1.5 percent in determining the proposed FY 2011 capital 

Federal rate for all hospitals. However, as discussed in greater detail in section V.E. of the 

preamble of this proposed rule, under the statutory authority at section 1886(g) of the Act, in 

conjunction with section 1886(d)(3)(A)(vi) of the Act and section 7(b) of Public Law 110-90, we 

are proposing an additional 2.9 percent reduction to the national capital Federal payment rate in 

FY 2011. The proposed -2.9 percent adjustment is based on our actuary’s analysis of the effect 

of changes in case-mix resulting from documentation and coding changes that do not reflect real 

changes in the case-mix in light of the adoption of MS-DRGs. Accordingly, we are proposing to 
CMS-1498-P 771 

apply a cumulative documentation and coding adjustment factor of 0.957 in determining the 

proposed FY 2011 capital Federal rate percent (that is, the existing -0.6 percent adjustment in FY 

2008 plus the -0.9 percent adjustment in FY 2009 plus the proposed additional -2.9 percent 

adjustment, computed as 1 divided by (1.006 x 1.009 x 1.029). (We note that we did not apply a 

documentation and coding adjustment to the capital Federal rate in FY 2010 (74 FR 43927).) As 

a result of the proposed 1.5 percent update and other proposed budget neutrality factors 

discussed above, we are proposing to establish a national capital Federal rate of $420.99 for 

FY 2011. The proposed national capital Federal rate for FY 2011 was calculated as follows: 

● The proposed FY 2011 update factor is 1.015, that is, the update is 1.5 percent. 

● The proposed FY 2011 budget neutrality adjustment factor that is applied to the 

proposed capital standard Federal payment rate for proposed changes in the MS-DRG 

classifications and relative weights and proposed changes in the GAFs is 1.0000. 

● The proposed FY 2011 outlier adjustment factor is 0.9424. 

● The proposed FY 2011 (special) exceptions payment adjustment factor is 0.9997. 

● The proposed cumulative adjustment factor for FY 2011 applied to the national capital 

Federal rate for changes in documentation and coding under the MS-DRGs is 0.957. 

 Because the proposed capital Federal rate has already been adjusted for differences in 

case-mix, wages, cost-of-living, indirect medical education costs, and payments to hospitals 

serving a disproportionate share of low-income patients, we are not proposing to make additional 

adjustments in the proposed capital standard Federal rate for these factors, other than the 

proposed budget neutrality factor for proposed changes in the MS-DRG classifications and 

relative weights and for proposed changes in the GAFs. 
CMS-1498-P 772 

 We are providing the following chart that shows how each of the proposed factors and 

adjustments for FY 2011 affects the computation of the proposed FY 2011 national capital 

Federal rate in comparison to the FY 2010 national capital Federal rate. The proposed FY 2011 

update factor has the effect of increasing the proposed capital Federal rate by 1.5 percent 

compared to the FY 2010 capital Federal rate. The proposed GAF/DRG budget neutrality factor 

of 1.000 has no net effect on the proposed capital Federal rate. The proposed FY 2011 outlier 

adjustment factor has the effect of decreasing the proposed capital Federal rate by 0.54 percent 

compared to the FY 2010 capital Federal rate. The proposed FY 2011 exceptions payment 

adjustment factor has the effect of decreasing the proposed capital Federal rate by 0.01 percent 

compared to the FY 2010 capital Federal rate. Furthermore, as shown in the chart below, the 

resulting cumulative adjustment for changes in documentation and coding that do not reflect real 

changes in patients’ severity of illness (that is, the proposed cumulative adjustment factor of 

0.957 has the net effect of decreasing the proposed FY 2011 national capital Federal rate by 2.8 

percent as compared to the FY 2010 national capital Federal rate. (As discussed in section 

VI.E.1. of the preamble of this proposed rule, a cumulative adjustment of -1.5 percent (that is, 

the -0.6 percent in FY 2008 and -0.9 percent in FY 2009) or a cumulative adjustment factor of 

0.985 has already been applied to the FY 2010 capital Federal rate for changes in documentation 

and coding that do not reflect real changes in patients’ severity of illness. We did not apply any 

additional documentation and coding adjustment to the capital Federal rate in FY 2010). The 

combined effect of all the proposed changes would decrease the proposed national capital 

Federal rate by approximately 1.93 percent compared to the FY 2010 national capital Federal 

rate. 
CMS-1498-P 773 

Comparison of Factors and Adjustments: 

FY 2010 Capital Federal Rate and 

Proposed FY 2011 Capital Federal Rate 

FY 2010 

Proposed 

FY 2011 Change 

Percent 

Change 

Update Factor1 1.0120 1.0150 1.0150 1.50

GAF/DRG Adjustment Factor1 0.9990 1.0000 1.0000 0.00

Outlier Adjustment Factor2 0.9475 0.9424 0.9946 -0.54

Exceptions Adjustment Factor2 0.9998 0.9997 0.9999 -0.01

MS-DRG Documentation and 

Coding Adjustment Factor 0.98503 0.95704 0.97165 -2.84

Capital Federal Rate $429.26 $420.99 0.9807 -1.93

1

 The update factor and the GAF/DRG budget neutrality factors are built permanently into the capital rates. Thus, for example, the incremental 

change from FY 2010 to FY 2011 resulting from the application of the proposed 1.000 GAF/DRG budget neutrality factor for FY 2011 is a net 

change of 1.00 (zero percent). 

2

 The outlier reduction factor and the 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 proposed net change resulting from the application of the proposed 

FY 2011 outlier adjustment factor is 0.9475/0.9424, or 0.9946. 

3

The documentation and coding adjustment factor includes the -0.6 percent in FY 2008, -0.9 percent in FY 2009, and no additional reduction in 

FY 2010. 

4

The documentation and coding adjustment factor includes the -0.6 percent in FY 2008, -0.9 percent in FY 2009, no additional reduction in 

FY 2010 and the proposed -2.9 percent reduction in FY 2011. 

5

The change is measured from the FY 2009 cumulative factor of 0.9850. 

6. Proposed Special Capital Rate for Puerto Rico Hospitals 

Section 412.374 provides for the use of a blended payment system for payments to 

hospitals located in Puerto Rico under the PPS for acute care hospital inpatient capital-related 

costs. Accordingly, under the capital PPS, we compute a separate payment rate specific to 

hospitals located in Puerto Rico 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 1, 2004, capital payments to hospitals located 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, 
CMS-1498-P 774 

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. The proposed national GAF budget neutrality factor is 1.0004 

and the proposed DRG adjustment is 0.9992, for a combined cumulative adjustment of 0.9965. 

 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 2010, the special capital rate for hospitals located in Puerto Rico was $203.56 (74 

FR 51499). Consistent with our development of the FY 2010 Puerto Rico-specific operating 

standardized amount, we have not applied the -0.6 percent adjustment in FY 2008 or the -0.9 
CMS-1498-P 775 

percent documentation and coding adjustment in FY 2009 (that is, the cumulative -1.5 percent 

adjustment) that was applied to the national capital Federal rate to the Puerto Rico-specific 

capital rate. However, we noted in the FY 2009 IPPS final rule (73 FR 48449 through 48550) 

that we may propose to apply such an adjustment to the Puerto Rico operating and capital rates 

in the future. 

 As noted above and discussed in greater detail in section V.E.4. of the preamble of this 

proposed rule, consistent with our development of the Puerto Rico-specific operating 

standardized amount, we are proposing to apply a -2.4 percent adjustment to account for changes 

in documentation and coding that resulted from the adoption of the MS-DRGs in determining the 

proposed FY 2011 Puerto Rico-specific capital rate. With the changes we are proposing to make 

to the other factors used to determine the capital rate, the proposed FY 2011 special capital rate 

for hospitals in Puerto Rico is $199.43. 

B. Calculation of the Proposed Inpatient Capital-Related Prospective Payments for FY 2011

 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 2011. 

For purposes of calculating payments for each discharge during FY 2011, the capital 

standard Federal rate is adjusted as follows: (Standard Federal Rate) x (DRG weight) x (GAF) x 

(COLA for hospitals located in Alaska and Hawaii) x (1 + DSH Adjustment Factor + IME 

Adjustment Factor, if applicable). The result is the adjusted capital Federal rate. 

 Hospitals also may receive outlier payments for those cases that qualify under the 

thresholds established for each fiscal year. Section 412.312(c) provides for a single set of 

thresholds to identify outlier cases for both inpatient operating and inpatient capital-related 
CMS-1498-P 776 

payments. The proposed outlier thresholds for FY 2011 are in section II.A. of this Addendum. 

For FY 2011, a case would qualify as a cost outlier if the cost for the case plus the (operating) 

IME and DSH payments is greater than the prospective payment rate for the MS-DRG plus the 

fixed-loss amount of $23,970. 

 An eligible hospital may also qualify for a special exceptions payment under §412.348(g) 

up through the 10th year beyond the end of the capital transition period if it meets the following 

criteria: (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. We note that this was a 10-year 

provision. Therefore, FY 2012 is the final year hospitals will be eligible for the special 

exceptions payment. 
CMS-1498-P 777 

 Currently, as provided in §412.304(c)(2), 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 price indexes to 

reflect the changing composition of inputs for operating and capital expenses. In the FY 2010 

IPPS final rule (74 FR44021), we rebased and revised the CIPI to a FY 2006 base year to reflect 

the more current structure of capital costs in hospitals. A complete discussion of this rebasing is 

provided in section IV. of the preamble of that final rule. 
CMS-1498-P 778 

2. Forecast of the CIPI for FY 2011 

 Based on the latest forecast by IHS Global Insight, Inc. (first quarter of 2010), we are 

forecasting the FY 2006-based CIPI to increase 1.2 percent in FY 2011. This reflects a projected 

1.8 percent increase in vintage-weighted depreciation prices (building and fixed equipment, and 

movable equipment), and a 1.9 percent increase in other capital expense prices in FY 2011, 

partially offset by 1.9 percent decline in vintage-weighted interest expenses in FY 2011. The 

weighted average of these three factors produces the 1.2 percent increase for the FY 2006-based 

CIPI as a whole in FY 2011. 

IV. Proposed Changes to Payment Rates for Excluded Hospitals: Rate-of-Increase 

Percentages 

 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, and updated annually by a rate-of-increase percentage. The updated 

target amount for that period was multiplied by the Medicare discharges during that period 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). 

Payments for services furnished in children’s hospitals and cancer hospitals that are 

excluded from the IPPS continue to be subject to the rate-of-increase ceiling based on the 
CMS-1498-P 779 

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 of the 

regulations.) 

We are proposing that the FY 2011 rate-of-increase percentage for updating the target 

amounts for cancer and children’s hospitals and RNHCIs be the estimated percentage increase in 

the FY 2011 IPPS operating market basket, estimated to be 2.4 percent, using the most recent 

data available based on IHS Global Insight, Inc.'s first quarter 2010 forecast, with historical data 

through the 2009 fourth quarter. (We are proposing to use more recent data when determining 

the estimated percentage increase for the FY 2011 IPPS operating market basket for the final 

rule, to the extent these data are available.) 

IRFs, IPFs, and LTCHs were previously paid 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 transitioning periods of varying lengths of time during which a portion of 

the prospective payment is based on cost-based reimbursement rules under 42 CFR Part 413 

(certain providers do not receive a transitioning period or may elect to bypass the transition as 

applicable under 42 CFR Part 412, Subparts N, O, and P.) We note that all of the various 

transitioning periods provided for under the IRF PPS, the IPF PPS, and the LTCH PPS have 

ended. 

The IRF PPS, the IPF PPS, and the LTCH PPS are updated annually. We refer readers to 

section VII. of the preamble and section V. of the Addendum to this proposed rule for the 

proposed update changes to the Federal payment rates for LTCHs under the LTCH PPS for RY 
CMS-1498-P 780 

2011. The annual updates for the IRF PPS and the IPF PPS are issued by the agency in separate 

Federal Register documents. 

V. Proposed Changes to the Payment Rates for the LTCH PPS for FY 2011 

A. Proposed LTCH PPS Standard Federal Rate for FY 2011

1. Background 

 In section VII. of the preamble of this proposed rule, we discuss our proposed changes to 

the payment rates, factors, and specific policies under the LTCH PPS for FY 2011. We note that 

on March 23, 2010, the Patient Protection and Affordable Care Act, Pub. L. 111-148, was 

enacted. Following the enactment of Pub. L. 111-148, the Health Care and Education 

Reconciliation Act of 2010, Pub. L. 111-152 (enacted on March 30, 2010), amended certain 

provisions of Pub. L. 111-148. A number of the provisions of Pub. L. 111-148, as amended by 

Pub. L. 111-152, affect the IPPS and the LTCH PPS and the providers and suppliers addressed in 

this proposed rule. However, due to the timing of the passage of the legislation, we are unable to 

address those provisions in this proposed rule. Therefore, the proposed policies and payment 

rates in this proposed rule do not reflect the new legislation. We plan to issue separate 

documents in the Federal Register addressing the provisions of Pub. L. 111-148, as amended, 

that affect our proposed policies and payment rates for FY 2011 under the IPPS and the LTCH 

PPS. In addition, we plan to issue further instructions implementing the provisions of Pub. L. 

111-148, as amended, that affect the policies and payment rates for FY 2010 under the IPPS and 

for RY 2010 under the LTCH PPS. 

At §412.523(c)(3)(ii) of the regulations, for LTCH PPS rate years beginning RY 2004 

through RY 2006, we updated the standard Federal rate by a factor to adjust for the most recent 

estimate of the increases in prices of an appropriate market basket of goods and services for 
CMS-1498-P 781 

LTCHs. We established that policy of annually updating the standard Federal rate because, at 

that time, we believed that was the most appropriate method for updating the LTCH PPS 

standard Federal rate annually for years after the initial implementation of the LTCH PPS in 

FY 2003. Under §412.523(c)(3)(ii), for RYs 2004 through 2006, the annual update to the LTCH 

PPS standard Federal rate was equal to the previous rate year’s Federal rate updated by the most 

recent estimate of increases in the appropriate market basket of goods and services included in 

covered inpatient LTCH services. 

In determining the annual update to the standard Federal rate for RY 2007, based on our 

ongoing monitoring activity, we believed that, rather than solely using the most recent estimate 

of the LTCH PPS market basket as the basis of the update factor, it was appropriate to adjust the 

standard Federal rate to account for the changes in documentation and coding practices in a prior 

period that were unrelated to patient severity of illness (71 FR 27818). Accordingly, we 

established regulations at §412.523(c)(3)(iii) to specify that the update to the standard Federal 

rate for RY 2007 is zero percent based on the most recent estimate of the LTCH PPS market 

basket at the time, offset by an adjustment to account for changes in case-mix in prior periods 

due to changes in documentation and coding that were unrelated to patient severity of illness in 

FY 2004. For RYs 2008 through 2010, we also considered changes in documentation and 

coding practices that were unrelated to patient severity of illness in establishing the annual 

update to the standard Federal rate as set forth in the regulations at §§412.523(c)(3)(iv) through 

(c)(3)(vi). (We note that section 114(e)(1) of Pub. L. 110-173 provided that the standard Federal 

rate for RY 2008 shall be the same as the standard Federal rate for RY 2007. In addition, section 

114(e)(2) of Pub. L. 110-173 specified that the revised standard Federal rate provided for under 

section 114(e)(1) "shall not apply to discharges occurring on or after July 1, 2007, and before 
CMS-1498-P 782 

April 1, 2008," effectively resulting in a delay of the application of the updated standard Federal 

rate for RY 2007 established in the RY 2008 LTCH PPS final rule (72 FR 26890).) Consistent 

with our historical practice, in the RY 2010 LTCH PPS final rule, we established an annual 

update to the standard Federal rate for RY 2010 based on the most recent estimate of the increase 

in the LTCH PPS market basket at that time (2.5 percent and an adjustment of -0.5 percent to 

account for the increase in case-mix in a prior period (FY 2007) due to changes in documentation 

and coding practices unrelated to an increase in patient severity of illness (74 FR 44022)). 

Accordingly, we established regulations at §412.523(c)(3)(vi) to specify that the update to the 

standard Federal rate for RY 2010 is 2.0 percent. 

2. Development of the Proposed FY 2011 LTCH PPS Standard Federal Rate 

While we continue to believe that an update to the LTCH PPS standard Federal rate 

should be based on the most recent estimate of the increase in the LTCH PPS market basket, we 

also believe it is appropriate that the standard Federal rate be offset by an adjustment to account 

for any changes in documentation and coding practices that do not reflect increased patient 

severity of illness. Such an adjustment protects the integrity of the Medicare Trust Funds by 

ensuring that the LTCH PPS payment rates better reflect the true costs of treating LTCH patients. 

Furthermore, as we discussed most recently in the FY 2010 IPPS/RY 2010 LTCH PPS final rule 

(74 FR 44022), we did not establish a case-mix budget neutrality factor (that is, a documentation 

and coding adjustment for changes in case-mix that are not due to changes in patient severity of 

illness) for the adoption of the severity adjusted MS-LTC-DRG patient classification system. 

Rather, we noted that, consistent with past LTCH payment policy, we would continue to monitor 

LTCH data and we could propose to make adjustments when updating the LTCH PPS standard 

Federal rate in the future to account for changes in documentation and coding that do not reflect 
CMS-1498-P 783 

any real changes in case-mix during these years that we are implementing MS-LTC-DRGs. As 

noted above, in the FY 2010 IPPS/RY 2010 LTCH PPS final rule, we applied a -0.5 percent 

adjustment to account for the effect of changes in documentation and coding on the increase in 

case-mix in FY 2007. Although we proposed a -1.3 percent adjustment to account for the effect 

of changes in documentation and coding on the increase in case-mix in FY 2008, in the final rule 

after consideration of public comments and consistent with IPPS policy, we delayed the 

application of that adjustment (74 FR 43970 through 43972). 

 For FY 2011, for this proposed rule as discussed in greater detail in section VII.C.3. of 

the preamble of this proposed rule, we performed a CMI analysis using the most recent available 

LTCH claims data (FY 2009) under both the current MS-LTC-DRG and the former CMS LTCDRG patient classification systems. Based on this evaluation, we determined that there was a 

cumulative increase in LTCH CMI of 2.5 percent due to changes in documentation and coding 

that did not reflect real changes in patient severity of illness for LTCH discharges occurring in 

FY 2008 and FY 2009. At this time, the most recent estimate of the increase in the proposed 

LTCH PPS market basket (that is, the FY 2002-based RPL market basket) for FY 2011 is 

2.4 percent, as discussed in section VII.B.2. of the preamble of this proposed rule. Consistent 

with our historical practice, in this proposed rule, we are proposing to update the LTCH PPS 

standard Federal rate for FY 2011 based on the full proposed LTCH PPS market basket increase 

estimate of 2.4 percent and an adjustment to account for the increase in case-mix in a prior 

periods (FYs 2008 and 2009) that resulted from changes in documentation and coding practices 

of -2.5 percent. The proposed update factor to the standard Federal rate for FY 2011 is –0.1 

percent (that is, we are proposing to apply a factor of 0.999 in determining the LTCH PPS 

standard Federal rate for FY 2011, calculated as 1.024 x 1 divided by 1.025 = 0.999 or -0.1 
CMS-1498-P 784 

percent). Therefore, in this proposed rule, under the broad authority conferred upon the 

Secretary under the BBRA and the BIPA to determine appropriate updates under the LTCH PPS, 

we are proposing to amend §412.523 to add a new paragraph (c)(3)(vii) to specify that the 

standard Federal rate for discharges occurring on or after October 1, 2010, through September 

30, 2011, is the standard Federal rate for the previous rate year updated by -0.1 percent. In 

determining the proposed standard Federal rate for FY 2011, we are applying the proposed 0.999 

update factor to the RY 2010 Federal rate of $39,896.65 (as established in the FY 2010 

IPPS/RY 2010 LTCH PPS final rule (74 FR 44022)). Consequently, the proposed standard 

Federal rate for FY 2011 is $39,856.75. We also are proposing that if more recent data become 

available, we would use those data, if appropriate, to determine the update to the standard 

Federal rate for FY 2011 in the final rule, and, thus, the standard Federal rate update specified in 

the proposed regulation text at §412.523(c)(3)(vii) could change accordingly. 

B. Proposed Adjustment for Area Wage Levels under the LTCH PPS for FY 2011

1. Background 

 Under the authority of section 123 of the BBRA as amended by section 307(b) of the 

BIPA, we established an adjustment to the LTCH PPS standard Federal rate to account for 

differences in LTCH area wage levels at §412.525(c). The labor-related share of the LTCH PPS 

standard Federal rate is adjusted to account for geographic differences in area wage levels by 

applying the applicable LTCH PPS wage index. The applicable LTCH PPS wage index is 

computed using wage data from inpatient acute care hospitals without regard to reclassification 

under section 1886(d)(8) or section 1886(d)(10) of the Act. 

 As we discussed in the August 30, 2002 LTCH PPS final rule (67 FR 56015), when we 

implemented the LTCH PPS, we established a 5-year transition to the full wage index 
CMS-1498-P 785 

adjustment. The wage index adjustment was completely phased in for cost reporting periods 

beginning in FY 2007. Therefore, for cost reporting periods beginning on or after 

October 1, 2006, the applicable LTCH wage index values are the full (five-fifths) LTCH PPS 

wage index values calculated based on acute care hospital inpatient wage index data without 

taking into account geographic reclassification under section 1886(d)(8) and section 1886(d)(10) 

of the Act. For additional information on the phase-in of the wage index adjustment under the 

LTCH PPS, we refer readers to the August 30, 2002 LTCH PPS final rule (67 FR 56017 through 

56019) and the RY 2008 LTCH PPS final rule (72 FR 26891). 

2. Proposed Updates to the Geographic Classifications/Labor Market Area Definitions 

a. Background 

 As discussed in the August 30, 2002 LTCH PPS final rule, which implemented the LTCH 

PPS (67 FR 56015 through 56019), in establishing an adjustment for area wage levels, the 

labor-related portion of a LTCH's Federal prospective payment is adjusted by using an 

appropriate wage index based on the labor market area in which the LTCH is located. 

Specifically, the application of the LTCH PPS wage index adjustment at §412.525(c) is made on 

the basis of the location of the LTCH in either an urban area or a rural area as defined in 

§412.503. Currently under the LTCH PPS at §412.503, an “urban area” is defined as a 

Metropolitan Statistical Area (which would include a metropolitan division, where applicable) as 

defined by the Executive OMB and a “rural area” is defined as any area outside of an urban area. 

In the RY 2006 LTCH PPS final rule (70 FR 24184 through 24185), in regulations at 

§412.525(c), we revised the labor market area definitions used under the LTCH PPS effective for 

discharges occurring on or after July 1, 2005, based on the Executive OMB's CBSA 

designations, which are based on 2000 Census data. We made this revision because we believe 
CMS-1498-P 786 

that the CBSA-based labor market area definitions will ensure that the LTCH PPS wage index 

adjustment most appropriately accounts for and reflects the relative hospital wage levels in the 

geographic area of the hospital as compared to the national average hospital wage level. We 

note that these are the same CBSA-based designations implemented for acute care hospitals 

under the IPPS at §412.64(b), effective October 1, 2004 (69 FR 49026 through 49034). (For 

further discussion of the CBSA-based labor market area (geographic classification) definitions 

currently used under the LTCH PPS, we refer readers to the RY 2006 LTCH PPS final rule 

(70 FR 24182 through 24191).) We have updated the LTCH PPS CBSA-based labor market area 

definitions annually since they were adopted for RY 2006 (73 FR 26812 through 26814, and 74 

FR 44023 through 44204). 

b. Update to the CBSA-Based Labor Market Area Titles and Principal Cities 

 On December 1, 2009, the Executive OMB announced changes to the principal cities and 

titles of a number of CBSAs and Metropolitan Divisions (OMB Bulletin No. 10-02). Under the 

broad authority conferred upon the Secretary by section 123 of the BBRA, as amended by 

section 307(b) of BIPA, to determine appropriate adjustments under the LTCH PPS, we update 

our titles and definitions using the Executive OMB’s bulletin. These changes are effective for 

discharges occurring on or after October 1, 2010. 

 Specifically, for FY 2011, the following CBSAs have new titles and new principal cities: 

● San Marcos, TX qualifies as a new principal city of the Austin-Round Rock, TX 

CBSA. The new title is Austin-Round Rock-San Marcos, TX CBSA (CBSA Code 12420). 

● Delano, CA qualifies as a new principal city of the Bakersfield, CA CBSA. The new 

title: Bakersfield-Delano, CA CBSA (CBSA Code 12540). 
CMS-1498-P 787 

● Conroe, TX qualifies as a new principal city of the Houston-Sugar Land-Baytown, TX 

CBSA (CBSA Code 26420). The CBSA title is unchanged. 

● North Port, FL qualifies as a new principal city of the Bradenton-Sarasota-Venice, FL 

CBSA (currently CBSA Code 14600). The new title is North Port-Bradenton-Sarasota, FL 

CBSA. The new code is CBSA 35840. 

● Sanford, FL qualifies as a new principal city of the Orlando-Kissimmee, FL CBSA 

(CBSA Code 36740). The new title is Orlando-Kissimmee-Sanford, FL CBSA. 

● Glendale, AZ qualifies as a new principal city of the Phoenix-Mesa-Scottsdale, AZ 

CBSA. The new title is Phoenix-Mesa-Glendale, AZ CBSA (CBSA Code 38060). 

● Palm Desert, CA qualifies as a new principal city of the Riverside-San BernardinoOntario, CA CBSA (CBSA Code 40140). The CBSA title is unchanged. 

● New Braunfels, TX qualifies as a new principal city of the San Antonio, TX CBSA. 

The new title is San Antonio-New Braunfels, TX CBSA (CBSA Code 41700). 

● Auburn, WA qualifies as a new principal city of the Seattle-Tacoma-Bellevue, WA 

CBSA (CBSA Code 42644). The CBSA title is unchanged. 

In addition, the following CBSAs have new titles as a result of changes to the order of 

principal cities based on population: 

● Rockville, MD replaces Frederick, MD as the second most populous principal city in 

the Bethesda-Frederick-Rockville, MD Metropolitan Division. The new title is BethesdaRockville-Frederick, MD Metropolitan Division (CBSA Code 13644). 

● Rock Hill, SC replaces Concord, NC as the third most populous principal city in the 

Charlotte-Gastonia-Concord, NC-SC CBSA. The new title is Charlotte-Gastonia-Rock Hill, NCSC CBSA (CBSA Code 16740). 
CMS-1498-P 788 

● Joliet, IL replaces Naperville, IL as the second most populous principal city in the 

Chicago-Naperville-Joliet, IL Metropolitan Division. The new title is Chicago-Joliet-Naperville, 

IL Metropolitan Division (CBSA Code 16974). 

● Crestview, FL replaces Fort Walton Beach, FL as the most populous principal city in 

the Fort Walton Beach-Crestview-Destin, FL CBSA (currently CBSA Code 23020). The new 

title is Crestview-Fort Walton Beach-Destin, FL CBSA. The new code is 18880. 

● Hillsboro, OR replaces Beaverton, OR as the third most populous principal city in the 

Portland-Vancouver-Beaverton, OR-WA CBSA. The new title is Portland-Vancouver-Hillsboro, 

OR-WA CBSA (CBSA Code 38900). 

● Steubenville, OH replaces Weirton, WV as the most populous principal city in the 

Weirton-Steubenville, WV-OH CBSA (currently CBSA Code 48260). The new title is 

Steubenville-Weirton, OH-WV CBSA. The new CBSA code is 44600. 

OMB Bulletin No. 10-02 is available on the OMB Web site at 

http://www.whitehouse.gov/OMB - go to “Bulletins” or “Statistical Programs and Standards.” 

 The proposed FY 2011 LTCH PPS wage index values presented in Tables 12A and 12B 

in the Addendum of this proposed rule reflect the revisions to the CBSA-based labor market area 

titles and codes described above. 

3. Proposed LTCH PPS Labor-Related Share 

As noted above in this section, under the adjustment for difference in area wage levels at 

§412.525(c), the labor-related share of a LTCH’s PPS Federal prospective payment is adjusted 

by the applicable wage index for the labor market area in which the LTCH is located. The 

LTCH PPS labor-related share represents the sum of the labor-related portion of operating costs 

(wages and salaries, employee benefits, professional fees, and all other labor-intensive services) 
CMS-1498-P 789 

and a labor-related portion of capital costs using the applicable LTCH PPS market basket. 

Currently, as established in the RY 2007 LTCH PPS final rule (71 FR 27829 through 27830), the 

LTCH PPS labor-related share is based on the relative importance of the labor-related share of 

operating costs and capital costs of the rehabilitation psychiatric long-term care (hospital) (RPL) 

market basket based on FY 2002 data, as they are the best available data that reflect the cost 

structure of LTCHs. For the past 3 years (RYs 2008, 2009, and 2010), we updated the LTCH 

PPS labor-related share annually based on the latest available data for the RPL market basket. 

For RY 2010, the labor-related share is 75.779 percent, as established in the RY 2010 LTCH 

PPS final rule (74 FR 43968 and 44024). (Additional background information on the historical 

development of the labor-related share under the LTCH PPS and the development of the RPL 

market basket can be found in the RY 2007 LTCH PPS final rule (71 FR 27810 through 27817 

and 27829 through 27830) and the RY 2010 LTCH PPS final rule (74 FR 43968).) 

 As discussed in greater detail in section VII.C.2.d. of the preamble of this proposed rule, 

we are proposing to use IHS Global Insight, Inc.’s first quarter 2010 forecast of the 

FY 2002-based RPL market basket for FY 2011 to determine the proposed labor-related share 

for the LTCH PPS for FY 2011 that would be effective for discharges occurring on or after 

October 1, 2010, and through September 30, 2011, as these are the most recent available data. 

The proposed labor-related share for FY 2011 would be the sum of the proposed FY 2011 

relative importance of each labor-related cost category, and would reflect the different rates of 

price change for these cost categories between the base year (FY 2002) and FY 2011. The sum 

of the proposed relative importance for FY 2011 for operating costs (wages and salaries, 

employee benefits, professional fees, and all-other labor-intensive services) would be 71.537 

percent and the labor-related share of capital costs would be 3.870 percent. Thus, the labor-
CMS-1498-P 790 

related share that we are proposing to use for LTCH PPS in FY 2011 would be 75.407 percent 

(71.537 percent + 3.870 percent), as shown in the chart in section VII.C.2.d. of the preamble of 

this proposed rule. 

 Accordingly, under the authority set forth in section 123 of the BBRA as amended by 

section 307(b) of the BIPA, we are proposing to establish a labor-related share of 75.407 percent 

under the LTCH PPS for the FY 2011. Furthermore, consistent with our historical practice of 

using the best data available, we also are proposing that if more recent data are available to 

determine the labor-related share used under the LTCH PPS for FY 2011, we would use these 

data for determining the FY 2011 LTCH PPS labor-related share in the final rule. 

4. Proposed LTCH PPS Wage Index for FY 2011 

 Historically, under the LTCH PPS, we have established LTCH PPS wage index values 

calculated from acute care IPPS hospital wage data without taking into account geographic 

reclassification under sections 1886(d)(8) and 1886(d)(10) of the Act (67 FR 56019). The wage 

adjustment established under the LTCH PPS is based on a LTCH's actual location without regard 

to the urban or rural designation of any related or affiliated provider. 

 In the RY 2010 LTCH PPS final rule (74 FR 44024 through 44026), we calculated the 

LTCH PPS wage indices using the same data used for the FY 2010 acute care hospital IPPS (that 

is, data from cost reporting periods beginning during FY 2006), without taking into account 

geographic reclassification under sections 1886(d)(8) and 1886(d)(10) of the Act. 

 To determine the applicable wage index values under the LTCH PPS for FY 2011, under 

the broad authority conferred upon the Secretary by section 123 of the BBRA, as amended by 

section 307(b) of BIPA, to determine appropriate adjustments under the LTCH PPS, consistent 

with our historical methodology, we are proposing to use wage data collected from cost reports 
CMS-1498-P 791 

submitted by IPPS hospitals for cost reporting periods beginning during FY 2007, without taking 

into account geographic reclassification under sections 1886(d)(8) and 1886(d)(10) of the Act, 

because these data (FY 2007) are the most recent complete data available at this time. These are 

the same data used to compute the proposed FY 2011 acute care hospital inpatient wage index, 

as discussed in section III. of the preamble of this proposed rule. For our rationale for using 

IPPS hospital wage data as a proxy for determining the wage index values used under the LTCH 

PPS, we refer readers to the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 44024 through 

44025). 

The proposed FY 2011 LTCH PPS wage index values are computed consistent with the 

urban and rural geographic classifications (labor market areas) discussed above in section V.B.2. 

of the Addendum of this proposed rule and consistent with the pre-reclassified IPPS wage index 

policy (that is, our historical policy of not taking into account IPPS geographic reclassifications 

in determining payments under the LTCH PPS). We also note that, as with the IPPS wage data, 

wage data for multicampus hospitals with campuses located in different labor market areas 

(CBSAs) are apportioned to each CBSA where the campus or campuses are located (discussed in 

section III.C. of the preamble of this proposed rule). We also would continue to use our existing 

policy for determining wage index values in areas where there are no IPPS wage data. 

 We established a methodology for determining a LTCH PPS wage index values for areas 

that have no IPPS wage data in the RY 2009 LTCH PPS final rule, and we are proposing to use 

this methodology for FY 2011. (We refer readers to 73 FR 26817 through 26818 for an 

explanation of and rationale for our policy.) Under this methodology, the LTCH PPS wage 

index value for urban CBSAs with no IPPS wage data is determined by using an average of all of 

the urban areas within the State. As was the case in RY 2010, there are currently no LTCHs 
CMS-1498-P 792 

located in labor areas without IPPS hospital wage data (or IPPS hospitals) for FY 2011. 

However, we calculate LTCH PPS wage index values for these areas using our established 

methodology in the event that, in the future, a LTCH should open in one of those areas. 

 Based on the current FY 2007 IPPS wage data that we are proposing to use to determine 

the proposed FY 2011 LTCH PPS wage index values, there are no IPPS wage data for the urban 

area of Anderson, SC (CBSA 11340) and Hinesville-Fort Stewart, GA (CBSA 25980). 

Consistent with the methodology discussed above, we calculated the proposed FY 2011 wage 

index value for CBSA 11340 as the average of the proposed wage index values for all of the 

other urban areas within the State of South Carolina (that is, CBSAs 12260, 16700, 16740, 

17900, 22500, 24860, 34820, 34820, 43900 and 44940) (reflected in Table 12A of the 

Addendum of this proposed rule). Similarly, for CBSA 25980 as the average of the proposed 

wage index values for all of the other urban areas within the State of Georgia (that is, CBSAs 

10500, 12020, 12060, 12260, 15260, 16860, 17980, 19140, 23580, 31420, 40660, 42340, 46660 

and 47580) (reflected in Table 12A of the Addendum of this proposed rule). (As noted above, 

there are currently no LTCHs located in CBSA 11340 or CBSA 25980.) As discussed in the 

RY 2009 final rule (73 FR 26817), as IPPS wage data are dynamic, it is possible that urban areas 

without IPPS wage data will vary in the future. 

 For FY 2011, using our established methodology, we calculated a LTCH PPS wage index 

value for rural areas with no IPPS wage data using the unweighted average of the wage indices 

from all of the CBSAs that are contiguous to the rural counties of the State (for an explanation of 

this policy, we refer readers to 73 FR 26818). For this purpose, we define "contiguous" as 

sharing a border.
CMS-1498-P 793 

 Based on the FY 2007 IPPS wage data, there are no IPPS wage data for the rural area of 

Massachusetts (CBSA code 22). Consistent with the methodology discussed above, the 

proposed FY 2011 wage index value for rural Massachusetts is computed using the unweighted 

average of the wage indices from all of the CBSAs contiguous to the rural counties in that State. 

Specifically, the entire Massachusetts rural area consists of Dukes and Nantucket counties. The 

borders of Dukes and Nantucket counties are “contiguous” with Barnstable County, MA, and 

Bristol County, MA. Therefore, the proposed FY 2011 LTCH PPS wage index value for rural 

Massachusetts is computed as the unweighted average of the proposed FY 2011 wage indexes 

for Barnstable County and Bristol County (reflected in Tables 12A and 12B in the Addendum of 

this proposed rule). (There are currently no LTCHs located in rural Massachusetts.) As 

discussed in the RY 2009 final rule (73 FR 26817), as IPPS wage data are dynamic, it is possible 

that rural areas without IPPS wage data will vary in the future. 

 The proposed FY 2011 LTCH wage index values that would be applicable for LTCH 

discharges occurring on or after October 1, 2010, through September 30, 2011, are presented in 

Table 12A (for urban areas) and Table 12B (for rural areas) in the Addendum of this proposed 

rule. 

5. Proposed LTCH PPS Cost-of-Living Adjustment for LTCHs Located in Alaska and Hawaii 

In the August 30, 2002 final rule (67 FR 56022), we established, under §412.525(b), a 

cost-of-living adjustment (COLA) for LTCHs located in Alaska and Hawaii to account for the 

higher costs incurred in those States. In the RY 2010 LTCH PPS final rule (74 FR 44026) 

(under the broad authority conferred upon the Secretary by section 123 of the BBRA as amended 

by section 307(b) of BIPA to determine appropriate adjustments under the LTCH PPS), for RY 
CMS-1498-P 794 

2010, we applied a COLA to payments to LTCHs located in Alaska and Hawaii by multiplying 

the standard Federal payment rate by the factors listed in Table III of that same rule. 

 For FY 2011, under the broad authority conferred upon the Secretary by section 123 of 

the BBRA, as amended by section 307(b) of BIPA, to determine appropriate adjustments under 

the LTCH PPS, we are proposing to apply a COLA to payments to LTCHs located in Alaska and 

Hawaii by multiplying the proposed standard Federal payment rate by the factors listed in the 

chart below because they are the most recent available data at this time. These proposed factors 

were obtained from the U.S. Office of Personnel Management (OPM) and are also proposed to 

be used under the IPPS effective October 1, 2010 (section II.B.2. of the Addendum of this 

proposed rule). We note that there has been no change in the COLA factors since the current 

factors were established in the RY 2010 LTCH PPS final rule. In addition, we are proposing that 

if OPM releases revised COLA factors before publication of the final rule, we would use the 

revised factors for the development of LTCH PPS payments for FY 2011 and publish those 

revised COLA factors in the final rule. 

Proposed Cost-of-Living Adjustment Factors for Alaska and Hawaii Hospitals for the 

LTCH PPS for FY 2011 

Alaska:

 City of Anchorage and 80-kilometer (50-mile) radius by road 1.23

 City of Fairbanks and 80-kilometer (50-mile) radius by road 1.23

 City of Juneau and 80-kilometer (50-mile) radius by road 1.23

 All other areas of Alaska 1.25

Hawaii:

 City and County of Honolulu 1.25

County of Hawaii 1.18

 County of Kauai 1.25

 County of Maui and County of Kalawao 1.25
CMS-1498-P 795 

C. Proposed Adjustment for LTCH PPS High-Cost Outlier (HCO) Cases 

1. Background 

 Under the broad authority conferred upon the Secretary by section 123 of the BBRA as 

amended by section 307(b) of BIPA, in the regulations at §412.525(a), we established an 

adjustment for additional payments for outlier cases that have extraordinarily high costs relative 

to the costs of most discharges. We refer to these cases as high cost outliers (HCOs). Providing 

additional payments for outliers strongly improves the accuracy of the LTCH PPS in determining 

resource costs at the patient and hospital level. These additional payments reduce the financial 

losses that would otherwise be incurred when treating patients who require more costly care and, 

therefore, reduce the incentives to underserve these patients. We set the outlier threshold before 

the beginning of the applicable rate year so that total estimated outlier payments are projected to 

equal 8 percent of total estimated payments under the LTCH PPS. 

 Under §412.525(a) in the regulations (in conjunction with §412.503), we make outlier 

payments for any discharges if the estimated cost of a case exceeds the adjusted LTCH PPS 

payment for the MS-LTC-DRG plus a fixed-loss amount. Specifically, in accordance with 

§412.525(a)(3) (in conjunction with §412.503), we pay outlier cases 80 percent of the difference 

between the estimated cost of the patient case and the outlier threshold, which is the sum of the 

adjusted Federal prospective payment for the MS-LTC-DRG and the fixed-loss amount. The 

fixed-loss amount is the amount used to limit the loss that a hospital will incur under the outlier 

policy for a case with unusually high costs. This results in Medicare and the LTCH sharing 

financial risk in the treatment of extraordinarily costly cases. Under the LTCH PPS HCO policy, 

the LTCH's loss is limited to the fixed-loss amount and a fixed percentage of costs above the 

outlier threshold (MS-LTC-DRG payment plus the fixed-loss amount). The fixed percentage of 
CMS-1498-P 796 

costs is called the marginal cost factor. We calculate the estimated cost of a case by multiplying 

the Medicare allowable covered charge by the hospital’s overall hospital cost-to-charge ratio 

(CCR). 

 Under the LTCH PPS, we determine a fixed-loss amount, that is, the maximum loss that a 

LTCH can incur under the LTCH PPS for a case with unusually high costs before the LTCH will 

receive any additional payments. We calculate the fixed-loss amount by estimating aggregate 

payments with and without an outlier policy. The fixed-loss amount results in estimated total 

outlier payments being projected to be equal to 8 percent of projected total LTCH PPS payments. 

Currently, MedPAR claims data and CCRs based on data from the most recent provider specific 

file (PSF) (or from the applicable statewide average CCR if a LTCH's CCR data are faulty or 

unavailable) are used to establish a fixed-loss threshold amount under the LTCH PPS. 

2. Determining LTCH CCRs under the LTCH PPS 

a. Background 

 The following is a discussion of CCRs that are used in determining payments for HCO 

and SSO cases under the LTCH PPS, at §412.525(a) and §412.529, respectively. Although this 

section is specific to HCO cases, because CCRs and the policies and methodologies pertaining to 

them are used in determining payments for both HCO and SSO cases (to determine the estimated 

cost of the case at §412.529(d)(2)), we are discussing the determination of CCRs under the 

LTCH PPS for both of these types of cases simultaneously. 

 In determining both HCO payments (at §412.525(a)) and SSO payments (at §412.529), 

we calculate the estimated cost of the case by multiplying the LTCH's overall CCR by the 

Medicare allowable charges for the case. In general, we use the LTCH's overall CCR, which is 

computed based on either the most recently settled cost report or the most recent tentatively 
CMS-1498-P 797 

settled cost report, whichever is from the latest cost reporting period, in accordance with 

§412.525(a)(4)(iv)(B) and §412.529(f)(4)(ii) for HCOs and SSOs, respectively. (We note that, 

in some instances, we use an alternative CCR, such as the statewide average CCR in accordance 

with the regulations at §412.525(a)(4)(iv)(C) and §412.529(f)(4)(iii), or a CCR that is specified 

by CMS or that is requested by the hospital under the provisions of the regulations at 

§412.525(a)(4)(iv)(A) and §412.529(f)(4)(i).) Under the LTCH PPS, a single prospective 

payment per discharge is made for both inpatient operating and capital-related costs. Therefore, 

we compute a single "overall" or "total" LTCH-specific CCR based on the sum of LTCH 

operating and capital costs (as described in Section 150.24, Chapter 3, of the Medicare Claims 

Processing Manual (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). 

b. LTCH Total CCR Ceiling 

 Generally, 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). This is because CCRs above this threshold are most likely due to 

faulty data reporting or entry, and, therefore, CCRs based on erroneous data should not be used 

to identify and make payments for outlier cases. Thus, under our established policy, generally, 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. 
CMS-1498-P 798 

 In the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 44027), in accordance with 

§412.525(a)(4)(iv)(C)(2) for HCOs and §412.529(f)(4)(iii)(B) for SSOs, using our established 

methodology for determining the LTCH total CCR ceiling, based on IPPS total CCR data from 

the March 2009 update of the Provider Specific File (PSF), we established a total CCR ceiling of 

1.232 under the LTCH PPS, effective October 1, 2009, through September 30, 2010. (For 

further detail on our current methodology for annually determining the LTCH total CCR ceiling, 

we refer readers to the FY 2007 IPPS final rule (71 FR 48119 through 48121).) 

In this proposed rule, in accordance with §412.525(a)(4)(iv)(C)(2) for HCOs and 

§412.529(f)(4)(iii)(B) for SSOs, using our established methodology for determining the LTCH 

total CCR ceiling (described above), based on IPPS total CCR data from the December 2009 

update of the PSF, we are proposing to establish a total CCR ceiling of 1.230 under the LTCH 

PPS that would be effective for discharges occurring on or after October 1, 2010, through 

September 30, 2011. 

c. LTCH Statewide Average CCRs 

Our general methodology established for determining the statewide average CCRs used 

under the LTCH PPS is similar to our established methodology for determining the LTCH total 

CCR ceiling (described above) because it is based on "total" IPPS CCR data. Under the LTCH 

PPS HCO policy at §412.525(a)(4)(iv)(C) and the SSO policy at §412.529(f)(4)(iii), the fiscal 

intermediary 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 circumstances: (1) 

new LTCHs that have not yet submitted their first Medicare cost report (for this purpose, 

consistent with current policy, 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 
CMS-1498-P 799 

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 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.) 

In Table 8C of the Addendum to the FY 2010 IPPS/RY 2010 LTCH PPS final rule 

(74 FR 44160 through 44161), in accordance with the regulations at §412.525(a)(4)(iv)(C) for 

HCOs and §412.529(f)(4)(iii) for SSOs, using our established methodology for determining the 

LTCH statewide average CCRs, based on using the most recent complete IPPS total CCR data 

from the March 2009 update of the PSF, we established the LTCH PPS statewide average total 

CCRs for urban and rural hospitals effective for discharges occurring on or after October 1, 

2009, through September 30, 2010. (For further detail on our current methodology for annually 

determining the LTCH statewide average CCRs, we refer readers to the FY 2007 IPPS final rule 

(71 FR 48119 through 48121).) 

In this proposed rule, using our established methodology for determining the LTCH 

statewide average CCRs, based on the most recent complete IPPS total CCR data from the 

December 2009 update of the PSF, we are proposing to establish LTCH PPS statewide average 

total CCRs for urban and rural hospitals that would be effective for discharges occurring on or 

after October 1, 2010, through September 30, 2011, in Table 8C of the Addendum to this 

proposed rule. 
CMS-1498-P 800 

We also note that all areas in the District of Columbia, New Jersey, Puerto Rico, and 

Rhode Island are classified as urban; therefore, there are no rural statewide average total CCRs 

listed for those jurisdictions in Table 8C of the Addendum to this proposed rule. This policy is 

consistent with the policy that 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 is the same as the policy applied under the IPPS. In addition, 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 2009. Therefore, for this proposed 

rule, there is no rural statewide average total CCR listed for rural Massachusetts in Table 8C of 

the Addendum of this proposed rule. 

In addition, 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 48120 through 

48121), in determining the urban and rural statewide average total CCRs for Maryland LTCHs 

paid under the LTCH PPS, in this proposed rule, we use, 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 PSF for Maryland 

hospitals may not be entirely accurate (as discussed in greater detail in that same final rule 

(71 FR 48120)). 

d. Reconciliation of LTCH HCO and SSO Payments 

We note that under the LTCH PPS HCO policy at §412.525(a)(4)(iv)(D) and the LTCH 

PPS SSO policy at §412.529(f)(4)(iv), the payments for HCO and SSO cases, respectively, are 

subject to reconciliation. Specifically, any reconciliation of outlier payments is based on the 

CCR that is calculated based on a ratio of CCRs computed from the relevant cost report and 
CMS-1498-P 801 

charge data determined at the time the cost report coinciding with the discharge is settled. For 

additional information, we refer readers to the RY 2009 LTCH PPS final rule (73 FR 26820 

through 26821). 

3. Establishment of the Proposed LTCH PPS Fixed-Loss Amount for FY 2011 

 When we implemented the LTCH PPS, as discussed in the August 30, 2002 LTCH PPS 

final rule (67 FR 56022 through 56026), under the broad authority of section 123 of the BBRA 

as amended by section 307(b) of BIPA, we established a fixed-loss amount so that total 

estimated outlier payments are projected to equal 8 percent of total estimated payments under the 

LTCH PPS. To determine the fixed-loss amount, we estimate outlier payments and total LTCH 

PPS payments for each case using claims data from the MedPAR files. Specifically, to 

determine the outlier payment for each case, we estimate the cost of the case by multiplying the 

Medicare covered charges from the claim by the applicable CCR. Under §412.525(a)(3) (in 

conjunction with §412.503), if the estimated cost of the case exceeds the outlier threshold (the 

sum of the adjusted Federal prospective payment for the MS-LTC-DRG and the fixed-loss 

amount), we pay an outlier payment equal to 80 percent of the difference between the estimated 

cost of the case and the outlier threshold (the sum of the adjusted Federal prospective payment 

for the MS-LTC-DRG and the fixed-loss amount). 

In the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 44028), we used our existing 

methodology to calculate the fixed-loss amount for RY 2010 in order to maintain estimated 

HCO payments at the projected 8 percent of total estimated LTCH PPS payments. Specifically, 

we used LTCH claims data from the March 2009 update of the FY 2008 MedPAR files and 

CCRs from the March 2009 update of the PSF to determine a fixed-loss amount that would result 

in estimated outlier payments projected to be equal to 8 percent of total estimated payments in 
CMS-1498-P 802 

RY 2010 because those data were the most recent complete LTCH data available at that time. In 

that same final rule, we established a fixed-loss amount of $18,425 for RY 2010. 

 In this proposed rule, we are proposing to continue to use our existing methodology to 

calculate the proposed fixed-loss amount for FY 2011 (based on updated data and the proposed 

rates and policies presented in this proposed rule) in order to maintain estimated HCO payments 

at the projected 8 percent of total estimated LTCH PPS payments. (For an explanation of our 

rationale for establishing an HCO payment “target” of 8 percent of total estimated LTCH 

payments, we refer readers to the August 30, 2002 LTCH PPS final rule (67 FR 56022 through 

56024).) Consistent with our historical practice of using the best data available, in determining 

the proposed fixed-loss amount for FY 2011, we use the most recent available LTCH claims data 

and CCR data. Specifically, for this proposed rule, we used LTCH claims data from the 

December 2009 update of the FY 2009 MedPAR files and CCRs from the December 2009 

update of the PSF to determine a fixed-loss amount that would result in estimated outlier 

payments projected to be equal to 8 percent of total estimated payments in FY 2011 because 

these data are the most recent complete LTCH data currently available. Consistent with the 

historical practice of using the best available data, we are proposing that if more recent LTCH 

claims data become available, we will use them for determining the fixed-loss amount for 

FY 2011 in the final rule. Furthermore, we are proposing to determine the proposed FY 2011 

fixed-loss amount based on the MS-LTC-DRG classifications and relative weights from the 

version of the GROUPER that will be in effect as of the beginning of FY 2011, that is, proposed 

Version 28.0 of the GROUPER (discussed in section VII.B. of the preamble of this proposed 

rule). 
CMS-1498-P 803 

In this proposed rule, under the broad authority of section 123(a)(1) of the BBRA and 

section 307(b)(1) of BIPA, we are proposing to establish a fixed-loss amount of $18,692 for 

FY 2011. Thus, we would pay an outlier case 80 percent of the difference between the estimated 

cost of the case and the outlier threshold (the sum of the adjusted Federal LTCH payment for the 

MS-LTC-DRG and the fixed-loss amount of $18,692). 

 The proposed fixed-loss amount for FY 2011 of $18,692 is slightly higher than the 

RY 2010 fixed-loss amount of $18,425. Based on our payment simulations using the most 

recent available data, the proposed slight increase in the fixed-loss amount for FY 2011 would be 

necessary to maintain the existing requirement that estimated outlier payments would equal 8 

percent of estimated total LTCH PPS payments. (For further information on the existing 8 

percent HCO “target” requirement, we refer readers to the August 30, 2002 LTCH PPS final rule 

(67 FR 56022 through 56024.) Maintaining the fixed-loss amount at the current level would 

result in HCO payments that are greater than the current regulatory requirement 8 percent 

requirement because a higher fixed-loss amount would result in fewer cases qualifying as outlier 

cases as well as decreases the amount of the additional payment for a HCO case because the 

maximum loss that a LTCH must incur before receiving an HCO payment (that is, the fixed-loss 

amount) would be larger. For these reasons, we believe that proposing to raise the fixed-loss 

amount is appropriate and necessary to maintain that estimated outlier payments would equal 8 

percent of estimated total LTCH PPS payments as required under §412.525(a). 

4. Application of Outlier Policy to SSO Cases 

As we discussed in the August 30, 2002 final rule (67 FR 56026), under some rare 

circumstances, a LTCH discharge could qualify as a SSO case (as defined in the regulations at 

§412.529 in conjunction with §412.503) and also as a HCO case. In this scenario, a patient 
CMS-1498-P 804 

could be hospitalized for less than five-sixths of the geometric average length of stay for the 

specific MS-LTC-DRG, and yet incur extraordinarily high treatment costs. If the costs exceeded 

the HCO threshold (that is, the SSO payment plus the fixed-loss amount), the discharge is 

eligible for payment as a HCO. Thus, for a SSO case in FY 2011, the HCO payment would be 

80 percent of the difference between the estimated cost of the case and the outlier threshold (the 

sum of the proposed fixed-loss amount of $18,692 and the amount paid under the SSO policy as 

specified in §412.529). 

D. Computing the Proposed Adjusted LTCH PPS Federal Prospective Payments for FY 2011

 In accordance with §412.525, the proposed standard Federal rate is adjusted to account 

for differences in area wages by multiplying the proposed labor-related share of the proposed 

standard Federal rate by the appropriate proposed LTCH PPS wage index (as shown in Tables 

12A and 12B of the Addendum of this proposed rule). The proposed standard Federal rate is 

also adjusted to account for the higher costs of hospitals in Alaska and Hawaii by multiplying the 

proposed nonlabor-related share of the proposed standard Federal rate by the appropriate 

cost-of-living factor (shown in the chart in section V.C.5. of the Addendum of this proposed 

rule). In this proposed rule, we are proposing to establish a standard Federal rate for FY 2011 of 

$39,856.75, as discussed in section V.A.2. of the Addendum of this proposed rule. We illustrate 

the methodology to adjust the proposed LTCH PPS Federal rate for FY 2011 in the following 

example: 

Example:

During FY 2011, a Medicare patient is in a LTCH located in Chicago, Illinois (CBSA 

16974). The proposed FY 2011 LTCH PPS wage index value for CBSA 16974 is 1.0573 

(Table 12A of the Addendum of this proposed rule). The Medicare patient is classified into MS-
CMS-1498-P 805 

LTC-DRG 28 (Spinal Procedures with MCC), which has a proposed relative weight for FY 2011 

of 1.0834 (Table 11 of the Addendum of this proposed rule). 

To calculate the LTCH's total adjusted Federal prospective payment for this Medicare 

patient, we compute the wage-adjusted proposed Federal prospective payment amount by 

multiplying the unadjusted proposed standard Federal rate ($39,856.75) by the proposed 

labor-related share (75.407 percent) and the proposed wage index value (1.0573). This 

wage-adjusted amount is then added to the proposed nonlabor-related portion of the unadjusted 

proposed standard Federal rate (24.593 percent; adjusted for cost of living, if applicable) to 

determine the adjusted proposed Federal rate, which is then multiplied by the proposed MSLTC-DRG relative weight (1.0834) to calculate the total adjusted proposed Federal LTCH PPS 

prospective payment for FY 2011 ($45,046.57). The table below illustrates the components of 

the calculations in this example. 

Unadjusted Proposed Standard Federal Prospective 

Payment Rate $39,856.75

Proposed Labor-Related Share x 0.75407 

Labor-Related Portion of the Proposed Federal Rate = $30,054.78

Proposed Wage Index (CBSA 16974) x 1.0573

Proposed Wage-Adjusted Labor Share of Federal Rate = $31,776.92

Proposed Nonlabor-Related Portion of the Federal Rate 

($39,856.75 x 0.24593) + $9,801.97 

Adjusted Proposed Federal Rate Amount = $41,578.89

Proposed MS-LTC-DRG 28 Relative Weight x 1.0834 

Total Adjusted Federal Prospective Payment = $45,046.57

VI. Tables 

 This section contains the tables referred to throughout the preamble to this proposed rule 

and in this Addendum. Tables 1A, 1B, 1C, 1D, 1E, 2, 3A, 3B, 4A, 4B, 4C, 4D-1, 4D-2, 4E, 4F, 
CMS-1498-P 806 

4J, 5, 7A, 7B, 8A, 8B, 8C, 9A, 9C, 10, 11, 12A, and 12B are presented below. Table 6G.—

Additions to the CC Exclusions List, Table 6H.—Deletions from the CC Exclusions List, Table 

6I.—Complete List of Complication and Comorbidity (CC) Exclusions, Table 6J.—Major 

Complication and Comorbidity (MCC) List, and Table 6K.—Complications and Comorbidity 

(CC) List are available only through the Internet on the CMS Web site at: 

http://www.cms.hhs.gov/AcuteInpatientPPS/. 

 We note that, because of the provisions of Pub. L. 111-148, as amended, that affect our 

proposed policies and payment rates for FY 2011 under the IPPS and the LTCH PPS, as well as 

the provisions of Pub. L. 111-148, as amended, that affect the policies and payment rates for 

FY 2010 under the IPPS and for RY 2010 under the LTCH PPS, tables 1A, 1B, 1C, 1D, 1E, 2, 

4A, 4B, 4C, 4D-1, 4D-2, 4J, 9A, 10, and 11 will need to be updated to reflect these provisions. 

We plan to issue separate documents in the Federal Register and instructions to address these 

changes and to issue new tables that reflect these provisions. 

 The tables presented below are as follows: 

Table 1A.—Proposed National Adjusted Operating Standardized Amounts, 

 Labor/Nonlabor (68.8 Percent Labor Share/31.2 Percent Nonlabor Share 

 If Wage Index Is Greater Than 1) 

Table 1B.—Proposed 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.—Proposed Adjusted Operating Standardized Amounts for Puerto Rico, 

 Labor/Nonlabor 

Table 1D.—Proposed Capital Standard Federal Payment Rate 
CMS-1498-P 807 

Table 1E.—Proposed LTCH Standard Federal Prospective Payment Rate 

Table 2.—Acute Care Hospitals Case-Mix Indexes for Discharges Occurring in Federal Fiscal 

Year 2009; Proposed Hospital Wage Indexes for Federal Fiscal Year 2011; Hospital 

Average Hourly Wages for Federal Fiscal Years 2009 (2005 Wage Data), 2010 (2006 

Wage Data), and 2011 (2007 Wage Data); and 3-Year Average of Hospital Average 

Hourly Wages 

Table 3A.—FY 2011 and 3-Year Average Hourly Wage for Acute Care Hospitals in Urban 

Areas by CBSA 

Table 3B.--FY 2011 and 3-Year Average Hourly Wage for Acute Care Hospitals in Rural Areas 

by CBSA 

Table 4A.—Proposed Wage Index and Capital Geographic Adjustment Factor (GAF) for Acute 

Care Hospitals in Urban Areas by CBSA and by State--FY 2011 

Table 4B.—Proposed Wage Index and Capital Geographic Adjustment Factor (GAF) for Acute 

Care Hospitals in Rural Areas by CBSA and by State--FY 2011 

Table 4C.—Proposed Wage Index and Capital Geographic Adjustment Factor (GAF) for Acute 

Care Hospitals That Are Reclassified by CBSA and by State--FY 2011 

Table 4D-1.—Proposed Rural Floor Budget Neutrality Factors for Acute Care Hospitals—

FY 2011 

Table 4D-2.--Urban Areas with Acute Care Hospitals Receiving the Statewide Rural Floor or 

Imputed Floor Wage Index--FY 2011 

Table 4E.—Urban CBSAs and Constituent Counties for Acute Care Hospitals--FY 2011 

Table 4F.—Proposed Puerto Rico Wage Index and Capital Geographic Adjustment Factor 

(GAF) for Acute Care Hospitals by CBSA--FY 2011 
CMS-1498-P 808 

Table 4J.—Proposed Out-Migration Adjustment for Acute Care Hospitals--FY 2011 

Table 5.--List of 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 7A.--Medicare Prospective Payment System Selected Percentile Lengths of Stay: 

FY 2009 MedPAR Update—December 2009 GROUPER V27.0 MS-DRGs 

Table 7B.--Medicare Prospective Payment System Selected Percentile Lengths of Stay: 

FY 2009 MedPAR Update—December 2009 GROUPER V28.0 MS-DRGs 

Table 8A.—Proposed Statewide Average Operating Cost-to-Charge Ratios (CCRs) for Acute 

Care Hospitals—March 2009 

Table 8B.—Proposed Statewide Average Capital Cost-to-Charge Ratios (CCRs) for Acute Care 

Hospitals—March 2009 

Table 8C.—Proposed Statewide Average Total Cost-to-Charge Ratios (CCRs) for 

LTCHs--March 2009 

Table 9A.--Hospital Reclassifications and Redesignations--FY 2011 

Table 9C.--Hospitals Redesignated as Rural under Section 1886(d)(8)(E) of the Act--FY 2011 

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 
CMS-1498-P 809 

Charges) or .75 of One Standard Deviation of Mean Charges by Medicare Severity 

Diagnosis-Related Group (MS-DRG) --March 2009 

Table 11.—Proposed MS-LTC-DRGs, Relative Weights, Geometric Average Length of Stay, 

and Short-Stay Outlier (SSO) Threshold for Discharges Occurring from October 1, 2010 

through September 30, 2011 under the LTCH PPS 

Table 12A.—Proposed LTCH PPS Wage Index for Urban Areas for Discharges Occurring from 

October 1, 2010 through September 30, 2011 

Table 12B.—Proposed LTCH PPS Wage Index for Rural Areas for Discharges Occurring From 

October 1, 2010 through September 20, 2011 

TABLE 1A.—PROPOSED NATIONAL ADJUSTED OPERATING STANDARDIZED 

AMOUNTS, LABOR/NONLABOR (68.8 PERCENT LABOR SHARE/31.2 PERCENT 

NONLABOR SHARE IF WAGE INDEX IS GREATER THAN 1) 

Full Update (2.4 Percent) Reduced Update (0.4 Percent) 

Labor-related Nonlabor-related Labor-related Nonlabor-related 

$3,566.91 $1,617.55 $3,497.24 $1,585.96

TABLE 1B.—PROPOSED 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)

Full Update (2.4 Percent) Reduced Update (0.4 Percent) 

Labor-related Nonlabor-related Labor-related Nonlabor-related

$3,214.37 $1,970.09 $3,151.58 $1,931.62
CMS-1498-P 810 

TABLE 1C.—PROPODSED ADJUSTED OPERATING STANDARDIZED AMOUNTS 

FOR PUERTO RICO, LABOR/NONLABOR 

Rates if Wage Index is 

Greater Than 1 

Rates if Wage Index is Less 

Than or Equal to 1 

Labor Nonlabor Labor Nonlabor 

National $3,566.91 $1,617.55 $3,214.37 1,970.09

Puerto Rico $1,530.25 $933.92 $1,527.79 $936.38

TABLE 1D.—PROPOSED CAPITAL STANDARD FEDERAL PAYMENT RATE 

Rate 

National $420.99

Puerto Rico $199.43

TABLE 1E.—PROPOSED LTCH STANDARD FEDERAL PROSPECTIVE PAYMENT 

RATE 

Rate 

Standard Federal Rate $39,856.75
CMS-1498-P 811 

TABLE 2.--HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN 

FEDERAL FISCAL YEAR 2009; PROPOSED HOSPITAL WAGE INDEXES FOR 

FEDERAL FISCAL YEAR 2011; HOSPITAL AVERAGE HOURLY WAGES FOR 

FEDERAL FISCAL YEARS 2009 (2005 WAGE DATA), 2010 (2006 WAGE DATA), AND 

2011 (2007 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE 

HOURLY WAGES 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

010001 1.6908 0.8539 25.0592 24.8712 27.6011 25.8542

010005 1.2841 0.8427 25.7771 24.9052 26.7660 25.7876

010006 1.4782 0.8028 25.1401 26.7013 27.1899 26.3024

010007 1.0377 0.7448 22.0185 20.0565 21.0524 21.0330

010008 1.1123 0.7622 23.2572 22.8443 24.6733 23.5882

010009 0.9990 0.8646 25.8420 26.1396 27.7497 26.5428

010010 1.2246 0.7744 24.8390 26.2416 27.1969 26.0938

010011 1.5830 0.8614 27.1997 28.6140 33.0361 29.6023

010012 1.1634 0.7634 26.4989 24.8944 25.4141 25.5688

010015 0.9011 0.7494 23.6821 22.9857 22.2077 22.9349

010016 1.5802 0.8614 28.9724 28.7392 30.3170 29.3596

010018 1.1555 0.8614 26.9514 26.7633 28.8087 27.5186

010019 1.3603 0.8028 25.0170 26.0567 29.0622 26.7038

010021 1.3329 0.7571 21.7601 24.3385 25.0343 23.6912

010022 0.9217 0.9563 28.7529 26.5348 30.6579 28.6538

010023 1.7864 0.8506 28.2135 30.0684 31.4256 29.9233

010024 1.6738 0.8506 26.6636 28.1766 29.2979 28.1013

010025 1.4344 0.8613 23.8617 20.1873 29.5803 23.9653

010027 0.7496 0.7510 18.2508 19.7740 22.3038 20.2061

010029 1.6510 0.8613 24.3622 28.3184 26.2864 26.2272

010032 0.8693 0.7773 20.8458 24.7706 22.5607 22.8612

010033 2.2117 0.8614 29.2036 29.3762 30.8243 29.8385

010034 1.1730 0.8506 21.3728 21.0565 23.7513 22.0213

010035 1.3475 0.8427 26.5299 28.0534 28.4993 27.6832

010036 1.1875 0.7448 23.3876 25.0011 25.7199 24.7026

010038 1.3776 0.7945 28.9646 29.7948 32.5231 30.4750

010039 1.8330 0.8994 29.8034 30.6619 31.7063 30.7533

010040 1.6522 0.7561 25.9856 25.2840 27.2842 26.1688

010043 1.2776 0.8614 25.3633 27.3636 26.3517 26.3192

010044 1.0295 0.7448 23.4020 27.3403 28.2131 26.2653

010045 1.0535 0.7670 24.2450 25.1108 27.0851 25.4649
CMS-1498-P 812 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

010046 1.5582 0.8427 25.4465 33.3112 21.9429 26.0994

010047 0.8765 0.7575 21.7349 17.0984 24.5251 21.0332

010049 1.0744 0.7510 23.1194 25.4446 27.0625 25.1500

010050 1.0266 0.8614 25.3678 27.0365 29.5491 27.2877

010051 0.8615 0.8225 20.0765 21.4140 20.9159 20.8071

010052 0.9419 0.8506 22.7571 22.1386 21.8148 22.2484

010054 1.0674 0.8646 25.4209 24.6126 24.5639 24.8520

010055 1.5928 0.8002 25.3306 26.4706 26.7456 26.1757

010056 1.6143 0.8614 25.7290 28.5668 31.1851 28.4494

010058 0.9816 0.8614 31.1865 23.6860 24.6105 25.8253

010059 1.0664 0.8646 27.8613 29.5434 26.7428 27.9872

010061 0.9602 0.8594 25.7048 26.5035 26.1463 26.1214

010062 1.0748 0.7743 22.9491 20.8224 23.0559 22.2543

010064 1.6120 0.8614 26.6333 * 23.3954 24.8292

010065 1.4982 0.8427 24.4454 25.9433 27.7120 26.0207

010066 0.8151 0.7448 25.6052 25.9301 26.7367 26.0555

010069 0.9679 0.7448 27.3438 29.4662 25.8964 27.5684

010073 0.9744 0.7448 20.7833 19.9743 21.0063 20.5785

010078 1.7376 0.7945 25.2897 24.5429 26.5654 25.4734

010079 1.3594 0.8994 23.1025 25.4118 27.2463 25.2397

010083 1.1948 0.7899 25.0422 25.2405 25.2017 25.1655

010084 *** * 27.5069 * * 27.5069

010085 1.4769 0.8646 24.0475 25.6072 26.5909 25.3882

010086 1.1077 0.7448 26.9753 24.9468 27.4146 26.3789

010087 2.4471 0.7899 27.4929 27.2725 26.8954 27.1988

010089 1.3862 0.8614 25.9719 26.9357 27.9079 26.8958

010090 1.8308 0.7899 25.6110 26.8029 28.3744 26.9471

010091 0.8685 0.7494 23.6555 27.8571 25.1201 25.3701

010092 1.5529 0.8225 28.8433 30.3263 28.7948 29.3311

010095 0.7991 0.8225 17.8248 21.6551 23.5564 21.0352

010097 0.8060 0.8506 18.4218 19.5147 21.2996 19.7766

010099 0.9382 0.7448 22.3686 20.8632 23.5835 22.2682

010100 1.7378 0.8144 25.4357 25.8178 26.8181 26.0446

010101 1.1605 0.8427 26.2744 25.0955 26.5747 25.9872

010102 0.9608 0.8506 26.6943 22.6883 22.4398 23.9594

010103 1.9636 0.8614 30.4032 27.9049 29.7010 29.3261

010104 1.6984 0.8614 30.4963 29.1001 30.1353 29.9264
CMS-1498-P 813 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

010108 1.0545 0.8506 26.8900 27.7601 29.5101 28.1758

010109 1.0134 0.7757 21.9300 19.3990 23.0918 21.4719

010110 0.8328 0.7663 22.1175 17.9438 25.5691 21.8242

010112 0.9041 0.7448 21.3904 22.0927 20.9602 21.4581

010113 1.6548 0.7899 25.0704 25.7852 28.0528 26.3173

010114 1.5070 0.8614 25.3666 25.8015 25.6005 25.5885

010118 1.3294 0.8015 25.3689 25.7663 27.7362 26.2760

010120 0.9119 0.7448 22.8177 22.0809 * 22.4473

010125 1.1026 0.7924 23.6549 24.1942 25.4328 24.3975

010126 1.0242 0.8506 25.7254 28.8995 27.0770 27.1824

010128 0.9834 0.7494 25.9421 25.1022 25.7453 25.6021

010129 1.1598 0.7582 24.4816 25.2104 27.6767 25.7944

010130 1.0145 0.8614 25.2790 23.8895 31.2319 26.5261

010131 1.4270 0.8994 28.0487 28.6759 32.2481 29.7152

010137 1.5361 0.8614 30.4361 30.7312 33.4983 31.5313

010138 0.6398 0.7514 15.0815 16.7541 16.6144 16.1902

010139 1.6830 0.8614 29.3560 29.3626 30.7489 29.8142

010143 1.1691 0.8646 25.0871 25.1522 25.9745 25.3833

010144 1.7207 0.7899 23.8601 25.4614 26.4008 25.1949

010145 1.5795 0.8225 27.3296 30.2093 29.5558 29.0313

010146 0.9412 0.7945 23.8076 24.6572 25.2484 24.5514

010148 0.9563 0.7448 25.0960 24.8409 24.3699 24.7693

010149 1.3663 0.8506 26.8920 28.1328 29.5254 28.2683

010150 1.0187 0.7575 25.0070 26.3342 25.9401 25.7372

010152 1.3718 0.7899 26.0793 23.0248 26.8322 25.2347

010157 1.1568 0.8028 27.1793 27.5674 27.3487 27.3636

010158 1.3394 0.7583 26.2363 26.8821 27.7665 26.9653

010164 1.1777 0.8427 25.6759 24.4625 23.9304 24.6859

010167 1.5767 0.8614 * 24.7643 29.1631 26.8653

010168 1.6115 0.9111 * 30.2040 27.0185 28.8600

010169 1.0410 * * * * *

020001 1.8974 1.1919 38.1784 39.2651 40.8325 39.4363

020006 1.3723 1.1919 37.2853 40.5422 42.4838 40.2757

020008 1.2207 1.1919 40.6783 42.8075 44.8291 42.8366

020012 1.4672 1.1919 36.1911 37.0181 38.4880 37.2462

020014 *** * 30.6343 * * 30.6343

020017 2.2168 1.1919 38.2157 41.2448 42.1762 40.5573
CMS-1498-P 814 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

020018 0.9117 1.8246 * * * *

020024 1.1323 1.1919 39.9943 35.9358 43.5298 39.9069

020026 1.5829 1.8246 * * * *

020027 0.8544 1.8246 * * * *

020028 *** * * * 42.1568 42.1568

030001 1.5123 1.0519 35.9083 38.1204 36.9465 37.0095

030002 2.1395 1.0519 32.9094 34.2998 35.5406 34.2817

030006 1.7866 0.9692 29.1248 32.1646 32.4565 31.2997

030007 1.5010 1.2318 35.5226 38.1199 40.1726 38.0212

030010 1.6899 0.9692 31.8640 33.3049 33.9522 33.0660

030011 1.6799 0.9692 30.2096 31.8532 32.9183 31.7320

030012 1.6785 1.2318 31.3068 33.4818 50.8525 36.5891

030013 1.5846 0.9455 31.9162 31.1767 33.0103 32.0532

030014 1.6003 1.0519 30.6308 31.8529 33.7100 32.1295

030016 1.3364 1.0519 31.1878 30.6196 34.0540 31.8987

030017 *** * 34.8488 34.9499 37.4893 35.7433

030018 *** * 31.7240 34.2870 35.7209 33.8731

030019 *** * 33.6553 36.3298 36.3760 35.4444

030022 1.6387 1.0519 35.0772 34.3377 34.4050 34.5355

030023 2.0211 1.2457 37.5523 41.8098 43.4901 40.9837

030024 2.1783 1.0519 35.3556 38.5575 40.6081 38.3107

030030 1.6996 1.0519 36.4772 38.9056 37.5980 37.7197

030033 1.3578 1.0519 32.0362 33.9716 35.7840 33.9594

030036 1.6971 1.0519 35.7464 37.1271 40.4842 37.7767

030037 1.9779 1.0519 35.1342 35.8129 37.1935 36.2152

030038 1.6840 1.0519 31.2928 33.8052 36.9266 34.1148

030043 1.3149 0.9120 28.3158 29.0816 31.0593 29.4840

030055 1.5838 1.0287 31.0806 37.2632 37.4315 35.3174

030061 1.7125 1.0519 33.0847 34.2000 35.3864 34.2660

030062 1.4495 0.9120 29.9359 30.3859 33.1874 31.2110

030064 2.1061 0.9692 31.6632 33.1535 35.0230 33.3240

030065 1.8343 1.0519 31.4602 33.8941 36.2534 33.8318

030067 1.0416 0.9418 27.0784 27.4410 31.2478 28.5865

030068 1.1142 0.9120 26.0296 26.8369 28.7966 27.2639

030069 1.5878 1.1429 30.7723 35.1793 35.6421 33.9927

030071 1.0518 1.4448 * * * *

030073 1.2775 1.4448 * * * *
CMS-1498-P 815 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

030074 0.9561 1.4448 * * * *

030077 0.9180 1.4448 * * * *

030078 1.2123 1.4448 * * * *

030080 *** * 30.7682 34.2723 * 32.4902

030083 1.5477 1.0519 35.8521 39.0888 39.9707 38.3254

030084 1.0830 1.4448 * * * *

030085 1.6913 0.9692 29.0774 30.7160 33.4062 31.0315

030087 1.7697 1.0519 31.1094 33.0362 37.2751 33.9611

030088 1.4335 1.0519 30.5738 33.5408 34.6877 33.0355

030089 1.7404 1.0519 31.3179 32.8874 34.7343 33.0017

030092 1.6022 1.0519 30.4394 31.6471 33.8309 32.0855

030093 1.4573 1.0519 33.0720 33.5029 34.3015 33.6746

030094 1.6808 1.0519 34.2040 35.9213 36.9133 35.7448

030099 0.7231 * 24.9127 * * 24.9127

030100 2.2953 0.9692 35.0981 36.9783 39.5385 37.2928

030101 1.4411 1.1811 33.2139 34.1060 33.6260 33.6535

030102 2.8130 1.0519 36.9539 39.4617 36.4149 37.5421

030103 1.8002 1.0519 34.2770 41.6469 41.1210 39.1558

030105 2.2878 1.0519 33.9875 37.6952 38.6741 36.8267

030106 *** * 40.1657 43.9022 * 41.9807

030107 2.1093 1.0519 35.4562 35.9171 37.6288 36.3377

030108 2.4034 1.0519 34.8507 33.2799 34.5124 34.1536

030110 1.7329 1.0519 36.2158 38.0468 39.0340 37.8801

030111 1.1668 0.9692 28.5146 33.3314 37.0123 33.6486

030112 2.0671 1.0519 33.4810 36.1513 40.1301 36.8711

030113 0.9505 1.4448 * * * *

030114 1.4510 0.9692 28.8466 30.2128 30.3754 29.8451

030115 1.5083 1.0519 32.5885 34.8409 36.8225 35.0086

030117 1.3318 1.0287 * 34.5349 36.6725 35.7305

030118 1.3327 1.2318 * 28.2945 32.6116 30.4114

030119 1.6200 1.0519 * 38.2362 40.7172 39.6384

030120 0.8520 1.0519 * 39.7676 47.5037 43.8726

030121 1.6902 1.0519 * * 36.6999 36.6999

030122 1.4640 1.0519 * * 35.1781 35.1781

030123 1.4739 1.0519 * * * *

030124 1.8948 1.0519 * * * *

030125 2.0742 1.0519 * * * *
CMS-1498-P 816 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

030126 1.8635 1.0519 * * * *

040001 1.0932 0.8648 24.4962 25.0147 25.5841 25.0463

040002 1.1071 0.7517 24.0487 26.2100 24.0639 24.7422

040004 1.7351 0.8648 29.2714 30.1320 31.6130 30.3580

040007 1.7451 0.8675 28.3305 29.3146 30.2051 29.2717

040010 1.4698 0.8648 28.2375 28.1618 29.2017 28.5990

040011 0.9266 0.7517 22.6327 25.6224 25.9642 24.7357

040014 1.3689 0.8490 34.8279 24.1271 24.6941 25.6001

040015 1.0662 0.7517 22.3148 23.2134 23.7403 23.0850

040016 1.7601 0.8675 26.4806 27.6568 28.6501 27.6411

040017 1.0990 0.8127 24.3772 25.3390 26.2509 25.3116

040018 1.2191 0.7742 26.2521 25.3362 26.6851 26.0819

040019 0.9918 0.7775 26.4932 25.5468 25.0491 25.6618

040020 1.6272 0.7833 26.1529 25.9754 26.6049 26.2463

040021 *** * 27.6799 28.7690 28.8903 28.4564

040022 1.4167 0.8648 30.0250 29.5992 29.4604 29.6905

040026 1.6410 0.9296 31.8588 32.2814 34.6944 32.9479

040027 1.5093 0.8413 25.7935 27.2441 28.4743 27.1878

040029 1.4958 0.8675 27.8882 27.8412 29.1988 28.3053

040036 1.6856 0.8675 30.4906 32.0772 33.1236 31.9038

040039 1.1753 0.8127 22.9807 23.4456 23.0760 23.1655

040041 1.1592 0.8490 26.4435 27.8594 27.4448 27.2474

040042 1.3566 0.9213 23.1661 23.5768 28.3874 25.0294

040047 0.9113 0.7634 23.3557 25.0102 27.5142 25.1265

040050 1.1590 0.7517 19.6946 21.0178 22.0146 20.9063

040051 0.9936 0.7517 22.1981 23.4783 24.9308 23.5416

040055 1.7558 0.7742 26.0150 26.3370 26.5702 26.3163

040062 1.6827 0.7742 25.6554 28.5888 28.4309 27.5460

040067 1.0555 0.7524 20.9700 21.3492 22.1772 21.5146

040069 0.9730 0.8127 23.3117 23.0880 22.6987 23.0306

040071 1.5474 0.8490 26.6645 25.0185 28.7130 26.7537

040072 1.1859 0.7517 22.9671 23.3205 24.0488 23.4429

040074 1.1781 0.8675 27.3897 27.4614 27.7915 27.5518

040076 1.0157 0.9071 24.7903 25.7464 25.0274 25.1722

040078 1.7507 0.9296 25.6886 27.9394 28.4481 27.3094

040080 1.0416 0.7833 26.5905 26.9354 26.1224 26.5524

040081 0.8641 0.7874 18.4759 18.5265 17.3969 18.1445
CMS-1498-P 817 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

040084 1.3107 0.8675 28.1570 28.7379 29.9634 29.0185

040085 0.9358 0.8981 26.6987 25.4981 26.7545 26.3201

040088 1.5419 0.8122 24.7119 26.7050 28.8877 26.7762

040091 1.1940 0.7517 22.3311 27.7747 29.9029 26.3939

040100 *** * 24.5458 24.7712 * 24.6638

040114 1.9109 0.8675 28.5702 29.1200 30.6358 29.4351

040118 1.6136 0.7517 26.5783 27.3360 30.6065 28.2493

040119 1.5157 0.8490 25.6779 26.9632 28.2765 27.0150

040132 0.8021 0.9296 21.8140 * 22.6953 22.2510

040134 2.2362 0.8675 34.9673 35.2045 36.1627 35.4829

040137 1.3325 0.8675 27.7638 28.2123 31.3247 29.2690

040138 *** * 33.0073 31.1138 32.6001 32.2159

040141 *** * 33.8791 34.8500 * 34.4114

040142 1.5826 0.9296 23.1302 24.4876 27.5086 25.1151

040145 1.9580 0.7833 20.3878 22.1731 22.3687 21.7125

040147 1.9130 0.8675 35.7669 33.6215 30.4256 32.7938

040148 *** * * * 35.6031 35.6031

040149 *** * * * 29.0721 29.0721

040152 2.5966 0.8648 * * * *

050002 1.5159 1.5855 43.1760 42.3825 45.4953 43.6748

050006 1.8102 1.3277 41.7714 43.8923 45.0094 43.5856

050007 1.5598 1.5182 49.5271 55.1636 52.2245 52.2511

050008 1.6354 1.5036 50.9569 50.4751 52.7669 51.4050

050009 1.7626 1.5173 49.7177 51.5510 53.0588 51.5292

050013 1.9184 1.5173 43.4906 46.3422 49.5453 46.5172

050014 1.2657 1.3217 42.2044 42.7255 41.0206 41.9545

050016 1.4193 1.2121 34.3863 36.3674 39.4584 36.8709

050017 2.1061 1.3217 44.4857 46.6209 48.7220 46.6321

050018 1.3007 1.2002 34.0338 34.7941 36.0324 34.9615

050022 1.7904 1.2002 36.6360 38.9203 41.5471 39.0977

050024 1.2891 1.2002 33.5247 34.6921 37.1807 34.9055

050025 1.9538 1.2002 36.9233 39.5330 42.5246 39.7669

050026 1.6191 1.2002 35.0306 36.3315 37.3290 36.2935

050028 1.2261 1.2002 28.1584 28.5839 * 28.3806

050030 1.2680 1.2002 33.5654 33.2455 34.4700 33.7632

050036 1.7457 1.2002 37.4298 39.2616 41.5393 39.4707

050038 1.7728 1.6059 55.2197 58.4851 61.3276 58.4346
CMS-1498-P 818 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

050039 1.5400 1.2002 34.9262 37.8559 40.9213 37.8428

050040 1.3721 1.2002 38.1665 41.9767 44.2571 41.5266

050042 1.5785 1.3277 40.5791 45.6660 50.9908 45.8022

050043 1.7576 1.5855 51.9529 55.4677 53.5411 53.6961

050045 1.3696 1.2002 28.5952 27.8903 31.4860 29.3287

050046 1.2182 1.2002 34.2529 34.0106 37.1982 35.1676

050047 1.8545 1.5036 48.5961 51.4298 53.1141 51.0350

050054 1.2411 1.2002 27.1320 27.9082 32.4947 29.1694

050055 1.4904 1.5036 48.2796 51.9993 52.9342 51.0882

050056 1.5972 1.2002 34.7964 33.2655 39.4954 35.7797

050057 1.6940 1.2002 33.7574 35.6340 38.6138 36.0669

050058 1.8187 1.2002 38.9843 41.4811 43.4764 41.3510

050060 1.6287 1.2002 34.1183 35.3108 36.7750 35.4314

050063 1.6524 1.2002 36.6301 40.9558 43.3599 40.2753

050065 *** * 42.0085 * * 42.0085

050067 1.3773 1.2002 41.8988 41.1549 34.0218 39.0746

050069 2.0169 1.2002 38.1339 40.0498 44.2637 40.8835

050070 1.4481 1.5182 48.9362 53.8300 55.6284 52.8293

050071 1.7718 1.6059 52.0696 55.3995 54.9153 54.1707

050072 1.5282 1.5536 51.4538 54.7774 55.8299 54.0528

050073 1.5376 1.5428 50.6523 54.2296 55.8359 53.6371

050075 1.6153 1.5855 51.1187 54.8332 56.6372 54.2184

050076 1.8135 1.5036 50.5761 53.8043 55.1835 53.2013

050077 1.6624 1.2002 37.4989 38.5242 38.0509 38.0339

050078 1.3299 1.2002 37.1940 38.9256 38.8489 38.3347

050079 1.5469 1.5536 48.3017 50.6578 65.1440 53.7676

050082 1.8234 1.2002 42.0181 41.8861 44.1069 42.6942

050084 1.6992 1.3217 41.1276 42.4418 46.0253 43.2693

050089 1.4757 1.2002 39.6297 39.9711 42.3990 40.7121

050090 1.4461 1.5428 41.6026 44.0838 44.4628 43.3851

050091 0.9802 1.2002 40.1063 34.8170 33.6732 36.0063

050093 1.5991 1.2002 37.7244 38.5686 41.6205 39.3792

050095 *** * 44.2400 * * 44.2400

050096 1.4571 1.2002 33.3803 27.6236 33.2850 31.4278

050099 1.6444 1.2002 34.3507 35.4717 37.9297 35.9486

050100 1.8716 1.2002 34.2839 37.1606 39.4312 36.9821

050101 1.6391 1.5428 48.7495 54.5185 56.2550 53.2934
CMS-1498-P 819 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

050102 1.4707 1.2002 33.2837 35.4740 35.1267 34.5871

050103 1.6949 1.2002 37.3608 38.8446 38.1720 38.1428

050104 1.5783 1.2002 37.4417 39.1121 41.8962 39.5439

050107 1.6748 1.2002 36.5843 40.5315 41.9627 39.7421

050108 2.0166 1.3217 45.3460 48.8199 53.1654 48.7805

050110 1.2043 1.2002 30.9054 32.3171 33.5933 32.2754

050111 1.0887 1.2002 31.9394 31.1160 32.2597 31.7697

050112 1.5483 1.2002 39.9951 41.8195 41.5924 41.1912

050113 1.4076 1.5182 46.3471 45.1998 42.4778 44.6111

050114 *** * 37.5924 36.6541 * 37.1115

050115 1.5983 1.2002 33.3013 37.7614 40.4397 37.1497

050116 1.7304 1.2002 45.7510 40.6863 42.7961 43.0779

050118 1.2522 1.2002 41.8191 43.4432 46.9088 44.0974

050121 1.2757 1.2002 35.1135 36.9069 41.8043 38.1805

050122 1.7509 1.2384 36.8821 40.4510 41.5112 39.6349

050124 1.3527 1.2002 31.7690 33.3080 34.6304 33.2610

050125 1.6861 1.6059 53.6300 57.6242 60.2474 57.1280

050126 1.6064 1.2002 35.1909 34.9807 36.0294 35.4292

050127 1.5461 1.3217 42.5226 46.9648 48.0928 46.1911

050128 1.6196 1.2002 34.2364 36.6986 39.3773 36.7615

050129 1.9659 1.2002 40.3786 41.4256 44.5762 42.1957

050131 1.4681 1.5428 52.8228 56.6586 53.6221 54.3340

050132 1.6276 1.2002 43.6747 42.8187 45.1737 43.9116

050133 1.4848 1.2180 35.2433 36.8254 37.6504 36.6555

050135 1.0726 1.2002 25.4431 28.5118 30.6553 28.0980

050136 1.4481 1.5428 51.8508 52.5398 57.3918 53.8780

050137 1.3773 1.2002 43.5305 45.2088 49.1420 45.8667

050138 1.9128 1.2002 45.1011 47.3839 51.2980 47.9183

050139 1.4368 1.2002 43.0734 44.5753 48.6963 45.4255

050140 1.4087 1.2002 42.7590 44.8911 46.8652 44.8787

050144 *** * 40.4760 * * 40.4760

050145 1.6332 1.5512 49.4479 54.8909 58.5220 54.4145

050146 1.8322 * * * * *

050149 1.5052 1.2002 43.1926 42.8003 45.3498 43.7950

050150 1.3011 1.3217 43.5937 44.3354 48.0733 45.3350

050152 1.6955 1.5428 54.7176 55.9738 57.1905 55.9904

050153 1.5690 1.6059 50.4884 53.5925 57.8841 54.0652
CMS-1498-P 820 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

050158 1.5055 1.2002 42.7874 42.9454 44.0747 43.2830

050159 1.3444 1.2002 35.0153 40.4701 42.5924 39.5664

050167 1.4923 1.2384 38.0742 39.9946 41.8816 40.0050

050168 1.6873 1.2002 40.8362 37.9746 43.4951 40.7650

050169 1.6805 1.2002 33.1130 35.4836 41.1246 36.5888

050173 1.3930 1.2002 32.3265 31.5434 32.8423 32.2554

050174 1.7399 1.5428 53.7113 54.7960 59.7549 56.0844

050179 1.2738 1.2002 34.6558 36.2060 33.9197 34.8615

050180 1.7149 1.5536 48.7425 51.1836 53.5567 51.2533

050188 1.4966 1.6059 45.8501 49.6669 54.1865 49.5983

050189 0.9575 1.5512 31.5805 27.5311 29.3459 29.4661

050191 1.6765 1.2002 41.7185 40.0694 41.5164 41.0746

050192 0.9069 1.2002 27.4611 29.4203 33.2102 30.1271

050193 1.2942 1.2002 36.7240 39.0111 43.0282 39.5133

050194 1.3701 1.6059 49.8539 49.9857 55.1169 51.6953

050195 1.6650 1.5855 57.6563 61.8312 65.0039 61.5445

050196 1.2008 1.2002 41.1300 43.7415 41.0270 41.9842

050197 1.9331 1.5855 55.3173 59.0280 63.2066 59.2051

050204 1.5451 1.2002 38.8689 37.5591 41.0566 39.2215

050205 1.5945 1.2002 30.6117 30.2818 31.5240 30.7776

050211 1.3252 1.5855 42.9254 44.8773 46.1770 44.5820

050219 1.3542 1.2002 26.7061 26.9022 26.0523 26.5448

050222 1.7729 1.2002 35.4045 36.0221 37.6975 36.4283

050224 1.7191 1.2002 37.3442 39.7119 41.8790 39.6769

050225 1.5650 1.2002 37.5252 38.9288 42.8450 39.8661

050226 1.5718 1.2002 36.5354 38.4952 39.4194 38.1228

050228 1.4239 1.5036 49.9063 54.5580 57.3422 54.0697

050230 1.7061 1.2002 38.8901 39.8582 42.1567 40.3322

050231 1.8460 1.2002 37.0245 38.7280 40.2191 38.7139

050232 1.7131 1.2121 35.4055 39.4290 42.5544 39.2518

050234 1.5381 1.2002 37.7125 37.6811 38.9602 38.1603

050235 1.7383 1.2002 39.1744 40.0962 40.2265 39.8347

050236 1.5208 1.2002 34.4257 42.5939 44.3842 40.4072

050238 1.7269 1.2002 35.1268 36.4272 37.0926 36.2576

050239 1.6695 1.2002 36.3257 37.2939 38.5937 37.4489

050242 1.4892 1.6059 53.8385 58.5684 59.7332 57.3859

050243 1.6103 1.2002 37.8538 40.0490 42.5305 40.1509
CMS-1498-P 821 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

050245 1.3766 1.2002 34.7153 36.9270 37.1180 36.2906

050248 1.1998 1.5512 46.0329 47.7637 51.0500 48.2742

050254 1.3843 1.3217 33.5069 34.8262 39.7976 36.0829

050256 *** * 32.6841 * * 32.6841

050257 0.8947 1.2002 29.2651 30.7766 29.8486 29.9463

050261 1.3026 1.2002 33.7196 34.8188 39.3041 36.0518

050262 2.3736 1.2002 43.7709 40.8071 44.0453 42.8188

050264 1.4655 1.5855 50.1691 54.4052 57.0188 53.7398

050272 1.5454 1.2002 32.2584 35.0624 37.3015 34.8914

050276 1.1140 1.5536 47.2432 53.7552 55.4715 52.2517

050277 1.2258 1.2002 * 48.9698 47.5707 48.2343

050278 1.7099 1.2002 38.5689 39.5929 42.8799 40.4121

050279 1.3099 1.2002 32.1695 31.0888 31.6803 31.6436

050280 1.8248 1.3277 43.6243 46.2628 50.0266 46.6861

050281 1.5342 1.2002 31.0706 31.4166 32.8623 31.7857

050283 1.7021 1.5855 45.1132 50.3066 51.3746 48.9680

050289 1.6807 1.5182 52.0918 53.8571 58.3774 54.8745

050290 1.7520 1.2002 42.0099 42.2249 42.6314 42.2987

050291 2.0918 1.5428 44.6102 49.6427 52.1353 48.7155

050292 1.1648 1.2002 35.0372 34.6404 39.9841 36.7557

050295 1.5834 1.2002 39.7399 39.3961 42.9356 40.7188

050296 1.1416 1.6044 44.8135 48.2583 50.4082 47.9062

050298 1.2079 1.2002 33.6947 31.7374 34.0150 33.1345

050300 1.4557 1.2002 37.1275 39.2722 43.0474 40.0013

050301 1.3483 1.2002 36.3681 36.7568 39.9485 37.7770

050305 1.5667 1.5855 56.9756 55.7229 54.6309 55.7281

050308 1.5864 1.6059 49.0132 51.0183 54.0475 51.4737

050309 1.5729 1.3217 42.9280 46.6901 47.4734 45.7112

050313 1.2453 1.2384 39.0663 42.3998 43.8913 41.8600

050315 1.4388 1.2002 37.3560 40.3132 47.1318 41.7255

050320 1.2324 1.5855 50.6708 50.9692 55.3663 52.3385

050324 1.8098 1.2002 37.1883 38.9511 41.1149 39.1426

050325 0.7767 1.2035 34.0343 * 47.6656 36.0502

050327 1.8597 1.2002 36.9550 37.7681 39.6815 38.2025

050329 1.3249 1.2002 36.7669 37.6975 37.0324 37.1628

050334 1.7820 1.5855 50.9834 54.9338 59.6727 55.2808

050335 1.4895 1.2002 37.2347 37.1670 39.1873 37.9135
CMS-1498-P 822 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

050336 1.2295 1.2384 33.0325 35.3658 38.7257 35.7910

050342 1.2591 1.2002 29.8389 31.6852 33.8443 31.8494

050348 1.7579 1.2002 33.5276 35.1080 37.4660 35.3772

050349 0.7643 1.2002 23.1095 23.5190 24.5969 23.7436

050350 1.5328 1.2002 34.6747 36.1856 37.1989 35.9750

050351 1.5646 1.2002 35.0042 35.6083 34.8470 35.1393

050352 1.4182 1.3217 38.6265 41.5370 41.4294 40.5216

050353 1.5266 1.2002 37.1716 37.4560 38.3124 37.6445

050357 1.4556 1.2002 38.9244 40.9999 41.8008 40.6080

050359 1.1943 1.2002 30.3988 30.9732 33.5096 31.6303

050360 1.6360 1.5428 55.3738 59.2147 57.2879 57.3315

050366 1.1199 1.3217 41.8324 43.0169 43.1165 42.6581

050367 1.6146 1.5428 40.0453 41.1059 44.3506 41.9320

050369 *** * 33.3357 34.7337 37.3679 35.1733

050373 1.4497 1.2002 37.6695 40.8506 43.5055 40.7260

050376 1.6492 1.2002 36.7270 40.0354 42.4754 39.8599

050378 1.1137 1.2002 42.0480 50.0875 51.5092 47.5470

050380 1.8224 1.6059 52.5804 58.6395 60.9625 57.5372

050382 1.6019 1.2002 32.9248 34.3636 36.6641 34.7208

050385 1.4871 1.5428 36.5644 38.9773 44.3026 40.0228

050390 1.2847 1.2002 33.0463 31.4134 33.7927 32.7377

050393 1.4304 1.2002 35.1887 35.5678 38.9873 36.6236

050394 1.7929 1.2002 32.9572 37.2557 40.0176 36.7479

050396 1.5923 1.2002 38.9944 41.2602 41.6933 40.7032

050397 0.8415 1.2002 31.1621 32.3700 36.0861 33.4783

050407 1.2178 1.5036 47.5591 47.7943 48.9123 48.1149

050411 1.4376 1.2002 42.9884 44.3404 47.5402 44.9714

050414 1.3420 1.3217 45.1621 48.5863 51.1532 48.4113

050417 1.3322 1.2002 37.9951 38.8418 38.4087 38.4269

050423 1.0535 1.2002 32.4108 41.3130 43.7795 38.6501

050424 1.9481 1.2002 37.5246 39.8802 42.7414 40.2044

050425 1.4308 1.3217 45.3743 52.0378 53.7887 50.3034

050426 1.7182 1.2002 37.6505 * 37.1444 37.3893

050430 1.0514 * 25.9368 28.7102 * 27.6338

050433 *** * 23.0949 * * 23.0949

050434 0.9730 1.2002 35.4807 34.4698 36.3651 35.4609

050435 1.2470 1.2002 35.7427 35.3040 36.3716 35.8152
CMS-1498-P 823 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

050438 1.6093 1.2002 38.2855 36.8507 37.7652 37.6241

050441 2.0773 1.6059 49.2129 50.0652 56.1662 51.9914

050444 1.4821 1.2235 39.3947 39.4231 41.6899 40.2059

050447 *** * 27.1271 * * 27.1271

050448 1.2055 1.2002 32.6682 32.9244 35.5744 33.7517

050454 2.1384 1.5036 43.5230 46.9602 50.6105 47.1838

050455 1.5674 1.2002 35.0232 38.9871 39.4869 37.8773

050456 *** * 27.9702 28.1444 * 28.0651

050457 1.7524 1.5036 53.3175 54.6802 57.1259 55.0565

050464 1.8533 1.2002 42.6699 44.9128 46.6301 44.6843

050468 1.5593 1.2002 37.3416 35.7136 37.0600 36.6946

050470 *** * 32.5041 * * 32.5041

050471 1.6569 1.2002 36.8185 37.6641 40.5399 38.3240

050476 *** * 41.7566 * * 41.7566

050478 0.9581 1.2002 41.5635 44.3775 46.6521 44.3460

050481 1.6201 1.2002 42.8536 47.2326 50.1977 46.8143

050485 1.7165 1.2002 34.7078 37.4203 39.3266 37.2228

050488 1.5157 1.5855 49.3604 53.8013 53.3366 52.2027

050492 1.4172 1.2002 32.6609 35.6838 39.4538 36.0641

050496 1.8243 1.5536 56.7446 57.1030 61.4808 58.5059

050498 1.4628 1.3217 45.3508 46.6560 47.6863 46.5454

050502 1.7474 1.2002 32.9791 40.2876 37.2580 36.7036

050503 1.5401 1.2002 37.7210 40.7324 43.1770 40.6385

050506 1.5155 1.2121 40.6534 42.3670 45.0204 42.6481

050510 1.4186 1.5428 51.3143 54.8690 55.9873 54.0800

050512 1.4447 1.5855 50.1470 53.9292 55.7732 53.3348

050515 1.4010 1.2002 42.0106 45.0972 48.0118 45.0227

050516 1.6158 1.3217 45.6228 48.5267 48.0618 47.4427

050517 1.4708 1.2002 29.3694 29.8385 27.5129 28.8628

050523 1.3871 1.5536 46.9870 49.5029 53.7305 50.2368

050526 1.4939 1.2002 35.5457 * 36.5894 36.0188

050528 1.1577 1.2002 38.3051 41.9922 43.2318 41.2013

050531 1.1682 1.2002 28.4890 28.4921 31.0366 29.3122

050534 1.6008 1.2002 38.1892 39.7655 42.3047 40.1251

050537 1.6440 1.3217 41.5275 43.1765 45.7187 43.4999

050541 1.6420 1.5855 51.4545 55.2594 56.3321 54.3652

050543 0.7871 1.2002 32.8367 29.0470 31.0801 30.9554
CMS-1498-P 824 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

050545 0.9027 1.2002 * 27.4889 * 27.4889

050547 1.0068 1.5428 * * * *

050548 0.7480 1.2002 * * * *

050549 1.6820 1.2002 40.6796 44.6715 46.9107 44.1208

050550 *** * 39.2163 * * 39.2163

050551 1.3889 1.2002 37.6223 39.4047 42.2041 39.7598

050552 0.9442 1.2002 35.3468 38.6658 41.1173 38.3633

050557 1.6479 1.2002 39.2224 41.9292 43.9916 41.7837

050561 1.3989 1.2002 40.1567 43.1147 46.9113 43.3701

050567 1.5237 1.2002 39.0114 41.7247 46.3879 42.4571

050568 1.1903 1.2002 26.7733 28.7691 30.1104 28.6056

050570 1.7113 1.2002 40.6761 40.3411 42.9671 41.3473

050573 1.6162 1.2002 36.8561 38.0175 41.0463 38.7328

050575 1.5692 1.2002 22.1018 32.1046 33.5745 29.0057

050578 *** * 43.4917 * * 43.4917

050580 1.3315 1.2002 35.0966 36.7968 33.1767 35.0893

050581 1.6333 1.2002 40.0909 41.9698 45.2924 42.4394

050583 *** * 40.5845 41.3920 * 40.9835

050584 *** * 31.9910 30.8650 * 31.4271

050586 1.6278 1.2002 31.1932 32.7348 32.8095 32.2361

050588 1.4763 1.2002 39.4251 39.0347 41.0641 39.8351

050589 1.2827 1.2002 37.2056 39.2646 40.8842 39.1776

050590 1.4972 1.3217 44.3382 50.0371 49.7328 48.1461

050592 *** * 32.2376 * * 32.2376

050597 1.4581 1.2002 32.8987 35.6567 37.5208 35.3960

050599 2.0012 1.3217 36.6146 38.9877 39.8105 38.5379

050601 *** * 43.2404 43.3329 46.0784 44.2186

050603 1.5047 1.2002 35.4809 37.4348 38.3834 37.1447

050604 1.6291 1.6059 49.6068 54.1687 55.6773 53.0805

050608 1.3872 1.2002 30.7280 28.3794 30.7212 29.9386

050609 1.4301 1.2002 43.4555 45.2475 49.1701 45.9890

050616 1.4949 1.2002 40.7388 45.2614 43.3018 43.0759

050618 0.9683 1.2002 34.9177 34.0584 35.2789 34.7493

050624 1.5075 1.2002 39.2553 40.2253 41.9206 40.5628

050625 1.8425 1.2002 44.8482 48.1826 46.7270 46.6153

050633 1.2030 1.2121 40.7383 41.1786 44.7463 42.2532

050636 1.4438 1.2002 35.4565 38.8844 39.6096 38.0088
CMS-1498-P 825 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

050641 1.3049 1.2002 32.0508 33.1417 34.1849 33.1406

050644 1.0475 1.2002 33.2777 32.1513 32.5153 32.6132

050660 1.6423 * * * * *

050662 1.1129 1.6059 * * * *

050663 1.3695 1.2002 17.7252 30.4117 33.0151 26.4022

050667 0.8006 1.4010 25.8460 30.1039 32.0624 28.9596

050668 1.0786 1.5428 52.7011 62.7714 65.4231 60.6295

050674 1.4993 1.3217 48.6880 51.3517 53.4854 51.2273

050677 1.5581 1.2002 41.8130 44.4567 47.7267 44.6382

050678 1.4527 1.2002 35.8411 38.3361 39.9167 38.1597

050680 1.4613 1.5428 39.0389 40.7514 44.0282 41.3411

050682 0.6944 1.2002 22.3903 22.4419 * 22.4133

050684 1.2570 1.2002 33.5915 33.0982 35.4682 34.0341

050686 1.3750 1.2002 42.1444 45.2231 48.0040 45.1124

050688 1.3358 1.6059 53.2741 54.5423 56.6466 54.9010

050689 1.5695 1.5536 48.9935 50.2942 53.7493 51.0590

050690 1.3287 1.5428 51.6179 55.1002 55.3847 54.0619

050693 1.4804 1.2002 42.8266 41.9594 44.4380 43.0972

050694 1.2375 1.2002 34.8486 33.8553 35.2422 34.6536

050696 2.5549 1.2002 39.4353 41.2315 44.0844 41.4935

050697 1.1148 1.3277 26.7600 29.0854 30.2726 28.7053

050701 1.3546 1.2002 37.2839 38.4382 42.7575 39.6135

050704 1.1342 1.2002 32.2017 31.7051 32.1670 32.0293

050707 *** * 44.0254 49.4684 * 46.9800

050708 1.8358 1.2002 28.3074 34.4063 34.8907 31.9717

050709 1.6404 1.2002 29.5364 30.4570 28.8514 29.5817

050710 1.4205 1.2002 46.2533 51.1460 52.8041 50.0857

050714 1.5922 1.6059 42.9797 45.2746 47.4228 45.3980

050717 1.5965 1.2002 37.0875 42.2736 41.8557 40.5623

050720 *** * 32.1173 33.8712 34.7221 33.4577

050722 0.9563 1.2002 35.6741 35.2177 37.3302 36.1210

050723 1.5436 1.2002 42.1571 43.3875 47.0388 44.1779

050724 1.9468 1.2002 35.1020 35.5224 39.0539 36.5017

050725 0.9517 1.2002 28.8389 27.8565 * 28.3307

050726 1.6175 1.2002 30.6105 35.3964 36.4404 34.1918

050727 1.3740 1.2002 33.0932 29.0789 35.3258 32.5219

050732 2.3923 1.2002 34.3475 37.4333 37.9684 36.6936
CMS-1498-P 826 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

050733 1.7727 1.3277 40.6320 44.7509 44.5719 43.2177

050735 1.4534 1.2002 36.6081 34.3859 34.2886 35.0721

050736 1.3576 1.2002 41.8938 38.0913 36.6220 38.8361

050737 1.7443 1.2002 38.0424 36.4535 38.0483 37.5164

050738 1.6053 1.2002 43.9259 40.3081 39.1266 41.0361

050739 1.6999 1.2002 57.2480 44.0540 40.0074 45.3865

050740 1.7415 1.2002 54.0370 44.8439 37.0976 43.5160

050741 *** * 51.1526 44.0305 * 47.5915

050742 1.6473 1.2002 39.2532 41.0036 44.3972 41.4615

050744 1.7380 1.2002 48.4951 56.5911 54.9148 53.1646

050745 1.4481 1.2002 42.5523 48.2903 48.8922 46.5732

050746 1.8123 1.2002 43.2015 46.3622 45.1988 44.9325

050747 1.8632 1.2002 44.5887 47.8242 47.3968 46.5482

050748 1.2527 1.2002 43.1008 50.6390 54.1242 49.3277

050749 1.3796 1.2002 28.2000 39.6030 41.4811 35.7689

050750 *** * 33.9915 * * 33.9915

050751 3.5931 1.2002 29.5488 34.0436 36.5150 33.0527

050752 1.4901 1.2002 39.8035 41.3783 42.4687 41.1950

050754 1.2220 1.5182 * 56.3628 * 56.3628

050755 1.6182 1.2002 * 36.5212 36.5251 36.5232

050756 *** * * 33.4951 * 33.4951

050757 1.7470 1.2002 * * 42.3546 42.3546

050758 1.5779 1.2002 * 17.6509 27.8366 21.8706

050759 *** * * * 36.7495 36.7495

050760 1.3958 1.5536 * * * *

050761 1.6126 1.2002 * * * *

050762 1.4125 1.2002 * * * *

050763 0.9992 1.2002 * * * *

050764 1.6615 1.3277 * * * *

050765 1.1291 1.2002 * * * *

050766 1.5412 1.2002 * * * *

060001 1.4318 1.0303 32.4226 32.5239 33.5009 32.8211

060003 1.5346 1.0303 31.8637 33.6264 34.9819 33.5098

060004 1.2485 1.0485 34.8428 34.5727 36.3214 35.2917

060006 1.2988 0.9581 27.6453 30.5664 30.7361 29.6331

060008 1.5166 0.9581 27.2071 26.0851 28.6913 27.3573

060009 1.6004 1.0485 34.0151 35.8398 36.9037 35.5950
CMS-1498-P 827 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

060010 1.5399 0.9581 30.6424 33.5549 32.9241 32.3981

060011 1.5301 1.0485 34.4171 34.6239 36.6800 35.2356

060012 1.5328 0.9581 29.4365 29.6957 31.4807 30.2506

060013 1.6156 0.9581 28.0800 29.5100 30.9706 29.5285

060014 2.0318 1.0485 33.0366 35.6231 36.9360 35.1981

060015 2.1471 1.0485 36.3296 36.6824 38.2231 37.1141

060016 1.1827 0.9581 28.3055 30.0601 30.4208 29.6098

060018 1.0992 * 26.5788 * * 26.5788

060020 1.6397 0.9581 26.7362 27.3823 29.0073 27.7438

060022 1.6431 0.9581 31.9376 32.0594 31.6915 31.8828

060023 1.6909 1.0303 32.7922 33.4798 34.9894 33.7723

060024 1.9110 1.0485 32.8206 36.1736 37.9233 35.6626

060027 1.5428 1.0303 31.6134 33.4869 33.6616 32.8750

060028 1.6913 1.0485 33.4966 35.8222 37.1167 35.5436

060030 1.4475 0.9581 31.2932 31.2752 32.9330 31.8568

060031 1.5069 1.0303 30.7381 32.0153 33.2299 32.0027

060032 1.6656 1.0485 34.6447 35.6500 37.4582 35.9181

060034 1.8224 1.0485 33.3656 34.6615 36.1706 34.7283

060036 1.1704 0.9581 20.9370 24.8220 25.3568 23.6418

060041 *** * 31.4739 * * 31.4739

060043 0.8976 0.9581 23.3908 19.9611 20.3282 21.2601

060044 1.2481 0.9581 28.9200 32.0455 32.7653 31.1835

060049 1.4153 0.9581 32.1589 34.5262 35.5353 34.0821

060054 1.4909 1.0051 24.6721 29.2998 32.8197 29.3593

060064 1.8838 1.0485 37.2407 34.7448 36.3099 36.0591

060065 1.4593 1.0485 34.9205 36.2377 37.7892 36.3163

060071 1.1608 0.9581 31.5388 32.1367 32.4497 32.0600

060075 1.4614 1.0051 35.8081 37.3019 40.1016 37.8404

060076 1.3290 0.9581 31.6044 31.5032 31.8373 31.6524

060096 1.8302 1.0303 38.2249 39.9302 42.6189 40.4330

060100 1.7950 1.0485 33.5356 35.7861 36.6803 35.3368

060103 1.4229 1.0303 33.7542 34.9964 36.7528 35.2095

060104 1.5478 1.0485 37.1434 37.4598 39.0604 37.9751

060107 2.0677 1.0485 30.3991 30.0308 30.5898 30.3552

060112 1.7503 1.0485 35.1308 36.4093 37.9928 36.6034

060113 1.5005 1.0485 35.2097 36.0794 38.0309 36.4956

060114 1.6645 1.0485 35.3056 37.1394 37.6554 36.8077
CMS-1498-P 828 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

060115 0.9083 0.9581 * * * *

060116 1.4913 1.0303 33.1547 36.3560 36.9071 35.6457

060117 1.3581 0.9581 28.3112 31.6734 31.3013 30.6152

060118 1.4926 1.0303 * 40.2136 39.9922 40.0904

060119 1.9646 0.9581 * * 34.0822 34.0822

060121 2.1298 1.0303 * * 38.3284 38.3284

060123 1.8589 1.0485 * * * *

070001 1.6363 1.2234 37.9438 38.4864 39.3014 38.5781

070002 1.7996 1.1251 36.4269 36.6624 39.3490 37.4818

070003 1.1819 1.1251 36.0524 36.6553 37.6699 36.7817

070004 1.1875 1.1251 31.2115 34.3803 35.1037 33.5419

070005 1.6586 1.2234 36.5502 37.3430 38.3363 37.4209

070006 1.6560 1.2817 41.2165 41.9550 43.2602 42.1481

070007 1.4209 1.1353 37.0984 38.9830 40.3319 38.8215

070008 1.3351 1.1251 35.4969 34.0603 35.8161 35.1073

070009 *** * 36.6382 38.1380 * 37.4141

070010 1.6960 1.2817 38.6114 38.7345 41.3102 39.5949

070011 1.4801 1.1251 32.6835 33.7313 36.9466 34.4150

070012 1.4730 1.1251 33.2477 35.4738 37.5683 35.3833

070015 1.5810 1.2817 39.9249 42.4738 43.1481 41.8469

070016 1.5918 1.2234 34.1266 34.5418 36.2707 34.9884

070017 1.4503 1.2234 37.5855 38.1713 41.0077 38.9339

070018 1.4031 1.2817 42.4771 44.1370 45.8974 44.2078

070019 1.5997 1.2234 35.8618 37.0666 39.8743 37.6317

070020 1.3867 1.1352 35.6542 40.4989 40.6182 39.0618

070021 1.1794 1.1251 39.7793 41.9076 43.8622 41.8599

070022 1.7333 1.2234 41.4721 41.5553 43.2394 42.1299

070024 1.5050 1.1353 36.8997 38.6301 39.2511 38.2737

070025 1.7003 1.1251 36.1322 38.7067 38.9328 37.9080

070027 1.5868 1.1251 33.5979 35.7677 36.5223 35.3536

070028 1.5644 1.2817 40.9645 41.2950 42.0488 41.4517

070029 1.3443 1.1251 32.8504 35.4716 36.0406 34.8141

070031 1.3419 1.2234 30.5924 33.2618 33.5139 32.4882

070033 1.4782 1.2817 44.6717 46.5982 47.7688 46.3583

070034 1.5225 1.2817 42.4111 45.7694 44.0374 44.0855

070035 1.4095 1.1251 33.4047 38.2298 35.3357 35.6697

070036 1.7475 1.1654 43.6374 44.0756 46.4609 44.7773
CMS-1498-P 829 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

070038 0.9441 1.2234 29.9516 33.5109 31.4454 31.4773

070039 1.0971 1.2234 32.7153 35.9137 36.2927 35.1271

070040 1.0743 1.1251 * 26.3824 30.5486 28.3408

080001 1.6907 1.0802 34.9507 37.4441 39.1835 37.2540

080002 *** * 33.0404 33.3472 35.2276 33.8892

080003 1.5403 1.0802 30.5132 29.0166 31.5225 30.4059

080004 1.6748 1.0690 34.3854 33.6190 35.0266 34.3423

080006 1.5520 1.0090 31.0327 30.7985 29.2411 30.3636

080007 1.7565 1.0903 33.4782 35.5425 37.5631 35.5927

090001 1.7104 1.0561 40.1658 38.3876 39.8134 39.3691

090003 1.3090 1.0561 34.4430 37.2088 37.3982 36.3730

090004 2.0589 1.0573 38.5681 39.9027 40.6216 39.7496

090005 1.3805 1.0561 35.2884 35.1327 36.9545 35.7927

090006 1.4341 1.0561 32.3654 32.5988 34.9946 33.3147

090008 1.5880 1.0561 36.6633 40.3260 41.7318 39.2644

090011 2.1681 1.0561 39.0111 39.5389 41.3036 39.9493

100001 1.6225 0.8902 27.8526 30.5213 30.2446 29.5877

100002 1.5581 1.0364 30.6668 33.1103 34.4039 32.7223

100006 1.6837 0.9178 28.9769 29.2697 31.1090 29.8250

100007 1.6560 0.9178 30.3379 30.6689 32.7648 31.2751

100008 1.6404 1.0222 32.1679 32.3397 34.9341 33.1587

100009 1.6764 1.0222 30.0492 32.0145 33.5623 31.8710

100012 1.6726 0.9167 30.8626 30.2066 32.0081 31.0290

100014 1.5567 0.9178 27.4064 28.8679 32.2443 29.5972

100015 *** * 28.6825 29.9757 31.5936 30.0347

100017 1.6037 0.9178 29.8705 31.2313 32.0601 31.0930

100018 1.7857 0.9809 32.8642 34.2077 34.9524 34.0313

100019 1.7306 0.9332 31.4549 32.2496 34.2627 32.6917

100022 1.7695 1.0364 36.3355 40.4664 42.4881 39.7952

100023 1.6827 0.9094 27.1032 27.7860 27.8953 27.6060

100024 1.2216 1.0222 29.8918 31.5160 30.5545 30.6338

100025 1.8056 0.8458 27.1665 28.7604 29.6928 28.5823

100026 1.6151 0.8458 27.3044 28.5877 27.8367 27.9162

100028 1.4448 0.9332 28.7801 28.1509 31.9846 29.6732

100029 1.3707 1.0222 31.6006 33.2920 34.8161 33.2424

100030 1.4694 0.9178 26.3113 27.0977 30.8824 28.0853

100032 1.7391 0.9094 27.8942 29.3641 30.3253 29.1887
CMS-1498-P 830 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

100034 1.8674 1.0222 28.9387 29.8997 29.6114 29.4885

100035 1.5772 0.9265 32.5593 31.2325 31.4578 31.7203

100038 1.6264 1.0364 32.8392 37.0928 37.1884 35.7516

100039 1.9693 1.0364 29.0236 32.6863 32.2419 31.3704

100040 1.7070 0.8902 28.3366 29.8029 29.6297 29.2510

100043 1.4166 0.9094 26.8417 29.1014 31.1972 28.9417

100044 1.5653 1.0762 34.3920 34.4743 41.7922 37.0061

100045 1.3103 0.9178 25.5621 27.8526 28.1643 27.2127

100046 1.5558 0.9094 27.7878 29.7844 30.9730 29.5992

100047 1.6811 0.9265 31.4072 31.8998 32.2047 31.8452

100048 0.9614 0.8458 21.7693 22.7260 23.5379 22.6813

100049 1.3320 0.8628 27.6316 26.9145 27.7020 27.4184

100050 1.2458 1.0222 23.5222 23.7419 24.5868 23.9540

100051 1.4875 0.9178 30.1492 28.7367 30.6461 29.8530

100052 1.4003 0.8628 25.1110 27.6591 28.4807 27.1112

100053 1.4162 1.0222 31.9268 33.6936 35.2550 33.5895

100054 1.4027 0.8762 30.9840 33.2237 36.2168 33.5037

100055 1.4759 0.9094 29.7027 28.5830 30.4298 29.5982

100057 1.4780 0.9178 27.7045 30.4258 30.5235 29.5810

100061 1.5789 1.0222 31.9174 33.9803 34.8482 33.5811

100062 1.7148 0.8578 26.3067 28.0821 29.2949 27.9112

100063 1.4087 0.9094 27.0769 29.5864 31.2488 29.3363

100067 1.5488 0.9094 27.5501 30.0555 31.5618 29.6772

100068 1.7784 0.9178 27.7707 28.5177 28.0307 28.1041

100069 1.8450 0.9094 29.0486 33.4008 32.7796 31.7251

100070 1.6892 0.9265 29.1117 27.1313 27.9973 28.0427

100071 1.3529 0.9094 25.1883 25.6870 27.8655 26.2748

100072 1.4518 0.9178 27.6947 28.6435 29.6882 28.7088

100073 1.7399 1.0364 31.0395 33.8783 33.7457 32.8947

100075 1.5788 0.9094 26.7571 29.2992 31.2004 29.0714

100076 1.2234 1.0222 24.0280 23.7078 26.3433 24.4935

100077 1.3992 0.9265 27.9783 28.0178 29.5962 28.5634

100079 1.5106 * * * * *

100080 1.6204 1.0364 31.0516 33.2091 35.4485 33.2130

100081 1.0281 0.8565 19.7406 17.2548 17.7222 18.2774

100084 1.6551 0.9178 30.6301 30.7165 35.1858 32.1812

100086 1.5751 1.0364 31.3187 33.0726 33.7048 32.7154
CMS-1498-P 831 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

100087 1.8405 0.9265 32.1314 33.4104 33.2328 32.9255

100088 1.7052 0.8902 29.4952 30.3481 30.9148 30.2877

100090 1.4563 0.8902 28.9581 27.4996 28.2012 28.2140

100092 1.5558 0.9332 28.6782 29.1433 29.6087 29.1462

100093 1.7452 0.8458 23.4847 24.9505 25.8345 24.7522

100099 1.1448 0.8628 28.0688 28.2871 30.0337 28.8423

100102 1.0551 0.8458 29.0396 30.0754 28.5248 29.1936

100105 1.5943 1.0283 30.8936 31.5294 33.0707 31.8950

100106 1.0979 0.8458 25.6288 20.6449 26.2560 24.0768

100107 1.2712 0.9167 31.2954 30.9662 32.4297 31.5714

100108 *** * 22.8153 17.9561 17.5426 19.1444

100109 1.3854 0.9178 26.7380 29.1403 29.2478 28.3934

100110 1.6147 0.9178 30.3758 32.4083 32.8616 31.9067

100113 2.0648 0.9406 30.6037 30.9741 33.2418 31.6327

100114 *** * 32.3956 34.3630 * 33.3214

100117 1.1720 0.8902 30.0281 30.6894 31.4492 30.7465

100118 1.4486 0.8458 28.3201 31.3833 28.6480 29.3969

100121 1.1958 0.8628 25.0320 20.0814 27.6294 24.2372

100122 1.2388 0.8762 27.6178 27.9970 28.5222 28.0534

100124 1.1993 0.8458 26.2329 28.2667 28.9298 27.8069

100125 1.2299 1.0222 33.3499 35.2588 37.2705 35.4531

100126 1.3809 0.9094 28.9164 30.3912 31.2105 30.1653

100127 1.6431 0.9094 27.0686 29.3856 31.1177 29.1793

100128 2.2037 0.9094 30.6202 29.6793 31.2298 30.5186

100130 1.3212 1.0364 29.5763 29.9727 29.8339 29.7970

100131 1.3800 1.0222 30.9614 32.2086 33.9594 32.3908

100132 1.3499 0.9094 27.6632 29.3380 30.9567 29.3475

100134 0.8526 0.8458 22.9635 24.7863 23.0684 23.5589

100135 1.6829 0.8981 29.8452 30.2093 34.2492 31.4439

100137 1.4023 0.8628 28.3000 27.8783 28.6777 28.2947

100139 0.9036 0.9406 21.4418 22.1683 21.4572 21.6824

100140 1.1241 0.8902 28.5485 29.7482 30.7155 29.6963

100142 1.2138 0.8458 26.8995 26.8829 25.1309 26.3144

100150 1.2062 1.0222 29.3711 33.0132 32.5785 31.6449

100151 1.9703 0.8902 31.3846 33.1725 34.9557 33.1543

100154 1.7005 1.0222 31.3640 32.3793 34.9899 32.9507

100156 1.1212 0.8458 28.3060 29.9029 31.1552 29.8254
CMS-1498-P 832 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

100157 1.5825 0.9094 30.3359 30.4870 31.8594 30.8981

100160 1.1017 1.0222 32.3136 33.8433 35.2448 33.8503

100161 1.6418 0.9178 30.8984 32.6427 33.0240 32.1874

100166 1.6290 0.9265 31.9072 33.0019 34.8424 33.2088

100167 1.5548 1.0364 32.4740 34.8085 36.1348 34.4179

100168 1.7112 1.0364 28.0543 31.1427 32.5053 30.6385

100172 *** * 20.5518 * * 20.5518

100173 1.7179 0.9094 30.2491 30.3599 30.9982 30.5313

100175 1.0188 0.8458 26.1723 26.8828 30.6970 27.8555

100176 1.7599 1.0364 35.5849 35.7433 37.0046 36.1156

100177 1.4618 0.9332 31.0085 31.3830 32.8491 31.7568

100179 1.7363 0.8902 30.5439 31.8790 33.3430 31.9272

100180 1.4792 0.9094 31.5485 32.3796 34.6817 32.8425

100181 1.4002 1.0222 26.0682 26.0880 26.4568 26.2189

100183 1.3902 1.0222 32.9893 31.6760 33.2466 32.6280

100187 1.4893 1.0222 31.6660 31.8020 34.2328 32.5967

100189 1.4419 1.0364 30.5516 32.8847 34.2447 32.5432

100191 1.3645 0.9094 30.9212 31.6024 33.7871 32.0675

100200 1.5295 1.0364 29.0731 32.5611 33.7050 31.7495

100204 1.6164 0.9406 29.9334 30.6252 31.4765 30.6899

100206 1.3259 0.9094 28.8625 30.4576 31.2653 30.2061

100209 1.6863 1.0222 29.0462 30.5582 32.8523 30.8033

100210 1.6173 1.0364 32.4566 33.3016 34.2993 33.3096

100211 1.2867 0.9094 28.8328 30.5902 31.6079 30.3679

100212 1.5679 0.8578 29.2500 30.5141 31.1368 30.3163

100213 1.5727 0.9265 30.2271 31.4309 33.1230 31.5995

100217 1.2905 1.0283 30.3325 33.5767 30.5641 31.4346

100220 1.6269 0.9167 30.8292 31.8393 33.1625 32.0038

100223 1.6223 0.8762 27.6775 28.6449 30.3741 28.8695

100224 1.3813 1.0364 29.2008 31.0307 33.6361 31.2128

100225 *** * 32.6906 31.8048 * 32.2587

100226 1.3734 0.8902 30.2857 30.8904 31.4361 30.8818

100228 1.4519 1.0364 31.0222 32.2672 34.6713 32.6412

100230 1.4348 1.0364 34.6133 35.9319 36.1673 35.6194

100231 1.6148 0.8458 28.3652 28.8912 29.8895 29.0352

100232 1.4309 0.9406 29.3797 30.3768 30.7940 30.1690

100234 1.3292 1.0364 29.7818 33.1508 35.3677 32.6857
CMS-1498-P 833 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

100236 1.4897 0.9265 30.5719 31.4385 33.2992 31.8165

100237 *** * 33.9626 33.9696 34.7138 34.1878

100238 1.6561 0.9094 31.6353 32.8745 35.1867 33.2711

100239 1.5075 0.9094 30.3234 32.7150 33.9579 32.2861

100240 1.1030 1.0222 31.0951 35.3888 36.6032 34.5027

100242 1.5952 0.8458 27.8169 28.5034 29.7347 28.6980

100243 1.5542 0.9094 29.8323 31.4863 32.5227 31.3056

100244 1.4331 0.9167 29.8287 29.1611 30.3453 29.7743

100246 1.5614 1.0762 30.0467 32.5063 33.5469 32.0515

100248 1.5668 0.9094 32.4725 33.7659 36.0601 34.0862

100249 1.3514 0.9094 28.5117 29.7981 30.5240 29.6388

100252 1.2169 1.0283 29.1448 31.5631 33.8245 31.4852

100253 1.4998 1.0364 28.5617 29.4959 31.3059 29.8138

100254 1.5108 0.8981 28.5262 28.9095 30.8142 29.4282

100255 1.3545 0.9094 29.5172 30.0466 31.9271 30.4950

100256 1.6224 0.9094 33.3936 34.6637 34.8304 34.2928

100258 1.6613 1.0364 35.2225 34.2862 36.3146 35.2877

100259 1.2922 0.9094 29.9294 32.2273 33.8210 31.9723

100260 1.5192 1.0762 29.4907 31.5667 33.8328 31.6747

100264 1.5444 0.9094 30.1980 31.5050 33.9279 31.9530

100265 1.4504 0.9094 26.6940 28.6915 30.9790 28.8513

100266 1.4224 0.8458 25.6382 26.4488 27.7418 26.6590

100267 1.2849 0.9265 30.6051 32.3955 33.7231 32.2103

100268 1.2089 1.0364 33.6225 33.5314 34.5858 33.9080

100269 1.4107 1.0364 28.3745 30.9572 33.5064 30.8897

100271 2.2229 * * * * *

100275 1.3264 1.0364 31.0487 31.5424 33.3199 32.0064

100276 1.3326 1.0364 31.7067 32.3992 34.3287 32.8345

100277 1.3799 1.0222 25.5926 27.0942 28.4949 27.0616

100279 *** * 31.1951 31.6691 33.9735 32.3443

100281 1.4063 1.0364 32.8840 36.3173 36.3681 35.2827

100284 1.1512 1.0222 21.4420 24.4155 25.5819 23.7595

100285 1.2393 1.0364 34.7999 36.2107 37.2874 36.2349

100286 1.6176 0.9809 26.5809 26.1494 32.3293 29.0001

100287 1.4754 1.0364 30.3085 32.3704 34.0899 32.1810

100288 1.7381 1.0364 32.9587 35.3363 36.0630 34.7728

100289 1.5892 1.0364 31.4727 31.7699 33.2012 32.2125
CMS-1498-P 834 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

100290 1.2699 0.9178 29.7588 31.7110 32.8039 31.5893

100291 1.2805 0.9332 28.3780 28.3455 28.7323 28.4870

100292 1.4540 0.8565 28.5807 29.8156 30.8473 29.8365

100296 1.4038 1.0222 31.1475 31.8730 34.2725 32.5067

100298 0.8558 0.8981 21.9247 17.8678 19.4952 19.4589

100299 1.4576 0.9265 31.6840 31.5048 31.4297 31.5278

100300 *** * 33.1693 * * 33.1693

100301 *** * * 33.6261 * 33.6261

100302 1.1221 0.9178 * 27.9362 29.7289 28.8052

100303 *** * * * 24.9650 24.9650

100307 1.5052 0.8902 * * * *

100308 1.8792 0.9094 * * * *

100309 2.7432 0.9824 * * * *

100310 3.4842 0.9824 * * * *

100311 2.4626 0.9094 * * * *

110001 1.4636 0.8602 27.6480 28.5465 29.5684 28.6101

110002 1.3129 0.8970 28.9013 32.2910 31.4618 30.8489

110003 1.3324 0.7782 25.0089 26.0330 25.4762 25.5083

110004 1.3418 0.8794 27.2528 26.8828 29.0667 27.7197

110005 1.4382 0.9572 29.6009 30.4924 30.9276 30.4128

110006 1.6178 0.9348 30.8495 32.2597 34.4102 32.5400

110007 1.7505 0.9098 28.0684 29.8618 31.7901 29.9011

110008 1.4810 0.9572 31.8387 33.5616 31.8787 32.4273

110010 2.4555 0.9572 33.9848 33.7073 37.5179 35.0462

110011 1.4340 0.9572 30.3534 32.2028 34.6167 32.4547

110015 1.0789 0.9572 30.5016 31.7245 32.9437 31.7570

110016 1.3214 0.8621 25.9209 26.3449 27.9587 26.7064

110018 1.4095 0.9572 30.9422 30.8295 32.9879 31.5762

110020 *** * 29.4641 30.4725 31.6465 30.4885

110023 1.4384 0.9572 29.2018 31.1890 31.5376 30.6943

110024 1.5142 0.8858 28.5660 30.7207 31.0718 30.1390

110025 1.4691 0.9352 31.8968 31.0532 32.4958 31.8053

110026 1.1774 0.7782 24.3863 25.6943 25.5958 25.1969

110027 1.0792 0.7782 25.6532 26.2689 26.5342 26.1268

110028 1.8270 0.9571 32.8706 34.0699 34.0976 33.6914

110029 1.8427 0.9572 30.1146 31.6425 33.8978 31.8764

110030 1.4738 0.9572 32.0275 33.2158 35.3984 33.6145
CMS-1498-P 835 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

110031 1.2980 0.9572 30.7462 30.4811 31.6496 30.9694

110032 1.2257 0.7782 24.4968 23.1156 25.3848 24.3265

110033 *** * 32.7039 31.9373 * 32.3312

110034 1.8212 0.9571 29.6819 30.4053 34.1394 31.4559

110035 1.6957 0.9572 31.5737 31.8545 33.7827 32.4229

110036 1.9192 0.8858 28.4041 29.4915 30.6530 29.5209

110038 1.6353 0.7840 23.3669 24.2742 26.0470 24.6113

110039 1.3610 0.9571 28.4376 28.9594 29.2688 28.9113

110040 1.0861 0.9572 21.5762 21.1939 23.4093 22.0778

110041 1.4490 0.9348 27.6609 29.2068 29.6983 28.8467

110042 1.0433 0.9572 34.5137 34.0568 35.6003 34.7521

110043 1.8463 0.8858 30.3728 31.1628 31.4697 31.0207

110044 1.1492 0.7782 27.0431 25.0449 25.2725 25.8029

110045 1.0749 0.9572 28.2232 31.6766 31.6090 30.4800

110046 1.1860 0.9572 28.6286 28.4212 30.3845 29.1786

110050 1.0846 0.8483 27.1533 29.2759 30.0217 28.7933

110051 1.1636 0.7782 22.1491 23.3866 25.5805 23.8633

110054 1.5235 0.9572 31.5798 27.9775 28.7220 29.3745

110059 1.1670 0.7782 24.9271 24.4436 25.3086 24.8831

110064 1.7636 0.9119 28.7296 30.0182 33.6996 30.7770

110069 1.4012 0.8970 30.6465 31.0168 29.2608 30.2522

110071 1.0603 0.7782 23.6499 22.6384 22.8137 23.0100

110073 1.1093 0.7782 23.0072 23.4570 24.6046 23.6849

110074 1.6250 0.9348 29.0310 30.4310 32.0070 30.5025

110075 1.3248 0.8858 26.1089 26.7302 27.8478 26.9319

110076 1.6273 0.9572 31.0661 30.4815 31.6821 31.0859

110078 2.1377 0.9572 32.0516 35.8457 34.2909 34.0297

110079 1.5730 0.9572 29.0905 28.9872 29.4495 29.1738

110082 2.0493 0.9572 31.1478 33.1144 35.7031 33.2771

110083 2.0957 0.9572 34.5798 34.7446 35.7676 35.0417

110086 1.3316 0.7782 23.4772 23.1298 23.4255 23.3429

110087 1.6146 0.9572 32.8029 33.9036 33.1508 33.2981

110089 1.0939 0.7782 26.0116 25.4960 27.7584 26.4217

110091 1.4186 0.9572 28.0637 29.4898 30.4058 29.2918

110092 1.1014 0.7782 22.8602 24.5262 28.2182 24.9164

110095 1.4911 0.8547 28.0480 31.2298 30.8338 30.0970

110100 0.9291 0.8572 20.0638 22.9014 22.3608 21.8873
CMS-1498-P 836 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

110101 1.0901 0.7849 23.8601 25.5998 27.0115 25.5015

110104 1.2299 0.7782 22.2596 22.3707 22.3377 22.3206

110105 1.3045 0.8547 23.7752 24.6128 25.9808 24.8167

110107 1.9862 0.9368 31.5783 34.3508 31.8817 32.6134

110109 0.9841 0.7782 21.6019 22.5719 24.1377 22.7275

110111 1.2997 0.9571 27.6501 25.7188 26.1218 26.4751

110112 1.0053 0.8547 24.2935 23.2426 23.9046 23.7940

110113 0.9056 0.9571 22.0472 24.2980 23.8703 23.3793

110115 1.8784 0.9572 33.3902 34.4864 35.7096 34.5483

110121 1.0235 0.7782 24.5653 27.4406 28.0044 26.6723

110122 1.5890 0.8795 26.3071 28.0334 29.0791 27.8028

110124 0.9766 0.7782 24.8552 28.7544 30.2200 27.9406

110125 1.3181 0.8970 26.5006 29.4103 30.8516 28.8615

110128 1.3499 0.7782 24.5284 27.1987 29.1767 26.8886

110129 1.6241 0.9119 29.7332 26.8229 29.6690 28.7891

110130 0.8616 0.7782 21.7089 21.0352 21.7302 21.5091

110132 0.9942 0.7782 21.6039 22.3816 23.0261 22.3425

110135 1.4233 0.7782 25.1027 25.6594 25.4541 25.3958

110142 0.9519 0.7967 22.2164 21.2836 23.4220 22.2520

110143 1.4910 0.9572 30.9621 31.3623 33.8251 32.0572

110146 0.9949 0.9352 30.1181 32.7307 33.2928 32.0816

110150 1.3556 0.8970 27.7920 28.7549 25.9718 27.3903

110153 1.2669 0.8970 30.5108 30.2843 29.0378 29.9181

110161 1.6539 0.9572 32.0002 32.9894 34.2402 33.1043

110163 1.5743 0.9098 29.5693 30.7798 31.5968 30.6951

110164 1.7796 0.9368 31.2830 32.7865 34.6876 32.9571

110165 1.5814 0.9572 28.7925 28.4324 29.6512 28.9468

110168 1.8987 0.9572 30.8750 31.8921 32.9718 31.9136

110172 *** * 33.0452 34.0243 * 33.5073

110177 1.9707 0.9571 30.5526 31.9338 34.1139 32.1851

110183 1.3243 0.9572 29.6622 32.0200 32.3945 31.3716

110184 1.2816 0.9572 30.2920 30.8380 33.5282 31.6112

110186 1.3175 0.9119 29.6503 32.0599 32.7164 31.3889

110187 1.2145 0.9572 31.0164 27.6729 30.2062 29.5462

110189 1.0743 0.9572 27.4207 28.9465 30.6935 29.0587

110190 1.0617 0.8470 29.4198 28.7747 35.0710 30.9664

110191 1.4803 0.9572 28.7505 30.0142 32.1599 30.3011
CMS-1498-P 837 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

110192 1.5471 0.9572 31.6627 32.6403 33.8949 32.7867

110194 0.8287 0.7782 20.5267 23.2382 22.8941 22.2276

110198 1.4509 0.9572 34.0050 33.2450 34.3576 33.8700

110200 2.3051 0.9119 29.4633 29.6256 31.9920 30.3302

110201 1.5909 0.9368 33.4292 35.8335 37.5429 35.6404

110203 1.0033 0.9572 32.0594 33.0119 39.2026 34.2394

110205 1.1254 0.8289 26.1973 25.5319 25.5795 25.7616

110209 0.8544 0.7782 22.4549 21.6681 24.1927 22.7937

110212 1.1580 0.8131 * 23.4398 24.7805 24.1197

110215 1.5772 0.9572 30.1793 31.2779 34.0438 31.9379

110219 1.5092 0.9572 33.4481 34.8875 35.5795 34.5964

110225 1.4407 0.9572 28.9773 29.6272 31.3111 30.0865

110226 1.2984 0.9572 32.1840 30.2150 31.1969 31.1849

110229 1.5914 0.9572 * * 30.3562 30.3562

110230 1.4559 0.9572 * * 35.0804 35.0804

110231 2.6459 0.9348 * * * *

120001 1.9654 1.1635 39.0371 39.2838 41.7842 40.0704

120002 1.3903 1.1292 37.7287 38.3420 40.8461 39.0696

120004 1.4516 1.1635 32.5164 33.3874 34.8788 33.5345

120005 1.4037 1.1292 35.1996 38.2915 39.9388 37.8326

120006 1.3827 1.1635 35.7089 37.6360 38.8087 37.4368

120007 1.6959 1.1635 35.0193 34.8231 35.1439 34.9953

120010 2.0707 1.1635 34.3371 37.3680 38.3032 36.3762

120011 1.6395 1.1635 43.7527 45.9848 46.1156 45.3395

120014 1.3862 1.1292 34.2127 38.1372 37.5329 36.5854

120019 1.1857 1.1292 36.1879 37.4564 39.5249 37.7583

120022 1.8805 1.1635 34.9048 35.3877 38.3908 36.2596

120026 1.4967 1.1635 35.8413 38.2128 40.8061 38.3647

120027 1.4876 1.1635 31.8177 32.7112 36.4792 33.4996

120028 1.3976 1.1292 34.6354 34.7783 35.3970 34.9858

130002 1.4862 0.9068 24.3501 26.4728 25.9204 25.6067

130003 1.7141 0.9659 29.8793 31.4275 32.0498 31.1265

130006 1.7583 0.9305 29.0504 30.0002 31.6998 30.3256

130007 1.8904 0.9305 31.2268 33.4536 33.5741 32.8364

130013 1.4315 0.9305 33.8928 33.6160 34.7966 34.1028

130014 1.2836 0.9305 28.2831 29.1200 31.1589 29.5140

130018 1.7913 0.9676 30.2047 31.8735 34.0700 32.0682
CMS-1498-P 838 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

130024 1.2438 0.8262 25.3197 24.4757 27.9247 25.9223

130025 1.2892 0.7587 23.8592 24.2424 25.4832 24.5583

130028 1.7322 0.9379 29.3374 30.5090 32.7435 30.8806

130049 1.6650 1.0384 29.7211 30.8293 32.3219 31.0108

130062 *** * 28.3419 38.1416 38.2016 35.1513

130063 1.5471 0.9305 27.7697 28.8897 30.6360 29.0590

130065 2.0187 0.9676 25.8998 29.4957 31.7109 28.7350

130066 2.3072 0.9535 28.1502 29.3049 30.2156 29.2289

130067 3.0407 0.9676 26.8285 28.6474 * 27.6699

130068 *** * * 25.8399 * 25.8399

130069 2.8776 0.9305 * * * *

130070 2.9727 0.9305 * * * *

140001 1.2495 0.8749 23.2233 23.7481 24.5618 23.9087

140002 1.5362 0.9060 29.1097 29.6312 30.7187 29.8279

140007 1.5429 1.0503 32.4449 34.2607 34.4024 33.7444

140008 1.5089 1.0515 32.7618 33.2563 33.8475 33.2685

1400103 1.5525 1.0515 39.3727 39.7245 41.6706 40.3259

140B103 *** * 39.3727 39.7245 41.6706 40.3212

140011 1.1871 0.8380 26.2135 27.0019 27.8999 27.0776

140012 1.1826 1.0370 31.9613 33.0198 33.9621 33.0388

140013 1.3956 0.9289 26.4199 28.2787 29.7601 28.1742

140015 1.3818 0.8955 25.2504 25.8304 27.2800 26.1224

140018 1.4659 1.0515 31.5624 31.2535 32.8781 31.9237

140019 0.9025 0.8380 22.2907 22.9179 22.1774 22.4623

140026 1.2390 0.8695 28.1718 28.5497 28.8965 28.5453

140029 1.6147 1.0503 34.8938 37.7285 39.2923 37.4109

140030 1.6091 1.0503 32.1135 32.8927 34.5324 33.1540

140032 1.2724 0.8955 28.5242 28.4605 28.8062 28.6026

140033 0.8477 1.0736 31.4347 32.3417 37.3159 32.3454

140034 1.2373 0.8955 26.7250 27.6121 29.4226 27.8956

140040 1.2933 0.9179 28.5016 30.5814 29.5659 29.5161

140043 1.2977 0.8658 31.3754 34.4429 36.6352 34.1714

140046 1.5473 0.8955 25.7925 26.8384 27.7909 26.8011

140048 1.3808 1.0515 31.6290 34.4373 35.6153 33.9229

140049 1.5889 1.0515 32.0239 33.6104 35.1305 33.5575

140051 1.6022 1.0515 32.6517 32.7898 35.9661 33.8131

140052 1.4729 0.9060 26.7916 27.7932 28.3571 27.6322
CMS-1498-P 839 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

140053 1.8431 0.8948 29.9487 32.7126 32.7073 31.7542

140054 1.5563 1.0515 34.5369 36.9786 37.5300 36.3814

140058 1.2163 0.8948 26.5671 28.6945 29.4589 28.2825

140059 1.1060 0.9060 22.8597 24.6248 27.1293 24.8684

140062 1.4327 1.0515 36.6718 38.3407 40.0353 38.3865

140063 1.5742 1.0515 31.1266 34.4732 34.2888 33.3236

140064 1.2440 0.9179 26.6249 28.5964 28.7175 28.0100

140065 1.5255 1.0515 32.4661 34.3988 34.8576 33.9264

140066 0.8358 0.9060 23.6304 24.3856 25.8813 24.6266

140067 1.8100 0.9289 30.6911 31.9470 33.6485 32.1175

140068 1.3473 1.0515 31.3463 32.8724 34.3346 32.8242

140075 *** * 33.6872 34.9376 37.0601 35.1205

140077 1.1765 0.9060 22.5074 24.2006 27.9915 24.7807

140080 1.6004 1.0515 30.3788 33.0275 33.9568 32.4504

140082 1.6828 1.0515 32.0562 33.4686 33.5580 33.0486

140083 1.0840 1.0515 26.1639 29.5034 26.0278 27.1377

140084 1.4066 1.0736 31.3307 32.1286 34.0802 32.4884

140088 2.0925 1.0515 34.4137 36.6991 39.5656 36.8355

140089 1.1697 0.8380 26.6955 27.5295 28.0437 27.4281

140091 1.7821 1.0161 29.7381 33.7851 35.7416 33.1415

140093 1.3604 0.9722 31.2973 29.3377 33.9418 31.5446

140094 0.7328 1.0515 28.8621 28.0819 31.7652 29.3420

140095 1.3861 1.0515 29.9626 35.7876 34.5168 33.4434

140100 1.5029 1.0736 37.3044 39.0405 53.2763 43.9761

140101 1.2867 1.0503 31.0070 32.4260 33.9464 32.5018

140103 1.1752 1.0515 25.3630 26.4236 27.1901 26.3291

140105 *** * 30.7154 * * 30.7154

140110 1.0816 1.0370 31.3486 33.7263 37.0537 34.0414

140113 1.5438 1.0161 31.6191 33.2262 34.9622 33.3322

140114 1.5369 1.0515 31.1412 31.7038 31.4289 31.4242

140115 1.1726 1.0515 26.2606 30.2062 33.4032 29.8398

140116 1.4871 1.0515 34.2519 35.6726 37.3731 35.8074

140117 1.6529 1.0515 28.5809 34.6766 33.8389 32.2626

140118 1.5189 1.0515 33.8168 34.9352 35.7829 34.8477

140119 1.9388 1.0515 34.6543 35.5146 39.1814 36.4476

140120 1.2850 0.9289 26.2418 27.0681 28.1509 27.1802

140122 1.6620 1.0503 32.4750 34.2512 35.7240 34.1638
CMS-1498-P 840 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

140124 1.2545 1.0515 38.8976 39.9267 42.6211 40.3601

140125 1.1748 0.9060 27.6352 28.3533 30.1443 28.6668

140127 1.5604 0.9567 29.3352 30.9124 32.7929 30.9550

140130 1.3285 1.0736 34.9907 35.8275 36.5321 35.7850

140133 1.3550 1.0515 32.8941 34.0222 33.5193 33.4793

140135 1.4489 0.9154 25.9057 26.6854 27.2912 26.6118

140137 1.0866 0.9060 * 27.0616 26.9569 27.0094

140143 1.1048 0.8380 27.0312 27.2878 28.8821 27.7646

140145 1.3204 0.9060 26.9344 28.3622 29.2121 28.2021

140147 1.0814 0.8380 22.1035 22.6508 23.5511 22.7827

140148 1.7060 0.8948 28.9471 30.1467 30.0605 29.7419

140150 1.6603 1.0515 39.0316 41.6125 42.0035 40.9013

140151 0.9472 1.0515 27.3552 28.0758 27.9212 27.7895

140152 *** * 32.2803 * * 32.2803

140155 1.3206 1.0370 35.0825 36.2360 42.9342 38.0739

140158 1.4480 1.0515 32.0137 31.7570 32.5513 32.1276

140160 1.3230 0.9874 28.9043 30.0100 29.7281 29.5556

140161 1.4829 1.0370 28.8150 33.5158 34.2463 32.1524

140162 1.6404 0.9567 33.0995 33.2372 34.3289 33.5598

140164 1.7410 0.8380 27.3133 27.5981 28.8827 27.9483

140166 1.2438 0.9154 27.6725 27.5406 28.8318 28.0436

140167 1.1637 0.8380 24.2749 21.2479 26.4163 23.8760

140172 1.4264 1.0515 33.4616 36.8394 37.7898 35.9979

140174 1.6817 1.0503 33.9382 35.1535 37.2213 35.4862

140176 1.2563 1.0515 33.2235 34.3901 35.2474 34.3194

140177 1.0534 1.0515 26.0727 28.0720 30.3713 28.2119

140179 1.4032 1.0515 31.3624 30.6997 31.6593 31.2406

140180 1.4341 1.0515 29.8009 31.4683 33.1831 31.5677

140181 1.2767 1.0515 27.5414 29.0862 28.5827 28.4001

140182 1.5270 1.0515 26.4103 34.4971 35.0847 31.5371

140184 1.4579 0.8380 27.5858 28.2155 30.8810 28.8696

140185 1.4880 0.9060 27.9433 29.7742 31.1163 29.6209

140186 1.5823 1.0370 32.8063 32.5128 33.6497 32.9984

140187 1.5586 0.9060 26.9265 29.2345 29.0150 28.4359

140189 1.2512 0.8380 29.1371 25.9192 29.7443 28.2279

140191 1.4166 1.0515 29.7684 31.4076 32.4757 31.2541

140197 1.0537 1.0515 24.8715 26.9930 26.0614 25.9598
CMS-1498-P 841 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

140200 1.5345 1.0503 31.3712 33.2897 34.0868 32.9105

140202 1.4834 1.0736 34.3789 38.4323 37.4214 36.7750

140206 1.1584 1.0515 31.1406 31.5212 27.6427 29.9651

140207 1.2953 1.0515 31.6818 25.8073 32.4874 29.9202

140208 1.8222 1.0515 26.1749 26.2434 36.5625 29.1083

140209 1.6452 0.9289 28.8774 31.5349 31.8673 30.7293

140210 1.0405 0.8380 22.2512 24.1193 24.7376 23.7498

140211 1.4102 1.0503 34.5917 36.0400 37.0954 35.9438

140213 1.2807 1.0503 33.3932 33.6351 35.2016 34.1074

140217 1.5985 1.0503 33.2172 34.8475 36.7916 35.0335

140223 1.6066 1.0515 34.6997 36.6437 38.4099 36.5719

140224 1.4303 1.0515 30.2241 34.4001 32.1594 32.1531

140228 1.4921 1.0052 28.7462 30.7381 33.1724 30.9914

140231 1.5719 1.0503 35.6724 36.3601 38.3032 36.8493

140233 1.7853 1.0052 32.3376 35.7752 36.3886 34.8790

140234 1.0863 0.8695 25.7660 26.9670 27.9382 26.9002

140239 1.7231 1.0052 33.7264 35.6391 35.7029 35.0237

140240 1.4344 1.0515 28.0986 32.9491 34.4714 31.9066

140242 1.6355 1.0503 36.8032 40.7474 41.8148 39.8954

140250 1.2990 1.0515 32.9414 33.7382 35.9552 34.1583

140251 1.4663 1.0515 29.5941 31.5378 33.9137 31.6519

140252 1.5144 1.0515 36.1531 37.6031 38.6010 37.4880

140258 1.7431 1.0515 34.5696 34.9198 36.5007 35.3489

140275 1.4119 0.8658 26.7394 26.7114 28.4089 27.3093

140276 2.0654 1.0515 32.7073 33.1620 35.5860 33.8463

140280 1.4890 0.8658 26.9835 28.0388 28.9833 28.0224

140281 1.7722 1.0515 37.5700 38.6663 40.3035 38.8921

140286 1.2278 1.0503 32.2246 38.2039 37.1421 35.9395

140288 1.6334 1.0503 32.5472 34.1167 37.2937 34.6391

140289 1.3772 0.9060 26.0872 26.7573 27.9748 26.9787

140290 1.5455 1.0515 35.9679 34.5766 36.0910 35.5293

140291 1.6451 1.0736 32.7884 34.2987 37.6820 34.9828

140292 1.3397 1.0503 32.4496 32.9675 34.8169 33.4335

140294 1.2039 0.8380 26.9789 27.4105 29.1291 27.8159

140300 1.0783 1.0515 37.4508 35.5837 50.8399 41.0132

140301 0.9779 1.0515 35.9742 * 25.6069 29.8693

140303 2.2113 1.0515 33.0359 31.4718 27.9269 30.4360
CMS-1498-P 842 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

140304 1.4263 1.0503 * * * *

150001 1.2764 0.9555 32.9804 32.5348 32.6297 32.7148

150002 1.6234 1.0370 28.1076 28.3271 29.6905 28.6820

150003 1.7222 0.9253 29.3660 30.1317 33.7073 30.8984

150004 1.5661 1.0370 31.7867 34.4889 35.7071 34.0029

150005 1.3511 0.9555 31.6090 32.6541 33.1179 32.4681

150006 1.4802 0.9488 28.3403 29.7289 30.6306 29.5973

150007 1.5994 0.9010 31.0384 32.4836 32.2298 31.9370

150008 1.4456 1.0370 29.1492 30.9426 33.9870 31.5695

150009 1.5710 0.8850 26.1517 25.9625 26.7891 26.3075

150010 1.6352 0.9010 28.2616 32.8116 30.3873 30.4161

150011 1.3841 0.9555 27.7870 27.8089 29.9431 28.4970

150012 1.5535 0.9889 31.6762 32.0116 33.6506 32.4574

150015 1.4932 0.9069 30.2516 32.6995 36.4154 32.8813

150017 1.7290 0.9245 27.1262 27.4538 30.5938 28.4044

150018 1.6443 0.9488 30.0928 30.9511 32.3280 31.1271

150021 1.7703 0.9245 31.1158 33.1505 34.1233 32.7891

150022 1.0676 0.8557 26.9525 29.7752 29.6975 28.8110

150023 1.5976 0.9555 30.3667 30.8457 32.8854 31.3908

150024 1.6680 0.9555 30.6154 32.1844 32.4374 31.8086

150026 1.2688 0.9488 31.9397 33.1225 34.1049 33.0885

150029 *** * 31.0692 32.1154 34.7470 32.5698

150030 1.1399 0.9555 31.1986 34.5137 33.5357 33.0658

150033 1.4780 0.9555 32.9469 31.7314 32.8768 32.5228

150034 1.5129 1.0370 30.0048 30.9961 32.0665 31.0341

150035 1.4857 0.9069 29.2039 27.9432 28.4279 28.5206

150037 1.4116 0.9555 30.4640 32.2960 34.2666 32.3692

150038 1.2551 0.9555 31.9552 32.2545 32.5543 32.2583

150042 1.3233 0.8757 25.2456 25.2218 26.7161 25.7175

150044 1.5944 0.8850 25.9284 26.6389 28.1622 26.9147

150045 0.9713 0.8399 29.4323 30.0052 30.9207 30.1025

150046 1.5593 0.9254 27.6228 29.7184 30.9654 29.3854

150047 1.6689 0.9245 27.1847 27.9365 31.6507 28.8997

150048 1.5145 0.9637 29.5588 30.5008 32.3958 30.8298

150051 1.6271 0.9555 30.3764 31.2746 32.2657 31.3278

150056 2.0215 0.9555 30.5777 30.8461 32.4031 31.2946

150057 1.8617 0.9555 29.2358 30.4490 32.1298 30.5843
CMS-1498-P 843 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

150058 1.6714 0.9889 31.7558 32.4036 35.0250 33.0649

150059 1.4935 0.9555 36.2570 30.4189 32.7391 32.9236

150061 1.1637 0.8399 23.2427 24.7808 25.5354 24.5382

150064 1.1633 0.9555 28.9430 29.7898 31.2189 29.8692

150065 1.2812 0.9555 30.7970 31.7556 30.5764 31.0263

150069 1.1856 0.9637 27.0740 28.6514 29.6637 28.4852

150072 1.1231 0.8504 23.0619 24.6596 25.9259 24.5284

150074 1.4197 0.9555 29.4135 31.6043 32.2693 31.1351

150075 1.1147 0.9245 26.5987 27.1412 29.3253 27.5816

150076 1.3188 0.9488 30.2972 29.4643 30.9772 30.2388

150082 1.5964 0.8399 28.1302 28.0003 28.9121 28.3718

150084 1.8928 0.9555 35.0288 35.4818 35.6641 35.4130

150086 1.1942 0.9637 27.2580 28.8279 29.7408 28.6114

150088 1.3132 0.9555 30.2396 31.9171 33.4869 31.8591

150089 1.7163 0.8736 26.7290 28.0389 28.6143 27.7655

150090 1.4939 1.0370 30.9274 33.6812 32.6472 32.3780

150091 1.1504 0.9245 33.0421 32.9027 32.9069 32.9497

150097 1.2299 0.9555 29.4797 29.9967 31.3599 30.2962

150100 1.6908 0.8399 27.6339 30.0246 30.5792 29.4364

150101 1.0091 0.9245 31.6031 32.5860 33.5799 32.5996

150102 1.0478 0.9069 25.4717 30.4952 30.6858 28.7323

150104 1.2531 0.9555 30.8984 31.2245 32.6367 31.6520

150109 1.6020 0.9253 29.0076 31.0757 31.1542 30.3473

150112 1.5048 0.9555 31.7966 32.0659 33.0833 32.3322

150113 1.2748 0.9555 26.9098 29.0485 31.1284 29.0331

150115 1.3849 0.8399 22.3571 25.0221 22.3911 23.2176

150125 1.5510 1.0370 30.7113 31.6959 31.3249 31.2479

150126 1.3388 1.0370 32.6488 34.5086 34.8705 34.0137

150128 1.4381 0.9555 31.1071 30.7549 33.5421 31.8223

150129 1.4581 0.9555 32.9629 36.4709 35.4468 35.0559

150133 1.1372 0.9488 23.0662 25.1415 27.9662 25.3965

150134 *** * 27.3983 30.4440 * 28.8978

150146 1.1222 0.9457 31.8757 32.9491 33.5246 32.8186

150147 *** * 28.9269 28.9204 25.8261 28.0014

150149 0.9508 0.8399 25.3350 26.4595 28.5387 26.8755

150150 1.3103 0.9245 26.5984 26.5020 30.8735 28.0119

150153 2.2954 0.9555 37.3948 38.6948 40.7215 38.9628
CMS-1498-P 844 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

150154 2.2826 0.9555 30.5775 32.3383 33.4212 32.1347

150157 1.7623 0.9555 32.9167 35.4134 36.4550 34.9919

150158 1.3123 0.9555 30.4355 31.5245 33.9116 32.0793

150159 *** * 27.5595 * * 27.5595

150160 2.0703 0.9555 27.6375 31.2957 35.6878 31.9424

150161 1.6991 0.9555 * 32.3409 32.7880 32.5716

150162 1.8807 0.9555 * 32.2317 34.3034 33.2490

150163 1.0317 0.8850 * 26.0437 25.0146 25.4847

150164 1.2919 0.9287 * * 34.3607 34.3607

150165 1.4820 1.0370 * * 29.3019 29.3019

150166 0.9623 1.0370 * * 22.9271 22.9271

150167 2.3686 0.9245 * * * *

150168 2.1247 0.9245 * * * *

150169 1.6356 0.9555 * * * *

150170 1.3876 1.0370 * * * *

150172 1.6329 0.8850 * * * *

150173 1.6384 0.9253 * * * *

150174 0.9714 0.9069 * * * *

150175 2.3255 0.8399 * * * *

150176 2.7334 0.8850 * * * *

160001 1.3311 0.9525 25.8686 27.4207 28.7099 27.3326

160005 1.2769 0.8533 24.8597 25.6204 27.4917 26.1096

160008 0.9769 0.8533 24.1282 24.3704 24.4497 24.3155

160013 1.2219 0.8712 25.5162 26.6913 28.1891 26.7376

160016 1.5478 0.9273 26.6537 27.9879 28.8021 27.8144

160024 1.5796 0.9525 32.4253 32.7762 34.4365 33.1992

160028 1.4350 0.9550 29.8343 32.4639 33.7785 32.0904

160029 1.5442 0.9550 32.2035 33.7679 34.1917 33.3869

160030 1.3905 1.0044 30.4779 32.0333 35.0846 32.5833

160032 0.9942 0.8768 28.5645 29.0326 31.8085 29.8300

160033 1.6046 0.8654 27.4810 27.6537 29.9665 28.3732

160040 1.4565 0.8533 28.2982 27.9810 28.9805 28.4165

160045 1.7963 0.8799 28.1681 30.0063 30.1557 29.4747

160047 1.2816 0.9550 29.4286 31.2897 32.5410 31.0812

160057 1.5524 0.9422 27.7969 28.3640 29.9080 28.7095

160058 2.0933 0.9550 29.8975 31.2742 33.2320 31.5155

160064 1.4740 0.9142 33.6082 32.7787 33.3370 33.2334
CMS-1498-P 845 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

160067 1.4190 0.8533 26.7679 27.2055 27.9863 27.3213

160069 1.5388 0.8562 28.4081 29.0981 30.1739 29.2235

160079 1.5326 0.8799 28.5034 29.8338 31.5836 30.0015

160080 1.2455 0.8654 27.8745 27.4136 29.4683 28.2508

160082 1.8108 0.9525 31.7508 34.0609 34.3141 33.3856

160083 1.7250 0.9525 29.9489 31.0514 33.2497 31.4494

160089 1.3913 0.8533 23.9194 25.0810 26.2942 25.0591

160101 1.1089 0.9525 26.8515 27.1889 27.7523 27.2723

160104 1.6136 0.8654 27.0538 27.8486 29.6187 28.2439

160110 1.5439 0.8533 29.9094 30.8876 32.2713 31.0216

160112 1.2738 0.8533 26.1721 26.7136 28.5427 27.1637

160117 1.4386 0.8562 24.3326 28.8434 29.5419 27.4138

160122 1.1901 0.8533 25.3192 26.6212 27.6209 26.5321

160124 1.0341 0.8533 25.5048 27.2937 27.7842 26.8757

160146 1.5275 0.8964 25.1834 27.1213 27.6992 26.6860

160147 1.1959 0.9273 33.6394 37.2058 33.7922 34.8361

160153 1.7431 0.8964 30.4356 32.1357 33.9188 32.1398

160155 *** * * 30.2301 * 30.2301

160156 1.6040 0.8799 * * * *

170001 1.1336 0.8027 24.5942 26.2914 27.4924 26.1347

170006 1.3107 0.8448 28.3527 30.5591 29.7039 29.5405

170009 1.1982 0.9558 32.2847 29.3342 35.8139 32.4214

170010 1.2280 0.8027 28.1802 28.6734 28.0225 28.2857

170012 1.6238 0.8027 28.7878 30.0388 31.3285 30.0679

170013 1.8476 0.8886 28.3051 29.6511 29.3136 29.1030

170014 1.0892 0.9558 25.8165 27.2909 28.6642 27.2564

170016 1.7045 0.9138 28.6817 31.9998 32.2154 30.9367

170017 1.1853 0.8860 29.1463 29.5447 30.5545 29.7618

170020 1.5234 0.8756 25.0561 26.1258 27.5267 26.2659

170023 1.4396 0.8027 24.8827 24.9932 23.5945 24.4631

170027 1.4459 0.8027 24.1133 24.6748 28.0618 25.5280

170033 1.2736 0.8756 25.0404 26.9830 28.5416 26.8290

170039 1.0418 0.8860 23.5975 24.1339 25.9946 24.6007

170040 1.9930 0.9558 30.0828 33.3813 34.7542 32.6359

170049 1.5816 0.9558 31.8595 34.8212 36.0453 34.2790

170058 1.0032 0.9558 28.1330 28.6239 28.3939 28.3847

170068 1.1495 0.8438 23.8509 25.6803 26.5991 25.3770
CMS-1498-P 846 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

170074 1.1194 0.8027 24.8871 26.7280 27.0989 26.2418

170075 0.8374 0.8027 21.1965 20.9091 23.3361 21.8104

170086 1.5306 0.9138 28.5260 30.0102 31.6797 30.1229

170094 0.9016 0.8027 17.1719 26.4808 26.5182 22.5983

170103 1.4110 0.8860 25.5671 26.2628 27.2927 26.3968

170104 1.5054 0.9558 29.7793 31.7058 33.9851 31.8232

170105 1.0539 0.8027 23.4332 24.4249 25.3842 24.4229

170109 1.2001 0.9558 29.0197 33.0257 35.5902 32.6026

170110 0.9742 0.8027 24.7927 26.7359 27.8054 26.4654

170120 1.5992 0.8027 23.5287 24.9819 25.5442 24.7148

170122 1.7938 0.8860 29.6337 31.0839 31.6953 30.8189

170123 1.8214 0.8860 28.7627 29.1591 30.2106 29.3841

170133 1.0783 0.9558 25.7129 27.6138 29.6857 27.6809

170137 1.5460 0.8027 26.8029 28.6556 29.7218 28.4175

170142 1.4422 0.8948 25.5567 26.4060 27.8156 26.6242

170145 1.2223 0.8027 25.3745 26.5981 26.7895 26.2826

170146 1.6495 0.9558 31.7023 31.6451 33.8549 32.3707

170147 *** * 21.4581 * * 21.4581

170150 1.1460 0.8193 22.0265 22.2379 22.4168 22.2250

170166 0.9627 0.8027 24.1079 24.4570 25.1569 24.5747

170175 1.2714 0.8756 31.7600 30.1456 32.3747 31.4397

170176 1.6710 0.9558 30.1135 31.4048 32.9892 31.5099

170182 1.4837 0.9558 30.3805 32.3903 32.5488 31.7971

170183 2.0144 0.8860 27.7207 27.5559 27.2280 27.4870

170185 1.3885 0.9558 29.3226 31.0813 31.8944 30.8239

170186 2.5662 0.8860 30.7673 36.3546 37.5555 34.8719

170187 1.8179 0.8027 24.6419 26.2236 27.0072 25.9990

170188 2.0192 0.9558 33.7247 34.0134 35.3969 34.4593

170190 1.0539 0.8027 27.3041 28.7392 29.4546 28.5196

170191 1.6762 0.8027 26.0305 26.2347 26.3239 26.2056

170192 1.8218 0.8860 30.9230 31.7531 31.2301 31.3156

170193 *** * 24.4131 21.9349 * 23.1732

170194 1.3210 0.9558 28.2004 29.8055 35.7190 31.0251

170195 2.6049 0.9558 29.1787 31.0187 31.1434 30.5894

170196 2.4657 0.8860 29.9671 29.9241 30.4796 30.1295

170197 2.3696 0.8860 * * 33.5871 33.5871

170198 1.9628 0.8027 * * 21.2698 21.2698
CMS-1498-P 847 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

180001 1.3332 0.9634 29.9674 29.7832 30.9838 30.2388

180002 1.0159 0.8060 27.3344 28.4044 31.5452 29.0298

180004 1.1704 0.7992 22.0626 25.7454 24.9532 24.2670

180005 1.1872 0.7992 27.4317 27.9687 27.9438 27.7826

180007 *** * 26.9440 29.3465 27.5457 27.8795

180009 1.7787 0.8919 28.7048 28.9804 29.4309 29.0610

180010 2.0260 0.8798 28.2168 29.8818 30.7775 29.6381

180011 1.7841 0.8798 25.0372 26.6072 27.6650 26.5198

180012 1.5168 0.8848 27.2851 27.8386 29.2425 28.1376

180013 1.5078 0.9320 26.8108 28.6307 30.5698 28.7209

180016 1.3865 0.7992 26.9539 28.2975 29.3722 28.1740

180017 1.3206 0.8347 25.4174 26.0927 26.1053 25.8753

180018 1.4264 0.7992 24.9874 25.0082 26.1033 25.3849

180019 1.1841 0.7992 27.6801 27.5969 28.3775 27.8968

180020 1.0587 0.8060 26.8865 29.8100 32.2271 29.5397

180021 0.9701 0.7992 22.3768 24.2127 25.2066 23.9245

180024 1.2076 0.8389 26.9553 27.8181 29.6250 28.1394

180025 1.4648 0.8848 28.4172 30.2576 30.4293 29.7381

180027 1.1926 0.7992 23.3881 24.0032 25.5862 24.3439

180029 1.3851 0.8798 26.3907 29.1400 33.4416 29.5244

180035 1.5342 0.9634 34.0370 36.6577 38.6645 36.4402

180036 1.4322 0.8919 30.2643 31.9987 31.3634 31.1868

180037 *** * 33.1897 28.5734 * 30.8765

180038 1.6881 0.7992 28.2430 28.5219 29.7930 28.8753

180040 1.8998 0.8848 30.2471 28.9562 29.2132 29.3762

180043 1.0208 0.7992 24.0582 25.0444 25.3256 24.8642

180044 1.7655 0.8767 25.7990 27.7934 29.8308 27.8637

180045 1.4112 0.9634 29.9366 29.9395 30.5356 30.1379

180046 1.1858 0.8798 28.5568 30.0536 32.2894 30.3563

180048 1.3799 0.8848 24.6800 25.3490 26.8313 25.6487

180049 1.5640 0.8480 23.5756 25.8921 26.3445 25.2345

180050 1.0789 0.7992 26.7726 29.9911 31.6423 29.3799

180051 1.3473 0.7992 25.2369 26.2560 27.0283 26.1992

180053 0.9345 0.7992 23.0302 24.6694 23.9194 23.8815

180056 1.1784 0.8393 26.3973 26.6223 27.8825 26.9638

180064 1.3127 0.8306 21.9517 22.5090 22.7958 22.4385

180066 1.0981 0.8431 24.9542 27.2184 27.9417 26.6868
CMS-1498-P 848 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

180067 2.0349 0.8798 29.6053 28.9896 30.0550 29.5697

180069 1.0562 0.8767 27.6785 29.9406 32.9994 30.0147

180070 1.3985 0.8232 21.3707 22.8450 24.2407 22.8589

180078 1.1477 0.8767 29.2136 27.4672 28.5438 28.3969

180079 1.1129 0.8251 24.9911 27.2710 26.6427 26.2944

180080 1.2983 0.7992 25.3013 27.2402 28.8798 27.1688

180087 1.3935 0.7992 22.1063 23.2617 24.6628 23.3436

180088 1.8784 0.8848 30.7954 31.8151 32.8838 31.8430

180092 1.2199 0.8798 25.2900 27.0330 26.1035 26.1598

180093 1.6163 0.7992 22.3330 23.5805 24.2302 23.4008

180095 0.9817 0.7992 21.2162 23.9869 25.2742 23.4675

180101 1.3075 0.8798 28.8772 29.6176 31.3685 30.0013

180102 1.5096 0.8361 27.3901 28.3445 26.8886 27.5244

180103 1.8987 0.8798 29.7648 31.7171 33.5024 31.6641

180104 1.5028 0.8361 27.1292 28.7669 29.7545 28.5731

180105 0.9798 0.7992 24.3663 22.9902 23.8783 23.7503

180106 0.8418 0.7992 21.2271 20.1899 21.6369 21.0328

180115 0.9093 0.7992 22.7095 24.9627 24.7222 24.1589

180116 1.3811 0.8361 26.8850 26.9052 28.8350 27.5313

180117 0.8909 0.7992 24.9571 25.9593 32.4322 27.4620

180124 1.4443 0.9320 27.1359 28.2511 30.0346 28.4149

180127 1.3104 0.9634 28.3635 29.8610 30.7333 29.6661

180128 0.9465 0.7992 23.7778 23.9098 25.5746 24.4176

180130 1.6650 0.8848 29.6751 31.2746 32.7395 31.2576

180132 1.3644 0.8798 29.0563 29.5884 29.0754 29.2355

180138 1.2014 0.8848 29.2603 30.7144 32.5413 30.8691

180139 1.0292 0.7992 26.2450 28.3450 28.6303 27.6831

180141 1.9520 0.8848 28.7329 29.5347 30.4173 29.5803

180143 1.7482 0.8798 28.0780 29.0323 30.9817 29.3864

180149 1.0602 0.7992 16.4918 16.3670 21.0293 17.8136

180150 *** * * 27.9388 * 27.9388

180151 *** * * * 30.5548 30.5548

190001 1.2286 0.7946 22.5331 25.3862 29.4366 25.9390

190002 1.6804 0.8473 25.9387 27.1770 27.9755 27.0325

190003 1.4192 0.8473 28.0899 30.5381 32.3943 30.3019

190004 1.5130 0.7992 24.6563 27.0776 27.9541 26.6299

190005 1.6165 0.9005 28.3308 32.9927 37.7220 33.1294
CMS-1498-P 849 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

190006 1.3802 0.8473 25.4826 28.9179 29.0341 27.9150

190007 1.1745 0.7946 24.0538 24.6117 25.6561 24.7757

190008 1.7700 0.7992 27.2683 28.1194 28.2325 27.8874

190009 1.0153 0.8164 25.0269 24.8263 26.5888 25.4978

190011 1.0472 0.8122 21.9174 24.2068 26.6802 24.1700

190013 1.5009 0.8202 22.8380 25.2468 25.4352 24.5312

190014 1.1793 0.7946 24.5410 25.6064 40.7501 28.3699

190015 1.4420 0.9005 26.9591 29.5241 30.0800 28.8947

190017 1.4652 0.8473 25.5477 26.9640 25.4720 25.9802

190019 1.7524 0.8164 27.6057 28.6311 28.7429 28.3536

190020 1.3278 0.8726 24.2361 25.9262 28.0273 26.1642

190025 1.3326 0.7946 26.5949 26.6296 28.3544 27.1661

190026 1.7583 0.8164 25.3752 27.0875 28.8897 27.0946

190027 1.6967 0.8202 31.5047 29.4789 30.4014 30.3905

190034 1.1283 0.8135 22.9920 24.3969 26.3116 24.6129

190036 1.7818 0.9005 29.1818 27.7969 28.4731 28.4470

190037 0.7254 0.8202 28.0463 19.5982 18.7972 23.3675

190039 1.6259 0.9005 24.6848 29.0738 29.9665 27.9939

190040 1.4743 0.9005 28.2444 29.0914 29.9696 29.1339

190041 1.5169 0.8651 28.7702 29.3296 30.0940 29.3847

190044 1.2801 0.8207 22.2462 23.1701 24.3770 23.2873

190045 1.5746 0.9005 27.5873 29.2569 30.1234 29.0388

190046 1.6328 0.9005 25.1890 30.9760 30.5410 29.0312

190050 1.2653 0.7990 22.7962 23.6921 25.5258 24.0045

190053 1.2074 0.8047 20.6289 22.1404 23.5988 22.1805

190054 1.3179 0.8031 23.5137 26.5586 26.1148 25.4390

190060 1.4983 0.8202 19.8911 25.1496 27.7720 23.8818

190064 1.7058 0.8726 26.9960 28.6273 31.9836 29.2661

190065 1.7366 0.8726 22.9861 24.3651 27.9398 25.1110

190078 1.1497 0.8133 25.6943 26.0185 29.3271 27.0437

190079 1.1235 0.9005 25.3344 28.0268 29.1127 27.5269

190081 0.8388 0.7946 20.4111 21.2224 19.7228 20.4547

190086 1.3020 0.8122 22.2852 24.2040 26.9719 24.3187

190088 1.0754 0.8333 24.7450 29.5999 28.2045 27.5180

190090 0.9838 0.7946 25.8610 25.0681 27.3204 26.0691

190098 1.7167 0.8651 27.5058 27.8846 30.6530 28.7025

190099 1.0253 0.8135 25.7488 25.7136 28.4919 26.6705
CMS-1498-P 850 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

190102 1.5099 0.8473 28.3090 28.6165 29.3771 28.7633

190106 1.1005 0.8164 24.2759 25.5188 28.9361 26.2131

190111 1.7590 0.8651 27.3192 28.8406 30.5678 28.9640

190114 1.0703 0.7946 20.3651 21.1463 21.6231 21.0606

190115 *** * 26.0285 25.7014 26.8130 26.0523

190116 1.0753 0.8031 24.2154 24.4439 24.8437 24.4763

190118 1.0876 0.8651 22.6572 22.3386 23.2836 22.7652

190122 1.0958 0.8726 22.8681 24.5686 31.3913 26.4871

190124 *** * 28.6713 * * 28.6713

190125 1.6466 0.8122 26.6269 26.9761 28.3593 27.4096

190128 1.0737 0.8726 31.1819 32.2095 33.7971 32.4200

190131 1.0333 0.8726 28.5946 29.9837 * 29.2828

190133 0.9268 0.8048 23.9550 27.2643 30.2477 27.1223

190135 1.4976 0.9005 35.0547 43.3956 30.1783 34.5478

190140 0.9443 0.7981 23.6713 23.2346 24.0204 23.6404

190144 1.3143 0.8651 24.8866 25.8501 28.3036 26.4021

190145 0.9783 0.8036 21.3988 22.1298 23.2156 22.2666

190146 1.5988 0.9005 28.5984 29.8336 31.9250 30.1773

190151 0.8796 0.7946 20.6970 23.0032 23.1695 22.2541

190152 *** * 34.6508 34.6962 * 34.6751

190158 *** * 21.5594 * * 21.5594

190160 1.5857 0.8122 25.8646 26.4460 30.4379 27.3739

190161 1.1145 0.8202 23.8073 24.8249 29.2908 26.0454

190164 1.1621 0.8022 27.7265 28.2630 29.1501 28.3895

190167 1.1858 0.8473 27.1981 29.3971 31.7116 29.4476

190175 1.4156 0.9005 30.5948 31.4039 32.4181 31.4544

190176 1.8915 0.9005 28.2192 32.2906 33.3670 31.0851

190177 1.8394 0.9005 29.7252 30.9158 33.1157 31.2414

190182 *** * 30.7058 * * 30.7058

190183 1.3719 0.7992 23.3462 25.0395 27.3509 25.2419

190184 0.9910 0.7993 22.6144 22.5006 23.5652 22.8901

190185 *** * 36.7317 * * 36.7317

190190 0.9500 0.8122 27.5051 27.5875 28.9875 28.1199

190191 1.2692 0.8133 26.9656 28.1116 32.0257 28.8862

190196 0.8810 0.8473 27.7824 28.4697 30.6579 29.0035

190197 *** * 28.7044 29.4072 * 29.0218

190199 1.0401 0.8726 36.7128 29.8286 28.2996 31.3500
CMS-1498-P 851 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

190201 1.1431 0.8202 26.8550 27.8244 29.9264 28.1877

190202 1.6103 0.8726 27.6463 27.8790 27.6445 27.7278

190204 1.5181 0.9005 32.9140 31.9034 33.9644 32.9173

190205 1.7463 0.8473 30.1687 31.6103 32.4248 31.3896

190206 *** * 32.0180 30.4228 * 31.2019

190208 0.8027 0.7946 24.9405 27.5238 30.0154 27.5723

190218 0.8614 0.8651 26.5251 26.9305 28.1252 27.1844

190236 1.4843 0.8651 26.9059 28.6472 30.3119 28.6612

190241 1.3729 0.7992 26.5320 27.5130 28.2954 27.5238

190242 1.3789 0.8726 26.9729 28.7307 28.2808 28.0344

190245 1.4118 0.8122 26.4166 26.6403 28.0180 26.9888

190246 2.1718 0.7993 31.7158 31.5003 31.9438 31.7321

190249 *** * 27.0975 28.3211 25.9997 26.9704

190250 2.2150 0.9005 32.8381 35.2699 34.8604 34.3606

190251 1.3719 0.8726 25.1594 27.3657 22.3853 24.6260

190253 *** * 22.2227 * * 22.2227

190255 0.8263 0.8473 23.8035 27.8066 29.2058 26.9371

190256 1.0879 0.9005 25.9365 28.7148 28.7915 27.9122

190257 1.7222 0.8122 22.7512 24.2936 25.5176 24.1258

190258 1.8369 0.8651 25.1993 27.7948 22.8748 24.8290

190259 2.1986 0.8473 27.5518 28.9188 32.6301 29.7424

190260 *** * 33.6227 * * 33.6227

190261 1.5307 0.8122 25.4757 28.7987 29.7560 28.0746

190263 2.3305 0.8473 29.7063 36.3082 35.0861 33.5957

190265 *** * 30.9260 * * 30.9260

190266 2.9075 0.8726 24.3809 32.3423 32.8535 29.9624

190267 1.4667 0.9005 24.2794 27.6254 30.2475 27.6505

190268 1.5022 0.8473 29.1425 25.8619 27.3050 27.2594

190270 1.8564 0.9005 * 28.5382 29.0574 28.8214

190272 1.3915 0.8473 28.4558 28.4184 23.0702 27.0083

190273 1.8338 0.8726 * 22.7627 21.7837 22.2231

190274 1.8427 0.9005 * * 28.1128 28.1128

190275 *** * * * 29.8209 29.8209

190278 2.3634 0.8651 * * 23.8972 23.8972

190297 1.1631 0.7946 * * * *

200001 1.3741 0.9695 28.1145 28.9839 29.1670 28.7667

200002 1.2267 0.9509 33.2695 30.4965 27.7502 29.9690
CMS-1498-P 852 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

200008 1.4018 0.9930 29.3538 32.3955 34.1427 32.0121

200009 1.9252 0.9930 35.0743 36.9995 36.6216 36.2321

200018 1.3541 0.8589 24.6790 25.4228 25.7060 25.2725

200019 1.4200 0.9930 28.3413 30.1233 30.4156 29.6126

200020 1.2880 1.0218 34.5762 36.9185 40.2167 37.3309

200021 1.2139 0.9930 28.7614 31.8322 32.8539 31.2416

200024 1.6897 0.9509 31.0799 31.6913 31.9731 31.6024

200025 1.0822 0.9930 29.3607 30.2866 27.5904 29.0492

200031 1.2922 0.8589 23.7553 25.5973 25.9030 25.1172

200032 1.0966 0.8920 27.2276 27.8426 29.5270 28.2308

200033 1.8148 0.9695 33.6293 34.8017 34.8344 34.4346

200034 1.5798 0.9509 28.0417 28.5612 29.9180 28.9063

200037 1.1561 0.8589 26.7815 27.9167 29.6936 28.2024

200039 1.3319 0.9509 28.8043 29.9958 31.1083 30.0137

200040 1.0262 0.9930 25.5519 29.6104 29.7535 28.2949

200041 1.2990 0.8589 27.5067 28.7604 34.7992 30.1914

200050 1.1681 0.9695 30.1473 32.0363 34.1295 32.1599

200052 1.0602 0.8589 25.6238 24.4545 27.8885 25.8956

200063 1.1945 0.8589 28.2203 29.6832 30.0507 29.3664

210001 1.5177 0.9692 31.2355 30.9218 34.1438 32.0935

210002 2.0643 1.0198 36.0252 36.8782 37.3977 36.7890

210003 1.5893 1.0561 28.2566 34.4117 33.3073 31.8002

210004 1.4458 1.0573 33.9037 32.4548 34.4088 33.6063

210005 1.4195 1.0573 32.4081 32.2224 36.0013 33.5795

210006 1.1291 1.0198 27.9859 31.8510 33.3367 31.1101

210007 1.7980 1.0198 31.4125 35.3019 40.3645 35.4047

210008 1.4858 1.0198 31.8535 33.0343 33.6017 32.8716

210009 1.8265 1.0198 31.8273 34.4385 37.6659 34.7016

210011 1.4747 1.0198 30.7547 29.7694 28.5986 29.6638

210012 1.7244 1.0198 32.5327 33.8099 34.9535 33.8058

210013 1.3276 1.0198 32.1180 35.6347 35.7358 34.5777

210015 1.3298 1.0198 31.6903 34.7961 35.0662 33.9077

210016 1.8075 1.0573 35.3253 37.1478 38.1774 36.9059

210017 1.1984 0.9305 26.6208 27.9652 27.6553 27.4194

210018 1.2329 1.0573 31.5460 33.7284 36.4156 33.9785

210019 1.7439 0.9305 30.5485 30.8121 31.7957 31.0539

210022 1.5465 1.0573 36.1833 35.8394 37.6708 36.5871
CMS-1498-P 853 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

210023 1.5697 1.0277 34.1664 35.8243 37.3156 35.8033

210024 1.7983 1.0198 34.5548 36.7920 36.9018 36.1089

210025 1.3682 0.9305 23.5175 28.3956 29.8053 27.1446

210027 1.4746 0.9305 25.2143 25.6339 27.5980 26.1526

210028 0.9952 0.9559 28.5214 31.7636 34.3131 31.6983

210029 1.3475 1.0198 32.9100 33.9139 34.5075 33.8223

210030 1.1460 0.9305 29.1790 33.8729 34.4330 32.5402

210032 1.2840 1.0802 29.2785 31.6516 32.2034 31.0732

210033 1.2494 1.0198 28.4350 33.0982 34.9230 32.1677

210034 1.3548 1.0198 33.0407 35.1533 36.2172 34.8437

210035 1.3316 1.0561 30.6692 28.7165 34.0007 31.1344

210037 1.2971 0.9305 28.8708 31.0096 32.7661 30.9387

210038 1.3568 1.0198 31.1563 32.7411 36.1404 33.3841

210039 1.1580 1.0561 35.1172 33.7557 36.9817 35.3260

210040 1.2899 1.0198 31.0882 30.5834 32.5361 31.4068

210043 1.3938 1.0277 29.2762 31.9196 36.7035 32.5832

210044 1.3943 1.0198 31.5463 31.9067 33.9671 32.5153

210045 0.9460 0.9305 19.6112 23.8454 23.8643 22.3580

210048 1.4049 1.0198 29.2464 30.6650 32.7111 30.9342

210049 1.3689 1.0198 28.5970 31.5740 32.8713 31.1060

210051 1.3877 1.0561 30.7954 33.0355 33.8704 32.6204

210054 1.3042 1.0561 28.6905 32.3079 30.9544 30.6912

210055 1.3146 1.0561 30.2010 36.7615 34.9377 33.7047

210056 1.4309 1.0198 33.2271 35.5593 36.1736 34.9799

210057 1.4422 1.0573 33.7287 34.3643 36.7381 34.9642

210058 1.3962 1.0198 32.0669 32.9569 31.3100 32.0828

210060 1.1535 1.0561 32.5141 34.1974 35.0184 33.9386

210061 1.3663 0.9305 26.6842 28.6561 29.3158 28.2516

220001 1.3129 1.1613 32.0843 34.3993 36.2517 34.3061

220002 1.3674 1.1613 35.9765 37.9204 41.2350 38.3812

220008 1.3871 1.1613 35.8680 37.3794 38.4715 37.2430

220010 1.2534 1.1613 33.7392 36.1759 37.2035 35.7194

220011 1.1936 1.1613 39.1234 41.0183 43.4600 41.2510

220012 1.4849 1.2825 41.7080 43.0551 45.5643 43.4397

220015 1.2957 1.0361 35.2373 36.6427 36.3548 36.1085

220016 1.1444 1.0361 33.1424 34.9714 36.4237 34.8489

220017 1.3175 1.2342 34.6575 38.0626 37.7006 36.8223
CMS-1498-P 854 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

220019 1.1234 1.1613 26.3018 28.0084 29.0921 27.8076

220020 1.2029 1.1613 32.1528 33.6332 35.4990 33.7696

220024 1.3423 1.0361 33.0415 33.8692 34.5389 33.8318

220025 0.9616 1.1613 27.6973 26.6082 29.5458 27.9060

220029 1.2117 1.1613 32.6792 34.8311 36.1946 34.5999

220030 1.0618 1.0361 29.3714 28.8797 29.5814 29.2776

220031 1.5941 1.2342 39.4214 43.7983 46.0432 43.1210

220033 1.2423 1.1613 34.7005 36.1938 40.1729 37.0696

220035 1.4532 1.1613 36.1799 37.2879 39.7370 37.7407

220036 1.5744 1.2342 37.7301 37.0998 37.8321 37.5495

220046 1.5340 1.0483 33.8604 36.3356 37.2026 35.8565

220049 1.2222 1.1613 35.1134 35.7550 37.2433 36.0618

220050 1.1147 1.0361 30.3176 32.4636 33.3155 32.0704

220051 1.4962 0.9671 32.8693 34.7850 33.7650 33.7771

220052 1.2183 1.2342 34.9151 34.9505 36.2809 35.4000

220058 0.9958 1.1613 30.0344 31.9532 34.4760 32.1059

220060 1.1949 1.2342 36.8668 39.1180 41.3006 39.2150

220062 0.7353 1.1613 27.4755 27.3983 28.6128 27.8434

220063 1.3010 1.1613 32.2442 34.6004 35.5788 34.2281

220065 1.2968 1.0361 32.3814 33.6328 34.7541 33.5673

220066 1.4186 1.0361 * 32.6289 35.0834 33.8457

220067 1.2573 1.2342 33.9836 35.7611 37.4704 35.7586

220070 1.1469 1.1613 35.6271 37.4036 39.9838 37.7577

220071 1.8988 1.2342 40.0313 44.2752 46.1244 43.5120

220073 1.2200 1.1613 37.4249 38.9942 39.6789 38.7046

2200744 1.3861 1.1613 33.2081 34.5531 36.8098 34.8867

220B744 *** * 33.2082 34.5530 36.8098 34.8283

220075 1.6785 1.2342 33.3578 33.9698 34.7027 34.0072

220077 1.7243 1.1117 34.7345 36.4382 37.4924 36.2651

220080 1.2906 1.1613 33.1640 36.8086 36.4484 35.4648

220082 1.4119 1.1613 32.2124 33.0780 34.8104 33.3699

220083 1.1280 1.2342 35.2758 37.6415 40.5366 37.8780

220084 1.3987 1.1613 34.6275 36.1148 37.5379 36.1306

220086 1.8041 1.2342 36.2385 38.7853 41.1551 38.7907

220088 2.0559 1.2342 37.0840 37.3891 39.2279 37.9115

220090 1.2951 1.1613 35.8969 36.8628 39.5926 37.5164

220095 1.1067 1.1613 31.1644 34.1504 35.3675 33.6005
CMS-1498-P 855 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

220098 1.1646 1.1613 31.1288 32.1864 33.5413 32.2804

220100 1.3340 1.2342 35.7309 36.5606 38.7440 37.0351

220101 1.4456 1.1613 37.7292 39.3939 41.7554 39.6905

220105 1.2292 1.1613 35.8179 36.6444 39.1029 37.2192

220108 1.2101 1.2342 35.7009 37.1981 38.4718 37.1647

220110 2.0616 1.2342 43.8444 45.3683 47.3232 45.5499

220111 1.2935 1.2342 35.6223 36.8788 39.2865 37.3009

220116 1.8798 1.2342 40.0982 44.6345 47.0582 43.9023

220119 1.1259 1.2342 33.7200 36.2751 37.4673 35.8320

220126 1.2307 1.2342 35.6278 40.5321 38.0733 38.0049

220135 1.4968 1.2825 39.0296 40.3011 42.8827 40.7443

220153 *** * 20.5063 17.4773 19.0273 19.2029

220154 *** * * * 43.7359 43.7359

220162 1.7710 * * * * *

220163 1.6759 1.1613 39.4893 41.6485 42.2659 41.1896

220171 1.6535 1.1613 36.4567 39.7385 38.8272 38.4029

220174 1.2280 1.1613 32.9140 35.8880 34.9007 34.5714

220175 1.3204 1.1613 34.1572 36.6376 38.0801 36.2674

220176 1.5591 1.1613 31.4220 36.2759 38.1158 35.1359

220177 0.9796 0.9671 * * * *

230002 1.4172 0.9849 33.9708 34.2904 35.4085 34.5484

230003 1.4546 0.9386 28.9886 28.5041 30.5808 29.4057

230004 1.7665 0.9829 33.4644 33.1555 34.1260 33.5840

230005 1.3107 0.9078 29.0634 30.5550 31.3029 30.3037

230013 1.3464 1.0134 28.6430 29.9019 31.7651 29.9529

230015 1.1276 0.8900 28.9601 29.8884 32.5133 30.4506

230017 1.7269 1.0313 36.8045 35.5276 37.9122 36.7658

230019 1.6780 1.0134 35.1440 34.8302 36.2716 35.4350

230020 1.7393 0.9849 29.9492 30.4302 31.1906 30.5265

230021 1.6302 0.9979 29.5414 30.4315 31.6153 30.5478

230022 1.1397 0.9759 25.7846 29.5713 32.6757 29.2761

230024 1.7276 0.9849 34.5278 35.1416 35.9913 35.2122

230029 1.7576 1.0134 33.1482 35.5257 33.5106 34.0740

230030 1.3448 0.9102 25.1929 27.8555 29.6479 27.5704

230031 1.5302 0.9725 30.8870 30.9321 31.8722 31.2241

230034 1.3190 0.8605 29.1098 29.8711 29.1077 29.3790

230035 1.3229 0.9315 25.7099 27.0372 27.3075 26.6792
CMS-1498-P 856 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

230036 1.4412 0.8891 31.0938 31.9872 32.2768 31.7900

230037 1.2616 0.9849 28.8547 31.4423 32.0467 30.7793

230038 1.7841 0.9386 30.1040 31.5536 32.5264 31.4308

230040 1.1548 0.9315 27.2850 27.6894 27.5684 27.5177

230041 1.6226 0.9481 30.3082 31.7229 32.9174 31.6784

230046 1.9829 1.0107 33.5304 34.3952 35.9760 34.6925

230047 1.6075 0.9776 32.0248 33.2300 33.7264 32.9936

230053 1.7703 0.9849 33.5440 34.1884 35.6490 34.5004

230054 1.8298 0.9249 28.1229 28.5274 28.7117 28.4479

230055 1.3352 0.8605 28.1881 28.2657 29.6910 28.7240

230058 1.2321 0.8605 27.9643 29.2185 29.8956 29.0455

230059 1.6857 0.9386 28.3602 30.3935 32.7833 30.4889

230060 1.2298 * 28.7760 30.7515 * 29.7837

230066 1.2837 0.9829 32.3582 32.8383 34.5386 33.2625

230069 1.2686 0.9849 31.9675 33.3136 33.1722 32.8338

230070 1.6133 0.9210 28.0366 32.2151 31.6902 30.6210

230071 1.2460 1.0134 28.8879 29.6172 29.7855 29.4320

230072 1.4884 0.9386 28.8024 29.3214 30.4713 29.5569

230075 1.5124 0.9806 32.1166 33.2981 33.0856 32.8458

230077 1.8634 1.0134 31.0123 32.2274 33.2565 32.1576

230078 1.1159 0.8605 27.0069 27.7143 28.9163 27.8714

230080 1.1863 0.8605 25.6204 25.9082 27.1896 26.2395

230081 1.3269 0.8605 27.8106 27.9649 28.8068 28.1980

230085 1.1525 1.0313 27.6474 28.1395 28.6603 28.1833

230089 1.4386 0.9849 32.2311 34.4092 * 33.3212

230092 1.4241 0.9483 30.5417 29.5262 32.3303 30.8026

230093 1.1780 0.8663 27.0572 27.7275 27.1808 27.3255

230095 1.1846 0.8891 25.9210 25.9787 26.7295 26.2107

230096 1.1720 0.9979 29.7225 30.9326 35.3084 32.0067

230097 1.6800 0.9315 31.5174 32.2990 31.8133 31.8763

230099 1.2400 0.9849 29.0975 30.7388 31.3316 30.3938

230100 1.4065 0.8605 25.6594 25.9480 27.1021 26.2240

230101 1.1279 0.8605 28.8608 29.4146 30.2722 29.5256

2301045 1.7305 0.9849 34.0195 34.0176 35.3943 34.4648

230B045 *** * 34.0195 34.0176 35.3943 34.4605

230105 1.7055 0.9315 32.1124 33.0444 32.7701 32.6587

230106 1.1686 0.9386 30.0223 29.0344 31.2500 30.1013
CMS-1498-P 857 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

230108 1.2433 0.8605 25.7477 25.4728 26.0197 25.7525

230110 1.3362 0.8605 27.0280 29.0921 30.1801 28.7817

230117 1.8114 1.0313 33.9176 33.6962 34.2863 33.9717

230118 1.2950 0.8605 24.8638 27.1359 28.4445 26.8191

230119 *** * 33.2050 33.6503 * 33.4472

230121 1.3766 1.0144 27.7512 28.9511 30.8615 29.1524

230130 1.7250 1.0134 32.5613 33.6704 34.9198 33.7273

230132 1.6023 1.1382 38.2454 39.2894 39.7151 39.0892

230133 1.3475 0.8605 25.8537 26.1806 25.7151 25.9203

230135 1.0031 0.9849 31.5194 32.6527 * 32.0720

230141 1.6878 1.1382 36.3124 36.2647 40.7648 37.7993

230142 1.4114 0.9849 29.9911 30.2157 31.2257 30.4794

230146 1.4359 0.9849 29.0218 29.3346 30.5060 29.6420

230151 1.4202 1.0134 28.6724 28.6413 30.4839 29.2693

230156 1.7070 1.0107 34.7865 35.1696 34.0537 34.6666

230165 1.6917 0.9849 32.2855 31.9887 33.4514 32.6026

230167 1.6598 1.0269 32.8092 35.8019 36.9076 35.1687

230174 1.4021 0.9386 31.2469 31.6387 31.5781 31.4917

230176 1.4667 0.9849 29.2688 29.5281 30.9173 29.9026

230180 1.2683 0.8605 24.6007 28.1401 29.3516 27.1906

230190 *** * 33.6724 30.7924 36.7558 33.6260

230193 1.4023 0.9725 28.4641 29.1474 31.5897 29.7561

230195 1.5647 0.9776 32.5549 33.4975 33.4337 33.2184

230197 1.7706 1.1382 34.8066 36.4129 39.0787 36.8022

230204 1.4815 0.9776 30.1982 31.5389 34.3475 31.9741

230207 1.4333 1.0134 26.8231 27.2054 27.4081 27.1461

230208 1.2571 0.9315 25.2481 25.8892 27.8814 26.3666

230212 1.0316 1.0107 33.4379 34.3917 34.3170 34.0488

230216 1.5184 0.9725 28.9586 30.7478 30.8494 30.1826

230217 1.5091 0.9806 33.0839 35.4957 36.9025 35.2407

230222 1.6616 0.8891 32.4404 30.6277 29.6522 30.8343

230223 *** * 31.8146 34.2971 * 33.0613

230227 1.5877 0.9776 34.2762 35.4364 37.2215 35.5888

230230 1.4717 1.0269 31.4953 31.2614 35.4132 32.7682

230236 1.5236 0.9386 31.9100 32.1973 33.9442 32.7342

230239 1.4068 0.8605 23.5461 26.8301 25.7446 25.3678

230241 1.2282 0.9725 30.0248 28.4771 28.1985 28.8297
CMS-1498-P 858 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

230244 1.4335 0.9849 32.5586 33.0082 34.3841 33.3260

230254 1.5845 1.0134 31.6332 33.3035 35.0125 33.2978

230257 0.9982 0.9776 30.0674 32.6298 33.3636 32.2062

230259 1.4407 1.0107 27.9572 28.7672 29.1866 28.6444

230264 2.1717 0.9776 29.2202 35.0990 32.8671 32.3761

230269 1.4542 1.0134 34.2694 34.4514 35.2440 34.6832

230270 1.4328 0.9849 29.2408 29.0416 30.1197 29.4618

230273 1.5702 0.9849 32.5730 32.6874 34.8800 33.4102

230275 0.5916 0.9210 22.3740 * 22.6311 22.5224

230277 1.6115 1.0134 32.2545 33.8036 33.9308 33.3444

230279 0.6904 0.9849 26.8552 26.8567 28.8581 27.5609

230297 1.8559 0.9849 * 35.4246 38.9109 37.1670

230300 *** * * 40.1731 * 40.1731

230301 1.2227 1.0134 * * 29.1394 29.1394

230302 1.4906 1.0134 * * * *

240001 1.5641 1.1027 37.2211 38.3979 41.1376 38.9343

240002 1.8190 1.0682 34.6368 36.8748 39.2785 37.0047

240004 1.8454 1.1027 33.4596 36.5476 38.0780 36.0985

240006 1.2478 1.0759 32.8229 29.6609 33.3951 31.7330

240010 2.0987 1.0759 35.9131 37.5473 37.9757 37.1825

240014 1.0711 1.1027 33.4492 35.0675 34.9155 34.4959

240018 1.3136 0.9951 30.5645 32.3271 33.2201 32.0521

240019 1.1884 1.0682 34.2547 36.7033 37.3681 36.1294

240020 1.1431 1.1027 34.5703 34.6135 36.6782 35.2976

240022 1.0184 0.9146 28.5905 29.9313 31.1852 29.9071

240030 1.5777 0.9146 27.6596 29.4253 30.4810 29.1808

240036 1.5881 1.1027 37.2207 39.2407 40.6853 39.1270

240038 1.5960 1.1027 34.7357 35.8365 37.8663 36.2048

240040 1.0412 1.0682 30.0255 31.3287 34.0437 31.7765

240043 1.2674 0.9146 25.7424 27.1539 28.4042 27.1230

240044 1.0396 0.9771 28.5705 29.8375 29.2879 29.2433

240047 1.5709 1.0682 35.6763 36.7122 36.2255 36.2136

240050 1.2531 1.1027 33.7964 34.6160 36.3370 34.9328

240052 1.2601 0.9146 31.0934 33.1438 33.8454 32.7273

240053 1.6040 1.1027 34.4210 35.4738 36.3414 35.4352

240056 1.3478 1.1027 35.8603 36.1085 32.7052 34.7799

240057 1.9154 1.1027 34.8374 35.4436 38.0303 36.0623
CMS-1498-P 859 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

240059 1.1327 1.1027 32.5958 33.5784 33.2499 33.1597

240061 1.8971 1.0759 34.6031 36.2545 37.5561 36.1385

240063 1.6747 1.1027 36.9822 38.3735 38.3869 37.9467

240064 1.2584 0.9280 29.9917 34.2284 35.6462 33.1970

240066 1.6077 1.1027 39.6609 38.4941 39.9654 39.3787

240069 1.2417 1.1027 31.1673 31.6325 35.5345 32.8398

240071 1.1899 1.1027 32.5460 33.1094 35.2567 33.6586

240075 1.2925 0.9146 30.3230 31.5984 32.9126 31.6235

240076 1.1549 1.1027 33.7950 35.4135 37.1723 35.5183

240078 1.7615 1.1027 36.2276 37.3608 39.4962 37.7013

240080 2.0360 1.1027 36.5390 37.7353 39.9460 38.0844

240084 1.1431 1.0682 29.0275 30.3789 32.3263 30.5812

240088 1.2605 0.9146 30.7240 31.4165 32.7525 31.5969

240093 1.5139 0.9270 30.4744 31.3517 32.3639 31.4358

240100 1.3557 0.9146 30.9481 32.5307 33.0821 32.1908

240101 1.1930 0.9146 28.5503 28.7121 29.5095 28.9269

240104 1.3000 1.1027 35.8839 36.0711 40.4033 37.5188

240106 1.6415 1.1027 33.9984 36.8942 39.4450 36.7952

240115 1.5182 1.1027 36.2788 37.5802 38.9388 37.6716

240117 1.2305 0.9673 29.0894 30.4437 29.6594 29.7231

240132 1.4186 1.1027 36.4252 37.0941 37.9072 37.1624

240141 1.1176 1.1027 34.2473 35.8696 37.1809 35.6971

240166 1.2510 0.9146 26.1732 27.3184 28.1765 27.2416

240187 1.2545 1.1027 30.9646 33.5186 33.4717 32.6497

240196 0.8864 1.1027 35.0345 35.4472 38.7978 36.4399

240206 0.8428 1.4448 * * * *

240207 1.3525 1.1027 36.4569 37.7179 39.4085 37.8940

240210 1.3728 1.1027 36.5950 37.7064 38.2195 37.5323

240211 0.6922 0.9958 16.6158 16.1460 16.5163 16.4219

240213 1.4249 1.1027 37.4608 38.4222 39.6158 38.5555

250001 2.1543 0.8125 24.3404 26.7079 28.0700 26.4339

250002 0.9292 0.8035 25.0342 31.2353 32.6776 29.5266

250004 1.8180 0.8981 24.8086 29.1096 30.0764 27.9177

250006 1.1385 0.8981 27.0511 26.9193 29.3899 27.7903

250007 1.1775 0.8923 29.3479 32.6672 31.9040 31.2803

250009 1.4344 0.8379 24.9118 25.9247 27.4133 26.1295

250010 1.0254 0.7738 22.7988 23.8749 24.5667 23.7460
CMS-1498-P 860 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

250012 0.9436 0.9213 26.4110 29.8873 27.8154 28.0019

250015 1.3891 0.7738 22.3685 22.7775 24.6835 23.2714

250017 0.9972 0.7738 25.7404 25.5007 22.3075 24.4789

250018 0.7464 0.7738 19.1108 19.5527 20.4538 19.7094

250019 1.6160 0.8923 27.7230 28.4743 30.6079 28.9597

250020 0.9777 0.7738 23.1521 26.9602 27.3319 25.8108

250023 0.8903 0.8350 19.5081 22.2932 17.2321 19.5475

250025 1.1249 0.7738 23.0555 26.0579 25.2972 24.7574

250027 0.9255 0.7738 32.5451 26.7593 26.0044 28.1387

250031 1.3465 0.8125 26.7507 28.6356 29.2948 28.1906

250034 1.6373 0.8981 27.9279 29.3365 30.0088 29.1234

250035 0.7907 0.7738 20.5251 24.0653 21.6802 22.1592

250036 0.9473 0.8182 22.5676 22.6781 24.7319 23.3935

250038 0.8901 0.8125 30.7960 27.1958 27.6152 28.2419

250040 1.6037 0.8350 26.2268 28.4423 29.0586 27.8924

250042 1.2263 0.8981 27.4610 25.8791 30.3623 27.9247

250043 1.0488 0.7738 21.1265 22.4618 22.6912 22.0994

250044 0.9899 0.7738 26.1732 26.9451 27.9188 27.0217

250048 1.5964 0.8125 27.6339 27.4186 27.6442 27.5667

250049 0.9434 0.7738 24.2227 24.2129 21.5835 23.2761

250050 1.2840 0.7738 22.4429 22.6843 23.7790 23.0068

250051 0.7692 0.7738 14.1662 15.6982 15.7373 15.2520

250057 1.2695 0.7738 22.9683 22.5524 25.9738 23.8179

250058 1.2848 0.7738 19.6720 20.4748 22.1248 20.7697

250059 0.9412 0.7738 25.5982 24.8145 23.7995 24.7437

250060 0.8138 0.7738 27.0354 31.0689 32.3114 29.8012

250061 0.8353 0.7738 25.1495 23.3006 22.9622 23.7108

250067 1.1274 0.7738 23.8027 28.2894 27.2284 26.3793

250069 1.6226 0.8022 23.4495 25.8456 27.7173 25.6762

250072 1.7556 0.8125 27.5791 30.5382 33.2443 30.4790

250077 0.9612 0.7738 19.6333 19.3962 20.7217 19.9362

250078 1.7165 0.8350 23.9598 26.5481 27.5440 26.0252

250079 0.8236 0.8125 46.0349 32.3758 33.2547 37.9283

250081 1.4366 0.8022 24.8281 23.1385 25.6748 24.4935

250082 1.5383 0.8311 25.6218 27.8096 29.4889 27.6785

250084 1.1549 0.7738 19.5694 20.1192 21.2261 20.3028

250085 0.9389 0.7738 24.6757 24.5765 25.8783 25.0289
CMS-1498-P 861 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

250093 1.2675 0.7738 26.4351 27.0937 28.9844 27.5340

250094 1.6566 0.8350 25.4232 26.1331 28.4550 26.7033

250095 1.1011 0.8125 25.9021 30.7505 25.2111 27.0637

250096 1.2779 0.8125 27.7291 27.5206 29.1993 28.1437

250097 1.5766 0.8580 22.7916 23.6607 24.1451 23.5520

250099 1.4358 0.8125 27.5757 25.0076 26.7877 26.4479

250100 1.4971 0.8022 27.5484 28.2019 29.4874 28.4283

250102 1.5878 0.8125 25.5327 27.8758 27.2188 26.8670

250104 1.4298 0.8022 25.4008 26.3140 25.7731 25.8274

250112 0.9397 0.7738 27.4162 29.6978 23.5300 26.6029

250117 1.0807 0.8350 24.5706 26.0965 24.8866 25.2046

250122 1.1551 0.7738 23.4908 27.3606 31.2642 27.3826

250123 1.3700 0.8923 29.8299 29.5520 32.4487 30.5969

250124 0.8592 0.8125 21.9420 22.4247 23.9262 22.8076

250125 *** * 32.7411 29.0819 31.9629 31.3858

250126 1.0391 0.9213 25.2581 26.8712 26.7811 26.3514

250127 0.8051 1.4448 * * * *

250128 1.0195 0.8184 23.5918 24.7051 26.7124 25.1932

250134 0.9778 0.8125 22.0846 40.7995 30.5066 30.6943

250136 1.0796 0.8125 27.1479 27.8270 30.6565 28.5419

250138 1.3635 0.8125 27.3132 27.0688 29.2021 27.8594

250141 1.5961 0.9213 33.4413 32.1496 31.6915 32.3561

250149 0.8744 0.7738 17.0964 17.2423 20.1488 18.0903

250151 0.6315 0.7738 * 17.3962 25.0894 22.4010

250152 0.9097 0.8125 28.5526 29.8216 30.9016 29.7410

250161 *** * * 26.0070 * 26.0070

250162 1.0038 0.8937 * * 31.4828 31.4828

260001 1.7887 0.8448 31.1866 28.6690 30.0120 29.9052

260004 0.9453 0.8127 23.9584 24.1764 25.5508 24.5784

260005 1.6662 0.9060 31.1050 33.1020 35.2618 33.2207

260006 1.5176 0.8127 33.8253 34.3548 36.2278 34.8344

260009 1.1928 0.8605 26.6685 26.2248 26.1705 26.3503

260011 1.6596 0.8605 31.2612 31.4415 31.7034 31.4717

260015 1.1557 0.8127 25.0250 25.1585 26.2721 25.5036

260017 1.3354 0.8605 26.2621 27.4586 29.5743 27.7703

260020 1.7611 0.9060 30.9599 32.0889 31.9904 31.7069

260021 1.4447 0.9060 19.5810 19.3770 32.4283 21.7242
CMS-1498-P 862 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

260022 1.4859 0.8261 25.9391 25.6866 26.7028 26.0941

260023 1.5492 0.9060 25.5899 26.7586 27.4201 26.6186

260024 1.1778 0.8127 20.7136 22.4347 22.9479 22.0397

260025 1.4225 0.8955 24.5042 24.4959 24.4546 24.4847

260027 1.8912 0.9558 31.0236 32.3066 33.7779 32.3722

260032 1.9415 0.9060 28.7183 29.8257 30.8428 29.7999

260034 0.9685 0.8127 28.7736 29.7821 29.4705 29.3435

260040 1.7603 0.8413 27.3680 28.5035 29.9909 28.6335

260047 1.4981 0.8127 27.2667 27.1986 27.8259 27.4384

260048 1.2788 0.9558 29.6969 30.1691 30.8650 30.2475

260050 1.0775 0.8127 27.8065 27.6085 33.8795 29.6615

260052 1.3299 0.9060 29.6998 31.5722 32.2076 31.2112

260057 1.0671 0.9558 23.8181 27.0128 27.1389 26.1324

260059 1.2757 0.8204 25.3025 26.9521 27.3419 26.5876

260061 1.1228 0.8127 23.6717 24.7824 27.0467 25.1434

260062 1.3726 0.9558 29.6156 30.7159 32.0976 30.8722

260064 1.4339 0.8216 21.4932 23.6002 25.8393 23.6092

260065 1.7126 0.8413 28.3411 29.9325 29.6384 29.3273

260068 1.7723 0.8261 28.1246 29.3972 29.5631 29.0347

260070 0.8779 0.8127 25.2997 26.2370 25.8550 25.8217

260074 1.2943 0.8261 28.6216 28.4171 29.3367 28.7901

260077 1.7066 0.9060 28.7204 28.9940 29.4958 29.0802

260078 1.2849 0.8127 23.1785 24.7794 25.1259 24.3417

260080 1.0588 0.8127 18.6813 19.0041 19.1541 18.9629

260081 1.6605 0.9060 32.0799 34.8761 40.1198 35.5606

260085 1.6239 0.9558 29.6514 30.4727 31.6239 30.5668

260091 1.5674 0.9060 30.2636 32.9623 33.9609 32.4273

260094 1.6223 0.8413 25.1491 27.0127 27.2078 26.4777

260095 1.5411 0.9558 29.9090 30.9142 30.5602 30.4766

260096 1.6341 0.9558 32.9383 33.1804 34.9570 33.7008

260097 1.1617 0.8427 27.3129 28.2444 28.5379 28.0218

260102 1.0526 0.9558 30.7678 29.1467 30.1752 29.9874

260104 1.7078 0.9060 29.5891 32.0122 33.6904 31.7812

260105 1.8595 0.9060 32.4292 33.4278 35.1672 33.6282

260107 *** * 29.7775 38.3668 * 33.8526

260108 1.8751 0.9060 28.5654 30.1064 31.5495 30.0747

260110 1.6558 0.8810 28.0381 28.5364 30.1062 28.9080
CMS-1498-P 863 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

260113 1.2656 0.8380 23.0826 23.6758 25.6538 24.1544

260115 1.2365 0.9060 25.5658 26.5268 27.1964 26.4347

260116 1.0191 0.8380 22.5536 25.1758 27.7471 24.8978

260119 1.3362 0.8363 31.5003 26.4382 26.5894 27.9902

260137 1.7978 0.8448 31.4091 28.3521 29.0069 29.4979

260138 2.0048 0.9558 31.7582 33.4156 34.9809 33.4163

260141 2.0499 0.8261 26.6684 28.3492 28.1099 27.7524

260142 1.2469 0.8127 22.8205 25.0940 24.1327 24.0438

260147 0.8251 0.8127 22.9689 22.8326 25.3191 23.5737

260159 *** * 24.3027 25.5039 26.0684 25.2758

260160 1.0383 0.8271 26.6715 27.9585 25.0259 26.6874

260162 1.4325 0.9060 30.5761 32.3673 33.0717 32.0297

260163 1.2350 0.8214 23.8644 25.0443 26.1076 25.0496

260166 *** * 29.5259 30.6020 * 30.0575

260175 1.0460 0.9558 25.7069 26.5767 28.1661 26.8058

260176 1.7475 0.9060 30.6205 32.4957 33.1495 32.1198

260177 1.3018 0.9558 29.0815 31.1662 33.9925 31.4147

260178 1.9849 0.8261 26.9902 28.9170 29.8616 28.6265

260179 1.5711 0.9060 29.6316 30.3276 30.8119 30.2731

260180 1.7531 0.9060 30.7336 31.4721 32.7989 31.6539

260183 1.6167 0.8810 31.4916 32.2621 31.3742 31.7100

260186 1.5186 0.8605 29.1874 30.8706 32.4493 30.8711

260190 1.3538 0.9558 30.9003 32.2069 34.1815 32.3839

260191 1.5869 0.9060 27.8648 28.7185 29.0100 28.5516

260193 1.3548 0.9558 29.5436 30.5190 31.7196 30.5601

260195 1.4152 0.8127 25.0294 25.6697 26.6828 25.8073

260198 *** * 27.9093 31.4660 * 29.5529

260200 1.4152 0.9060 30.5032 32.0910 35.5276 32.9288

260207 1.1898 0.8413 23.6392 22.8308 22.7884 23.0797

260209 1.0738 0.8605 26.4203 33.7185 32.9213 30.8380

260210 1.2999 0.9060 36.4055 33.5701 35.4741 35.1652

260211 1.3016 0.9558 37.1557 42.4297 36.1850 38.3836

260214 1.3113 0.9558 31.0175 31.7957 34.1199 32.2663

260216 1.3206 0.9558 * 32.4039 33.4387 32.9968

260217 *** * * 12.2879 * 12.2879

260219 1.3400 0.9060 * * 30.7118 30.7118

260220 *** * * * 28.4885 28.4885
CMS-1498-P 864 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

260221 2.0760 0.8413 * * * *

260222 3.1344 0.9558 * * * *

260223 2.1186 1.0377 * * * *

270002 1.1098 0.8439 28.3379 26.9419 28.2480 27.8202

270003 1.2908 0.8439 28.0543 28.5127 29.8638 28.8333

270004 1.7281 0.8944 28.5869 29.4694 31.2252 29.8125

270012 1.6404 0.8618 28.0672 27.9087 28.8521 28.2738

270014 2.0243 0.8811 28.2582 30.1101 30.2981 29.5713

270017 1.3880 0.8618 29.3542 29.4260 31.2231 30.0045

270023 1.6600 0.8811 28.1896 30.9908 31.5012 30.2124

270032 1.0183 0.8439 21.6360 21.5106 23.5705 22.2266

270049 1.8451 0.8944 29.8891 31.3941 31.2349 30.8507

270051 1.4506 0.8618 29.3941 29.1163 30.1070 29.5459

270057 1.4282 0.8439 28.3627 29.5317 31.6476 29.8918

270074 0.9307 1.4446 * * * *

270086 1.4090 0.8439 21.9017 27.3995 29.1257 26.4704

270087 1.5197 0.8439 24.9197 24.2168 24.9946 24.6957

280003 1.8427 0.9490 32.3780 33.7700 34.2000 33.4257

280009 1.8904 0.9490 28.1559 31.9280 33.6269 31.2504

280013 1.7682 0.9554 30.3120 31.9793 32.8493 31.7431

280020 1.6813 0.9490 29.4831 30.3731 32.3597 30.7314

280023 1.4338 0.9490 30.0717 31.9420 31.3884 31.1400

280030 1.8814 0.9554 31.8758 33.4544 34.0104 33.0874

280032 1.4305 0.8886 25.6549 25.8707 27.6089 26.3994

280040 1.6949 0.9554 30.7406 32.1005 32.7707 31.9093

280060 1.7924 0.9554 30.4625 32.0607 33.5256 32.0484

280061 1.4381 0.8886 28.9591 29.2231 30.8542 29.7095

280065 1.2973 0.9418 29.5470 30.1143 30.8900 30.1783

280077 1.3795 0.9490 29.9223 29.7362 31.3194 30.3231

280081 1.6286 0.9554 28.9696 31.0768 35.8382 31.9389

280105 1.2687 0.9554 30.0472 33.3196 33.1407 32.1834

280111 1.1463 0.8886 28.3541 29.0865 29.9691 29.1189

280119 0.8685 1.4448 * * * *

280123 *** * 20.2741 20.6384 29.1514 22.7020

280125 1.5076 0.8968 24.7466 25.1212 30.7311 26.8386

280127 1.9295 0.9490 26.5659 28.4607 27.8198 27.6863

280128 2.7835 0.9490 27.1024 19.2781 30.1879 25.4888
CMS-1498-P 865 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

280129 2.0282 0.9554 27.9511 30.4258 30.9589 29.8728

280130 1.4549 0.9554 29.9645 32.4243 33.1336 31.9744

280131 2.1542 0.9554 * * * *

290001 1.7980 1.0439 33.3318 32.3610 34.3377 33.3434

290002 0.8656 0.9960 22.7362 25.4458 22.9980 23.6418

290003 1.8020 1.1811 34.6433 36.8494 40.5365 37.2945

290005 1.5573 1.1811 34.2373 34.2514 36.3971 34.9747

290006 1.1041 1.0439 33.3243 32.9232 35.2729 33.8405

290007 1.8733 1.1811 41.2395 44.0851 42.0134 42.4287

290008 1.2259 0.9555 33.2473 36.1620 38.0995 35.8471

290009 1.8183 1.0439 34.2103 38.6692 40.9685 37.9159

290012 1.3732 1.1811 38.3731 38.1494 39.8936 38.8324

290019 1.6158 1.0439 32.2817 34.3215 35.6893 34.1535

290020 0.9789 0.9555 27.2908 25.3592 28.1710 26.9891

290021 1.6573 1.1811 36.8728 39.5976 41.5629 39.3340

290022 1.7355 1.1811 38.8262 40.9896 41.3493 40.4278

290027 0.8303 0.9555 29.1123 25.1315 17.5194 22.5706

290032 1.4270 1.0439 36.9175 38.9632 37.5999 37.8103

290039 1.6578 1.1811 34.6359 37.5722 41.3057 37.8449

290041 1.4861 1.1811 38.4445 40.0602 42.8383 40.5654

290045 1.7861 1.1811 38.2560 38.5440 40.6077 39.1861

290046 1.5403 1.1811 38.3112 41.5550 42.1303 40.8035

290047 1.7100 1.1811 35.6381 38.6892 41.6528 38.6969

290049 1.4003 1.0439 33.4278 33.2014 34.9166 33.8543

290051 2.0280 1.0282 32.5277 37.2727 37.4812 35.6526

290053 1.7043 1.1811 * * 41.7596 41.7596

290054 1.3973 1.1811 * * * *

290055 1.5038 1.0282 * * * *

300001 1.4814 1.0054 31.0122 31.4533 31.9222 31.4790

300003 2.0987 1.0054 37.7246 37.3007 37.8482 37.6390

300005 1.4367 1.0054 28.8402 29.4927 32.0379 30.1494

300011 1.3554 1.0990 33.0785 32.7459 35.9010 33.9466

300012 1.4793 1.0990 33.0569 34.8519 34.3089 34.0963

300014 1.2376 1.0218 30.7735 32.8211 33.7545 32.5359

300017 1.4332 1.1021 33.4164 35.2028 37.5444 35.3995

300018 1.3748 1.0218 31.5028 32.7008 33.9529 32.7460

300019 1.3351 1.0258 28.3114 30.5332 31.7382 30.2375
CMS-1498-P 866 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

300020 1.4207 1.0990 32.4655 34.7678 36.3083 34.5838

300023 1.4607 1.0054 32.3202 34.2636 35.1291 33.9582

300029 1.8966 1.1021 32.0033 35.3112 36.0190 34.4466

300034 1.8501 1.0990 33.5537 33.7397 32.8443 33.3569

310001 1.8394 1.2884 41.4946 44.8619 50.6238 45.4383

310002 1.8317 1.2619 37.9484 39.7599 41.2456 39.6858

310003 1.3084 1.2884 40.1543 39.8679 42.8065 40.9664

310005 1.3923 1.1099 34.7657 34.4087 36.0844 35.0992

310006 1.4947 1.2884 30.4296 29.1025 36.9201 33.0307

310008 1.4134 1.2884 34.3268 36.2903 37.2702 35.9673

310009 1.4910 1.2619 35.4624 37.9098 37.8328 37.0580

310010 1.3390 1.1069 36.0823 34.1071 34.7174 34.9269

310011 1.3734 1.1069 37.4855 34.0850 38.0642 36.5086

310012 1.5578 1.2884 41.9630 41.3814 44.1956 42.5328

310013 *** * 32.9488 * * 32.9488

310014 1.9878 1.1069 35.0124 39.7527 42.5981 39.1445

310015 1.9757 1.2619 40.8229 39.5076 41.0862 40.4747

310016 1.3519 1.2884 41.0363 39.7563 42.6321 41.1071

310017 1.3342 1.2619 35.9806 34.8881 36.6814 35.8577

310018 *** * 32.6956 33.5069 33.6869 33.3032

310019 1.5578 1.2884 31.8930 34.6618 36.9116 34.4783

310020 *** * 38.4266 34.8440 33.1591 35.6399

310021 1.5817 1.1069 32.2064 33.2554 32.9745 32.8103

310022 1.3683 1.1069 32.8079 32.8154 35.0037 33.5940

310024 1.4947 1.1099 36.8666 34.7011 38.7731 36.8133

310025 1.4049 1.2884 32.1481 35.2564 40.8475 35.5411

310026 *** * 30.1321 31.9905 * 31.0489

310027 1.5531 1.1099 34.6471 34.1653 35.4202 34.7452

310028 1.2605 1.1099 34.8332 37.2987 38.5629 36.9482

310029 1.7816 1.1069 35.2084 36.5179 37.3225 36.3377

310031 2.6733 1.1069 39.5911 38.2643 39.1387 39.0033

310032 1.4461 1.1069 35.2402 35.8019 38.1019 36.3949

310034 1.4950 1.1069 36.8614 37.1191 38.7316 37.5645

310037 *** * 40.4642 44.3134 40.6768 41.8620

310038 1.8962 1.2619 39.8707 40.7395 41.0737 40.5745

310039 1.3494 1.2619 32.6425 33.4253 37.6948 34.5052

310040 1.2885 1.2884 41.2246 38.3232 42.0647 40.5945
CMS-1498-P 867 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

310041 1.3677 1.1069 35.2009 34.4308 35.9905 35.2159

310044 1.4058 1.1069 33.5868 35.9981 36.7851 35.4384

310045 1.6751 1.2884 39.2097 40.3222 39.4667 39.6718

310047 1.3605 1.1069 37.7220 38.1213 38.6544 38.1625

310048 1.3744 1.1099 34.5256 33.9641 35.1089 34.5372

310050 1.3717 1.2619 37.9214 32.5213 36.1607 35.4032

310051 1.5361 1.1099 39.7671 37.9104 41.4326 39.7291

310052 1.4235 1.1069 36.5494 36.2042 36.6736 36.4774

310054 1.3353 1.2619 38.2432 37.2851 38.6073 38.0262

310057 1.4774 1.1069 34.2052 32.8649 33.3760 33.4433

310058 1.0417 1.2884 30.4436 32.1349 27.4856 30.0784

310060 1.4272 1.1069 27.9134 30.4626 31.0602 29.7917

310061 1.3306 1.1069 33.5586 33.6084 36.9685 34.7294

310063 *** * 38.1481 36.7131 40.5744 38.4253

310064 1.6138 1.1069 39.8091 39.9456 39.4518 39.7314

310069 1.2782 1.1069 35.1376 36.9367 38.6358 36.8960

310070 1.4374 1.2619 36.9999 36.8951 38.3936 37.4045

310073 1.8090 1.1069 36.9249 37.5317 38.0676 37.5047

310074 1.3788 1.2884 39.0729 35.9044 36.5051 37.2159

310075 1.3708 1.1069 33.5253 33.8979 36.8738 34.7688

310076 1.7422 1.2619 38.1671 39.0325 41.7283 39.6466

310081 1.4281 1.1069 31.7981 32.1241 34.1491 32.7041

310083 1.5302 1.2619 28.3406 28.2875 32.3793 29.6429

310084 1.2977 1.1069 34.9626 34.3130 35.9514 35.1066

310086 1.2760 1.1069 30.9467 31.4837 32.6634 31.7177

310088 1.1089 1.1069 31.2437 28.1703 30.2907 29.8993

310090 *** * 33.9174 36.2502 39.0484 36.2524

310091 1.2160 1.1069 35.2913 34.8679 36.3009 35.4738

310092 1.5401 1.1069 32.8431 34.8028 35.8723 34.4902

310093 *** * 32.3860 33.4460 31.7831 32.5380

310096 1.7501 1.2619 34.2014 36.3201 35.9746 35.5053

310105 *** * 32.0277 31.3423 38.1225 33.7325

310108 1.5387 1.2619 36.2848 38.3403 40.4235 38.3602

310110 1.3629 1.1069 35.6825 36.5227 34.9354 35.6895

310111 1.3887 1.1069 36.0748 38.3519 38.6478 37.7170

310112 1.3763 1.1069 34.5337 33.6207 34.5131 34.2210

310113 1.3519 1.1069 35.0245 38.0066 38.4702 37.2154
CMS-1498-P 868 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

310115 1.4081 1.1069 32.1197 33.7061 34.3696 33.4228

310116 1.3231 1.2884 27.8677 35.3805 35.7518 32.7295

310118 1.3491 1.2884 32.8286 33.2234 33.7344 33.2605

310119 1.9233 1.2619 41.2997 46.1339 47.1035 44.7858

310120 1.0481 1.1099 35.1661 36.3365 37.6331 36.3759

310126 *** * 34.3189 * * 34.3189

310127 *** * * 40.1255 * 40.1255

320001 1.8271 0.9638 31.4193 33.6433 35.9775 33.8378

320002 1.5849 1.0788 34.1610 35.6036 37.4477 35.7737

320003 1.0965 1.0400 31.5792 31.4445 34.6790 32.5200

320004 1.3353 0.9030 28.2407 30.5543 31.0096 29.9078

320005 1.6317 0.9505 25.2168 26.4658 27.9464 26.5665

320006 1.2566 0.9505 28.5177 31.6888 35.2623 31.7638

320009 1.7026 0.9638 31.3296 31.7240 33.1269 32.2269

320011 1.1092 0.9374 28.9951 30.6151 31.5915 30.3549

320013 1.2176 1.0400 31.2890 31.7159 31.8550 31.6268

320014 1.0148 0.9183 30.4803 29.8578 33.1461 31.2305

320016 1.1858 0.9030 26.6392 27.7121 27.8593 27.4337

320017 1.3865 0.9638 30.5787 30.9261 28.3807 29.6659

320018 1.5868 0.9207 28.3465 29.9038 32.8908 30.3587

320019 *** * 28.7067 31.8205 34.4963 30.4182

320021 1.5923 0.9638 29.6464 31.3577 32.8369 31.4496

320022 1.1128 0.9030 27.5152 28.7195 30.9229 28.9228

320030 0.9864 0.9030 25.5267 28.5145 29.5507 27.9621

320033 1.2665 1.0400 30.1846 32.8631 36.8262 33.1229

320037 1.1970 0.9638 27.8982 28.6968 29.0394 28.5512

320038 1.2537 0.9030 31.6526 33.2147 34.1644 33.0257

320057 0.8901 1.4448 * * * *

320058 0.7912 1.4448 * * * *

320059 1.0293 1.4448 * * * *

320060 1.0719 1.4448 * * * *

320061 1.0731 1.4448 * * * *

320062 0.8817 1.4448 * * * *

320063 1.2855 0.9315 27.4946 30.2997 31.3336 29.7847

320065 1.2319 0.9030 26.9130 27.9999 31.2804 28.6457

320067 0.8536 0.9030 25.4121 23.6677 26.3413 25.1468

320069 1.0613 0.9030 25.3151 26.5521 25.6533 25.8355
CMS-1498-P 869 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

320070 0.9578 1.4448 * * * *

320074 1.3254 0.9638 28.8088 29.8317 31.0548 30.0014

320079 *** * 31.5661 30.3600 * 30.9560

320083 2.2519 0.9638 32.9476 35.1125 33.6069 33.8474

320084 0.8797 0.9030 24.2902 25.9161 27.1350 25.8609

320085 1.7238 0.9207 28.4537 28.7114 30.1280 29.0969

320086 1.3497 0.9030 * * 25.1198 25.1198

320087 1.6719 1.0788 * * 42.5428 42.5428

320088 2.4348 0.9207 * * 34.8348 34.8348

330002 1.7166 1.3154 34.7270 35.3553 37.0389 35.6963

330003 1.4425 0.8708 26.8363 27.7173 28.8520 27.8126

330004 1.3751 0.9785 30.3221 30.8305 31.6848 30.9524

330005 1.6498 0.9628 33.2851 34.1763 35.4979 34.3373

330006 1.4087 1.3154 36.3305 38.6645 38.8190 37.9639

330008 1.1596 0.9628 26.2141 26.7882 28.4993 27.1558

330009 1.4682 1.3154 41.3797 42.4137 43.3382 42.4122

330010 1.1603 0.8487 20.5805 24.3033 * 22.4266

330011 1.2668 0.8932 26.8269 29.2672 30.3716 28.8455

330013 1.9518 0.8708 28.8039 29.2399 30.3522 29.4870

330014 1.4172 1.3154 46.3170 48.1054 48.9173 47.8284

330019 1.2184 1.3154 44.5669 46.8153 47.5751 46.3311

330023 1.5195 1.2884 37.5135 40.9595 42.7458 40.4809

330024 1.8856 1.3154 44.8070 46.2954 46.9066 46.0301

330025 1.1126 0.9628 24.2702 26.5550 27.7959 26.2089

330027 1.3420 1.2884 45.9571 49.0573 51.4887 48.8103

330028 1.5496 1.3154 38.0149 38.7770 44.2973 40.0572

330029 0.6085 0.9628 22.9332 23.7555 23.2845 23.3244

330030 1.2366 0.8708 25.5089 27.4344 29.0646 27.3460

330033 1.1516 0.8643 25.0215 26.7551 25.6393 25.7911

330036 1.2446 1.3154 30.4659 31.2701 33.0839 31.6283

330037 1.1595 0.8708 23.4915 24.4428 25.1766 24.3854

330041 1.3783 1.3154 37.1651 41.2299 45.4010 40.9876

330043 1.5215 1.2591 40.6094 42.4560 43.3176 42.1465

330044 1.3451 0.8737 28.2638 29.4872 31.0628 29.6090

330045 1.5074 1.2591 41.6565 44.7551 43.4805 43.2898

330046 1.5094 1.3154 52.2397 53.4532 55.0516 53.5982

330047 1.3009 0.8487 22.9948 27.4392 27.9776 26.2104
CMS-1498-P 870 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

330049 1.6219 1.1418 34.9740 38.0110 39.1050 37.4092

330053 1.0453 0.8708 20.1303 21.4837 22.9142 21.4899

330055 1.6466 1.3154 44.2343 44.6905 45.0891 44.6857

330056 1.5790 1.3154 39.9662 40.5499 43.3731 41.2870

330057 1.8056 0.8708 30.1821 30.5006 31.3091 30.6714

330058 1.4159 0.8708 23.6296 25.3712 26.6416 25.2427

330059 1.6093 1.3154 45.3691 47.7115 48.5102 47.2325

330061 1.2404 1.3154 37.8649 38.8790 38.2257 38.3275

330064 1.4200 1.3154 41.5737 39.5994 39.7532 40.3486

330065 1.1305 0.9628 26.2288 28.6809 29.2490 28.0535

330066 *** * 27.2085 30.7011 31.6665 29.8079

330067 1.4686 1.1418 30.7537 31.5572 33.4719 31.8968

330072 *** * 41.4605 40.5965 41.2397 41.0975

330073 1.1842 0.8708 25.1392 24.8055 27.0827 25.6766

330074 1.1789 0.8708 23.1016 24.6973 24.5262 24.0899

330075 1.1415 0.9710 23.7522 27.5360 29.7333 26.9519

330078 1.4769 0.9628 27.6682 30.8157 31.7996 30.0981

330079 1.4095 0.9328 27.9479 28.7349 30.3415 29.0021

330080 1.2278 1.3154 40.2067 47.4529 47.6661 45.2191

330084 1.0795 0.8420 27.3434 28.8661 32.3490 29.4885

330085 1.1543 0.8420 27.1707 27.7050 29.8188 28.2639

330086 1.4037 1.3154 40.9768 44.0362 43.8907 42.9617

330088 1.0424 1.2591 37.4716 41.8635 40.8115 40.0302

330090 1.5852 0.9187 27.7306 29.5626 31.1822 29.4923

330091 1.3864 0.9628 28.3034 30.9457 31.7515 30.3752

330094 1.2966 1.0158 28.6213 33.0706 34.7858 32.0911

330096 1.2839 0.8420 24.7895 24.8667 25.8292 25.1613

330100 1.0060 1.3154 39.3170 38.6625 42.2645 40.0975

330101 1.9953 1.3154 45.5412 49.6431 49.8588 48.3746

330102 1.5567 0.9628 27.2543 31.6270 31.8101 30.2074

330103 1.2588 0.8551 25.4919 26.1064 27.2392 26.3017

330104 1.4546 1.3154 36.5894 38.4254 39.2321 38.0457

330106 1.7129 1.2884 48.2903 47.2240 50.3199 48.5977

330107 1.2256 1.2591 38.0262 40.2541 42.4304 40.1994

330108 1.1028 0.8540 25.3023 25.5480 26.9810 25.9259

330111 0.9381 0.9628 23.2134 25.1572 26.0179 24.6747

330115 1.1378 0.9710 24.3898 27.0362 25.4507 25.6316
CMS-1498-P 871 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

330119 1.8188 1.3154 41.2365 43.8894 44.0249 43.0193

330125 1.7757 0.8708 29.4817 30.4389 30.4103 30.1168

330126 1.3867 1.2884 37.7807 40.0542 41.7981 39.8971

330127 1.4712 1.3154 45.2554 51.8817 48.5274 48.5452

330128 1.2873 1.3154 43.3437 41.7875 46.9809 44.0332

330132 1.0753 0.8551 22.1452 23.4437 23.9298 23.1468

330133 *** * 39.9025 * * 39.9025

330135 1.2525 1.2060 33.2314 35.3624 39.4523 36.0995

330136 1.6306 0.8708 25.4198 27.9525 28.3358 27.2668

330140 1.8705 0.9710 31.1333 32.7905 33.3826 32.4461

330141 1.3455 1.2591 39.1733 41.4127 44.4198 41.7713

330144 0.9644 0.8454 24.9304 26.0623 28.4224 26.4223

330151 1.2456 0.8454 21.6339 23.4664 23.7227 22.9394

330152 1.4485 1.3154 39.5754 45.9310 54.7885 46.5567

330153 1.7004 0.8708 28.9944 31.7611 31.6854 30.8216

330154 1.5936 * * * * *

330157 1.3987 0.9710 29.7622 30.2745 31.5462 30.5482

330158 1.8465 1.3154 39.5946 41.6800 45.4100 42.4088

330159 1.3174 0.9710 33.8484 35.6944 36.1910 35.2789

330160 1.5849 1.3154 39.0970 42.1789 42.6001 41.2794

330162 1.2954 1.3154 38.7638 39.3460 39.3481 39.1620

330163 1.0935 0.9628 28.6252 26.3050 28.3979 27.7803

330164 1.5397 0.8708 29.8458 30.3023 31.3949 30.5335

330166 0.8986 0.8420 22.8506 23.2773 24.1281 23.4282

330167 1.6650 1.2884 39.2421 40.8753 40.4764 40.2069

330169 1.4020 1.3154 47.5404 49.7924 52.6481 49.9729

330175 1.1395 0.8680 26.7883 28.2085 29.0736 28.0498

330177 0.9519 0.8420 23.4299 26.0397 26.3552 25.2331

330180 1.3073 0.8708 26.8658 28.0975 28.8360 27.9626

330181 1.4442 1.2884 46.2181 47.2523 47.5998 47.0087

330182 2.3077 1.2884 42.7962 46.6346 47.1719 45.5399

330184 1.4461 1.3154 39.7242 41.3935 44.1215 41.7428

330185 1.3245 1.2591 39.6724 41.3543 42.6846 41.2528

330188 1.3394 0.9628 29.7318 30.7222 31.9349 30.8079

330189 0.9639 0.8708 25.8125 26.4233 27.1290 26.4668

330191 1.3966 0.8708 28.2949 29.3753 30.8219 29.5362

330193 1.5971 1.3154 40.0280 40.7257 41.4653 40.7612
CMS-1498-P 872 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

330194 1.7160 1.3154 49.8886 49.9208 51.5125 50.4577

330195 1.6426 1.3154 43.3213 46.0878 46.8783 45.3774

330196 1.3574 1.3154 38.6949 42.8106 47.1254 42.9572

330197 1.1361 0.8420 26.5525 27.6437 28.8743 27.7160

330198 1.5031 1.2884 35.8715 37.9641 39.0864 37.7000

330199 1.1339 1.3154 39.4076 47.5059 46.3505 44.4308

330201 1.8227 1.3154 46.5114 51.2179 54.5822 50.6852

330202 1.3722 1.3154 38.7624 42.1074 46.7852 42.6301

330203 1.5060 0.9710 34.6525 33.9161 34.8968 34.4914

330204 1.3905 1.3154 39.5324 44.8153 45.9057 43.4038

330205 1.3126 1.2060 35.3792 37.0171 39.7040 37.4547

330208 1.2411 1.3154 37.1735 38.7279 40.4900 38.7610

330211 1.2386 0.8420 24.9432 25.6929 25.1977 25.2864

330213 1.0549 0.8737 28.5370 30.0957 30.7737 29.8133

330214 1.9522 1.3154 43.3229 43.6872 45.3214 44.1777

330215 1.3738 0.8420 26.3978 28.0026 29.8652 28.0726

330218 1.1081 0.9710 28.4113 28.4369 28.6896 28.5177

330219 1.7911 0.9628 33.2147 38.3321 35.2787 35.5523

330221 1.6164 1.3154 42.5486 40.5201 40.5359 41.2446

330222 1.4126 0.8724 28.7858 30.5142 30.9231 30.1149

330223 0.9881 0.8420 27.1970 28.2638 29.7060 28.4078

330224 1.3051 1.1246 30.4784 32.4518 32.2402 31.7207

330225 1.2507 1.2884 32.9036 33.7052 32.9394 33.1790

330226 1.5413 0.8708 26.3685 25.7981 25.8056 25.9824

330229 1.2515 0.8420 23.9243 24.9977 25.8926 24.9413

330230 *** * 39.3863 39.5043 38.2724 39.1655

330231 1.1081 1.3154 48.9021 49.1983 55.0629 51.0168

330232 1.3400 0.8708 27.9615 28.7263 30.4424 29.0437

330233 1.7151 1.3154 40.8539 43.4873 45.0313 43.1279

330234 2.3642 1.3154 49.8804 55.2159 52.8431 52.7054

330235 1.1918 0.8420 30.8034 31.2218 32.2728 31.3938

330236 1.5342 1.3154 42.6205 45.0321 46.2233 44.6274

330238 1.1263 0.8708 23.3953 24.7086 25.0088 24.3863

330239 1.2644 0.8420 24.6391 24.7255 25.3756 24.9143

330240 1.2759 1.3154 41.6132 42.5871 39.9681 41.3705

330241 1.8864 0.9710 32.9275 34.7013 35.6452 34.4408

330242 *** * 38.7875 40.2224 38.6084 39.2370
CMS-1498-P 873 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

330245 1.7049 0.8737 28.6698 29.3183 29.9976 29.3388

330246 1.4001 1.2591 35.9577 39.4705 37.8934 37.7571

330247 *** * 41.3465 39.8390 41.3991 40.8503

330249 1.3877 0.9710 26.9856 29.4003 31.3898 29.2579

330250 1.4215 1.0071 29.6186 32.1740 32.6642 31.4918

330259 1.4278 1.2884 39.0213 38.5914 37.9733 38.5494

330261 1.2872 1.3154 38.0216 37.9563 43.0206 39.7053

330263 0.9364 0.8420 24.2125 25.5991 27.1890 25.6737

330264 1.4015 1.2060 32.5050 35.1876 37.0730 34.9405

330265 1.2783 0.8708 22.7433 22.8141 23.4393 23.0082

330267 1.5186 1.3154 35.3907 38.1619 39.3105 37.7127

330268 0.9270 0.8420 23.9135 25.7738 27.2044 25.6557

330270 2.1604 1.3154 52.3154 55.7360 54.4915 54.2881

330273 1.4195 1.3154 39.7880 41.3568 43.8576 41.7263

330276 1.0974 0.8456 27.0445 28.5781 29.1322 28.2518

330277 1.3453 0.9187 30.8156 30.8543 30.9283 30.8668

330279 1.6990 0.9628 31.2393 33.7210 34.1573 33.0755

330285 1.9158 0.8708 31.8987 33.0830 34.8538 33.3318

330286 1.3682 1.2591 38.8556 40.3250 42.5791 40.6255

330290 1.6635 1.3154 39.8036 43.2989 45.9549 43.0520

330304 1.3128 1.3154 39.4632 39.7987 39.8891 39.7160

330306 1.5933 1.3154 39.0409 40.3216 43.4869 40.9711

330307 1.3162 0.9777 30.8121 33.6277 34.1345 32.8690

330314 *** * 22.6885 38.7241 * 24.3594

330316 1.3911 1.3154 37.9357 40.3783 41.6082 39.9746

330331 1.3669 1.2884 44.1734 44.3947 46.9048 45.1731

330332 1.3212 1.2884 38.6932 40.8557 43.4228 41.0514

330339 *** * 25.0057 26.8982 28.5075 26.7655

330340 1.2054 1.2591 38.4726 38.4180 42.2175 39.7075

330350 1.5307 1.3154 44.2389 47.8575 48.0009 46.7458

330353 1.4414 1.3154 46.0215 45.8432 49.5882 47.1722

330354 1.9646 * * * * *

330357 1.5294 1.3154 40.2132 45.4617 46.6428 43.1989

330372 1.3511 1.2884 37.0323 40.3348 43.4028 40.1441

330385 1.1384 1.3154 47.4017 51.5393 45.1489 48.1275

330386 1.3008 1.1332 32.9990 35.2560 36.5454 34.8018

330389 *** * 37.5908 39.3586 * 38.5126
CMS-1498-P 874 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

330390 1.5026 1.3154 38.7652 35.4546 38.7532 37.4670

330393 1.7670 1.2591 38.9324 40.1511 41.2486 40.1584

330394 1.6358 0.8932 28.8074 30.5684 31.6244 30.3603

330395 1.3609 1.3154 50.1316 41.6484 45.4826 45.3889

330396 1.5484 1.3154 39.1956 41.6293 44.4691 41.8352

330397 1.4662 1.3154 41.1682 41.0651 42.6933 41.6049

330399 1.2742 1.3154 39.8023 41.7487 43.7557 41.7446

330401 1.3844 1.2591 41.7839 47.0780 45.2281 44.6412

330403 0.8761 0.8708 28.7282 26.7473 23.7571 26.0020

330404 1.1578 1.3154 36.1069 36.8792 36.7400 36.5676

330405 1.1290 1.3154 35.2720 38.6588 39.7124 37.3537

330406 1.1795 0.8708 28.2733 28.0950 29.0800 28.3975

330407 *** * * * 22.8305 22.8305

340001 1.5740 0.9299 29.9718 30.6910 31.4272 30.7359

340002 1.8308 0.9055 30.7403 31.6973 32.7669 31.7640

340003 1.4893 0.8476 26.6831 28.0732 28.5497 27.8127

340004 1.5876 0.8974 27.9200 30.6110 31.1689 29.9152

340008 1.2878 0.8768 29.0661 30.7569 34.1051 31.2995

340010 1.4897 0.8476 29.5232 31.0327 32.4035 31.0271

340011 1.1201 0.8476 22.5152 23.6040 24.0602 23.4067

340012 1.2071 * 24.9271 * * 24.9271

340013 1.2699 0.9162 26.9152 29.2509 27.6445 27.9355

340014 1.6864 0.8974 29.5350 29.4771 30.8373 29.9760

340015 1.4756 0.9162 30.0979 30.7573 28.8959 29.8838

340016 1.4468 0.8476 27.9651 27.2226 28.5561 27.9443

340017 1.4517 0.9055 28.4866 28.4785 30.0523 29.0201

340020 1.2373 0.8632 28.3461 30.5510 32.0755 30.2875

340021 1.5313 0.9162 31.3630 32.5625 31.4752 31.8018

340023 1.4538 0.9127 27.6921 29.5911 30.1104 29.1815

340024 1.3148 0.8653 26.9001 27.4770 28.5059 27.6241

340025 *** * 25.2846 25.8195 27.0389 26.0605

340027 1.2773 0.9192 26.6528 27.2788 27.9469 27.2947

340028 1.5908 0.9453 31.9872 31.7634 33.0069 32.2702

340030 2.1669 0.9662 31.2051 31.5786 33.0418 31.9615

340032 1.5602 0.9299 29.2080 29.3927 31.1516 29.9329

340035 1.0454 0.8476 26.0846 26.8821 28.5418 27.1710

340036 1.1481 0.9713 29.0646 29.9160 32.2510 30.4372
CMS-1498-P 875 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

340037 1.3488 0.9162 30.5362 32.0484 32.2585 31.6367

340038 1.2142 0.8729 26.2600 26.9487 27.5626 26.9249

340039 1.3643 0.8974 29.5069 30.2952 30.5891 30.1244

340040 1.9443 0.9343 30.1280 31.3866 32.6226 31.4428

340041 1.5949 0.8650 27.1285 27.8408 26.9709 27.3113

340042 1.2562 0.8476 27.0597 27.0729 27.4651 27.2070

340047 1.8790 0.8974 28.7620 30.6701 31.8492 30.4241

340049 1.9406 0.9662 31.5555 35.4171 37.3166 34.8797

340050 1.3906 0.9238 29.2290 30.4447 30.6267 30.1189

340051 1.3116 0.8537 25.4981 25.4162 27.3196 26.0657

340053 1.6844 0.9299 30.8342 30.9274 32.3100 31.3844

340055 1.3835 0.8650 29.0116 29.5040 29.9587 29.5167

340060 1.1756 0.8996 26.8387 27.3403 27.6220 27.2840

340061 1.8918 0.9662 31.2910 33.4821 35.0126 33.3710

340064 1.3481 0.8476 25.0814 27.2184 23.8863 25.2967

340068 1.3615 0.8680 24.7409 27.3499 29.9975 27.4065

340069 1.8686 0.9662 32.2171 32.5361 34.5413 33.1296

340070 1.3306 0.8996 27.7679 29.0391 30.6796 29.1889

340071 1.1590 0.9713 29.7343 31.3756 33.3407 31.6507

340073 1.8342 0.9662 33.1054 33.2705 35.0550 33.8504

340075 1.4189 0.8650 26.8315 29.1504 29.2000 28.3921

340084 1.2918 0.9299 25.6885 27.4289 28.6175 27.2158

340085 1.3401 0.8996 29.1095 29.9176 30.6564 29.9103

340087 1.2638 0.8476 23.8360 25.0091 24.8627 24.5696

340090 1.4562 0.9713 28.3615 28.6805 30.2246 29.1062

340091 1.6471 0.8974 30.4371 31.2643 32.1069 31.2828

340096 1.2936 0.8996 26.5814 26.8103 28.8274 27.3932

340097 1.2417 0.8476 27.9810 29.8702 31.1005 29.7098

340098 1.6521 0.9299 31.3916 31.8472 32.6891 31.9928

340099 1.3129 0.8476 26.0077 28.1143 27.2332 27.0988

340104 *** * 19.9492 20.2901 22.6845 20.9674

340106 1.1483 0.8476 24.5154 24.4254 24.4668 24.4681

340107 1.1997 0.9123 27.3565 28.5859 31.3986 29.1909

340109 1.3875 0.8954 26.6479 28.6310 29.6145 28.2997

340113 2.0509 0.9299 32.3786 32.4983 33.7477 32.8917

340114 1.6329 0.9662 30.1207 32.3730 33.9019 32.1940

340115 1.6196 0.9662 28.0974 28.9265 30.1329 29.0563
CMS-1498-P 876 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

340116 1.6601 0.8650 29.9447 30.8834 31.7109 30.8405

340119 1.5385 0.9299 27.2938 28.1090 27.5712 27.6658

340120 1.1905 0.8476 26.1465 26.6358 25.4889 26.0896

340121 1.2056 0.8476 25.1577 25.7488 27.4932 26.1656

340123 1.4033 0.8996 28.7150 29.9077 30.2556 29.6505

340124 *** * 25.7294 25.2498 * 25.5286

340126 1.4018 0.9713 30.6902 31.7266 32.8511 31.7775

340127 1.3442 0.9662 28.8675 30.8152 29.2765 29.6601

340129 1.4724 0.9162 31.7863 27.7470 28.6231 29.2827

340130 1.3943 0.9299 29.5294 30.4887 31.5667 30.5985

340131 1.5012 0.9192 29.6571 32.1743 32.7180 31.5487

340132 1.2123 0.8476 25.3264 25.9153 27.9450 26.4203

340133 1.0352 0.8795 26.8850 27.2630 27.7506 27.3138

340137 *** * 27.0874 28.8723 * 27.9808

340138 0.7851 0.9662 * * * *

340141 1.7657 0.9264 29.3372 30.8628 32.7734 31.0073

340142 1.3540 0.8476 28.2413 28.4951 28.8034 28.5181

340143 1.6608 0.8650 29.3861 30.7162 30.7369 30.3039

340144 1.3389 0.9162 27.6548 26.5581 28.9693 27.6935

340145 1.3578 0.9162 28.0647 28.4230 30.2759 28.9487

340147 1.4283 0.9713 29.6960 30.2620 31.9805 30.6482

340148 1.5162 0.8974 27.9136 28.6607 29.4141 28.6790

340151 1.2488 0.8528 24.5782 25.9633 27.4868 26.0151

340153 2.2501 0.9299 29.8278 30.9065 31.9428 30.9177

340155 1.5111 0.9662 31.7570 31.6719 33.3228 32.2613

340156 0.9566 1.4446 * * * *

340158 1.2800 0.9264 29.4110 29.2570 30.5810 29.7971

340159 1.2531 0.9662 28.1706 27.8427 28.4492 28.1630

340160 1.3305 0.8476 24.2016 24.9127 26.6329 25.2921

340166 1.4619 0.9299 29.9122 31.0779 32.0934 31.0482

340168 0.6198 0.9264 * * * *

340171 1.2836 0.9299 31.1954 31.7831 32.9707 32.0444

340173 1.3664 0.9662 30.9843 30.9025 33.6286 31.9191

340183 1.4456 0.9299 30.1261 31.4691 33.8741 32.0540

340184 1.2205 0.9055 * * * *

350002 1.9786 0.7641 23.6051 25.2966 25.6152 24.8333

350003 1.3396 * 24.5812 27.3546 * 25.9392
CMS-1498-P 877 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

350006 1.5896 0.7451 23.4343 26.6508 24.5023 24.8210

350009 1.1530 * 23.9795 * * 23.9795

350011 1.9178 0.8102 26.0201 27.3884 28.6631 27.4053

350015 1.7512 0.7641 22.9120 27.6960 27.5676 26.0667

350017 *** * 24.0968 * * 24.0968

350019 1.7575 0.8034 24.9890 27.0960 28.0496 26.7628

350030 *** * 23.1023 * * 23.1023

350063 0.9324 1.4448 * * * *

350064 0.7461 1.4448 * * * *

350070 1.7884 0.8102 26.2871 28.1430 27.2743 27.2399

360001 1.6025 0.9624 30.1038 31.8522 32.7842 31.5960

360002 1.4501 0.8696 25.2209 26.7549 28.6674 26.8773

360003 1.8677 0.9624 31.8976 31.9294 33.1679 32.3384

360006 1.9087 1.0163 31.8814 35.3579 37.9929 35.0514

360008 1.5052 0.8757 28.0202 28.5988 29.5464 28.7459

360009 1.6126 0.9254 28.2423 30.2452 30.8841 29.8023

360010 1.3386 0.8612 26.6040 27.3194 29.0985 27.6697

360011 1.4401 1.0025 29.9882 31.3142 31.2797 30.8745

360012 1.4610 1.0163 31.9837 32.9127 33.7117 32.8731

360013 1.1783 0.9254 30.2406 30.9331 32.0183 31.0838

360014 1.2374 1.0025 28.1811 28.9635 31.9691 29.7242

360016 1.5885 0.9624 30.2190 30.5892 31.9656 30.9288

360017 1.8785 1.0163 32.6006 34.8774 37.9269 35.0847

360019 1.3519 0.9082 28.8568 29.3536 29.9006 29.3780

360020 1.5714 0.9082 27.8079 29.5312 30.6901 29.3408

360025 1.4669 0.9246 28.4761 29.5329 30.0999 29.3797

360026 1.6064 0.9172 27.5757 27.3618 26.3380 27.0570

360027 1.5697 0.9082 29.9449 30.8898 32.5281 31.0972

360029 1.1553 0.9374 28.0191 29.0633 29.4172 28.8392

360032 1.3121 0.8555 27.2636 27.4896 29.0836 27.9439

360035 1.7082 1.0163 32.0858 32.5622 33.7737 32.7945

360036 1.2891 0.8917 29.9410 31.5027 32.2558 31.2400

360037 1.6216 0.9082 30.6552 31.5221 32.0751 31.4189

360038 1.7378 0.9624 31.3776 32.3095 34.0962 32.4982

360039 1.5460 0.8555 25.8216 27.3636 28.7284 27.2681

360040 1.2153 0.8942 26.7450 28.4404 29.8190 28.4196

360041 1.3782 0.9082 28.4439 29.3331 29.9816 29.2239
CMS-1498-P 878 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

360044 1.2307 0.8682 24.7698 25.7011 25.6594 25.3785

360046 1.3090 0.9624 28.2972 28.5624 28.9068 28.5940

360048 1.8571 0.9374 30.0390 33.3273 39.7450 34.2489

360051 1.7630 0.9172 29.4434 30.5937 31.1421 30.4107

360052 1.6740 0.9172 28.4731 29.8072 31.5097 29.8835

360054 1.5310 0.8757 23.6606 26.8828 27.5188 25.9621

360055 1.4571 0.9082 31.4794 31.2738 32.8952 31.8741

360056 1.5298 0.9624 31.3936 31.8378 33.3691 32.2230

360058 1.1411 0.8555 25.9295 27.7073 27.9521 27.1876

360059 1.7410 0.9082 30.6294 31.3956 32.6539 31.5860

360062 *** * 32.9025 35.2065 * 34.0497

360064 1.6958 0.8628 28.6101 28.5325 29.7002 28.9332

360065 1.2957 0.9082 31.5066 31.6781 32.9311 32.0490

360066 1.4780 0.9254 30.9652 32.1991 33.3925 32.2022

360068 1.9074 0.9374 28.6335 30.0212 30.0149 29.5525

360070 1.7211 0.8650 28.8739 30.0192 30.7774 29.8917

360071 1.1589 0.8590 25.7956 26.6139 29.0698 27.1686

360072 1.4371 1.0163 29.1514 29.8851 29.9298 29.6482

360074 1.4181 0.9374 28.0283 30.1333 30.4801 29.5360

360075 1.3041 0.9082 28.3930 29.8181 31.5315 29.9856

360076 1.6207 0.9624 29.5342 28.8462 39.7210 32.3956

360077 1.6129 0.9082 28.3022 26.2961 29.4388 28.0016

360078 1.3461 0.9082 27.3652 28.2973 29.8163 28.5296

360079 1.9369 0.9172 31.3132 32.0935 34.0345 32.4653

360080 1.2318 0.8555 21.8806 22.9825 23.4889 22.7871

360081 1.3978 0.9374 31.4293 33.2532 33.2079 32.6352

360082 1.3923 0.9082 30.5837 29.7447 31.0704 30.4761

360084 1.6721 0.8650 29.2489 29.2527 30.7559 29.7670

360085 1.9801 1.0163 33.1295 35.9664 36.9965 35.5221

360086 1.6162 0.9172 29.1579 31.9690 31.4898 30.8314

360087 1.5016 0.9082 28.6336 30.0084 31.6840 30.0619

360089 1.1498 0.8555 28.0779 28.5192 31.2561 29.2567

360090 1.4048 0.9374 29.2662 30.3175 30.9528 30.1599

360091 1.3254 0.9082 28.2009 29.6324 30.4266 29.4199

360092 1.3143 1.0163 28.0813 28.3576 30.1497 28.8462

360095 1.5618 0.9246 30.2138 30.0996 29.4352 29.8848

360096 1.1693 0.8626 27.9514 29.8687 30.9621 29.5853
CMS-1498-P 879 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

360098 1.4382 0.9082 26.5839 27.6752 29.8125 28.0156

360100 *** * 25.8143 25.9628 25.6754 25.8206

360101 1.4306 0.9082 30.6650 29.4661 30.1728 30.0962

360107 1.0926 0.8674 26.8180 29.9869 30.3832 29.1302

360109 1.1223 1.0025 30.4643 30.7873 32.3056 31.1780

360112 1.8127 0.9653 32.4403 34.6063 34.7090 33.9241

360113 1.3049 0.9624 30.3914 33.3293 33.4370 32.4622

360115 1.4149 0.9082 27.9711 29.0971 30.1635 29.1065

360116 1.2562 0.9624 26.8632 29.3122 29.7886 28.5973

360118 1.5008 0.8917 29.9823 30.1189 30.7835 30.3015

360121 1.3059 0.9246 31.6766 22.1967 32.9106 28.0639

360123 1.5042 0.9082 28.5435 30.0862 31.5149 30.0236

360125 1.2614 0.8555 27.1776 28.8237 28.0379 28.0071

360130 1.3605 0.9082 28.1811 28.5433 29.7395 28.7979

360131 1.4918 0.8650 27.3426 28.3618 28.7700 28.1660

360132 1.4508 0.9624 29.8411 29.5751 31.5629 30.3076

360133 1.7092 0.9624 33.1812 33.9534 34.8154 33.9938

360134 1.7893 0.9624 29.9198 31.9438 32.3503 31.4241

360137 1.8571 0.9082 30.3116 32.2727 33.2378 32.0143

360141 1.7533 0.8628 31.9397 32.0733 32.7782 32.2474

360143 1.4331 0.9082 28.0693 27.0053 28.0817 27.7280

360144 1.4492 0.9082 29.6547 29.5081 31.0418 30.0723

360145 1.5767 0.9082 29.3271 29.8688 30.7653 29.9946

360147 1.4745 0.8555 29.2371 28.0794 29.5821 28.9716

360148 1.2665 0.8555 25.7460 28.4538 29.4819 27.8748

360150 1.4450 0.9082 27.8840 27.8860 28.7383 28.1724

360151 1.3858 0.8650 26.9672 28.3917 29.2479 28.3557

360152 1.6437 1.0163 33.1017 35.3636 38.6208 35.6295

360153 1.0408 0.8555 21.8416 22.3028 22.2992 22.1453

360155 1.5129 0.9082 29.1711 30.0263 31.6318 30.2212

360156 1.2161 0.8674 26.2268 27.4185 28.7732 27.4930

360159 1.5048 1.0025 29.0187 29.1683 31.7186 29.9873

360161 1.4352 0.8639 27.7423 29.4713 29.7974 29.0175

360163 1.8520 0.9624 31.2087 31.1214 35.9313 32.7672

360170 1.3566 1.0163 30.0688 30.9891 30.4758 30.5174

360172 1.4106 0.9082 30.2330 31.2620 33.1946 31.5024

360174 1.4016 0.9172 28.3769 29.2419 29.6556 29.0991
CMS-1498-P 880 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

360175 1.3096 1.0025 29.7499 31.8340 31.7026 31.1036

360179 1.6158 0.9624 31.3540 30.6820 31.6922 31.2533

360180 2.5220 0.9082 32.0225 30.3025 32.9705 31.8017

360185 1.4175 0.8555 26.4210 27.4008 27.6522 27.1534

360187 *** * 27.3745 28.2630 31.4188 28.8678

360189 1.1225 1.0163 28.3738 28.8931 29.4708 28.9364

360192 1.4530 0.9082 29.1999 31.7957 32.2091 31.1258

360195 1.1421 0.9082 27.2630 28.4907 29.0980 28.3002

360197 1.3514 0.8555 28.5267 30.3316 31.0116 29.9915

360203 1.1956 0.8555 27.7569 28.7975 29.7199 28.7550

360210 1.4152 1.0163 31.8182 35.1678 37.5771 34.9693

360211 1.6242 0.8555 27.5081 26.9504 26.8677 27.1117

360212 1.4042 0.9082 28.5882 28.8865 31.1956 29.5446

360218 1.3838 1.0163 31.1641 31.4458 31.3310 31.3170

360230 1.5862 0.9082 30.5995 29.9181 31.6669 30.7266

360234 1.4362 0.9624 30.7926 29.5412 33.3664 31.1901

360236 1.4186 0.9624 29.9367 31.7585 32.1567 31.3134

360239 1.4331 0.9172 31.7938 32.3401 33.2718 32.5127

360241 *** * 25.8137 28.0304 29.5279 27.8946

360242 1.9199 * * * * *

360245 0.8463 0.9082 20.4589 20.8560 21.7637 21.1049

360247 0.6198 1.0163 * * 20.0037 20.0037

360253 *** * 34.6887 33.3121 37.3905 35.0706

360259 1.3694 0.9374 28.0886 29.3681 31.0669 29.4823

360261 1.2686 0.8909 26.6262 28.2317 32.7931 29.2218

360262 1.3275 0.9374 31.5637 33.1908 34.1099 32.9417

360263 1.9512 0.9254 28.1671 25.5127 26.8628 26.7667

360266 2.2686 1.0163 29.8385 31.3706 33.4559 31.8486

360269 1.9619 0.9624 25.5191 26.3965 34.8464 29.0819

360270 1.1560 0.8555 28.8677 30.0580 32.1049 30.6384

360271 1.4738 0.9624 28.4353 30.8070 32.9727 30.7694

360272 *** * 38.1014 * * 38.1014

360273 *** * 37.6645 * * 37.6645

360274 1.6329 0.9172 * * 41.5894 41.5894

360275 *** * * * 35.3416 35.3416

360276 1.3571 0.8628 * * 30.8602 30.8602

360347 1.2052 1.0163 * * * *
CMS-1498-P 881 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

360348 1.6182 1.0163 * * * *

360349 1.4026 0.9374 * * * *

360350 1.8062 0.9624 * * * *

360351 1.9867 0.8850 * * * *

360352 1.0842 0.8628 * * * *

360354 1.4011 0.9624 * * * *

360355 1.5439 0.9183 * * * *

370001 1.6993 0.8903 28.4907 27.2881 29.2907 28.3843

370002 1.2418 0.8052 26.2486 26.5804 28.5178 27.1335

370004 1.1751 0.8446 28.2804 27.2378 29.4714 28.3160

370006 1.2115 0.8798 25.2307 27.5299 28.6399 27.1064

370007 0.9619 0.8052 21.1260 25.7680 29.2831 25.4572

370008 1.4129 0.8900 27.9944 29.1467 29.2458 28.8413

370011 0.9562 0.8900 23.1761 24.5886 26.7301 24.8297

370013 1.4968 0.8900 28.3502 29.7899 32.8050 30.3615

370014 1.2150 0.8445 28.8962 29.3407 28.8058 29.0123

370015 0.9979 0.8798 27.8061 27.6086 27.9015 27.7724

370016 1.5857 0.8900 30.4672 29.6737 30.9822 30.3796

370018 1.5379 0.8798 31.2335 29.3285 29.9348 30.1154

370019 1.1741 0.8052 26.7613 30.4599 30.9046 29.3782

370020 1.5729 0.8900 24.7520 24.7484 26.5784 25.3619

370022 1.3858 0.8306 26.4836 24.4735 26.1508 25.6663

370023 1.3323 0.8142 24.9580 27.4272 27.9018 26.8583

370025 1.3829 0.8798 24.8336 27.0211 27.6951 26.4528

370026 1.4507 0.8900 26.0203 26.8057 28.1146 26.9937

370028 2.0270 0.8900 29.9849 31.9029 33.9521 31.9991

370029 1.1511 0.8052 30.0134 30.3712 31.0013 30.4602

370030 0.9910 0.8798 26.0831 26.5853 27.9552 26.8681

370032 1.4856 0.8900 28.0739 30.2497 29.6486 29.2901

370034 1.2867 0.8052 23.2192 23.9679 29.5364 25.5443

370036 1.0370 0.8052 21.1544 22.1686 21.3785 21.5609

370037 1.8563 0.8900 26.8992 28.9215 30.8721 28.8559

370039 1.1530 0.8903 25.3422 26.7579 27.7301 26.6250

370040 0.9917 0.8052 19.7644 21.6739 23.4331 21.6824

370041 0.8609 0.8903 29.5074 26.4346 25.4871 27.1154

370047 1.4945 0.8900 27.8937 29.6739 32.3165 30.0356

370048 0.9653 0.8052 23.4848 24.2668 24.1343 23.9599
CMS-1498-P 882 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

370049 1.4371 0.8052 24.2099 22.8526 28.2783 25.0600

370051 1.0771 0.8052 21.8716 22.8411 25.2437 23.3375

370054 1.2593 0.8052 23.4644 25.4821 31.2786 26.7359

370056 1.7795 0.8616 27.6178 26.9562 31.0225 28.6018

370057 0.9892 0.8903 23.1814 21.0790 21.6866 21.9676

370060 *** * 25.5571 29.0333 * 27.1132

370065 1.0374 0.8148 24.0062 23.7889 27.6147 25.2679

370072 0.7840 0.8310 22.8598 17.3061 22.6081 20.6800

370078 1.6690 0.8903 30.4837 28.7496 30.0395 29.7756

370080 0.9537 0.8052 23.7231 22.4258 20.5624 22.2160

370083 0.8441 0.8103 21.9162 21.3677 19.0707 20.7313

370084 1.0783 0.8052 17.4202 17.7119 16.9006 17.3311

370089 1.5651 0.8052 22.0607 23.8318 25.9159 24.0554

370091 1.7197 0.8903 28.0487 28.3945 29.9801 28.8357

370093 1.9314 0.8900 26.7272 29.0161 30.3405 28.6784

370094 1.4661 0.8900 28.3512 29.5931 29.7407 29.2592

370097 1.3617 0.8616 28.0911 28.1234 28.0485 28.0899

370099 1.0863 0.8900 30.5437 28.8908 29.8196 29.7121

370100 0.8879 0.8152 20.6298 18.2493 20.4983 19.7870

370103 1.0503 0.8052 22.2675 23.4746 23.9559 23.2347

370105 2.1142 0.8900 30.5438 30.9068 36.1174 32.0645

370106 1.5245 0.8900 29.6797 31.4433 32.4747 31.2193

370112 1.0149 0.8052 19.0130 20.2239 20.4699 19.9447

370113 1.1529 0.8646 30.0061 28.3511 28.2888 28.8884

370114 1.7327 0.8903 27.1348 32.9928 34.7611 31.4511

370138 1.0298 0.8052 23.6348 24.7631 28.4293 25.7195

370139 0.9194 0.8052 21.0759 19.3691 22.7663 21.0194

370148 1.5057 0.8900 29.3447 30.8781 32.6383 30.9688

370149 1.3740 0.8354 23.0764 25.0025 27.3475 25.0933

370153 1.0947 0.8052 25.9238 30.0891 28.8427 28.2741

370156 1.0078 0.8173 22.7140 22.3940 23.9498 23.0193

370158 0.9116 0.8900 22.0056 22.2823 23.6271 22.6383

370166 0.9198 0.8903 26.3420 22.9735 24.2071 24.5055

370169 0.7920 0.8215 24.5389 20.5348 20.0430 21.8109

370170 0.9052 1.4444 * * * *

370171 1.0000 1.4444 * * * *

370172 0.8044 1.4702 * * * *
CMS-1498-P 883 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

370173 1.0007 1.4444 * * * *

370176 *** * 26.6687 27.2899 * 26.9843

370178 0.9180 0.8052 15.6720 17.3536 21.1275 17.9568

370180 1.2523 1.4444 * * * *

370183 0.9346 0.8903 30.3850 25.4218 25.6096 27.0506

370190 1.6477 0.8903 32.5635 35.6046 42.6067 37.1583

370192 1.9251 0.8900 19.1346 28.9574 32.6197 27.3274

370196 *** * 24.6984 * * 24.6984

370199 0.9552 0.8900 23.9376 25.9775 26.7845 25.6708

370200 *** * 19.7060 27.9940 35.8719 26.8170

370201 1.5046 0.8900 25.5882 30.4213 30.9026 28.9180

370202 1.4666 0.8903 25.8261 29.3845 30.9936 28.8532

370203 1.8920 0.8900 30.3641 31.6266 32.1871 31.6717

370206 1.9178 0.8900 30.8151 28.9491 30.0585 29.9057

370210 1.9062 0.8903 25.7905 29.4082 29.9079 28.4566

370211 1.1934 0.8900 30.9656 32.7888 34.6101 32.9440

370212 1.9722 0.8900 20.0919 23.4166 27.1375 23.5295

370214 0.8377 0.8173 20.1495 22.3796 25.0447 22.5261

370215 2.2825 0.8900 32.0950 32.7257 33.2373 32.7263

370216 2.1658 0.8903 29.6658 29.1189 26.1707 28.1248

370218 1.4156 0.8903 23.7517 29.6378 28.7572 27.2714

370219 *** * 41.4392 * * 41.4392

370220 2.2137 0.8900 21.3168 22.2077 20.9298 21.4203

370222 1.9360 0.8900 26.9175 28.6123 28.3453 27.9656

370223 *** * 24.0154 * 19.6604 21.4670

370224 *** * * 21.5542 * 21.5542

370225 1.1413 0.8900 * * * *

370226 *** * * * 37.1390 37.1390

370227 1.0250 0.8903 * * 25.9830 25.9830

370228 1.1823 0.8903 * * 29.2557 29.2557

370229 1.0257 0.8052 * * * *

370231 0.9969 0.8903 * * * *

370232 1.1109 0.8052 * * * *

380001 1.2530 1.1221 33.8490 36.3316 37.7584 36.0275

380002 1.3507 1.0089 32.6830 32.7006 33.7907 33.0702

380004 1.6902 1.1221 36.1021 37.7310 38.7848 37.5392

380005 1.4128 1.0089 33.5765 33.5424 36.4765 34.5241
CMS-1498-P 884 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

380007 1.9680 1.1221 36.4222 37.9358 39.2842 37.8818

380009 2.1862 1.1221 36.5688 36.8442 39.1393 37.5615

380014 1.9778 1.0340 35.7101 36.4373 36.1111 36.0952

380017 1.7902 1.1221 36.8103 37.5098 38.6492 37.6722

380018 2.0193 1.0089 32.4884 32.3945 33.4301 32.7883

380020 1.4677 1.1331 35.7392 37.4343 42.4903 38.6506

380021 1.5246 1.1221 33.0628 33.3855 35.2942 33.9333

380022 1.4159 1.0149 30.9181 32.6138 34.0849 32.6081

380025 1.2343 1.1221 38.1507 38.7401 40.2542 39.0981

380027 1.4336 1.1032 31.4398 33.7027 35.3681 33.5331

380029 1.3160 1.1119 33.3368 34.4907 36.3780 34.8151

380033 1.1325 1.1331 36.0798 36.6589 38.9026 37.2572

380037 1.4089 1.1221 34.0321 36.0715 37.8397 36.1223

380038 1.3228 1.1221 35.0350 36.3586 37.3367 36.2465

380040 1.5283 1.0089 34.4500 37.3200 39.0280 37.0491

380047 1.8942 1.1032 35.8165 37.9901 39.2864 37.8086

380050 1.4662 1.0089 31.3088 32.4377 35.5034 33.1746

380051 1.8579 1.1221 35.0114 37.3363 39.5771 37.3333

380052 1.2455 1.0089 27.7656 29.1449 30.5763 29.1627

380056 1.2401 1.1119 31.0210 31.9034 32.2946 31.7201

380060 1.5979 1.1221 35.1106 36.9581 37.6168 36.6196

380061 1.6961 1.1221 35.8922 37.9554 39.8524 37.8861

380071 1.5130 1.1221 31.6821 32.7466 36.1630 33.5296

380075 1.4781 1.0089 34.0197 36.0119 37.8963 35.9417

380082 1.3415 1.1221 37.7268 38.8914 40.5892 39.0683

380089 1.3650 1.1221 37.0017 37.7878 39.3331 38.0936

380090 1.3301 1.1032 41.4540 41.3541 36.1957 39.4825

380091 1.6124 1.1221 39.7431 47.7003 43.5979 43.8371

380100 *** * 45.3882 * * 45.3882

380102 1.8467 1.1331 * * * *

390001 1.5928 0.8521 25.4188 27.9772 27.1369 26.8091

390002 1.4560 0.8579 25.9827 26.9670 28.0217 26.9883

390003 1.1897 0.8521 26.2872 26.6558 28.5550 27.1598

390004 1.7151 0.9172 26.5054 29.3249 30.1116 28.6336

390006 1.9048 0.9172 30.9914 32.8108 34.0319 32.6975

390008 1.1052 0.8581 22.9417 25.0200 23.3722 23.7761

390009 1.7909 0.8521 29.0286 29.4416 29.4788 29.3179
CMS-1498-P 885 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

390010 *** * 26.0966 27.8944 * 26.9767

390012 1.2900 1.0780 34.2004 35.6251 36.5075 35.4492

390013 1.4998 0.9172 28.3039 26.8792 28.6128 27.9375

390016 1.3710 0.8521 26.1802 25.6660 28.0791 26.6336

390019 1.2656 0.9418 25.3185 25.2047 27.4886 25.9672

390023 1.2198 1.0780 36.2618 37.9254 40.0307 38.0623

390024 *** * 37.4815 * * 37.4815

390025 0.5715 1.0780 * * * *

390026 1.2953 1.0780 36.0608 36.6927 37.8982 36.8748

390027 1.8176 1.0780 40.9110 42.5592 43.2863 42.2614

390028 1.7616 0.8579 29.6218 31.3868 29.7659 30.2416

390030 1.1774 0.8856 26.5678 26.9684 29.2589 27.6203

390031 1.2218 0.8856 26.1258 27.5747 30.8796 28.1344

390032 1.3312 0.8579 25.3756 27.3294 28.0123 26.9158

390035 1.2342 1.0780 27.2130 27.6331 30.9600 28.6617

390036 1.5866 0.8579 26.1956 30.1286 32.9773 29.7227

390037 1.4602 0.8579 27.0788 31.6832 31.5443 30.0435

390039 1.3655 0.8558 22.1531 23.3456 24.9694 23.4740

390041 1.2656 0.8579 25.1190 26.4415 26.5753 26.0714

390042 1.5148 0.8579 29.6213 30.6691 30.9971 30.4337

390043 1.2296 0.8521 24.3590 26.4451 27.6266 26.1527

390044 1.6128 0.9047 29.9959 30.6946 30.4850 30.4001

390045 1.4760 0.8521 25.8800 26.4450 25.4029 25.8954

390046 1.8301 0.9760 32.5273 32.1156 34.3559 33.0452

390048 1.1692 0.9172 28.4563 29.0278 30.0870 29.1884

390049 1.5518 0.9418 31.0290 32.7809 33.9546 32.6141

390050 2.1229 0.8579 29.6715 32.0935 32.6719 31.5014

390052 1.1984 0.8568 26.3700 27.4028 28.0662 27.3003

390054 *** * 27.5696 * * 27.5696

390056 1.1238 0.8557 24.7038 25.5903 26.0944 25.4676

390057 1.3731 1.0780 31.0279 33.9576 34.1227 33.0166

390058 1.4268 0.9172 29.6620 29.4647 31.4346 30.2160

390061 1.5125 0.9760 30.9208 30.2319 33.2839 31.3678

390062 1.1590 0.8529 22.8856 37.2849 24.7403 28.3031

390063 1.9432 0.8521 28.3987 30.3687 29.6085 29.4599

390065 1.3869 1.0539 31.8841 31.2628 34.1509 32.4868

390066 1.4935 0.9172 29.0033 28.3747 28.4545 28.6018
CMS-1498-P 886 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

390067 1.8047 0.9760 32.2891 30.5601 32.7009 31.8523

390068 1.2866 0.9760 29.6984 28.2183 31.3686 29.7350

390070 1.3814 1.0780 34.5501 33.4969 34.5022 34.1840

390071 1.0479 0.8521 26.3830 27.8695 29.4067 27.8637

390072 1.0365 0.8521 28.8145 28.0714 29.3008 28.7479

390073 1.7549 0.8529 27.0876 28.8519 30.4073 28.7640

390076 1.3590 1.0780 33.9908 34.0355 36.0337 34.6436

390079 1.8713 0.8762 26.0199 26.9676 29.0245 27.3480

390080 1.4522 1.0780 31.6210 33.0003 34.7963 33.0758

390081 1.3314 1.0780 36.4788 37.7643 37.7381 37.3396

390084 1.2793 0.8521 24.3191 24.8010 26.7795 25.2800

390086 1.5945 0.8521 24.7454 25.3096 25.8212 25.3007

390090 1.8764 0.8579 30.1256 31.9282 33.7323 31.8674

390091 1.2620 0.8521 23.2118 23.9434 24.9895 24.0598

390093 1.2290 0.8521 23.8846 23.5291 23.4916 23.6341

390095 1.2005 0.8521 25.3859 25.9594 25.8271 25.7150

390096 1.6264 0.9047 30.3910 31.7443 32.9599 31.7312

390097 1.2966 1.0780 28.1285 30.4946 31.2933 29.9565

390100 1.6541 0.9760 32.7836 32.8949 33.8098 33.1901

390101 1.3191 0.9539 25.9850 28.6622 30.5652 28.4498

390102 1.4762 0.8579 25.5336 26.3716 27.4078 26.4615

390104 1.0256 0.8521 20.4552 26.8407 25.5500 24.5842

390107 1.7718 0.8579 25.6790 26.6305 27.5113 26.6481

390108 1.3264 1.0780 34.3066 33.3017 33.0812 33.5657

390110 1.6616 0.8521 25.7159 28.5314 29.2114 27.8372

390111 2.3297 1.0780 37.7322 34.5571 37.4034 36.5385

390112 1.1114 0.8558 18.4185 19.5361 21.7618 19.8898

390113 1.3636 0.8521 24.8669 25.9952 27.3239 26.1026

390114 1.5335 0.8579 28.5336 28.2039 31.1727 29.3417

390115 1.4010 1.0780 32.5058 32.8427 32.4906 32.6138

390116 1.4090 1.0780 33.9295 34.5119 35.8124 34.7722

390117 1.2284 0.8523 22.2327 26.0642 29.4532 25.9021

390118 1.2756 0.8521 23.6535 23.7128 24.9150 24.0866

390119 1.3599 0.8521 25.3907 25.9784 27.7668 26.4246

390122 1.0543 0.8574 24.6434 24.0424 25.6753 24.7750

390123 1.2379 1.0780 35.1244 34.1121 36.2907 35.1769

390125 1.2563 0.8543 24.0199 24.4654 28.2329 25.5409
CMS-1498-P 887 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

390127 1.5706 1.0780 33.1227 34.6488 37.2911 35.0077

390128 1.2760 0.8579 25.1858 26.0441 26.6048 25.9610

390130 1.2073 0.8521 30.7083 26.7324 27.8831 28.3944

390131 1.4113 0.8579 27.7146 26.9190 27.7765 27.4675

390132 1.6245 1.0780 30.0751 33.1853 34.6686 32.6204

390133 1.8571 1.0663 33.0604 35.0046 33.5858 33.8932

390137 1.5065 0.8521 26.9156 27.9033 28.8768 27.9121

390138 1.3244 0.9172 27.7565 29.0224 31.9340 29.6092

390139 1.3858 1.0780 36.5001 36.8337 38.9715 37.4666

390142 1.5812 1.0780 33.3509 38.1793 41.7965 37.8882

390145 1.4739 0.8579 26.9212 27.6510 28.4472 27.7026

390146 1.1970 0.8543 23.9878 27.5267 28.5944 26.6700

390147 1.4098 0.8579 29.0995 30.4797 29.9003 29.8258

390150 1.1325 0.8552 22.6483 27.2922 29.5097 26.6124

390151 1.4533 1.0539 31.8967 35.0627 36.1838 34.4568

390153 1.3662 1.0780 36.0287 37.0995 38.6509 37.2968

390154 1.2217 0.8521 23.9785 24.6857 26.5297 25.0858

390156 1.3617 1.0780 33.7057 34.9903 37.3076 35.3187

390157 1.2496 0.8579 23.0989 23.7167 25.3304 24.0528

390160 1.4641 0.8579 25.2043 27.5196 28.6869 27.1706

390162 1.5709 1.1296 35.1844 36.7008 37.4703 36.4185

390163 1.3306 0.8579 24.8761 25.4594 26.9809 25.7955

390164 2.2789 0.8579 29.7778 29.0556 30.3482 29.7279

390166 *** * 28.2178 * * 28.2178

390168 1.6857 0.8579 27.3674 28.2578 30.9235 28.8822

390169 1.1762 0.8521 26.6063 28.4619 28.7411 27.9870

390173 1.3215 0.8558 27.6039 28.0999 29.4695 28.4211

390174 1.8138 1.0780 35.1118 36.5352 38.5670 36.7628

390176 1.0420 0.8579 * 27.5270 32.1051 29.5889

390178 1.4445 0.8612 23.9166 25.2325 26.0853 25.0756

390179 1.4701 1.0780 31.5498 33.9916 35.7591 33.8296

390180 1.4303 1.0780 38.2997 37.8677 39.2901 38.4851

390181 *** * 27.8833 * * 27.8833

390183 1.1887 0.8521 28.2211 28.8361 29.9287 29.0390

390184 1.0458 0.8579 23.9973 24.1461 24.6116 24.2542

390185 1.3942 0.9418 25.5318 28.1346 29.5155 27.8683

390189 1.0954 0.8521 23.4902 25.3686 26.8189 25.2753
CMS-1498-P 888 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

390192 1.0196 0.8521 23.7958 24.7427 25.0085 24.5203

390194 1.2336 0.9418 23.7367 27.8231 27.5260 26.2940

390195 1.6061 1.0780 37.2504 36.8626 39.5226 37.8846

390196 1.5301 * * * * *

390197 1.3716 0.9418 27.7303 28.1999 28.4855 28.1347

390198 1.0016 0.8521 21.0861 21.3574 23.6249 22.0336

390199 1.1525 0.8521 24.5469 24.9642 25.6275 25.0628

390201 1.5511 0.9691 28.5668 28.7755 33.2321 30.2676

390203 1.5230 1.0780 30.7244 33.0056 39.2667 34.4792

390204 1.3951 1.0780 32.0242 33.8120 31.6920 32.4668

390211 1.4122 0.8612 27.7875 28.0796 29.5567 28.4769

390217 1.2688 0.8579 26.2706 25.6917 27.0886 26.3518

390219 1.3817 0.8579 26.3263 27.2812 28.9463 27.5217

390220 1.2574 1.0780 32.0891 33.0323 34.0933 33.0447

390222 1.4380 1.0780 32.7077 34.5835 35.0162 34.1313

390223 2.1413 1.0780 36.5784 35.8030 36.4686 36.2827

390225 1.3671 0.9760 26.3642 * 37.2003 31.3972

390226 1.7682 1.0780 35.4683 35.5564 37.7252 36.2815

390228 1.5300 0.8579 25.5120 28.4321 28.7341 27.5570

390231 1.4535 1.0780 35.2312 35.0675 35.2479 35.1832

390233 1.4332 0.8521 28.3660 29.5938 31.2920 29.7908

390236 1.0294 0.8524 24.5574 25.1866 26.6442 25.4333

390237 1.6878 0.8521 29.9748 29.6917 29.3123 29.6520

390256 1.9907 0.9172 28.5887 31.6455 32.5650 30.9753

390258 1.4564 1.0780 32.0551 33.7330 37.1156 34.3523

390263 1.6615 0.9418 30.2069 31.1718 31.3913 30.9524

390265 1.6237 0.8579 27.7795 27.8241 30.8343 28.8119

390266 1.1383 0.8612 23.0142 23.5248 24.2255 23.5948

390267 1.5021 0.8579 25.7571 28.4250 30.7224 28.2795

390268 1.4705 0.8640 28.4200 30.0652 30.2637 29.6045

390270 1.7441 0.8521 27.0301 29.3622 31.2862 29.3404

390272 0.6330 1.0780 32.9918 29.4836 28.9815 30.3399

390278 0.7864 1.0780 28.8318 33.9596 32.6176 31.7776

390285 *** * 38.4703 43.0793 42.6411 41.2248

390286 *** * 31.7337 32.6998 34.3467 32.9330

390290 1.8432 1.0780 47.7663 41.9121 45.5855 45.0203

390304 1.4348 1.0780 33.4134 35.0741 31.4118 33.2717
CMS-1498-P 889 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

390307 1.9281 0.8612 22.9474 27.2053 28.6025 26.1219

390311 *** * 49.9027 * * 49.9027

390312 1.4452 1.0780 51.3372 42.3481 47.4912 46.6973

390313 1.1402 0.8856 * 27.3018 28.2730 27.7674

390314 1.9104 0.9418 * * 31.2627 31.2627

390315 *** * * * 33.7886 33.7886

390316 2.1098 0.9047 * * 27.5474 27.5474

390317 0.8038 1.0780 * * 40.0462 40.0462

390318 1.4192 0.9418 * * 28.8744 28.8744

390319 0.9481 0.8579 * * * *

390320 2.7965 1.0780 * * * *

390321 1.7804 0.9418 * * * *

400001 1.3274 0.4302 15.4249 15.9192 16.7467 16.0408

400002 *** * 12.9793 14.2946 * 13.6163

400003 1.4027 0.4278 14.6859 15.8816 16.1022 15.5378

400004 1.1337 0.4302 13.5197 14.5542 15.6128 14.5649

400005 1.1494 0.4302 11.7590 12.6516 13.5902 12.6912

400006 1.2753 0.4302 * * 11.3150 11.3150

400007 1.3194 0.4302 10.4934 10.7767 12.4403 11.1611

400009 1.0496 0.3577 10.1212 14.0016 12.1371 11.8594

400010 0.8029 0.3384 10.4206 12.8584 9.9686 10.7816

400011 1.2081 0.4302 9.4068 10.7620 11.2889 10.4922

400012 1.6634 0.4302 * 11.1553 12.3642 11.7247

400013 1.3877 0.4302 12.3073 12.7900 13.8665 13.0128

400014 1.4610 0.3612 12.3301 11.0722 11.8099 11.7048

400015 1.2566 0.4302 21.9225 17.6943 20.6014 19.9015

400016 1.5854 0.4302 17.9107 19.1577 18.3119 18.4599

400017 *** * 10.0590 * * 10.0590

400018 1.3636 0.4302 13.1572 13.6091 14.0267 13.6205

400019 1.5566 0.4302 15.2364 15.0604 15.9353 15.3872

400021 1.5607 0.4570 14.9779 16.3677 16.9832 16.1033

400022 1.4793 0.4278 15.2124 15.3660 16.3760 15.6441

400024 0.7732 0.3612 13.7215 14.2708 12.9549 13.5783

400026 1.2407 0.3577 8.9064 9.8155 10.7169 9.7988

400028 *** * 9.6941 11.1923 10.2934 10.3638

400032 1.1343 0.4302 10.7844 11.9013 12.2669 11.6859

400044 1.7300 0.4278 12.1393 13.4579 14.6579 13.6085
CMS-1498-P 890 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

400048 1.2979 0.3577 10.5176 11.5766 13.1850 11.7959

400061 2.1704 0.4302 17.4504 18.5327 20.5087 18.8372

400079 1.5588 0.3384 10.6127 11.3550 11.9824 11.3404

400087 1.2640 0.4302 12.0034 12.6233 13.4288 12.6871

400098 1.2431 0.4302 12.8756 13.2365 13.3671 13.1717

400102 1.2316 0.4302 12.1257 12.6314 10.9542 11.7721

400103 2.0761 0.3612 11.3314 12.7285 11.9853 12.0090

400104 1.3358 0.4302 12.6934 12.9616 11.8195 12.5011

400105 1.0711 0.4302 17.0463 25.3823 19.6129 19.9057

400106 1.1191 0.4302 14.8544 14.1766 15.1456 14.7145

400109 1.4847 0.4302 14.5713 15.4910 16.2304 15.4433

400110 1.2368 0.3544 10.8214 11.2311 12.3738 11.4462

400111 1.2060 0.3384 10.7892 11.0467 12.0683 11.3123

400112 1.2379 0.4302 11.2303 9.6181 13.0534 11.1342

400113 1.3390 0.4278 11.5948 11.9672 12.8788 12.1619

400114 1.2113 0.4302 11.6872 11.5514 12.7842 12.0298

400115 1.0598 0.4302 10.6809 12.0201 10.9564 11.2441

400117 1.0324 0.4302 12.1540 12.2159 13.0609 12.4850

400118 1.3323 0.4302 12.6199 13.3983 14.0618 13.3770

400120 1.4734 0.4302 14.5205 14.6591 15.3683 14.8571

400121 1.0669 0.4302 9.9713 11.7462 11.7441 11.2726

400122 2.2443 0.4302 10.0966 13.1851 13.6602 12.0852

400123 1.2369 0.3612 13.8601 13.4317 14.3030 13.8583

400124 2.8599 0.4302 19.1704 21.9082 22.0619 21.0750

400125 1.2425 0.3892 13.1078 12.7141 13.5864 13.1629

400126 1.2276 0.4570 * 14.2108 13.0372 13.5539

400127 2.2024 0.4302 * 12.0796 10.6621 11.1995

400128 1.0442 0.4302 * 23.6366 14.1088 17.2092

410001 1.3296 1.1613 30.5865 30.8038 33.6421 31.6567

410004 1.3994 1.1613 35.2384 33.7118 35.8403 34.9238

410005 1.2979 1.1613 34.2846 38.2842 38.0619 36.9368

410006 1.4558 1.0751 33.9961 35.4462 36.1985 35.2228

410007 1.7064 1.1613 34.4774 37.0287 38.3867 36.7006

410008 1.3757 1.0751 33.6384 34.6138 35.3809 34.5644

410009 1.3355 1.0751 34.3427 36.0892 36.4091 35.6362

410010 1.1199 1.1613 34.9330 38.4603 39.9638 37.7769

410011 1.4645 1.1613 36.7668 38.5007 37.6589 37.6665
CMS-1498-P 891 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

410012 1.6248 1.1613 36.5207 37.5223 38.6851 37.5744

410013 1.2620 1.1412 39.8659 38.2253 38.6414 38.8940

420002 1.6629 0.9300 31.2247 32.3569 33.2952 32.2569

420004 2.1010 0.9295 30.0764 31.8610 34.1012 32.1498

420005 1.2940 0.8450 26.5044 28.0173 29.8412 28.1181

420006 2.1518 * 29.1404 31.5368 32.2965 30.9655

420007 1.7111 0.9128 28.9557 31.1080 31.3033 30.4861

420009 1.4017 0.9128 28.6648 29.1084 29.6808 29.1549

420010 1.1694 0.8478 26.5523 27.0435 27.8709 27.1665

420011 1.1720 0.9357 26.0585 25.9484 25.1689 25.7394

420015 1.3418 0.9357 27.4929 27.9759 29.5582 28.3316

420016 1.0027 0.8438 23.4323 23.2125 23.4618 23.3687

420018 1.9284 0.8799 29.0923 28.9660 30.2579 29.4553

420019 1.1621 0.8596 25.8119 23.7910 26.9977 25.5119

420020 1.3033 0.9295 29.2935 28.9093 30.9488 29.7089

420023 1.8241 0.9357 30.4492 31.2602 32.2488 31.4072

420026 1.9124 0.8799 29.5066 31.2504 32.5572 31.1347

420027 1.6300 0.9128 31.3797 30.6779 * 31.0258

420030 1.4921 0.9295 30.3424 31.3260 33.0987 31.5744

420033 1.3463 0.9357 32.4287 33.8157 33.5699 33.2702

420036 1.2688 0.8695 26.3480 27.1715 28.0250 27.1767

420037 1.4064 0.9357 32.7124 33.5291 34.1076 33.4635

420038 1.2847 0.9357 27.1524 29.5673 31.5388 29.4623

420039 1.0619 0.8970 26.3127 24.5270 26.0489 25.6075

420043 1.1861 0.8595 25.8366 24.2727 25.6018 25.2202

420048 1.3049 0.8799 27.4353 29.9094 30.5167 29.3111

420049 1.3260 0.8681 28.0920 28.4801 29.1163 28.5669

420051 1.8299 0.8478 27.6130 28.0711 29.6261 28.4477

420053 1.2963 0.8473 25.4820 26.4997 27.1081 26.3512

420054 1.1210 0.8446 26.7900 27.1580 28.2725 27.4120

420055 1.1416 0.8467 25.3144 25.9899 26.0255 25.7592

420056 1.3094 0.8438 29.7774 27.8175 29.3188 28.9542

420057 1.2963 0.8478 27.7137 29.5662 29.8897 29.0709

420062 1.0833 0.8563 27.2263 28.3129 29.4726 28.3826

420064 1.5616 0.8681 25.0654 26.4352 28.3216 26.6452

420065 1.5441 0.9295 28.1896 28.2922 28.9626 28.4895

420066 0.9570 0.8478 20.5743 26.0307 27.0504 24.3154
CMS-1498-P 892 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

420067 1.4142 0.8858 27.7167 29.0379 29.2066 28.6526

420068 1.5378 0.9571 28.0316 28.1555 30.0666 28.7169

420069 1.2850 0.8438 24.4656 25.1993 25.9447 25.2155

420070 1.4122 0.8695 27.6431 28.4000 28.5579 28.2053

420071 1.5208 0.9128 28.1099 28.6098 30.2531 29.0105

420072 1.1647 0.8438 20.7716 24.4951 25.2077 23.5012

420073 1.4865 0.8799 28.2671 29.5999 30.4941 29.4818

420078 1.9867 0.9357 32.8731 34.3181 33.3691 33.5209

420079 1.5363 0.9295 30.5981 31.7686 32.4626 31.6252

420080 1.4096 0.8858 32.8712 33.8785 35.2949 34.0334

420082 1.5126 0.9571 34.8864 33.5290 33.6670 33.9910

420083 1.4791 0.9128 29.6587 29.2264 33.5329 30.7160

420085 1.5196 0.9265 29.9085 31.3391 32.5361 31.2837

420086 1.5308 0.8799 29.6349 30.1406 30.5884 30.1347

420087 1.8321 0.9295 28.4632 28.8860 29.6136 29.0043

420089 1.6898 0.9295 31.7367 33.0906 35.2407 33.3707

420091 1.5567 0.8478 27.9062 28.0471 30.7482 28.8706

420098 1.1976 0.8462 27.6722 28.2058 29.6500 28.5992

420100 *** * 29.2979 * * 29.2979

420101 1.0052 0.8858 33.1995 33.5957 33.0451 33.2696

420102 1.8906 0.9357 * * 34.3207 34.3207

420103 1.2387 0.9357 * * * *

430005 1.4208 0.8435 25.4385 27.1759 29.2386 27.2448

430008 1.1323 0.8970 27.2275 27.2961 28.1278 27.5654

430012 1.3663 0.9388 27.0195 28.5808 28.9595 28.1941

430013 1.2067 0.8435 28.4962 28.3679 29.7388 28.8759

430014 1.5187 0.8435 28.9295 29.2921 30.3630 29.5359

430015 1.3611 0.8435 28.0414 28.0093 28.9296 28.3270

430016 1.6144 0.9388 31.1336 31.5894 34.2610 32.4635

430027 1.7295 0.9388 29.2617 29.2432 31.1835 29.9366

430048 1.2480 0.8564 25.6428 26.9537 28.6697 27.1026

430060 0.9026 0.8435 * 11.7801 * 11.7801

430064 0.9703 * 17.7334 * * 17.7334

430077 1.7929 1.0990 31.1945 35.3480 39.6547 35.4000

430081 1.0199 1.4448 * * * *

430082 0.7513 1.4448 * * * *

430083 1.0550 1.4448 * * * *
CMS-1498-P 893 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

430084 0.8832 1.4448 * * * *

430089 2.2827 0.8968 24.9060 28.3217 28.7338 27.4480

430090 2.0301 0.9388 32.7395 33.8350 34.0212 33.5658

430091 2.0885 1.0990 26.7258 28.3496 29.0916 28.0819

430092 2.0494 0.8435 23.2527 26.6750 28.3015 26.0017

430093 0.9808 1.0990 24.7426 30.7398 30.2337 28.4605

430094 1.7420 0.8564 23.6624 23.9005 24.9804 24.2133

430095 2.3107 0.9388 32.5881 31.8141 38.2085 34.0836

430096 2.3728 0.8435 24.9623 28.0608 28.3796 27.0773

440001 1.1423 0.7919 25.4855 23.9380 25.8019 25.0735

440002 1.7402 0.8907 26.9133 28.4828 28.7976 28.0851

440003 1.3257 0.9246 26.0115 31.4162 31.1666 29.3051

440006 1.6645 0.9246 31.7394 32.6924 33.2995 32.6609

440007 1.1248 0.8138 22.7571 23.4825 23.6870 23.3271

440008 1.0281 0.8368 26.8857 26.2003 28.2870 27.1392

440009 1.1708 0.7919 24.4423 25.1184 26.0040 25.1835

440010 0.9243 0.7919 20.2497 23.8087 24.9022 22.8411

440011 1.4425 0.7919 24.8300 25.7912 27.1600 25.9502

440012 1.5952 0.7919 24.9261 26.2076 26.5953 25.9396

440015 1.9977 0.7919 27.1603 28.1389 28.4467 27.9223

440016 1.0765 0.8063 25.2512 25.4197 27.4924 26.0451

440017 1.8177 0.7919 26.1820 28.6110 27.1081 27.3237

440018 1.1740 0.7919 24.8568 26.0748 26.3363 25.7740

440019 *** * 26.2464 28.0387 30.1931 28.0787

440020 1.0657 0.7919 27.5626 28.0269 28.6636 28.0709

440024 *** * 26.2534 25.4398 * 25.8750

440025 1.2561 0.8407 24.0289 25.5605 26.7642 25.4762

440026 *** * 28.4615 26.5911 29.9514 28.3617

440029 1.4714 0.9246 31.4652 31.8872 32.1072 31.8356

440030 1.3554 0.7919 22.3144 23.1116 23.2575 22.8992

440031 1.2845 0.7938 22.0711 23.0937 24.1851 23.1142

440032 1.2903 0.7919 23.8030 25.4122 25.3202 24.8770

440033 1.1176 0.7946 23.9792 24.3197 24.4996 24.2751

440034 1.7491 0.7919 25.9138 26.7987 27.0736 26.5997

440035 1.3762 0.9246 27.9217 26.8725 27.7533 27.5134

440039 2.2785 0.9246 30.1918 32.4190 32.3384 31.6681

440040 0.8602 0.7919 21.1288 21.3795 23.0134 21.8153
CMS-1498-P 894 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

440046 1.5007 0.9246 30.7334 31.5146 32.8764 31.6731

440047 0.9783 0.8257 25.2150 26.8032 28.6702 26.9106

440048 1.8888 0.9137 30.6725 31.5584 32.5404 31.5872

440049 1.7063 0.9137 29.8623 31.7148 32.6356 31.4058

440050 1.4510 0.7919 26.3825 27.1284 29.3303 27.5657

440051 0.9297 0.8001 23.6560 23.1773 24.8037 23.8861

440052 1.0648 * 24.4071 28.1868 * 26.2378

440053 1.3950 0.9246 30.3907 31.3189 32.4503 31.4080

440054 1.2435 0.7919 21.9641 25.7785 25.9377 24.4630

440056 1.2204 0.7919 24.0635 25.2050 25.9743 25.0917

440057 1.1740 0.7940 19.3546 25.1519 22.9222 22.2785

440058 1.1492 0.8582 29.1184 28.5093 28.0299 28.5506

440059 1.5321 0.9246 29.4532 30.4489 30.5995 30.1903

440060 1.3363 0.8257 26.5867 26.5518 27.3024 26.8209

440061 1.1152 0.7919 25.4134 25.9969 26.5212 25.9931

440063 1.7344 0.7952 26.0763 25.4344 24.7803 25.4192

440064 0.9734 0.8721 26.7957 26.9014 28.9331 27.5492

440065 1.4389 0.9246 25.6111 27.3501 27.6328 26.8707

440067 1.0879 0.7919 26.0866 26.5062 27.4606 26.6924

440068 1.1836 0.8531 27.9082 27.2646 28.3925 27.8565

440070 0.9667 0.8028 23.2228 24.4477 23.7568 23.8061

440072 1.1077 0.7919 26.1661 27.6990 29.4625 27.8065

440073 1.4586 0.9246 27.5133 28.3950 33.8232 29.7943

440081 1.3267 0.7971 21.9681 23.3000 24.5259 23.2799

440082 1.9820 0.9246 32.8941 34.4535 34.2270 33.8164

440083 0.9678 0.7919 25.7074 25.5397 31.8133 27.4028

440084 1.1913 0.7944 19.8950 21.3873 22.1562 21.1576

440091 1.8112 0.8721 28.9697 30.0650 31.3375 30.1465

440102 1.0781 0.7919 22.1114 23.5525 24.5121 23.3354

440104 2.0266 0.8721 28.0905 29.7326 30.2301 29.3691

440105 0.9050 0.7952 23.7154 24.6039 25.1558 24.4882

440109 1.0319 0.7989 22.5878 23.8465 25.0329 23.8752

440110 1.2059 0.7919 23.6275 23.8010 25.2412 24.2401

440111 1.3708 0.9246 29.7461 33.0828 34.8033 32.5048

440115 1.0246 0.8257 24.9778 25.2508 26.5072 25.5829

440120 1.5835 0.7919 26.0621 28.0271 29.3067 27.8170

440125 1.7354 0.7919 24.0934 24.7908 25.9494 24.9465
CMS-1498-P 895 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

440130 1.1307 0.7919 26.3192 27.5525 29.7509 27.8864

440131 1.1097 0.9137 28.3162 29.0546 29.2776 28.8882

440132 1.2404 0.7919 29.3377 26.1823 26.0031 27.0744

440133 1.7764 0.9246 32.5726 33.2319 32.4641 32.7486

440135 *** * 27.2094 28.7658 * 27.7843

440137 1.1024 0.8657 24.6143 25.6931 26.9374 25.7242

440141 1.0666 0.7919 24.8737 24.3575 26.3678 25.1500

440144 1.2612 0.8531 26.3225 26.6282 28.1527 27.0256

440147 *** * 36.6978 33.5900 37.8346 36.1793

440148 1.2607 0.8215 28.0708 26.2483 26.9352 27.0789

440150 1.5299 0.9246 30.5513 32.9854 32.8334 32.1424

440151 1.2054 0.9246 28.6585 28.8412 29.7082 29.0660

440152 2.5625 0.9137 29.0588 28.7357 30.1779 29.3307

440153 1.0707 0.7919 23.3790 23.8797 25.5049 24.2283

440156 1.6720 0.8721 30.5161 31.0506 31.6017 31.0718

440159 1.4664 0.9137 27.2785 26.2728 29.3516 27.6174

440161 2.1078 0.9246 31.0667 32.2343 33.4813 32.2916

440162 *** * 24.6425 27.8605 32.8708 28.2006

440168 0.9044 0.9137 31.3316 37.0865 35.6076 34.6194

440173 1.5174 0.7919 23.1370 23.5486 24.5617 23.7711

440174 0.9085 0.8907 27.4579 27.4578 29.2147 28.0222

440175 1.0307 0.7919 26.7705 29.2713 28.1637 28.0598

440176 1.4968 0.7919 24.9420 26.1477 25.8830 25.6676

440180 1.1625 0.7946 24.3376 26.9310 28.0126 26.4469

440181 1.1717 0.8284 26.4763 26.2247 26.8006 26.5057

440182 0.9173 0.8063 24.9899 24.4173 26.1132 25.1673

440183 1.5613 0.9137 30.9923 31.9159 33.2870 32.0523

440184 1.1262 0.7952 26.9086 25.3287 23.3322 25.0223

440185 1.2332 0.8531 26.3974 25.6005 27.2121 26.4383

440186 0.9656 0.9246 28.2840 30.0775 29.4231 29.3781

440187 1.1201 0.7919 27.4034 27.2669 29.4492 28.0330

440189 1.3670 0.8310 30.5786 29.9065 32.4791 31.0665

440192 1.1026 0.9246 30.6533 32.0772 30.4030 31.0183

440193 1.4241 0.9246 25.9726 27.8132 29.2015 27.6576

440194 1.3855 0.9246 32.3020 32.1073 33.3464 32.6095

440197 1.5649 0.9246 31.4317 32.3241 33.1604 32.2961

440200 1.1684 0.9246 23.8288 23.3049 25.6800 24.2881
CMS-1498-P 896 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

440217 *** * 31.6650 33.8684 33.5264 33.0112

440218 2.3018 0.9246 36.9273 31.7847 34.8600 34.3070

440222 *** * 30.5148 32.4230 33.4779 32.1341

440225 0.8351 0.7919 26.9687 29.8273 31.2189 29.5476

440226 1.8051 0.7919 28.3199 28.4491 31.2423 29.3511

440227 1.4445 0.9246 31.9119 32.1862 33.3005 32.4840

440228 1.5313 0.9137 29.5372 31.2049 32.7230 31.2589

450002 1.5584 0.8594 29.7180 30.0562 31.6279 30.4327

450005 1.2589 0.8456 27.3473 27.9825 28.6433 28.0242

450007 1.2745 0.9071 24.4630 26.2568 27.9008 26.2410

450008 1.3007 0.8775 24.4372 26.1215 28.5492 26.3295

450010 1.6966 0.9929 30.1034 32.9053 35.9573 32.9324

450011 1.6446 0.9244 29.9302 30.9903 32.9877 31.3013

450015 1.7472 0.9734 30.3168 30.3228 30.4911 30.3779

450018 1.7997 0.9946 31.3131 32.9922 35.5712 33.2965

450021 2.0024 0.9734 31.7360 34.5462 35.7307 34.0291

450023 1.3908 0.8038 25.1683 25.6361 27.9984 26.2980

450024 1.7757 0.8594 27.3814 27.8816 27.1925 27.4827

450028 1.6425 0.9486 29.5689 29.8049 34.0997 31.2123

450029 1.5534 0.8312 28.6465 27.2662 28.3780 28.0928

450031 *** * 29.2141 28.8891 34.0104 30.5763

450032 1.3782 0.8593 26.3159 25.7989 24.7722 25.5859

450033 1.6415 0.9486 29.7668 31.6557 32.7706 31.4322

450034 1.5659 0.8456 29.6309 28.2761 30.5057 29.4205

450035 1.7041 0.9946 30.3369 30.8574 * 30.5883

450037 1.5611 0.8593 28.2622 26.8661 31.6332 28.8487

450039 1.6804 0.9584 29.8145 29.5097 31.1550 30.1911

450040 1.7943 0.8940 28.5469 30.0844 31.7878 30.1162

450042 1.7837 0.8648 27.6131 28.3649 29.9591 28.7245

450044 1.7955 0.9734 32.9921 36.3786 36.8350 35.4324

450046 1.6799 0.8576 27.2439 28.4297 29.1115 28.2783

450047 *** * 24.9670 24.6290 * 24.8091

450051 2.0476 0.9734 30.3976 31.0740 32.5581 31.3450

450052 1.1232 0.8018 24.3964 25.8142 26.8780 25.6896

450054 1.8685 0.8775 30.2211 30.7196 31.8152 30.9786

450055 0.9581 0.8018 24.1418 24.6436 24.1331 24.3059

450056 1.7335 0.9523 32.0902 33.7634 35.1758 33.7275
CMS-1498-P 897 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

450058 1.6760 0.9071 27.7318 27.8963 29.3038 28.3582

450059 *** * 28.5645 29.9336 30.4251 29.6617

450064 1.6215 0.9584 29.0495 30.6704 31.2918 30.3637

450068 2.2983 0.9946 32.0372 34.9179 36.0902 34.3951

450072 1.2590 0.9946 28.0921 28.7063 30.1911 29.0674

450073 0.8084 0.8018 22.2322 23.1471 27.3607 24.1130

450076 1.7389 * * * * *

450078 0.9125 0.8018 20.7800 21.0876 22.8792 21.5781

450079 1.5567 0.9734 36.8936 34.1533 35.0924 35.3302

450080 1.2802 0.9584 26.8111 28.6334 28.2834 27.9102

450082 1.2045 0.8018 25.5654 27.1314 28.0686 26.8222

450083 1.8349 0.8259 30.2054 28.6628 27.8743 28.9055

450085 1.1963 0.8018 26.3610 28.1669 28.9441 27.8191

450087 1.5252 0.9584 32.6556 34.2493 35.5922 34.2084

450090 1.3411 0.8668 22.7822 22.2148 21.7004 22.2188

450092 1.4103 0.8312 28.2278 28.3891 30.5314 29.0936

450097 1.5643 0.9946 31.9782 33.8910 34.3604 33.4331

450099 1.3224 0.8434 29.8491 25.5799 25.4382 26.8735

450101 1.6811 0.8648 28.4220 29.3777 30.4843 29.3988

450102 1.7949 0.8259 27.3364 27.5145 28.5283 27.8122

450104 1.2249 0.9071 27.7851 30.4631 31.5834 29.9121

450107 1.7114 0.8594 29.0328 29.6790 31.5472 30.1274

450108 1.1643 0.9071 22.4293 21.7619 23.4651 22.5508

450119 1.6775 0.8888 34.4161 31.0699 34.4231 33.3604

450123 1.0012 0.8456 24.0433 27.6445 25.6415 25.8683

450124 1.8454 0.9523 31.9797 32.9774 34.3913 33.0155

450126 *** * 32.0370 32.9729 33.9635 33.0184

450128 1.3469 0.8888 28.3171 28.9733 25.6071 27.5150

450130 1.2316 0.9071 26.9208 28.3786 29.5020 28.2589

450132 1.6455 0.9426 31.1361 34.8719 33.2761 33.1083

450133 1.6806 0.9554 30.9622 31.3911 33.3058 31.9181

450135 1.7157 0.9584 30.7909 30.8734 32.1719 31.2968

450137 1.6678 0.9584 35.7775 33.8235 36.3832 35.3104

450143 1.0086 0.9523 24.4346 25.1702 26.2306 25.2759

450144 0.8810 0.9554 31.1552 31.4041 33.9298 32.1350

450147 1.4830 0.8576 26.3032 27.3607 28.1864 27.2675

450148 1.3368 0.9584 30.0542 29.9522 32.0315 30.7189
CMS-1498-P 898 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

450151 *** * 22.8768 * * 22.8768

450152 1.2507 0.8775 24.3442 25.7523 27.2981 25.8872

450154 1.3577 0.8018 24.2582 23.2210 26.8036 24.6426

450155 0.9518 0.8018 24.8773 25.2546 27.0261 25.7426

450162 1.1826 0.8940 33.7823 27.1453 27.1885 29.3979

450163 1.0821 0.8072 27.0967 27.6273 28.6735 27.8002

450165 1.1390 0.9071 30.2236 30.3796 31.6216 30.7510

450176 1.6011 0.8888 25.8587 28.4561 29.1369 27.9379

450177 1.1127 0.8018 26.0895 27.7791 28.5027 27.4708

450178 0.9348 0.9311 28.5990 27.5779 28.9534 28.3711

450184 1.7708 0.9946 30.9726 32.7090 34.0933 32.6058

450187 1.1680 0.9946 29.2749 29.3048 32.4972 30.4075

450188 0.9030 0.8018 24.6823 23.0844 23.5026 23.7701

450191 1.2449 0.9523 31.1339 30.0686 32.6122 31.2546

450192 1.0167 0.8289 26.9884 27.5539 29.0941 27.8974

450193 2.2410 0.9946 37.1906 38.2891 38.8688 38.1249

450194 1.2453 0.8231 30.4381 28.6816 28.5747 29.3155

450196 1.4787 0.8018 25.4842 29.8107 34.5610 29.7868

450200 1.5357 0.8018 27.9843 27.5112 27.4356 27.6508

450201 *** * 22.5464 * * 22.5464

450203 1.3080 0.9427 28.0986 29.4706 30.6946 29.4199

450209 1.8635 0.8574 31.9882 30.4150 32.0113 31.4497

450210 1.0230 0.8169 22.9055 23.7777 24.1082 23.5571

450211 1.4423 0.8593 28.8485 27.7427 28.6208 28.3857

450213 1.9743 0.9071 28.0307 29.2061 31.8766 29.7730

450214 1.2952 0.9946 28.2261 27.0761 29.7013 28.2460

450219 0.9672 0.8018 24.7274 28.0584 26.5426 26.4061

450221 1.0166 0.8018 20.7118 23.9462 26.0548 23.4307

450222 1.8038 0.9946 31.9255 33.2164 35.4314 33.5503

450224 1.3332 0.8259 28.7931 29.8428 34.2896 30.7490

450229 1.6776 0.8416 26.8039 27.2189 28.6814 27.5782

450231 1.7396 0.8574 27.0545 27.7289 29.0463 27.9560

450234 1.1803 0.8018 21.6799 23.2715 24.5744 23.0923

450235 0.9372 0.8018 23.8001 24.3335 26.5480 24.8876

450236 1.2391 0.8407 24.5942 24.1409 24.7381 24.4954

450237 1.6644 0.9071 31.2197 36.8412 38.6993 35.7648

450239 0.9838 0.8775 18.4234 19.1203 20.1484 19.2749
CMS-1498-P 899 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

450241 1.0529 0.8018 28.4948 24.3518 23.6473 25.3644

450243 1.0338 0.8018 19.0180 19.9804 19.3327 19.4422

450253 0.8658 0.9946 22.9918 24.3618 24.8454 24.0810

450270 1.2977 0.8289 12.9999 19.0341 23.1601 17.6868

450271 1.3816 0.9427 23.9534 27.4614 27.2326 26.3228

450272 1.2457 0.9523 29.0917 29.5124 30.9357 29.8687

450280 1.6447 0.9734 34.9349 33.8297 36.7763 35.1896

450283 1.1064 0.9584 28.2094 24.3428 26.0914 26.1061

450289 1.5582 0.9946 32.6137 32.4591 33.0717 32.7210

450292 1.2182 0.9734 29.0243 29.2485 29.9357 29.4213

450293 0.7961 0.8018 24.1556 23.7577 24.0607 23.9932

450296 1.0761 0.9946 33.4545 34.1708 36.4604 34.6820

450299 1.6942 0.9244 29.4593 30.3493 31.1239 30.4022

450306 0.8749 0.8416 22.6818 25.9877 26.8169 25.0749

450315 2.1271 0.9734 31.4227 32.3840 33.7842 32.7212

450324 1.6326 0.9584 27.9899 26.8023 29.4539 28.0902

450330 1.3508 0.9946 27.7419 29.4471 30.3251 29.1461

450340 1.4176 0.8479 29.6617 28.7672 30.5815 29.6840

450346 1.5986 0.8456 24.8434 26.7809 28.3085 26.7155

450347 1.2930 0.9946 28.5789 30.0644 39.0879 31.7620

450348 0.8857 0.8018 22.6828 23.1190 24.9786 23.5721

450351 1.1747 0.9427 29.9598 30.3441 31.5335 30.6264

450352 1.1455 0.9734 27.6480 29.3516 30.7631 29.2850

450358 2.1150 0.9946 33.9103 36.9859 37.7186 36.2668

450369 0.8990 0.8018 24.1953 22.7433 26.2247 24.2072

450370 1.1848 0.9946 29.0816 28.8348 29.9689 29.2856

450372 1.3896 0.9734 30.9345 33.7023 35.7078 33.4644

450373 0.8488 0.8018 27.4251 25.3691 24.2932 25.7191

450378 *** * 33.0583 33.9891 36.4075 34.4205

450379 1.4175 0.9734 35.0637 35.9067 32.6271 34.4741

450388 1.7639 0.9071 29.5386 30.3720 31.6070 30.5182

450389 1.2142 0.9584 26.8499 24.6733 25.7364 25.7517

450393 *** * 39.0266 12.9286 27.1107 24.0530

450395 1.1582 0.8459 28.4272 27.2714 29.8846 28.5726

450399 0.8847 0.8018 20.6307 23.2716 22.6787 22.2015

450400 1.0362 0.9244 29.5020 29.8965 30.9996 30.1497

450403 1.5366 0.9734 31.7065 33.1710 35.4782 33.5113
CMS-1498-P 900 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

450411 1.0111 0.8018 21.7877 20.9108 22.4110 21.7020

450419 1.3410 0.9584 34.9972 33.6834 34.9747 34.5445

450422 1.2762 0.9734 32.4669 36.7309 34.1134 34.3580

450424 1.5450 0.9946 29.8290 32.4674 34.5569 32.3014

450431 1.7403 0.9523 28.5289 29.6446 30.6654 29.6328

450438 1.3139 0.9946 27.7734 25.1006 25.4692 26.1366

450446 0.8334 0.9946 15.4641 12.4405 15.5216 14.4421

450447 1.1936 0.9584 28.3724 29.9936 31.8935 29.9931

450451 1.0730 0.8554 25.8836 26.5422 31.4824 27.8675

450460 0.8984 0.8071 25.2165 27.6224 25.4765 26.1120

450462 1.7382 0.9734 30.6516 31.7311 33.7989 32.0439

450465 1.2421 0.9946 28.1853 28.0105 30.1955 28.8001

450469 1.5261 0.9584 31.1348 29.2172 29.6203 29.9824

450475 1.1705 0.8593 24.7037 25.0642 25.7533 25.1909

450484 1.5134 0.8593 27.7792 29.4306 31.9711 29.7496

450488 1.1850 0.8593 24.9109 26.6089 19.2414 24.1030

450489 1.0148 0.8018 26.9543 25.3695 27.9844 26.7321

450497 1.0021 0.8393 23.0712 24.6056 25.5912 24.4315

450498 0.9124 0.8018 20.6873 19.3077 20.7519 20.2120

450508 1.4192 0.8593 29.1519 30.4829 31.5816 30.4268

450514 *** * 26.4196 * * 26.4196

450518 1.4458 0.8456 27.5880 28.9969 30.5901 29.0765

450530 1.3988 0.9946 30.7745 31.5033 33.7675 32.0278

450537 1.6268 0.9734 30.9167 33.1500 33.2793 32.4461

450539 1.2570 0.8085 25.0191 25.5268 27.9134 26.1684

450547 0.9127 0.9584 25.4140 24.6575 25.2773 25.1206

450558 1.7520 0.8416 28.7747 30.9433 32.3359 30.6894

450563 1.5978 0.9584 32.6875 35.8856 35.5273 34.6996

450565 1.3413 0.9427 27.4774 28.0400 20.2604 24.6775

450571 1.6736 0.8479 26.5313 26.2046 29.0276 27.1996

450573 1.0624 0.8144 24.6750 28.8508 27.5686 27.0771

450578 0.9388 0.8018 25.2478 25.7938 24.6928 25.2301

450580 0.9863 0.8018 25.9881 23.7932 24.3360 24.7329

450584 1.0404 0.8018 23.6044 23.7329 23.9279 23.7525

450586 1.0322 0.8018 18.3289 19.8656 21.2418 19.8421

450587 1.1286 0.8018 25.9364 27.1505 29.0095 27.3368

450591 1.2132 0.9946 27.9867 26.8802 27.3228 27.3932
CMS-1498-P 901 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

450596 1.3215 0.9427 31.6590 30.9701 32.6451 31.7682

450597 0.9543 0.8021 24.8443 26.3300 28.5346 26.5850

450604 1.5282 0.9071 29.1543 27.9983 29.6711 28.9317

450605 1.0389 0.8576 14.8039 23.3169 25.9294 19.8604

450610 1.6708 0.9946 30.5977 32.1314 33.4177 32.0231

450615 0.9227 0.8018 22.6331 25.1269 24.9073 24.2185

450617 1.6748 0.9946 30.2923 31.5691 32.8524 31.6194

450620 0.8835 0.8018 21.2535 21.7871 21.8114 21.6178

450630 1.5995 0.9946 31.8014 32.3195 33.9731 32.6640

450634 1.6926 0.9734 31.8008 31.9667 35.0494 32.9472

450638 1.7216 0.9946 33.3237 34.1802 33.8596 33.7803

450639 1.5533 0.9584 34.3754 33.3962 35.2238 34.3245

450641 0.9255 0.8393 21.7292 20.0231 21.9208 21.2237

450643 1.4481 0.8312 27.2538 28.7747 28.9744 28.3464

450644 1.6896 0.9946 31.6874 33.5265 34.8463 33.3746

450646 1.6538 0.8594 27.4631 27.8352 29.9319 28.4242

450647 1.9676 0.9734 34.1016 35.2696 36.5367 35.3425

450651 1.6423 0.9734 33.6498 34.9917 35.6621 34.7071

450653 1.1352 0.8018 26.5361 27.8569 30.2644 28.1938

450654 0.9530 0.8018 25.0755 23.5856 24.5622 24.3772

450656 1.4433 0.8593 29.7290 30.0651 32.2787 30.6407

450658 1.0226 0.8018 22.7090 21.8183 23.5451 22.6654

450659 1.6318 0.9946 34.2657 35.0007 37.4041 35.4287

450661 1.6239 0.9426 29.2381 29.1701 32.8505 30.5685

450662 1.7067 0.9486 30.9630 32.8936 34.5875 32.8475

450668 1.5975 0.8594 30.2083 30.7673 32.0366 30.9613

450669 1.2140 0.9734 32.1244 32.6777 35.4345 33.3993

450670 1.6341 0.9946 26.2954 28.8285 30.3037 28.5168

450672 1.8489 0.9584 33.0858 34.5171 35.3309 34.3346

450674 0.9275 0.9946 31.9316 33.4719 34.3708 33.2937

450675 1.5462 0.9584 32.6380 34.4049 35.3618 34.1567

450677 1.3956 0.9584 27.1603 29.5819 31.0723 29.3313

450678 1.6140 0.9734 33.5513 33.6167 35.4020 34.2062

450683 1.2254 0.9734 24.8440 28.7984 29.3788 27.6756

450684 1.5209 0.9946 31.2765 31.8794 35.0768 32.7040

450686 1.7733 0.8940 26.4871 28.8211 30.3945 28.6469

450688 1.5690 0.9734 29.4393 30.4156 39.5212 33.4935
CMS-1498-P 902 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

450690 1.4264 0.8259 30.0577 31.8607 33.2142 31.5431

450694 1.1250 0.8018 27.0862 28.3456 29.6365 28.3309

450697 1.6210 0.9071 28.3002 29.0148 30.4461 29.3085

450698 0.9036 0.8145 23.3062 21.5450 22.3625 22.2982

450702 1.6646 0.8593 27.1318 26.9753 30.2610 28.1063

450709 1.5374 0.9946 31.3239 31.0331 32.2101 31.5528

450711 1.6479 0.8888 28.1040 29.2934 31.1833 29.5133

450713 1.7474 0.9523 30.4933 31.3274 32.4793 31.4789

450715 *** * * 27.0982 * 27.0982

450716 1.4846 0.9946 33.9926 33.4960 35.7265 34.4031

450718 1.6829 0.9523 29.7609 30.6623 32.6777 31.1373

450723 1.5586 0.9734 31.0481 32.1316 32.6655 31.9568

450730 1.5137 0.9734 32.8920 34.9137 33.1903 33.6228

450742 1.2662 0.9734 30.4204 31.4270 33.0463 31.6358

450743 1.4816 0.9734 29.5098 30.3302 31.3249 30.4344

450746 1.1292 0.8018 23.3484 22.7535 25.0694 23.7092

450747 1.2515 0.8259 28.3935 27.1975 28.8858 28.1491

450749 0.9107 0.8018 23.9269 23.0265 23.2733 23.4142

450754 0.9768 0.8018 22.8572 23.4607 24.3117 23.5585

450755 1.0767 0.8294 24.7428 22.4195 31.3204 25.7528

450758 *** * 28.3305 29.5013 28.2010 28.6514

450760 *** * 23.7157 24.0691 25.7775 24.3542

450766 1.9556 0.9734 31.2084 33.3435 35.1683 33.2474

450770 1.3684 0.9523 23.6093 25.5863 18.0459 22.2518

450771 1.6045 0.9734 32.5014 32.6206 33.7565 32.9584

450774 1.6654 0.9946 27.5065 29.1151 * 28.3542

450775 1.5260 0.9946 31.6656 33.1582 34.3654 33.1091

450779 1.4365 0.9584 32.0770 31.4350 31.9592 31.8179

450780 2.1639 0.9071 28.5560 29.4960 31.6556 29.8709

450788 1.6154 0.8576 29.7667 31.5593 32.7687 31.3701

450795 1.1190 0.9946 43.8574 31.1871 28.4802 34.7233

450796 2.6228 0.8574 39.4762 31.6590 33.6154 34.7499

450797 1.7663 0.9946 26.0302 29.7074 31.7739 29.3070

450801 1.6105 0.8018 25.6379 27.2635 26.6634 26.5192

450803 1.3194 0.9946 28.7041 28.4345 33.0146 29.9070

450804 2.0163 0.9946 31.1891 33.2767 34.1951 32.9236

450808 2.3057 0.9523 29.6476 27.4132 29.9055 29.0173
CMS-1498-P 903 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

450809 1.7258 0.9523 29.4696 30.4031 31.4588 30.4836

450811 *** * 31.3007 32.5513 31.9859 31.9444

450813 1.1372 0.8144 26.5803 24.0804 20.6715 23.5616

450820 1.7477 0.9946 34.7445 36.4796 38.2108 36.6079

450822 1.3504 0.9734 34.4060 34.7760 36.6675 35.3212

450824 2.6197 0.9523 31.8413 34.8301 39.0190 35.1987

450825 1.6530 0.8888 25.8006 23.6674 24.3308 24.5730

450827 1.4304 0.9929 24.3659 23.6628 23.9496 23.9877

450828 1.3734 0.8018 26.9553 26.3231 28.2632 27.1681

450830 0.9681 * 28.4007 * * 28.4007

450831 1.7089 0.9946 24.4141 24.2732 29.1549 25.8378

450832 1.5453 0.9946 28.1389 31.2830 32.4824 30.7550

450833 1.1420 0.9734 29.0256 30.3604 32.5010 30.7618

450834 1.7933 0.9244 26.7253 28.1564 29.1031 27.9224

450838 *** * 19.2949 20.3039 19.0487 19.5634

450839 1.0081 0.8018 27.5330 28.0060 28.5894 28.0255

450840 1.2748 0.9734 32.4162 34.1412 35.8725 34.2963

450841 1.6187 0.9486 24.4389 24.6321 23.9682 24.3370

450844 1.4764 0.9946 33.0758 34.7070 36.5371 34.8354

450845 1.8367 0.8594 28.5039 30.9556 31.2402 30.2207

450847 1.3939 0.9946 30.7431 31.6028 32.1869 31.6098

450848 1.4727 0.9946 31.1476 32.0471 33.4153 32.3022

450850 *** * 27.2653 * * 27.2653

450851 2.0867 0.9734 32.8377 35.2085 38.8802 35.5622

450853 2.0083 0.9734 38.3600 37.5237 36.5101 37.2120

450855 1.8608 0.9486 30.7353 33.0196 32.9107 32.1835

450856 2.5479 0.9071 35.5006 35.5221 33.9274 34.9300

450860 1.8566 0.9946 33.3404 36.0060 39.5352 36.4526

450862 1.8415 0.9946 33.7962 34.2163 35.3982 34.5218

450864 2.6098 0.8259 25.3535 26.6579 27.1210 26.4353

450865 1.1060 0.9523 31.9200 34.6338 35.8513 34.1920

450867 1.2922 0.9523 31.4953 33.8712 34.7654 33.3974

450868 *** * 27.7501 28.4524 30.9119 29.0597

450869 1.9926 0.8888 28.7422 27.9532 33.2135 30.1400

450871 1.9451 0.9523 32.3990 35.2470 37.9738 35.1792

450872 1.3983 0.9584 31.7345 30.7510 30.9726 31.1239

450874 1.8676 0.9734 35.6839 37.4432 36.9974 36.7518
CMS-1498-P 904 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

450875 1.9516 0.8574 23.2962 26.9904 20.1676 22.8117

450876 1.7122 0.8940 30.3515 30.7721 30.9806 30.7060

450877 1.5299 0.8594 29.2353 28.0504 28.0186 28.4103

450878 2.5973 0.9071 33.6269 33.5225 36.1310 34.4610

450879 *** * 36.4874 31.1510 33.9546 33.6692

450880 1.9228 0.9584 32.6713 32.1245 34.4319 33.1600

450883 1.9373 0.9734 37.1525 38.5954 37.3049 37.6847

450884 1.0402 0.8642 23.5799 25.0230 25.7645 24.7956

450885 1.5264 0.9734 36.0954 33.7612 36.0679 35.3127

450886 2.1922 0.9584 30.1571 33.2011 34.2513 32.5780

450887 *** * 25.5590 * * 25.5590

450888 1.9205 0.9451 28.5995 26.3027 33.6718 29.5947

450889 1.3218 0.9734 35.6151 29.1149 37.7768 33.7885

450890 1.6403 0.9734 32.2000 33.9068 30.5718 32.1704

450891 1.8038 0.9734 39.0890 29.7832 28.6689 31.5429

450892 *** * 39.5333 * * 39.5333

450893 1.6541 0.9734 36.2660 37.8279 38.4890 37.6102

450894 2.5125 0.9734 25.9441 34.3388 30.1201 30.2587

460001 2.0520 0.9273 30.7040 32.3262 33.1209 32.1021

460003 1.6576 0.9362 29.6450 31.8128 33.2304 31.5395

460004 1.8788 0.9362 29.8773 32.2759 33.1810 31.8222

460005 1.5680 0.9362 29.4188 29.6947 32.5526 30.5747

460006 1.7333 0.9362 28.9653 30.3798 31.5156 30.3358

460007 1.3358 0.9311 29.1191 30.8583 31.3963 30.5244

460008 *** * 27.6906 30.5351 31.2708 29.8198

460009 2.0509 0.9362 29.4705 31.5120 32.4915 31.2060

460010 2.0371 0.9362 30.9813 32.8157 33.5686 32.4990

460011 1.3290 0.8714 26.5486 27.0189 29.7484 27.7675

460013 1.5423 0.9273 29.7252 31.2945 33.2639 31.4115

460014 1.1697 0.9362 30.6450 30.0229 31.5876 30.7603

460015 1.4935 0.8843 28.8014 30.7369 31.4843 30.3806

460017 1.3823 0.9097 28.7126 29.8556 32.9922 30.5250

460018 1.0014 * 22.0935 24.7761 * 23.4535

460019 1.1788 0.8714 25.1615 24.9579 29.0338 26.4222

460021 1.9540 0.9311 29.7397 31.5207 32.5066 31.3092

460023 1.4134 0.9273 28.9473 30.5888 31.3338 30.3465

460026 0.9596 0.9272 29.2775 31.3552 32.2647 30.9963
CMS-1498-P 905 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

460030 1.1661 0.8714 26.8979 30.0714 29.9269 28.9836

460033 0.9059 0.8714 27.9108 29.0346 30.0615 29.0242

460035 0.9434 0.8714 23.8682 23.4736 25.1957 24.1858

460039 1.1592 0.9354 30.0677 32.8010 35.0008 32.6853

460041 1.4984 0.9362 26.7356 29.4568 30.8887 29.0180

460042 1.5807 0.9362 36.2903 35.5686 32.3029 34.4949

460043 0.8631 0.9273 29.5660 31.2717 32.7481 31.2613

460044 1.4132 0.9362 29.5079 31.4469 32.6644 31.2589

460047 1.7647 0.9362 31.0020 33.0291 35.1263 33.0272

460049 2.1169 0.9362 28.6267 32.0329 32.9633 31.2669

460051 1.5507 0.9362 28.1140 28.6559 29.4759 28.9591

460052 1.7033 0.9273 28.7455 30.2613 31.8515 30.3626

460054 1.5710 0.8843 26.3939 28.1478 28.0120 27.5238

460055 *** * * * 23.1431 23.1431

460056 0.8224 0.8714 * * * *

470001 1.3548 1.0071 32.2887 34.5891 33.5241 33.3804

470003 1.7940 1.0340 30.0535 35.8753 36.7362 34.6784

470005 1.3682 0.9465 33.9969 32.1087 32.9379 33.0059

470011 1.2239 0.9465 30.8742 32.1668 33.3394 32.1525

470012 1.2953 1.0158 29.8259 30.9839 32.7025 31.2202

470024 1.3785 1.0340 27.3106 28.9203 29.2657 28.4919

490001 1.1846 0.8060 24.6883 25.2705 26.8850 25.6328

490002 0.9564 0.8063 24.0672 26.2533 27.6367 26.0235

490004 1.4283 0.9243 28.8660 30.6657 32.4538 30.6807

490005 1.7029 1.0559 31.4909 32.7159 34.9053 33.0668

490007 2.0623 0.8953 30.7411 31.5954 32.4614 31.6048

490009 2.0440 0.9243 31.4260 30.5748 31.9496 31.3136

490011 1.7060 0.8953 28.8780 30.5522 31.9508 30.4122

490012 1.1797 0.8060 21.8322 22.3339 24.4301 22.9678

490013 1.3615 0.9661 27.3486 27.4108 28.5324 27.7697

490017 1.6019 0.8953 29.6784 29.5853 30.9047 30.0811

490018 1.3937 0.9243 27.8682 28.8491 29.5589 28.7713

490019 1.3345 0.9243 29.8891 33.5636 33.7765 32.4062

490020 1.3546 0.9536 30.6013 32.5621 33.3461 32.1198

490021 1.4713 0.8527 28.1254 28.1343 30.0869 28.7596

490022 1.5783 1.0559 31.7985 34.5366 33.3639 33.2694

490023 1.4038 1.0559 32.6308 33.4561 35.6316 33.9527
CMS-1498-P 906 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

490024 1.7367 0.9020 29.0407 29.9188 31.4854 30.2069

490027 1.4257 0.8060 24.3834 23.6876 25.1699 24.4425

490032 2.0641 0.9536 28.0120 30.0331 32.8661 30.3741

490033 1.2418 1.0559 30.9910 32.1854 35.3543 32.8355

490037 1.1921 0.8060 26.2951 28.9020 27.7807 27.6377

490038 1.1365 0.8063 24.0852 25.7219 26.5823 25.5525

490040 1.6870 1.0559 35.6822 36.5546 38.2247 36.8591

490041 1.7419 0.8953 29.1244 30.4198 31.6506 30.4422

490042 1.3852 0.8864 26.6078 28.1989 28.6351 27.8261

490043 1.4528 1.0571 36.5982 33.4364 35.4380 35.1246

490044 1.5021 0.8953 24.1763 30.3606 31.1639 28.6723

490045 1.4362 1.0559 32.8774 34.0289 33.2301 33.3822

490046 1.5611 0.8953 29.3882 30.5445 32.0244 30.6581

490048 1.5181 0.9020 28.0320 29.1952 32.3457 29.8101

490050 1.6932 1.0559 31.1370 33.3979 35.3441 33.2738

490052 1.7570 0.8953 25.4179 26.5858 27.5800 26.5238

490053 1.2123 0.8060 24.6206 25.5300 27.6516 26.0148

490057 1.6341 0.8953 29.0700 30.5163 31.4342 30.3581

490059 1.7476 0.9536 32.1031 32.7894 33.7315 32.8906

490060 1.0988 0.8060 25.7765 26.2620 26.8764 26.2885

490063 1.9288 1.0571 34.1179 35.7722 36.5676 35.5145

490066 1.3993 0.9536 31.4298 31.1949 32.8018 31.8232

490067 1.3116 0.9536 26.7802 27.5172 28.6635 27.6322

490069 1.7572 0.9536 30.1482 33.1140 33.7580 32.4106

490071 *** * 33.7118 36.1311 37.5474 35.7436

490073 *** * 46.4210 * * 46.4210

490075 1.4728 0.8168 27.3424 27.8663 28.5221 27.8788

490077 1.4245 0.9243 31.0016 33.5266 33.9868 32.8758

490079 1.2258 0.8973 24.2066 25.3814 26.8381 25.4605

490084 1.1514 0.8247 26.3234 28.0861 29.2001 27.8967

490088 1.0343 0.8527 26.0285 26.5138 27.3105 26.6200

490089 1.0904 0.9020 27.4587 28.7200 28.6746 28.3003

490090 1.1170 0.8060 27.0760 28.1280 30.1159 28.4491

490092 1.0905 0.8060 27.5277 26.9546 27.9480 27.4786

490093 1.5805 0.8953 28.7122 29.2159 30.8707 29.6194

490094 1.0446 0.9536 29.7990 33.4960 35.2427 32.9163

490097 1.1213 0.8060 27.4608 27.3832 30.3702 28.3815
CMS-1498-P 907 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

490098 1.2490 0.8060 26.7152 29.1195 30.2724 28.7604

490101 1.5529 1.0571 32.9516 36.2501 37.1100 35.5137

490104 0.8635 0.9536 19.0056 21.5140 25.4797 21.5647

490105 0.7752 0.8063 * * * *

490106 0.7217 * 26.2318 28.0073 29.6648 27.8955

490107 1.5612 1.0571 35.0272 36.5156 37.8948 36.4952

490108 0.9350 0.8527 27.8717 26.8474 28.1422 27.6252

490109 0.8360 0.8953 21.6711 26.3100 35.3956 26.6243

490110 1.4981 0.8478 26.3089 28.6114 30.4140 28.4403

490111 1.3002 0.8060 26.4297 25.9801 25.5933 26.0180

490112 1.8616 0.9536 31.2549 32.6940 34.4483 32.7850

490113 1.3453 1.0559 34.7841 34.3609 35.7020 34.9658

490114 1.2877 0.8060 23.0533 23.6217 24.3756 23.7176

490115 1.1261 0.8060 23.2118 24.2056 24.5732 24.0079

490116 1.1200 0.8060 25.0351 26.8981 27.6062 26.5245

490117 1.1400 0.8060 20.3038 19.0627 21.2554 20.2023

490118 1.7126 0.9536 31.2407 32.7697 34.4087 32.7699

490119 1.3791 0.8953 29.5222 30.2401 31.8001 30.5988

490120 1.5447 0.8953 27.1990 29.8199 31.3588 29.5073

490122 1.6804 1.0571 35.2234 36.8356 37.2409 36.4506

490123 1.1733 0.8060 24.6011 25.9018 26.5759 25.6908

490126 1.2835 0.8060 25.3294 26.4277 28.1112 26.5960

490127 1.1572 0.8060 23.1399 23.5161 25.8521 24.1618

490130 1.3539 0.8953 25.9782 27.8912 28.5506 27.5060

490134 0.8484 0.8060 31.1495 36.6290 38.4799 35.3431

490135 0.8329 0.9020 27.2795 29.4817 30.6983 29.1252

490136 1.5986 0.9536 31.2911 33.2256 33.6199 32.9138

490137 *** * * 33.7203 * 33.7203

490138 *** * * * 29.6062 29.6062

490140 1.1707 1.0559 * * * *

500001 1.6920 1.1393 37.5323 34.4057 36.7516 36.1864

500002 1.4064 1.0107 30.1872 32.8317 34.4481 32.6052

500003 1.3883 1.1272 32.7983 34.5869 35.4284 34.3657

500005 1.9139 1.1393 36.0918 36.7598 34.3832 35.6947

500007 1.3046 1.1272 31.0313 32.8189 34.5520 32.8250

500008 2.0942 1.1393 34.7810 37.6578 39.2151 37.2339

500011 1.5112 1.1393 38.3979 35.9571 39.3411 37.8813
CMS-1498-P 908 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

500012 1.6682 1.0107 33.1685 34.1650 36.8979 34.8623

500014 1.7774 1.1393 37.2698 36.3915 39.1505 37.5950

500015 1.4145 1.1393 40.8683 41.8914 37.7765 39.9793

500016 1.7006 1.1272 34.2828 35.1946 36.9961 35.5244

500019 1.2954 1.0238 33.8882 33.3151 33.7113 33.6367

500021 1.2735 1.1272 33.5610 34.1696 35.5039 34.4442

500024 1.6970 1.1080 37.4529 38.1144 38.4388 38.0019

500025 2.0660 1.1393 44.7105 45.7929 46.4667 45.6979

500026 1.5246 1.1393 35.5080 38.9294 39.8935 38.0803

500027 1.5514 1.1393 42.4974 43.3521 46.0534 43.9702

500030 1.6107 1.1302 36.9489 37.8938 39.5003 38.1941

500031 1.3816 1.1015 34.1651 37.1418 39.3882 37.0143

500033 1.3025 1.0107 32.6753 33.5611 34.6180 33.6561

500036 1.3062 1.0107 31.9164 33.0937 34.4581 33.2430

500037 1.0522 1.0107 29.1773 31.5221 33.5698 31.4598

500039 1.6290 1.1272 34.5739 35.7525 36.9804 35.8188

500041 1.4539 1.1212 36.9273 37.1754 37.2841 37.1483

500044 1.8709 1.0588 32.0743 32.9066 37.2547 34.2357

500049 1.3589 1.0107 30.8135 32.9904 35.3710 33.0668

500050 1.6841 1.1212 35.7254 35.8576 38.7771 36.8297

500051 1.7983 1.1393 36.4764 38.1805 40.4444 38.4149

500052 0.5257 1.1393 * * * *

500053 1.2927 1.0107 28.5664 35.5776 32.3889 32.3866

500054 2.0439 1.0588 34.8114 36.0163 37.0037 35.9970

500058 1.7819 1.0107 32.6843 33.9116 35.3683 34.0086

500060 1.3839 1.1393 40.3040 33.4139 36.1561 36.3222

500064 2.1038 1.1393 34.7925 36.5889 38.6388 36.7061

500072 1.2795 1.0399 33.1148 33.7689 34.6614 33.8664

500077 1.6554 1.0588 34.3114 35.6352 36.5941 35.5623

500079 1.4615 1.1272 34.2420 35.0285 39.6971 36.2958

500084 1.2299 1.1393 33.3072 35.9603 37.4223 35.5895

500088 1.5216 1.1393 38.5194 39.5328 42.2213 40.1754

500108 1.7135 1.1272 35.8918 36.9874 38.4486 37.1566

500119 1.3965 1.0588 31.7125 33.2862 37.1560 34.2985

500124 1.5615 1.1393 36.3338 36.2555 38.4951 37.0807

500129 1.7301 1.1272 37.3189 39.0479 40.9416 39.1501

500134 *** * 28.9759 27.6000 * 28.2473
CMS-1498-P 909 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

500139 1.5940 1.1080 37.5709 37.3065 40.1626 38.3039

500141 1.3018 1.1393 34.2384 35.0996 36.5770 35.3417

500143 0.8345 1.1080 26.3893 27.6976 27.0786 27.0516

500148 1.2582 1.0107 24.6347 29.1435 29.3580 27.8028

500150 1.3469 1.1212 34.8480 37.1238 39.5124 37.2763

500151 1.2724 1.1264 * * * *

510001 1.9015 0.8266 26.7924 27.6648 28.5579 27.6991

510002 1.3699 0.8820 24.8846 25.3769 26.9879 25.7394

510006 1.3756 0.8266 26.6421 27.5033 28.3986 27.5167

510007 1.7093 0.8875 28.5783 29.7125 31.3109 29.8649

510008 1.4922 0.9455 27.4709 30.6397 31.5292 29.9314

510012 0.9949 0.7660 22.9038 23.9222 23.9062 23.5707

510013 1.1575 0.7536 22.9612 22.1864 22.8779 22.6690

510018 1.1130 0.8093 23.7736 22.6582 24.2196 23.5313

510022 1.8567 0.8093 27.6119 28.4911 28.9389 28.3550

510023 1.1934 0.7536 23.1461 21.1483 23.2098 22.4635

510024 1.6521 0.8266 31.1327 32.3022 29.9740 31.1328

510026 1.0087 * 17.8275 18.6662 * 18.2486

510029 1.4261 0.8093 25.3925 24.6743 25.6860 25.2487

510030 1.1745 0.7536 25.5600 26.0174 26.6707 26.0891

510031 1.6207 0.8093 26.7872 29.5993 29.4024 28.5765

510033 1.5597 0.7536 24.2839 24.4150 24.9115 24.5148

510038 1.1536 0.7536 21.7545 21.1103 22.4112 21.7748

510039 1.3776 0.7536 21.3819 21.7158 22.0335 21.7116

510046 1.4481 0.8020 24.7187 23.2634 24.7177 24.2383

510047 1.2916 0.8266 28.8794 30.0461 31.1243 30.0454

510048 1.3054 0.7536 23.6396 25.0987 26.5418 25.1357

510050 1.8089 0.8441 23.5794 24.3081 24.5207 24.1225

510053 1.0042 0.7536 22.6288 24.3853 25.0147 24.0222

510055 1.6973 0.8875 30.7382 32.3284 33.3163 32.1773

510058 1.3980 0.7536 24.8770 24.9360 23.8781 24.5564

510059 *** * 21.9053 20.5651 23.5300 22.1135

510062 1.2221 0.8093 27.7971 30.4515 32.4834 30.2773

510067 *** * 25.2248 25.4499 * 25.3238

510070 1.3121 0.8093 25.4981 26.1227 28.1871 26.6091

510071 1.3504 0.7746 23.4553 21.7085 23.4390 22.8860

510072 1.0600 0.7536 20.2387 20.1981 21.4895 20.6336
CMS-1498-P 910 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

510077 1.0537 0.8723 27.1611 24.7849 27.0319 26.3370

510082 1.2339 0.7536 21.1665 24.7558 22.7658 22.9281

510085 1.4818 0.8093 26.8133 27.6206 24.4240 26.3575

510086 1.1482 0.7536 20.1965 21.2628 20.3576 20.5850

510090 *** * 39.0787 * * 39.0787

520002 1.3482 0.9113 28.3413 28.2765 26.7116 27.7254

520004 1.4996 0.9864 30.9212 32.9848 34.1865 32.6654

520008 1.6075 1.0226 33.6774 36.6697 38.2815 36.3308

520009 1.8579 0.9375 29.6290 31.0683 31.6106 30.8052

520011 1.3433 0.9019 29.5024 31.8421 33.2873 31.5935

520013 1.6336 1.1027 32.1721 33.9209 34.9944 33.6882

520017 1.2107 0.9600 31.0537 31.8512 33.6624 32.2031

520019 1.2522 0.9019 30.2189 28.8256 25.1409 27.9904

520021 1.3391 1.0370 29.7809 29.0525 30.3673 29.7460

520027 1.4301 1.0226 33.5836 33.5264 35.9033 34.3676

520028 1.3940 1.1096 29.4694 28.1055 30.4362 29.3795

520030 1.7246 0.9581 31.6807 32.0646 34.2167 32.6070

520033 1.3879 0.9019 30.2631 29.5690 31.1389 30.3366

520034 1.3078 0.9019 28.1819 30.4913 31.6386 30.1603

520035 1.5330 0.9375 29.4076 31.0972 32.7626 31.1082

520037 1.7279 0.9113 32.2206 33.1606 33.0449 32.8212

520038 1.2914 1.0226 30.5267 32.6502 32.9167 32.0875

520040 *** * 35.9652 * * 35.9652

520041 1.0128 1.1316 26.1586 28.3889 30.2068 28.2350

520044 1.5130 0.9375 28.6620 * 31.9599 30.2726

520045 1.7890 0.9536 30.0856 29.6250 33.3652 30.9444

520048 1.6586 0.9536 30.1483 31.8604 33.1944 31.7313

520049 1.9727 0.9443 29.4238 29.8707 30.8224 30.0316

520051 1.5852 1.0226 32.4131 32.5510 35.4345 33.4292

520057 1.2057 0.9212 29.1597 31.7777 34.0671 31.7455

520059 1.4262 1.0226 31.1798 32.1905 33.6526 32.3663

520062 1.3557 1.0226 32.7015 37.5630 37.0520 35.8645

520063 1.2023 1.0226 31.5200 32.6383 34.1781 32.7561

520064 1.6643 1.0226 33.1269 34.1899 36.0924 34.4301

520066 1.4525 0.9694 31.6793 31.2257 33.7033 32.1994

520070 1.8311 0.9600 30.0475 30.2454 32.1644 30.8209

520071 1.2720 1.0226 31.5452 32.9974 33.3852 32.6894
CMS-1498-P 911 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

520075 1.8243 0.9443 32.2773 33.5393 34.0973 33.3083

520076 1.2579 1.0226 26.8943 28.0857 30.1903 28.4165

520078 1.6147 1.0226 32.0200 32.8377 33.6214 32.8336

520083 1.6732 1.1316 34.7230 36.8165 38.2281 36.6451

520087 1.6998 0.9864 31.9771 33.5759 34.5519 33.3848

520088 1.3791 0.9470 30.7482 32.9061 32.7670 32.1576

520089 1.5783 1.1316 34.9357 36.3819 38.0516 36.4973

520091 1.3243 0.9019 28.7180 29.9318 31.2611 29.9703

520095 1.2864 1.1096 33.2426 33.3298 35.6079 34.0578

520096 1.4255 1.0226 29.2895 31.5023 37.8499 32.7151

520097 1.4507 0.9443 30.5442 32.2225 34.3493 32.3376

520098 2.0458 1.1316 38.0993 39.1444 41.0919 39.4919

520100 1.3212 0.9694 31.7772 32.4038 34.0159 32.7405

520102 1.2714 1.0226 31.5756 31.9275 34.1568 32.5763

520103 1.5487 1.0226 34.5640 35.3825 36.9411 35.6386

520107 1.3724 0.9178 30.0354 31.6500 31.1976 30.9724

520109 1.0287 0.9019 25.9740 27.2739 28.4742 27.2711

520113 1.4088 0.9249 33.3040 34.9718 35.6843 34.6401

520116 1.2781 1.0226 31.6702 32.7105 34.6508 33.0184

520136 1.8091 1.0226 32.3504 32.8906 33.7189 32.9955

520138 1.9849 1.0226 32.5677 33.5487 36.0676 34.0683

520139 1.4138 1.0226 31.7086 32.9369 34.1039 32.9713

520160 1.7449 0.9375 30.3052 31.0392 33.4129 31.5467

520170 1.6326 1.0226 31.7610 35.2627 33.8589 33.5756

520177 1.7357 1.0226 33.1243 34.6960 35.6005 34.5408

520189 1.3474 1.0370 29.2229 29.0333 31.6752 29.9942

520193 1.7818 0.9443 29.4737 30.8077 32.6949 31.0673

520194 1.7194 1.0226 31.0015 36.9520 35.9064 34.6592

520195 *** * 41.6120 37.8891 * 39.7179

520196 1.7921 0.9600 33.4890 32.0197 35.9711 33.8028

520198 1.4018 0.9536 29.9803 30.6303 32.9887 31.2354

520199 2.1323 1.0226 37.0128 45.5967 46.6518 43.7293

520202 1.7481 0.9581 * 33.6427 30.8076 32.2276

520203 *** * * * 44.8123 44.8123

520204 1.0509 1.0226 * * * *

520205 2.1096 1.0226 * * * *

530002 1.1686 0.9392 29.2418 32.5654 34.0190 32.0426
CMS-1498-P 912 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

530006 1.2785 0.9392 30.3724 32.8615 33.0523 32.1254

530008 1.1051 0.9392 30.6010 30.6600 30.9960 30.7519

530009 0.8427 0.9392 27.0555 27.3359 30.2467 28.1948

530010 1.2811 0.9392 28.5534 30.1134 32.0732 30.2646

530011 1.1057 0.9392 31.1329 31.8923 31.4146 31.4720

530012 1.6294 0.9444 30.6109 31.1738 32.9710 31.6237

530014 1.4706 0.9418 29.6724 31.2573 32.7666 31.2186

530015 1.2800 0.9392 33.4903 36.0871 37.1114 35.5281

530017 1.1557 * 25.8183 24.0911 * 24.8262

530025 1.2173 0.9392 28.8963 31.4614 30.9906 30.4574

530032 1.1632 0.9392 25.4267 26.7025 31.0922 27.6747

530033 2.0646 0.9444 * * * *

640001 0.8536 * * * * *

650001 1.4006 * * * * *

660001 1.0796 * * * * *

670002 1.0505 0.9734 29.1376 29.9545 30.5438 29.8867

670003 *** * 33.8986 33.4713 33.2183 33.4927

670004 1.1660 0.8018 25.3706 25.5671 26.9631 25.9396

670005 1.7721 0.9946 31.9464 41.2085 29.7605 33.4908

670006 1.9552 0.9523 27.1064 34.6785 36.8199 32.5839

670007 *** * * 29.5985 30.3445 30.0121

670008 1.5966 0.9946 * 30.3978 30.7957 30.6253

670009 *** * * 31.8096 29.0715 30.1581

670010 0.8338 0.9734 * 35.6620 29.6612 31.5941

670011 1.0270 0.9523 * 32.1855 30.2158 30.9733

670012 2.2140 0.9946 * 24.1597 24.2305 24.1941

670013 *** * * 29.4886 * 29.4886

670014 *** * * 34.6108 * 34.6108

670015 *** * * 35.3054 * 35.3054

670016 *** * * * 30.9543 30.9543

670017 *** * * * 30.4743 30.4743

670018 0.9687 0.9946 * * 34.7939 34.7939

670019 1.5202 0.9946 * * 42.1599 42.1599

670020 *** * * * 39.6181 39.6181

670022 *** * * 32.9889 34.0570 33.5229

670023 1.4036 0.9427 * * 32.5158 32.5158

670024 1.6178 0.9946 * * 30.0165 30.0165
CMS-1498-P 913 

Provider Number 

Case-Mix 

Index2

FY 2011 

Wage 

Index 

Average 

Hourly 

Wage 

FY 2009 

Average 

Hourly 

Wage 

FY 2010 

Average 

Hourly 

Wage 

FY 20111

Average 

Hourly Wage** 

(3 years) 

670025 3.0845 0.9734 * * 39.9558 39.9558

670026 *** * * * 21.8681 21.8681

670027 1.9240 0.9946 * * 19.3451 19.3451

670028 *** * * * 43.4052 43.4052

670029 1.7447 0.9946 * * 24.7438 24.7438

670030 *** * * * 32.0527 32.0527

670031 1.3908 0.9946 * * 32.9130 32.9130

670033 1.1449 0.9734 * * * *

670034 1.4385 0.9523 * * 31.7770 31.7770

670040 0.8256 0.9946 * * 20.5126 20.5126

670041 1.5612 0.9523 * * * *

670042 1.7645 0.9427 * * * *

670043 1.2712 0.9523 * * * *

670044 1.2345 0.9734 * * * *

670046 1.2291 0.9427 * * * *

670047 1.4178 0.8594 * * * *

670048 1.2701 0.9946 * * * *

670049 1.4828 0.9734 * * * *

670050 1.2258 0.8940 * * * *

670051 1.7132 0.9244 * * * *

670052 0.9734 0.9427 * * * *

670053 1.5075 0.9946 * * * *

670054 2.1510 0.9071 * * * *

670055 1.4073 0.9071 * * * *

1. Based on salaries adjusted for occupational mix, according to the calculation in section III.H. of this proposed 

rule. 

2. The case-mix index is based on the billed MS-DRGs in the FY 2009 MedPAR file. It is not transfer-adjusted. 3. Provider 140010 is part of a multi-campus provider (MCH) that is comprised of campuses that are located in two 

different CBSAs. The provider number with a “B” in the 4th position, 140B10, indicates the portion of the wage and 

hours of the MCH that is allocated to CBSA 29404; provider number 140010 indicates the portion of wages and 

hours of the MCH that is allocated to CBSA 16974. 

4. Provider 220074 is part of a MCH that is comprised of campuses that are located in two different CBSAs. The 

provider number with a “B” in the 4th position, 220B74, indicates the portion of the wage and hours of the MCH that 

is allocated to CBSA 14484; provider number 220074 indicates the portion of wages and hours of the MCH that is 

allocated to CBSA 39300. 

5. Provider 230104 is part of a MCH that is comprised of campuses that are located in two different CBSAs. The 

provider number with a “B” in the 4th position, 230B04, indicates the portion of the wage and hours of the MCH that 

is allocated to CBSA 47644; provider number 230104 indicates the portion of wages and hours of the MCH that is 

allocated to CBSA 19804. 

Notes: 
CMS-1498-P 914 

* Denotes wage data not available for the provider for that year. 

** Based on the sum of the salaries and hours computed for Federal FYs 2009, 2010, and 2011. 

*** Denotes MedPAR data not available for the provider for FY 2009. 
CMS-1498-P 915 

TABLE 3A.--FY 2011 and 3-YEAR* AVERAGE HOURLY 

WAGE FOR ACUTE CARE HOSPITALS IN URBAN AREAS BY CBSA 

[*Based on the salaries and hours computed for Federal FYs 2009, 2010, and 2011.] 

CBSA 

Code Urban Area 

FY 2011 

Average 

Hourly 

Wage 

3-Year 

Average 

Hourly 

Wage 

10180 Abilene, TX 29.3949 28.1776

10380 Aguadilla-Isabela-San Sebastián, PR 11.8160 11.2855

10420 Akron, OH 30.9394 29.7268

10500 Albany, GA 31.7616 30.0124

10580 Albany-Schenectady-Troy, NY 30.4027 29.4970

10740 Albuquerque, NM 33.6484 32.1367

10780 Alexandria, LA 28.4818 27.3679

10900 Allentown-Bethlehem-Easton, PA-NJ 32.9853 32.3982

11020 Altoona, PA 29.8723 28.7214

11100 Amarillo, TX 29.9470 29.2820

11180 Ames, IA 35.0846 32.5833

11260 Anchorage, AK 41.3142 39.7621

11300 Anderson, IN 32.4243 30.5946

11340 1Anderson, SC ---- 31.0258

11460 Ann Arbor, MI 35.2875 34.4775

11500 Anniston-Oxford, AL 27.5967 26.3204

11540 Appleton, WI 32.6349 31.2420

11700 Asheville, NC 31.6157 30.6097

12020 Athens-Clarke County, GA 32.6369 31.0325

12060 Atlanta-Sandy Springs-Marietta, GA 33.4176 32.3815

12100 Atlantic City-Hammonton, NJ 38.5037 38.3789

12220 Auburn-Opelika, AL 26.2864 26.2272

12260 Augusta-Richmond County, GA-SC 33.4130 32.0531

12420 Austin-Round Rock-San Marcos, TX 33.2627 31.9957

12540 Bakersfield-Delano, CA 41.2731 38.7144

12580 Baltimore-Towson, MD 35.6052 33.9776

12620 Bangor, ME 33.8045 33.3702

12700 Barnstable Town, MA 44.7757 42.6501

12940 Baton Rouge, LA 30.4662 28.2098

12980 Battle Creek, MI 34.0719 33.4413

13020 Bay City, MI 32.9174 31.6784

13140 Beaumont-Port Arthur, TX 29.5372 28.3888
CMS-1498-P 916 

CBSA 

Code Urban Area 

FY 2011 

Average 

Hourly 

Wage 

3-Year 

Average 

Hourly 

Wage 

13380 Bellingham, WA 39.5003 38.1941

13460 Bend, OR 39.2471 37.6920

13644 Bethesda-Rockville-Frederick, MD 36.3603 34.8330

13740 Billings, MT 31.2292 30.2506

13780 Binghamton, NY 31.1847 29.8256

13820 Birmingham-Hoover, AL 30.1026 29.0144

13900 Bismarck, ND 26.6755 25.4947

13980 Blacksburg-Christiansburg-Radford, VA 28.9603 27.7355

14020 Bloomington, IN 32.4229 31.4114

14060 Bloomington-Normal, IL 33.4002 31.9474

14260 Boise City-Nampa, ID 32.4846 31.3466

14484 Boston-Quincy, MA 43.0901 41.0488

14500 Boulder, CO 35.3221 34.0847

14540 Bowling Green, KY 30.4559 28.6498

14740 Bremerton-Silverdale, WA 36.9804 35.8188

14860 Bridgeport-Stamford-Norwalk, CT 44.1289 43.0332

15180 Brownsville-Harlingen, TX 33.1329 31.3922

15260 Brunswick, GA 32.4958 31.8053

15380 Buffalo-Niagara Falls, NY 33.6124 32.5065

15500 Burlington, NC 30.6796 29.1889

15540 Burlington-South Burlington, VT 36.0988 34.0281

15764 Cambridge-Newton-Framingham, MA 39.4299 37.7800

15804 Camden, NJ 36.2670 34.9790

15940 Canton-Massillon, OH 30.1085 29.2640

15980 Cape Coral-Fort Myers, FL 32.0534 31.0627

16020 Cape Girardeau-Jackson, MO-IL 30.7590 30.1921

16180 Carson City, NV 35.8985 34.3321

16220 Casper, WY 32.9710 31.6237

16300 Cedar Rapids, IA 30.7335 29.6900

16580 Champaign-Urbana, IL 35.4749 33.2063

16620 Charleston, WV 28.2186 27.7498

16700 Charleston-North Charleston-Summerville, SC 32.4496 31.0970

16740 Charlotte-Gastonia-Rock Hill, NC-SC 32.4685 31.5651

16820 Charlottesville, VA 32.2777 31.5688

16860 Chattanooga, TN-GA 30.7014 29.7023

16940 Cheyenne, WY 32.7666 31.2186
CMS-1498-P 917 

CBSA 

Code Urban Area 

FY 2011 

Average 

Hourly 

Wage 

3-Year 

Average 

Hourly 

Wage 

16974 Chicago-Joliet-Naperville, IL 36.6687 34.9381

17020 Chico, CA 39.7055 37.2221

17140 Cincinnati-Middletown, OH-KY-IN 33.6443 32.0501

17300 Clarksville, TN-KY 27.4198 26.9255

17420 Cleveland, TN 27.2121 26.2003

17460 Cleveland-Elyria-Mentor, OH 31.7487 30.5792

17660 Coeur d'Alene, ID 32.1766 30.7795

17780 College Station-Bryan, TX 32.2874 30.8937

17820 Colorado Springs, CO 32.2511 31.9296

17860 Columbia, MO 28.8423 28.3106

17900 Columbia, SC 30.7179 29.8385

17980 Columbus, GA-AL 31.8363 30.1940

18020 Columbus, IN 33.0833 32.3322

18140 Columbus, OH 35.5317 33.8232

18580 Corpus Christi, TX 29.9543 28.8144

18700 Corvallis, OR 36.1111 36.0952

18880 2Crestview-Fort Walton Beach-Destin, FL 30.6368 29.2681

19060 Cumberland, MD-WV 28.7642 26.6875

19124 Dallas-Plano-Irving, TX 33.9994 32.8345

19140 Dalton, GA 29.6173 28.6311

19180 Danville, IL 33.9418 31.5446

19260 Danville, VA 28.5221 27.8788

19340 Davenport-Moline-Rock Island, IA-IL 29.4290 28.1402

19380 Dayton, OH 32.0635 31.0431

19460 Decatur, AL 26.2777 25.6527

19500 Decatur, IL 27.8420 27.0898

19660 Deltona-Daytona Beach-Ormond Beach, FL 30.6744 29.6824

19740 Denver-Aurora-Broomfield, CO 37.0948 35.6553

19780 Des Moines-West Des Moines, IA 33.2680 31.9747

19804 Detroit-Livonia-Dearborn, MI 34.0881 33.1008

20020 Dothan, AL 27.0561 25.7662

20100 Dover, DE 35.0266 34.3423

20220 Dubuque, IA 29.9069 28.4340

20260 Duluth, MN-WI 37.2948 35.6803

20500 Durham-Chapel Hill, NC 33.7364 32.4388

20740 Eau Claire, WI 33.5152 32.1516
CMS-1498-P 918 

CBSA 

Code Urban Area 

FY 2011 

Average 

Hourly 

Wage 

3-Year 

Average 

Hourly 

Wage 

20764 Edison-New Brunswick, NJ 38.0887 36.9892

20940 El Centro, CA 32.5187 30.4057

21060 Elizabethtown, KY 29.2425 28.1376

21140 Elkhart-Goshen, IN 32.9702 31.8127

21300 Elmira, NY 29.8159 28.3066

21340 El Paso, TX 30.0169 29.1999

21500 Erie, PA 29.1769 28.9316

21660 Eugene-Springfield, OR 39.5694 37.5142

21780 Evansville, IN-KY 29.3081 28.4396

21820 Fairbanks, AK 38.4880 37.2462

21940 Fajardo, PR 13.5864 13.1629

22020 Fargo, ND-MN 28.2861 27.3617

22140 Farmington, NM 27.9464 26.5665

22180 Fayetteville, NC 33.0069 32.2702

22220 Fayetteville-Springdale-Rogers, AR-MO 30.1927 29.7252

22380 Flagstaff, AZ 43.4901 40.9837

22420 Flint, MI 39.7366 37.7705

22500 Florence, SC 29.6001 28.2550

22520 Florence-Muscle Shoals, AL 27.7915 26.5477

22540 Fond du Lac, WI 32.7670 32.1576

22660 Fort Collins-Loveland, CO 33.2168 32.4365

22744 Fort Lauderdale-Pompano Beach-Deerfield 34.9003 33.5974

22900 Fort Smith, AR-OK 27.0278 26.3924

23060 Fort Wayne, IN 32.2565 30.3718

23104 Fort Worth-Arlington, TX 32.9268 31.9797

23420 Fresno, CA 39.9087 37.8308

23460 Gadsden, AL 24.8236 26.1400

23540 Gainesville, FL 32.8864 31.4434

23580 Gainesville, GA 33.8978 31.8764

23844 Gary, IN 31.4542 30.7534

24020 Glens Falls, NY 30.8219 29.5362

24140 Goldsboro, NC 32.4035 31.0271

24220 Grand Forks, ND-MN 28.0496 26.7628

24300 Grand Junction, CO 34.4738 32.8228

24340 Grand Rapids-Wyoming, MI 32.5225 31.2449

24500 Great Falls, MT 28.8603 28.2315
CMS-1498-P 919 

CBSA 

Code Urban Area 

FY 2011 

Average 

Hourly 

Wage 

3-Year 

Average 

Hourly 

Wage 

24540 Greeley, CO 33.5991 32.8595

24580 Green Bay, WI 32.9660 31.7777

24660 Greensboro-High Point, NC 31.4115 30.5532

24780 Greenville, NC 32.6226 31.4428

24860 Greenville-Mauldin-Easley, SC 32.6686 32.3059

25020 Guayama, PR 12.4886 11.4528

25060 Gulfport-Biloxi, MS 31.1513 29.7538

25180 Hagerstown-Martinsburg, MD-WV 33.1846 31.3132

25260 Hanford-Corcoran, CA 40.0252 37.9890

25420 Harrisburg-Carlisle, PA 32.1215 30.8066

25500 Harrisonburg, VA 32.4538 30.6807

25540 Hartford-West Hartford-East Hartford, C 38.8127 37.6851

25620 Hattiesburg, MS 27.7551 26.1804

25860 Hickory-Lenoir-Morganton, NC 30.2030 29.6952

25980 1Hinesville-Fort Stewart, GA ---- ----

26100 Holland-Grand Haven, MI 30.7086 29.9212

26180 Honolulu, HI 40.6203 38.8534

26300 Hot Springs, AR 32.4533 30.8422

26380 Houma-Bayou Cane-Thibodaux, LA 27.9003 26.7495

26420 Houston-Sugar Land-Baytown, TX 34.7363 33.3876

26580 Huntington-Ashland, WV-KY-OH 31.1470 30.3284

26620 Huntsville, AL 31.4293 30.1542

26820 Idaho Falls, ID 33.7810 31.5660

26900 Indianapolis-Carmel, IN 33.3588 32.4485

26980 Iowa City, IA 33.3562 31.7675

27060 Ithaca, NY 34.1345 32.8690

27100 Jackson, MI 32.3303 30.8026

27140 Jackson, MS 28.3657 27.2938

27180 Jackson, TN 29.2532 28.4242

27260 Jacksonville, FL 31.1293 30.3737

27340 Jacksonville, NC 27.4651 27.2070

27500 Janesville, WI 33.8440 32.4434

27620 Jefferson City, MO 30.0429 29.6671

27740 Johnson City, TN 24.9085 25.3818

27780 Johnstown, PA 29.1342 27.8673

27860 Jonesboro, AR 27.3474 26.4977
CMS-1498-P 920 

CBSA 

Code Urban Area 

FY 2011 

Average 

Hourly 

Wage 

3-Year 

Average 

Hourly 

Wage 

27900 Joplin, MO 29.4636 29.6834

28020 Kalamazoo-Portage, MI 36.0038 35.2099

28100 Kankakee-Bradley, IL 36.9046 34.8205

28140 Kansas City, MO-KS 33.3682 31.9790

28420 Kennewick-Pasco-Richland, WA 34.3233 33.4579

28660 Killeen-Temple-Fort Hood, TX 30.6493 29.6099

28700 Kingsport-Bristol-Bristol, TN-VA 26.7971 26.4513

28740 Kingston, NY 31.9507 31.3235

28940 Knoxville, TN 27.4247 26.4301

29020 Kokomo, IN 31.4563 31.3022

29100 La Crosse, WI-MN 34.4391 33.1590

29140 Lafayette, IN 32.3043 30.6089

29180 Lafayette, LA 29.5826 28.5502

29340 Lake Charles, LA 28.6346 26.6076

29404 Lake County-Kenosha County, IL-WI 37.4834 35.3301

29420 Lake Havasu City-Kingman, AZ 35.9129 34.5415

29460 Lakeland-Winter Haven, FL 30.1679 29.0320

29540 Lancaster, PA 34.1814 32.6061

29620 Lansing-East Lansing, MI 35.8522 33.4940

29700 Laredo, TX 28.7425 28.4271

29740 Las Cruces, NM 31.8991 29.9182

29820 Las Vegas-Paradise, NV 41.2359 39.5656

29940 Lawrence, KS 29.7218 28.4175

30020 Lawton, OK 30.0871 28.4155

30140 Lebanon, PA 28.4545 28.6018

30300 Lewiston, ID-WA 32.0498 31.1265

30340 Lewiston-Auburn, ME 31.2669 30.6891

30460 Lexington-Fayette, KY 30.7246 29.8100

30620 Lima, OH 32.3533 31.2513

30700 Lincoln, NE 33.1312 31.8977

30780 Little Rock-N.Little Rock-Conway,AR 30.2877 29.2865

30860 Logan, UT-ID 30.8717 29.8653

30980 Longview, TX 30.0153 27.9402

31020 Longview, WA 37.2841 37.1483

31084 Los Angeles-Long Beach-Santa Ana, CA 41.8223 40.3432

31140 Louisville-Jefferson County, KY-IN 30.8966 30.1980
CMS-1498-P 921 

CBSA 

Code Urban Area 

FY 2011 

Average 

Hourly 

Wage 

3-Year 

Average 

Hourly 

Wage 

31180 Lubbock, TX 31.2259 29.6499

31340 Lynchburg, VA 29.7754 28.5576

31420 Macon, GA 32.7055 32.8408

31460 Madera-Chowchilla, CA 30.1104 28.6056

31540 Madison, WI 39.5054 37.8696

31700 Manchester-Nashua, NH 34.5930 33.9822

31740 Manhattan, KS 27.6635 26.5957

31860 Mankato-North Mankato, MN 32.3639 31.4358

31900 Mansfield, OH 30.7835 30.3015

32420 Mayagüez, PR 12.6118 12.4907

32580 McAllen-Edinburg-Mission, TX 31.0449 30.1056

32780 Medford, OR 35.0103 33.9125

32820 Memphis, TN-MS-AR 32.1641 31.1231

32900 Merced, CA 42.0265 40.4262

33124 Miami-Fort Lauderdale-Pompano Beach, FL 35.7435 33.7683

33140 Michigan City-La Porte, IN 32.8129 30.9515

33260 Midland, TX 33.3058 31.8597

33340 Milwaukee-Waukesha-West Allis, WI 35.6954 34.2353

33460 Minneapolis-St. Paul-Bloomington, MN-WI 38.4952 36.9220

33540 Missoula, MT 30.7656 29.8216

33660 Mobile, AL 27.6019 26.3141

33700 Modesto, CA 42.0519 41.0061

33740 Monroe, LA 28.3557 26.8341

33780 Monroe, MI 31.3315 30.3938

33860 Montgomery, AL 29.7248 28.3780

34060 Morgantown, WV 28.9024 28.5485

34100 Morristown, TN 24.8315 24.2612

34580 Mount Vernon-Anacortes, WA 35.1691 33.8802

34620 Muncie, IN 28.6143 27.7649

34740 Muskegon-Norton Shores, MI 34.3151 33.4379

34820 

Myrtle Beach-North Myrtle Beach-Conway, 

SC 30.3085 29.1823

34900 Napa, CA 50.6166 48.0443

34940 Naples-Marco Island, FL 34.2982 32.9979

34980 

Nashville-Davidson-Murfreesboro-Franklin, 

TN 32.5483 31.7724
CMS-1498-P 922 

CBSA 

Code Urban Area 

FY 2011 

Average 

Hourly 

Wage 

3-Year 

Average 

Hourly 

Wage 

35004 Nassau-Suffolk, NY 43.9572 42.5759

35084 Newark-Union, NJ-PA 39.5622 38.2213

35300 New Haven-Milford, CT 40.3584 39.1449

35380 New Orleans-Metairie-Kenner, LA 31.4388 30.2046

35644 New York-White Plains-Wayne, NY-NJ 45.9252 44.0840

35660 Niles-Benton Harbor, MI 31.3865 30.3136

35840 2North Port-Bradenton-Sarasota, FL 32.3943 31.9392

35980 Norwich-New London, CT 39.8427 38.5763

36084 Oakland-Fremont-Hayward, CA 55.5972 53.3129

36100 Ocala, FL 29.9935 28.8386

36140 Ocean City, NJ 38.0642 36.5086

36220 Odessa, TX 32.9220 32.1340

36260 Ogden-Clearfield, UT 32.6211 31.3730

36420 Oklahoma City, OK 31.0777 29.6784

36500 Olympia, WA 38.2620 37.6059

36540 Omaha-Council Bluffs, NE-IA 33.3566 31.9233

36740 Orlando-Kissimmee-Sanford, FL 32.0901 30.6557

36780 Oshkosh-Neenah, WI 33.2157 31.2415

36980 Owensboro, KY 29.7930 28.8753

37100 Oxnard-Thousand Oaks-Ventura, CA 43.2233 40.5774

37340 Palm Bay-Melbourne-Titusville, FL 32.6298 31.2779

37380 Palm Coast, FL 28.6480 29.3969

37460 

Panama City-Lynn Haven-Panama City Beach, 

FL 28.4491 28.1718

37620 Parkersburg-Marietta-Vienna, WV-OH 25.9479 25.8732

37700 Pascagoula, MS 28.5637 27.4171

37764 Peabody, MA 38.4760 36.5635

37860 Pensacola-Ferry Pass-Brent, FL 28.4556 27.3708

37900 Peoria, IL 32.4315 31.0327

37964 Philadelphia, PA 37.7549 36.4016

38060 Phoenix-Mesa-Glendale, AZ 36.7246 35.1010

38220 Pine Bluff, AR 28.7130 26.7537

38300 Pittsburgh, PA 30.0448 28.9335

38340 Pittsfield, MA 36.5974 35.4692

38540 Pocatello, ID 32.7435 30.8807

38660 Ponce, PR 14.9358 14.1175
CMS-1498-P 923 

CBSA 

Code Urban Area 

FY 2011 

Average 

Hourly 

Wage 

3-Year 

Average 

Hourly 

Wage 

38860 Portland-South Portland-Biddeford, ME 34.6681 33.6576

38900 Portland-Vancouver-Hillsboro, OR-WA 39.1861 37.7069

38940 Port St. Lucie, FL 37.6301 34.3690

39100 Poughkeepsie-Newburgh-Middletown, NY 39.8644 37.7073

39140 Prescott, AZ 43.0057 36.4216

39300 Providence-New Bedford-Fall River, RI-M 37.5354 36.1121

39340 Provo-Orem, UT 32.3723 31.4543

39380 Pueblo, CO 30.0091 28.7443

39460 Punta Gorda, FL 31.7131 30.7467

39540 Racine, WI 37.1869 32.6652

39580 Raleigh-Cary, NC 33.9133 32.4239

39660 Rapid City, SD 38.3671 34.5099

39740 Reading, PA 31.0160 30.6990

39820 Redding, CA 47.5125 44.9345

39900 Reno-Sparks, NV 36.4465 34.9208

40060 Richmond, VA 33.2980 31.4929

40140 Riverside-San Bernardino-Ontario, CA 39.9014 37.9847

40220 Roanoke, VA 31.4982 29.9865

40340 Rochester, MN 37.5616 36.5729

40380 Rochester, NY 30.4032 29.5889

40420 Rockford, IL 35.0956 33.6906

40484 Rockingham County, NH 35.0486 33.6796

40580 Rocky Mount, NC 31.8553 30.3489

40660 Rome, GA 30.5837 30.5032

40900 Sacramento--Arden-Arcade--Roseville, CA 47.2994 45.2291

40980 Saginaw-Saginaw Township North, MI 32.1555 31.1518

41060 St. Cloud, MN 40.6853 39.1270

41100 St. George, UT 32.5066 31.3092

41140 St. Joseph, MO-KS 36.2278 34.8344

41180 St. Louis, MO-IL 31.6290 30.3438

41420 Salem, OR 38.8312 36.7534

41500 Salinas, CA 55.5109 51.7900

41540 Salisbury, MD 31.1946 30.3645

41620 Salt Lake City, UT 32.6863 31.4867

41660 San Angelo, TX 29.6151 28.0559

41700 San Antonio-New Braunfels, TX 31.6824 30.2027
CMS-1498-P 924 

CBSA 

Code Urban Area 

FY 2011 

Average 

Hourly 

Wage 

3-Year 

Average 

Hourly 

Wage 

41740 San Diego-Carlsbad-San Marcos, CA 40.5279 38.5285

41780 Sandusky, OH 30.0999 29.3797

41884 San Francisco-San Mateo-Redwood City, CA 53.8091 51.6664

41900 San Germán-Cabo Rojo, PR 15.9545 15.6643

41940 San Jose-Sunnyvale-Santa Clara, CA 57.4157 54.3198

41980 San Juan-Caguas-Guaynabo, PR 15.0192 14.6360

42020 San Luis Obispo-Paso Robles, CA 43.3776 40.8126

42044 Santa Ana-Anaheim-Irvine, CA 41.9435 39.8926

42060 Santa Barbara-Santa Maria-Goleta, CA 41.2648 39.8280

42100 Santa Cruz-Watsonville, CA 56.9566 54.4353

42140 Santa Fe, NM 37.6618 35.8749

42220 Santa Rosa-Petaluma, CA 55.3076 52.3185

42340 Savannah, GA 30.9240 29.9675

42540 Scranton--Wilkes-Barre, PA 28.7281 27.7860

42644 Seattle-Bellevue-Everett, WA 39.8184 38.4963

42680 Sebastian-Vero Beach, FL 32.4326 31.7794

43100 Sheboygan, WI 32.4662 30.8688

43300 Sherman-Denison, TX 29.4908 28.9887

43340 Shreveport-Bossier City, LA 30.2022 28.7466

43580 Sioux City, IA-NE-SD 31.3111 29.8813

43620 Sioux Falls, SD 32.7745 31.1879

43780 South Bend-Mishawaka, IN-MI 34.5236 32.8075

43900 Spartanburg, SC 31.7207 30.5331

44060 Spokane, WA 37.0084 35.4231

44100 Springfield, IL 31.2379 30.6699

44140 Springfield, MA 36.1737 35.1312

44180 Springfield, MO 29.3703 28.6119

44220 Springfield, OH 31.4540 29.8060

44300 State College, PA 30.2637 29.6045

44600 2Steubenville-Weirton, OH-WV 25.4395 25.3407

44700 Stockton, CA 43.8475 41.3450

44940 Sumter, SC 28.5579 28.2053

45060 Syracuse, NY 33.9000 32.9463

45104 Tacoma, WA 39.3681 37.5711

45220 Tallahassee, FL 31.4039 29.7448

45300 Tampa-St. Petersburg-Clearwater, FL 31.7974 30.3381
CMS-1498-P 925 

CBSA 

Code Urban Area 

FY 2011 

Average 

Hourly 

Wage 

3-Year 

Average 

Hourly 

Wage 

45460 Terre Haute, IN 32.3071 30.7568

45500 Texarkana, TX-Texarkana, AR 26.8927 26.8786

45780 Toledo, OH 32.7715 31.4781

45820 Topeka, KS 31.9034 30.4681

45940 Trenton-Ewing, NJ 35.1805 34.8810

46060 Tucson, AZ 33.8370 32.2980

46140 Tulsa, OK 31.0910 29.4632

46220 Tuscaloosa, AL 28.7402 29.0146

46340 Tyler, TX 28.7095 28.5924

46540 Utica-Rome, NY 30.4893 29.2712

46660 Valdosta, GA 28.3875 27.3859

46700 Vallejo-Fairfield, CA 50.8429 48.5255

47020 Victoria, TX 28.0779 26.7203

47220 Vineland-Millville-Bridgeton, NJ 38.1019 36.3949

47260 Virginia Beach-Norfolk-Newport News, VA 31.2647 29.9721

47300 Visalia-Porterville, CA 38.0071 35.3637

47380 Waco, TX 30.2079 29.0730

47580 Warner Robins, GA 29.2281 30.2010

47644 Warren-Troy-Farmington-Hills, MI 33.9524 33.0850

47894 Washington-Arlington-Alexandria DC-VA 36.8726 35.7731

47940 Waterloo-Cedar Falls, IA 29.6525 28.7768

48140 Wausau, WI 33.4493 32.5485

48300 Wenatchee-East Wenatchee, WA 33.8234 32.3786

48424 West Palm Beach-Boca Raton-Boynton FL 34.3519 32.7302

48540 Wheeling, WV-OH 23.4746 23.0898

48620 Wichita, KS 30.9307 30.0110

48660 Wichita Falls, TX 34.6795 32.0396

48700 Williamsport, PA 25.4029 25.8954

48864 Wilmington, DE-MD-NJ 37.7128 36.0069

48900 Wilmington, NC 32.2983 30.6626

49020 Winchester, VA-WV 34.9053 33.0668

49180 Winston-Salem, NC 31.3330 30.1817

49340 Worcester, MA 39.1354 37.4410

49420 Yakima, WA 35.0663 33.5431

49500 Yauco, PR 12.3738 11.4462

49620 York-Hanover, PA 33.4110 31.9488
CMS-1498-P 926 

CBSA 

Code Urban Area 

FY 2011 

Average 

Hourly 

Wage 

3-Year 

Average 

Hourly 

Wage 

49660 Youngstown-Warren-Boardman, OH-PA 30.1643 29.3613

49700 Yuba City, CA 37.6504 36.6555

49740 Yuma, AZ 33.0103 32.0532 1 This area has no average hourly wage because there are no short-term, acute care hospital wage data for the area. 2 This is a new CBSA for FY 2011. To calculate the 3-year average hourly wage for this new area, we included the 

hospitals’ data from their previous geographic location for FY 2009 and FY 2010.
CMS-1498-P 927 

TABLE 3B.--FY 2011 AND 3-YEAR* AVERAGE HOURLY WAGE 

 FOR ACUTE CARE HOSPITLAS IN RURAL AREAS BY CBSA 

(*Based on the sum of the salaries and hours computed for Federal FYs 2009, 2010, and 2011.)

CBSA 

Code Nonurban Area 

FY 2011 

Average 

Hourly 

Wage 

3-Year 

Average Hourly 

Wage 

01 Alabama 26.0264 25.1568

02 Alaska 44.1146 40.4763

03 Arizona 31.8393 29.9784

04 Arkansas 25.9685 25.2920

05 California 42.9541 40.4802

06 Colorado 33.8979 32.2217

07 Connecticut 39.4836 37.7398

08 Delaware 34.5676 33.5989

10 Florida 29.5728 28.7958

11 Georgia 27.1671 26.2403

12 Hawaii 39.4229 37.8491

13 Idaho 26.1426 25.4397

14 Illinois 29.2557 28.1409

15 Indiana 29.3235 28.4347

16 Iowa 29.8030 28.9280

17 Kansas 27.8665 27.0309

18 Kentucky 27.6898 26.5212

19 Louisiana 27.7399 26.2678

20 Maine 29.9878 28.8613

21 Maryland 32.4848 30.6740

22 Massachusetts1 ---- ----

23 Michigan 30.0405 29.4059

24 Minnesota 31.6251 30.5376

25 Mississippi 27.0138 25.8819

26 Missouri 27.2630 26.6216

27 Montana 29.4658 28.4050

28 Nebraska 31.0214 29.3825

29 Nevada 32.7810 32.3514

30 New Hampshire 34.6904 33.8700

31 New Jersey2 ---- ----

32 New Mexico 31.5263 30.1115

33 New York 29.0517 27.9458

34 North Carolina 29.5268 28.7455

35 North Dakota 24.5023 24.8120

36 Ohio 29.9108 28.7616
CMS-1498-P 928 

CBSA 

Code Nonurban Area 

FY 2011 

Average 

Hourly 

Wage 

3-Year 

Average Hourly 

Wage 

37 Oklahoma 28.0420 26.6656

38 Oregon 34.9774 34.1391

39 Pennsylvania 29.7971 28.2813

40 Puerto Rico2 ---- ----

41 Rhode Island2 ---- ----

42 South Carolina 29.4603 28.4856

43 South Dakota 29.3712 28.1981

44 Tennessee 27.8764 26.6861

45 Texas 27.9871 26.9747

46 Utah 30.4214 28.6155

47 Vermont 33.0189 32.4250

49 Virginia 28.1471 27.0795

50 Washington 35.3253 34.0250

51 West Virginia 26.4462 25.3997

52 Wisconsin 31.4858 30.9851

53 Wyoming 32.7909 31.3477

1

Massachusetts has area(s) designated as rural. However, no short term, acute care hospitals are located 

in the area(s) for FY 2011. 

2

All counties within the State or territory are classified as urban. 
CMS-1498-P 929 

TABLE 4A.—PROPOSED WAGE INDEX AND CAPITAL GEOGRAPHIC 

ADJUSTMENT FACTOR (GAF) FOR ACUTE CARE HOSPITALS IN URBAN AREAS 

BY CBSA AND BY STATE--FY 2011 

[Constituent counties are listed in Table 4E.] 

(Wage Index Includes Rural Floor Budget Neutrality Adjustment) 

CBSA 

Code Urban Area State

Proposed 

Wage 

Index 

Proposed 

GAF 

10180 Abilene, TX TX 0.8416 0.8886 

10380 Aguadilla-Isabela-San Sebastián, PR PR 0.3384 0.4762 

10420 Akron, OH OH 0.8850 0.9197 

10500 Albany, GA GA 0.9098 0.9373 

10580 Albany-Schenectady-Troy, NY NY 0.8708 0.9096 

10740 Albuquerque, NM NM 0.9638 0.9751 

10780 Alexandria, LA LA 0.8164 0.8703 

10900 Allentown-Bethlehem-Easton, PA-NJ NJ 1.1069 1.0720 

10900 Allentown-Bethlehem-Easton, PA-NJ PA 0.9418 0.9598 

11020 Altoona, PA PA 0.8529 0.8968 

11100 Amarillo, TX TX 0.8574 0.9000 

11180 Ames, IA IA 1.0044 1.0030 

11260 Anchorage, AK AK 1.1919 1.1277 

11300 Anderson, IN IN 0.9287 0.9506 

11340 Anderson, SC SC 0.8438 0.8902 

11460 Ann Arbor, MI MI 1.0107 1.0073 

11500 Anniston-Oxford, AL AL 0.7898 0.8508 

11540 Appleton, WI WI 0.9348 0.9549 

11700 Asheville, NC NC 0.9055 0.9343 

12020 Athens-Clarke County, GA GA 0.9348 0.9549 

12060 Atlanta-Sandy Springs-Marietta, GA GA 0.9572 0.9705 

12100 Atlantic City-Hammonton, NJ NJ 1.1069 1.0720 

12220 Auburn-Opelika, AL AL 0.7522 0.8228 

12260 Augusta-Richmond County, GA-SC GA 0.9571 0.9704 

12260 Augusta-Richmond County, GA-SC SC 0.9571 0.9704 

12420 Austin-Round Rock-San Marcos, TX TX 0.9523 0.9671 

12540 Bakersfield-Delano, CA CA 1.2002 1.1331 

12580 Baltimore-Towson, MD MD 1.0198 1.0135 

12620 Bangor, ME ME 0.9695 0.9790 

12700 Barnstable Town, MA MA 1.2825 1.1858 

12940 Baton Rouge, LA LA 0.8726 0.9109 

12980 Battle Creek, MI MI 0.9759 0.9834 

13020 Bay City, MI MI 0.9429 0.9605 

13140 Beaumont-Port Arthur, TX TX 0.8456 0.8915 

13380 Bellingham, WA WA 1.1302 1.0874 

13460 Bend, OR OR 1.1239 1.0833 
CMS-1498-P 930 

CBSA 

Code Urban Area State

Proposed 

Wage 

Index 

Proposed 

GAF 

13644 Bethesda-Rockville-Frederick, MD MD 1.0573 1.0389 

13740 Billings, MT MT 0.8944 0.9264 

13780 Binghamton, NY NY 0.8932 0.9256 

13820 Birmingham-Hoover, AL AL 0.8614 0.9029 

13900 Bismarck, ND ND 0.7641 0.8317 

13980 Blacksburg-Christiansburg-Radford, VA VA 0.8293 0.8797 

14020 Bloomington, IN IN 0.9287 0.9506 

14060 Bloomington-Normal, IL IL 0.9567 0.9701 

14260 Boise City-Nampa, ID ID 0.9305 0.9519 

14484 Boston-Quincy, MA MA 1.2342 1.1550 

14500 Boulder, CO CO 0.9983 0.9988 

14540 Bowling Green, KY KY 0.8722 0.9106 

14740 Bremerton-Silverdale, WA WA 1.0580 1.0394 

14860 Bridgeport-Stamford-Norwalk, CT CT 1.2575 1.1699 

15180 Brownsville-Harlingen, TX TX 0.9486 0.9645 

15260 Brunswick, GA GA 0.9352 0.9552 

15380 Buffalo-Niagara Falls, NY NY 0.9628 0.9744 

15500 Burlington, NC NC 0.8787 0.9153 

15540 Burlington-South Burlington, VT VT 1.0340 1.0232 

15764 Cambridge-Newton-Framingham, MA MA 1.1294 1.0869 

15804 Camden, NJ NJ 1.1069 1.0720 

15940 Canton-Massillon, OH OH 0.8612 0.9027 

15980 Cape Coral-Fort Myers, FL FL 0.9167 0.9422 

16020 Cape Girardeau-Jackson, MO-IL IL 0.8810 0.9169 

16020 Cape Girardeau-Jackson, MO-IL MO 0.8810 0.9169 

16180 Carson City, NV NV 1.0282 1.0192 

16220 Casper, WY WY 0.9444 0.9616 

16300 Cedar Rapids, IA IA 0.8799 0.9161 

16580 Champaign-Urbana, IL IL 1.0161 1.0110 

16620 Charleston, WV WV 0.8093 0.8651 

16700 Charleston-North Charleston-Summerville, SC SC 0.9295 0.9512 

16740 Charlotte-Gastonia-Rock Hill, NC-SC NC 0.9299 0.9514 

16740 Charlotte-Gastonia-Rock Hill, NC-SC SC 0.9300 0.9515 

16820 Charlottesville, VA VA 0.9243 0.9475 

16860 Chattanooga, TN-GA GA 0.8794 0.9158 

16860 Chattanooga, TN-GA TN 0.8721 0.9105 

16940 Cheyenne, WY WY 0.9392 0.9580 

16974 Chicago-Joliet-Naperville, IL IL 1.0503 1.0342 

17020 Chico, CA CA 1.2002 1.1331 

17140 Cincinnati-Middletown, OH-KY-IN IN 0.9637 0.9750 

17140 Cincinnati-Middletown, OH-KY-IN KY 0.9634 0.9748 

17140 Cincinnati-Middletown, OH-KY-IN OH 0.9624 0.9741 
CMS-1498-P 931 

CBSA 

Code Urban Area State

Proposed 

Wage 

Index 

Proposed 

GAF 

17300 Clarksville, TN-KY KY 0.7992 0.8577 

17300 Clarksville, TN-KY TN 0.7919 0.8523 

17420 Cleveland, TN TN 0.7919 0.8523 

17460 Cleveland-Elyria-Mentor, OH OH 0.9082 0.9362 

17660 Coeur d'Alene, ID ID 0.9216 0.9456 

17780 College Station-Bryan, TX TX 0.9244 0.9476 

17820 Colorado Springs, CO CO 0.9581 0.9711 

17860 Columbia, MO MO 0.8261 0.8774 

17900 Columbia, SC SC 0.8799 0.9161 

17980 Columbus, GA-AL AL 0.9111 0.9382 

17980 Columbus, GA-AL GA 0.9119 0.9388 

18020 Columbus, IN IN 0.9476 0.9638 

18140 Columbus, OH OH 1.0163 1.0111 

18580 Corpus Christi, TX TX 0.8576 0.9001 

18700 Corvallis, OR OR 1.0340 1.0232 

18880 Crestview-Fort Walton Beach-Destin, FL FL 0.8762 0.9135 

19060 Cumberland, MD-WV MD 0.9305 0.9519 

19060 Cumberland, MD-WV WV 0.8196 0.8726 

19124 Dallas-Plano-Irving, TX TX 0.9734 0.9817 

19140 Dalton, GA GA 0.8483 0.8935 

19180 Danville, IL IL 0.9722 0.9809 

19260 Danville, VA VA 0.8168 0.8706 

19340 Davenport-Moline-Rock Island, IA-IL IL 0.8658 0.9060 

19340 Davenport-Moline-Rock Island, IA-IL IA 0.8654 0.9057 

19380 Dayton, OH OH 0.9172 0.9425 

19460 Decatur, AL AL 0.7583 0.8274 

19500 Decatur, IL IL 0.8380 0.8860 

19660 Deltona-Daytona Beach-Ormond Beach, FL FL 0.8773 0.9143 

19740 Denver-Aurora-Broomfield, CO CO 1.0485 1.0330 

19780 Des Moines-West Des Moines, IA IA 0.9525 0.9672 

19804 Detroit-Livonia-Dearborn, MI MI 0.9776 0.9846 

20020 Dothan, AL AL 0.7743 0.8393 

20100 Dover, DE DE 1.0090 1.0062 

20220 Dubuque, IA IA 0.8562 0.8991 

20260 Duluth, MN-WI MN 1.0682 1.0462 

20260 Duluth, MN-WI WI 1.0682 1.0462 

20500 Durham-Chapel Hill, NC NC 0.9662 0.9767 

20740 Eau Claire, WI WI 0.9600 0.9724 

20764 Edison-New Brunswick, NJ NJ 1.1069 1.0720 

20940 El Centro, CA CA 1.2002 1.1331 

21060 Elizabethtown, KY KY 0.8389 0.8867 

21140 Elkhart-Goshen, IN IN 0.9457 0.9625 
CMS-1498-P 932 

CBSA 

Code Urban Area State

Proposed 

Wage 

Index 

Proposed 

GAF 

21300 Elmira, NY NY 0.8540 0.8976 

21340 El Paso, TX TX 0.8594 0.9014 

21500 Erie, PA PA 0.8521 0.8962 

21660 Eugene-Springfield, OR OR 1.1331 1.0893 

21780 Evansville, IN-KY IN 0.8399 0.8874 

21780 Evansville, IN-KY KY 0.8393 0.8869 

21820 Fairbanks, AK AK 1.1919 1.1277 

21940 Fajardo, PR PR 0.3892 0.5240 

22020 Fargo, ND-MN MN 0.9146 0.9407 

22020 Fargo, ND-MN ND 0.8102 0.8658 

22140 Farmington, NM NM 0.9030 0.9325 

22180 Fayetteville, NC NC 0.9453 0.9622 

22220 Fayetteville-Springdale-Rogers, AR-MO AR 0.8648 0.9053 

22220 Fayetteville-Springdale-Rogers, AR-MO MO 0.8648 0.9053 

22380 Flagstaff, AZ AZ 1.2457 1.1624 

22420 Flint, MI MI 1.1382 1.0927 

22500 Florence, SC SC 0.8478 0.8931 

22520 Florence-Muscle Shoals, AL AL 0.8028 0.8603 

22540 Fond du Lac, WI WI 0.9386 0.9575 

22660 Fort Collins-Loveland, CO CO 0.9581 0.9711 

22744 

Fort Lauderdale-Pompano Beach-Deerfield Beach, 

FL FL 1.0364 1.0248 

22900 Fort Smith, AR-OK AR 0.7742 0.8392 

22900 Fort Smith, AR-OK OK 0.8052 0.8621 

23060 Fort Wayne, IN IN 0.9245 0.9477 

23104 Fort Worth-Arlington, TX TX 0.9427 0.9604 

23420 Fresno, CA CA 1.2002 1.1331 

23460 Gadsden, AL AL 0.7448 0.8173 

23540 Gainesville, FL FL 0.9406 0.9589 

23580 Gainesville, GA GA 0.9709 0.9800 

23844 Gary, IN IN 0.9069 0.9353 

24020 Glens Falls, NY NY 0.8828 0.9182 

24140 Goldsboro, NC NC 0.9280 0.9501 

24220 Grand Forks, ND-MN MN 0.9146 0.9407 

24220 Grand Forks, ND-MN ND 0.8034 0.8608 

24300 Grand Junction, CO CO 1.0051 1.0035 

24340 Grand Rapids-Wyoming, MI MI 0.9315 0.9526 

24500 Great Falls, MT MT 0.8439 0.8903 

24540 Greeley, CO CO 0.9581 0.9711 

24580 Green Bay, WI WI 0.9443 0.9615 

24660 Greensboro-High Point, NC NC 0.8996 0.9301 

24780 Greenville, NC NC 0.9343 0.9545 
CMS-1498-P 933 

CBSA 

Code Urban Area State

Proposed 

Wage 

Index 

Proposed 

GAF 

24860 Greenville-Mauldin-Easley, SC SC 0.9357 0.9555 

25020 Guayama, PR PR 0.3577 0.4946 

25060 Gulfport-Biloxi, MS MS 0.8923 0.9249 

25180 Hagerstown-Martinsburg, MD-WV MD 0.9505 0.9658 

25180 Hagerstown-Martinsburg, MD-WV WV 0.9455 0.9623 

25260 Hanford-Corcoran, CA CA 1.2002 1.1331 

25420 Harrisburg-Carlisle, PA PA 0.9172 0.9425 

25500 Harrisonburg, VA VA 0.9294 0.9511 

25540 Hartford-West Hartford-East Hartford, CT CT 1.1251 1.0841 

25620 Hattiesburg, MS MS 0.7950 0.8546 

25860 Hickory-Lenoir-Morganton, NC NC 0.8650 0.9055 

26100 Holland-Grand Haven, MI MI 0.8796 0.9159 

26180 Honolulu, HI HI 1.1635 1.1093 

26300 Hot Springs, AR AR 0.9296 0.9512 

26380 Houma-Bayou Cane-Thibodaux, LA LA 0.7992 0.8577 

26420 Houston-Sugar Land-Baytown, TX TX 0.9946 0.9963 

26580 Huntington-Ashland, WV-KY-OH KY 0.8919 0.9246 

26580 Huntington-Ashland, WV-KY-OH OH 0.8909 0.9239 

26580 Huntington-Ashland, WV-KY-OH WV 0.8875 0.9215 

26620 Huntsville, AL AL 0.8994 0.9300 

26820 Idaho Falls, ID ID 0.9676 0.9777 

26900 Indianapolis-Carmel, IN IN 0.9555 0.9693 

26980 Iowa City, IA IA 0.9550 0.9690 

27060 Ithaca, NY NY 0.9777 0.9847 

27100 Jackson, MI MI 0.9260 0.9487 

27140 Jackson, MS MS 0.8125 0.8675 

27180 Jackson, TN TN 0.8310 0.8809 

27260 Jacksonville, FL FL 0.8902 0.9234 

27340 Jacksonville, NC NC 0.8476 0.8929 

27500 Janesville, WI WI 0.9694 0.9789 

27620 Jefferson City, MO MO 0.8605 0.9022 

27740 Johnson City, TN TN 0.7919 0.8523 

27780 Johnstown, PA PA 0.8521 0.8962 

27860 Jonesboro, AR AR 0.7833 0.8460 

27900 Joplin, MO MO 0.8448 0.8909 

28020 Kalamazoo-Portage, MI MI 1.0313 1.0213 

28100 Kankakee-Bradley, IL IL 1.0571 1.0388 

28140 Kansas City, MO-KS KS 0.9558 0.9695 

28140 Kansas City, MO-KS MO 0.9558 0.9695 

28420 Kennewick-Pasco-Richland, WA WA 1.0107 1.0073 

28660 Killeen-Temple-Fort Hood, TX TX 0.8775 0.9144 

28700 Kingsport-Bristol-Bristol, TN-VA TN 0.7919 0.8523 
CMS-1498-P 934 

CBSA 

Code Urban Area State

Proposed 

Wage 

Index 

Proposed 

GAF 

28700 Kingsport-Bristol-Bristol, TN-VA VA 0.8060 0.8627 

28740 Kingston, NY NY 0.9152 0.9411 

28940 Knoxville, TN TN 0.7919 0.8523 

29020 Kokomo, IN IN 0.9010 0.9311 

29100 La Crosse, WI-MN MN 0.9864 0.9907 

29100 La Crosse, WI-MN WI 0.9864 0.9907 

29140 Lafayette, IN IN 0.9253 0.9482 

29180 Lafayette, LA LA 0.8473 0.8927 

29340 Lake Charles, LA LA 0.8202 0.8731 

29404 Lake County-Kenosha County, IL-WI IL 1.0736 1.0498 

29404 Lake County-Kenosha County, IL-WI WI 1.0736 1.0498 

29420 Lake Havasu City-Kingman, AZ AZ 1.0287 1.0196 

29460 Lakeland-Winter Haven, FL FL 0.8628 0.9039 

29540 Lancaster, PA PA 0.9760 0.9835 

29620 Lansing-East Lansing, MI MI 1.0269 1.0183 

29700 Laredo, TX TX 0.8312 0.8811 

29740 Las Cruces, NM NM 0.9183 0.9433 

29820 Las Vegas-Paradise, NV NV 1.1811 1.1207 

29940 Lawrence, KS KS 0.8513 0.8956 

30020 Lawton, OK OK 0.8616 0.9030 

30140 Lebanon, PA PA 0.8521 0.8962 

30300 Lewiston, ID-WA ID 0.9180 0.9431 

30300 Lewiston, ID-WA WA 1.0107 1.0073 

30340 Lewiston-Auburn, ME ME 0.8956 0.9273 

30460 Lexington-Fayette, KY KY 0.8798 0.9160 

30620 Lima, OH OH 0.9254 0.9483 

30700 Lincoln, NE NE 0.9490 0.9648 

30780 Little Rock-North Little Rock-Conway, AR AR 0.8675 0.9072 

30860 Logan, UT-ID ID 0.8843 0.9192 

30860 Logan, UT-ID UT 0.8843 0.9192 

30980 Longview, TX TX 0.8593 0.9014 

31020 Longview, WA WA 1.0667 1.0452 

31084 Los Angeles-Long Beach-Glendale, CA CA 1.2002 1.1331 

31140 Louisville-Jefferson County, KY-IN IN 0.8850 0.9197 

31140 Louisville-Jefferson County, KY-IN KY 0.8848 0.9196 

31180 Lubbock, TX TX 0.8940 0.9261 

31340 Lynchburg, VA VA 0.8527 0.8966 

31420 Macon, GA GA 0.9368 0.9563 

31460 Madera-Chowchilla, CA CA 1.2002 1.1331 

31540 Madison, WI WI 1.1316 1.0884 

31700 Manchester-Nashua, NH NH 1.0054 1.0037 

31740 Manhattan, KS KS 0.8027 0.8603 
CMS-1498-P 935 

CBSA 

Code Urban Area State

Proposed 

Wage 

Index 

Proposed 

GAF 

31860 Mankato-North Mankato, MN MN 0.9270 0.9494 

31900 Mansfield, OH OH 0.8917 0.9245 

32420 Mayagüez, PR PR 0.3612 0.4979 

32580 McAllen-Edinburg-Mission, TX TX 0.8888 0.9224 

32780 Medford, OR OR 1.0089 1.0061 

32820 Memphis, TN-MS-AR AR 0.9213 0.9454 

32820 Memphis, TN-MS-AR MS 0.9213 0.9454 

32820 Memphis, TN-MS-AR TN 0.9137 0.9401 

32900 Merced, CA CA 1.2002 1.1331 

33124 Miami-Miami Beach-Kendall, FL FL 1.0222 1.0151 

33140 Michigan City-La Porte, IN IN 0.9399 0.9584 

33260 Midland, TX TX 0.9554 0.9692 

33340 Milwaukee-Waukesha-West Allis, WI WI 1.0226 1.0154 

33460 Minneapolis-St. Paul-Bloomington, MN-WI MN 1.1027 1.0692 

33460 Minneapolis-St. Paul-Bloomington, MN-WI WI 1.1027 1.0692 

33540 Missoula, MT MT 0.8811 0.9170 

33660 Mobile, AL AL 0.7899 0.8509 

33700 Modesto, CA CA 1.2002 1.1331 

33740 Monroe, LA LA 0.8122 0.8672 

33780 Monroe, MI MI 0.9666 0.9770 

33860 Montgomery, AL AL 0.8506 0.8951 

34060 Morgantown, WV WV 0.8266 0.8777 

34100 Morristown, TN TN 0.7919 0.8523 

34580 Mount Vernon-Anacortes, WA WA 1.0107 1.0073 

34620 Muncie, IN IN 0.8399 0.8874 

34740 Muskegon-Norton Shores, MI MI 0.9829 0.9883 

34820 Myrtle Beach-North Myrtle Beach-Conway, SC SC 0.8681 0.9077 

34900 Napa, CA CA 1.4144 1.2680 

34940 Naples-Marco Island, FL FL 0.9809 0.9869 

34980 Nashville-Davidson-Murfreesboro-Franklin, TN TN 0.9246 0.9477 

35004 Nassau-Suffolk, NY NY 1.2591 1.1709 

35084 Newark-Union, NJ-PA NJ 1.1099 1.0740 

35084 Newark-Union, NJ-PA PA 1.1296 1.0870 

35300 New Haven-Milford, CT CT 1.1654 1.1105 

35380 New Orleans-Metairie-Kenner, LA LA 0.9005 0.9307 

35644 New York-White Plains-Wayne, NY-NJ NJ 1.2884 1.1895 

35644 New York-White Plains-Wayne, NY-NJ NY 1.3154 1.2065 

35660 Niles-Benton Harbor, MI MI 0.8990 0.9297 

35840 North Port-Bradenton-Sarasota-Venice, FL FL 0.9265 0.9491 

35980 Norwich-New London, CT CT 1.1353 1.0908 

36084 Oakland-Fremont-Hayward, CA CA 1.5536 1.3522 

36100 Ocala, FL FL 0.8578 0.9003 
CMS-1498-P 936 

CBSA 

Code Urban Area State

Proposed 

Wage 

Index 

Proposed 

GAF 

36140 Ocean City, NJ NJ 1.1069 1.0720 

36220 Odessa, TX TX 0.9426 0.9603 

36260 Ogden-Clearfield, UT UT 0.9354 0.9553 

36420 Oklahoma City, OK OK 0.8900 0.9233 

36500 Olympia, WA WA 1.1015 1.0684 

36540 Omaha-Council Bluffs, NE-IA IA 0.9550 0.9690 

36540 Omaha-Council Bluffs, NE-IA NE 0.9554 0.9692 

36740 Orlando-Kissimmee-Sanford, FL FL 0.9178 0.9430 

36780 Oshkosh-Neenah, WI WI 0.9514 0.9665 

36980 Owensboro, KY KY 0.8532 0.8970 

37100 Oxnard-Thousand Oaks-Ventura, CA CA 1.2078 1.1380 

37340 Palm Bay-Melbourne-Titusville, FL FL 0.9332 0.9538 

37380 Palm Coast, FL FL 0.8458 0.8916 

37460 Panama City-Lynn Haven-Panama City Beach, FL FL 0.8458 0.8916 

37620 Parkersburg-Marietta-Vienna, WV-OH OH 0.8555 0.8986 

37620 Parkersburg-Marietta-Vienna, WV-OH WV 0.7536 0.8239 

37700 Pascagoula, MS MS 0.8182 0.8716 

37764 Peabody, MA MA 1.1021 1.0688 

37860 Pensacola-Ferry Pass-Brent, FL FL 0.8458 0.8916 

37900 Peoria, IL IL 0.9289 0.9507 

37964 Philadelphia, PA PA 1.0780 1.0528 

38060 Phoenix-Mesa-Glendale, AZ AZ 1.0519 1.0353 

38220 Pine Bluff, AR AR 0.8311 0.8810 

38300 Pittsburgh, PA PA 0.8579 0.9004 

38340 Pittsfield, MA MA 1.0483 1.0328 

38540 Pocatello, ID ID 0.9379 0.9570 

38660 Ponce, PR PR 0.4278 0.5591 

38860 Portland-South Portland-Biddeford, ME ME 0.9930 0.9952 

38900 Portland-Vancouver-Hillsboro, OR-WA OR 1.1221 1.0821 

38900 Portland-Vancouver-Hillsboro, OR-WA WA 1.1212 1.0815 

38940 Port St. Lucie, FL FL 1.0762 1.0516 

39100 Poughkeepsie-Newburgh-Middletown, NY NY 1.1418 1.0951 

39140 Prescott, AZ AZ 1.2318 1.1535 

39300 Providence-New Bedford-Fall River, RI-MA MA 1.0751 1.0508 

39300 Providence-New Bedford-Fall River, RI-MA RI 1.0751 1.0508 

39340 Provo-Orem, UT UT 0.9272 0.9496 

39380 Pueblo, CO CO 0.9581 0.9711 

39460 Punta Gorda, FL FL 0.9070 0.9353 

39540 Racine, WI WI 1.0651 1.0441 

39580 Raleigh-Cary, NC NC 0.9713 0.9803 

39660 Rapid City, SD SD 1.0990 1.0668 

39740 Reading, PA PA 0.8856 0.9202 
CMS-1498-P 937 

CBSA 

Code Urban Area State

Proposed 

Wage 

Index 

Proposed 

GAF 

39820 Redding, CA CA 1.3277 1.2142 

39900 Reno-Sparks, NV NV 1.0439 1.0299 

40060 Richmond, VA VA 0.9536 0.9680 

40140 Riverside-San Bernardino-Ontario, CA CA 1.2002 1.1331 

40220 Roanoke, VA VA 0.9020 0.9318 

40340 Rochester, MN MN 1.0759 1.0514 

40380 Rochester, NY NY 0.8708 0.9096 

40420 Rockford, IL IL 1.0052 1.0036 

40484 Rockingham County-Strafford County, NH NH 1.0218 1.0149 

40580 Rocky Mount, NC NC 0.9123 0.9391 

40660 Rome, GA GA 0.8760 0.9133 

40900 Sacramento--Arden-Arcade--Roseville, CA CA 1.3217 1.2105 

40980 Saginaw-Saginaw Township North, MI MI 0.9210 0.9452 

41060 St. Cloud, MN MN 1.1654 1.1105 

41100 St. George, UT UT 0.9311 0.9523 

41140 St. Joseph, MO-KS KS 1.0377 1.0257 

41140 St. Joseph, MO-KS MO 1.0377 1.0257 

41180 St. Louis, MO-IL IL 0.9060 0.9346 

41180 St. Louis, MO-IL MO 0.9060 0.9346 

41420 Salem, OR OR 1.1119 1.0753 

41500 Salinas, CA CA 1.5512 1.3507 

41540 Salisbury, MD MD 0.9305 0.9519 

41620 Salt Lake City, UT UT 0.9362 0.9559 

41660 San Angelo, TX TX 0.8479 0.8932 

41700 San Antonio-New Braunfels, TX TX 0.9071 0.9354 

41740 San Diego-Carlsbad-San Marcos, CA CA 1.2002 1.1331 

41780 Sandusky, OH OH 0.8610 0.9026 

41884 San Francisco-San Mateo-Redwood City, CA CA 1.5036 1.3222 

41900 San Germán-Cabo Rojo, PR PR 0.4570 0.5849 

41940 San Jose-Sunnyvale-Santa Clara, CA CA 1.6044 1.3823 

41980 San Juan-Caguas-Guaynabo, PR PR 0.4302 0.5612 

42020 San Luis Obispo-Paso Robles, CA CA 1.2121 1.1408 

42044 Santa Ana-Anaheim-Irvine, CA CA 1.2002 1.1331 

42060 Santa Barbara-Santa Maria-Goleta, CA CA 1.2002 1.1331 

42100 Santa Cruz-Watsonville, CA CA 1.6059 1.3832 

42140 Santa Fe, NM NM 1.0788 1.0533 

42220 Santa Rosa-Petaluma, CA CA 1.5455 1.3473 

42340 Savannah, GA GA 0.8858 0.9203 

42540 Scranton--Wilkes-Barre, PA PA 0.8521 0.8962 

42644 Seattle-Bellevue-Everett, WA WA 1.1393 1.0934 

42680 Sebastian-Vero Beach, FL FL 0.9276 0.9498 

43100 Sheboygan, WI WI 0.9299 0.9514 
CMS-1498-P 938 

CBSA 

Code Urban Area State

Proposed 

Wage 

Index 

Proposed 

GAF 

43300 Sherman-Denison, TX TX 0.8443 0.8906 

43340 Shreveport-Bossier City, LA LA 0.8651 0.9055 

43580 Sioux City, IA-NE-SD IA 0.8964 0.9278 

43580 Sioux City, IA-NE-SD NE 0.8968 0.9281 

43580 Sioux City, IA-NE-SD SD 0.8968 0.9281 

43620 Sioux Falls, SD SD 0.9388 0.9577 

43780 South Bend-Mishawaka, IN-MI IN 0.9889 0.9924 

43780 South Bend-Mishawaka, IN-MI MI 0.9889 0.9924 

43900 Spartanburg, SC SC 0.9086 0.9365 

44060 Spokane, WA WA 1.0588 1.0399 

44100 Springfield, IL IL 0.8948 0.9267 

44140 Springfield, MA MA 1.0361 1.0246 

44180 Springfield, MO MO 0.8413 0.8884 

44220 Springfield, OH OH 0.8997 0.9302 

44300 State College, PA PA 0.8640 0.9047 

44600 Steubenville-Weirton, OH-WV OH 0.8555 0.8986 

44600 Steubenville-Weirton, OH-WV WV 0.7536 0.8239 

44700 Stockton, CA CA 1.2252 1.1492 

44940 Sumter, SC SC 0.8438 0.8902 

45060 Syracuse, NY NY 0.9710 0.9800 

45104 Tacoma, WA WA 1.1264 1.0849 

45220 Tallahassee, FL FL 0.8981 0.9290 

45300 Tampa-St. Petersburg-Clearwater, FL FL 0.9094 0.9370 

45460 Terre Haute, IN IN 0.9254 0.9483 

45500 Texarkana, TX-Texarkana, AR AR 0.7703 0.8363 

45500 Texarkana, TX-Texarkana, AR TX 0.8018 0.8596 

45780 Toledo, OH OH 0.9374 0.9567 

45820 Topeka, KS KS 0.9138 0.9401 

45940 Trenton-Ewing, NJ NJ 1.1069 1.0720 

46060 Tucson, AZ AZ 0.9692 0.9788 

46140 Tulsa, OK OK 0.8903 0.9235 

46220 Tuscaloosa, AL AL 0.8225 0.8748 

46340 Tyler, TX TX 0.8259 0.8772 

46540 Utica-Rome, NY NY 0.8737 0.9117 

46660 Valdosta, GA GA 0.8131 0.8679 

46700 Vallejo-Fairfield, CA CA 1.4207 1.2718 

47020 Victoria, TX TX 0.8038 0.8611 

47220 Vineland-Millville-Bridgeton, NJ NJ 1.1069 1.0720 

47260 Virginia Beach-Norfolk-Newport News, VA NC 0.8954 0.9271 

47260 Virginia Beach-Norfolk-Newport News, VA VA 0.8953 0.9271 

47300 Visalia-Porterville, CA CA 1.2002 1.1331 

47380 Waco, TX TX 0.8648 0.9053 
CMS-1498-P 939 

CBSA 

Code Urban Area State

Proposed 

Wage 

Index 

Proposed 

GAF 

47580 Warner Robins, GA GA 0.8470 0.8925 

47644 Warren-Troy-Farmington-Hills, MI MI 0.9725 0.9811 

47894 Washington-Arlington-Alexandria, DC-VA DC 1.0561 1.0381 

47894 Washington-Arlington-Alexandria, DC-VA MD 1.0561 1.0381 

47894 Washington-Arlington-Alexandria, DC-VA VA 1.0559 1.0380 

47894 Washington-Arlington-Alexandria, DC-VA WV 1.0506 1.0344 

47940 Waterloo-Cedar Falls, IA IA 0.8533 0.8971 

48140 Wausau, WI WI 0.9581 0.9711 

48300 Wenatchee-East Wenatchee, WA WA 1.0107 1.0073 

48424 West Palm Beach-Boca Raton-Boynton Beach, FL FL 0.9824 0.9879 

48540 Wheeling, WV-OH OH 0.8555 0.8986 

48540 Wheeling, WV-OH WV 0.7536 0.8239 

48620 Wichita, KS KS 0.8860 0.9205 

48660 Wichita Falls, TX TX 0.9929 0.9951 

48700 Williamsport, PA PA 0.8521 0.8962 

48864 Wilmington, DE-MD-NJ DE 1.0802 1.0543 

48864 Wilmington, DE-MD-NJ MD 1.0802 1.0543 

48864 Wilmington, DE-MD-NJ NJ 1.1069 1.0720 

48900 Wilmington, NC NC 0.9264 0.9490 

49020 Winchester, VA-WV VA 0.9996 0.9997 

49020 Winchester, VA-WV WV 0.9946 0.9963 

49180 Winston-Salem, NC NC 0.8974 0.9285 

49340 Worcester, MA MA 1.1210 1.0814 

49420 Yakima, WA WA 1.0107 1.0073 

49500 Yauco, PR PR 0.3544 0.4915 

49620 York-Hanover, PA PA 0.9539 0.9682 

49660 Youngstown-Warren-Boardman, OH-PA OH 0.8628 0.9039 

49660 Youngstown-Warren-Boardman, OH-PA PA 0.8612 0.9027 

49700 Yuba City, CA CA 1.2002 1.1331 

49740 Yuma, AZ AZ 0.9455 0.9623 
CMS-1498-P 940 

TABLE 4B.—PROPOSED WAGE INDEX AND CAPITAL GEOGRAPHIC 

ADJUSTMENT FACTOR (GAF) FOR ACUTE CARE HOSPITALS IN RURAL AREAS 

BY CBSA AND BY STATE--FY 2011 

(Wage Index Includes Rural Floor Budget Neutrality Adjustment)

CBSA 

Code Rural Area State 

Proposed 

Wage 

Index 

Proposed 

GAF 

01 Alabama AL 0.7448 0.8173 

02 Alaska AK 1.1919 1.1277 

03 Arizona AZ 0.9120 0.9389 

04 Arkansas AR 0.7517 0.8225 

05 California CA 1.2002 1.1331 

06 Colorado CO 0.9581 0.9711 

07 Connecticut CT 1.1251 1.0841 

08 Delaware DE 1.0090 1.0062 

10 Florida FL 0.8458 0.8916 

11 Georgia GA 0.7782 0.8422 

12 Hawaii HI 1.1292 1.0868 

13 Idaho ID 0.7587 0.8277 

14 Illinois IL 0.8380 0.8860 

15 Indiana IN 0.8399 0.8874 

16 Iowa IA 0.8533 0.8971 

17 Kansas KS 0.8027 0.8603 

18 Kentucky KY 0.7992 0.8577 

19 Louisiana LA 0.7946 0.8543 

20 Maine ME 0.8589 0.9011 

21 Maryland MD 0.9305 0.9519 

22 Massachusetts MA 0.9671 0.9774 

23 Michigan MI 0.8605 0.9022 

24 Minnesota MN 0.9146 0.9407 

25 Mississippi MS 0.7738 0.8389 

26 Missouri MO 0.8127 0.8676 

27 Montana MT 0.8439 0.8903 

28 Nebraska NE 0.8886 0.9223 

29 Nevada NV 0.9555 0.9693 

30 New Hampshire NH 1.0054 1.0037 

31 New Jersey1 NJ 1.1069 1.0720 

32 New Mexico NM 0.9030 0.9325 

33 New York NY 0.8420 0.8889 

34 North Carolina NC 0.8476 0.8929 

35 North Dakota ND 0.7018 0.7847 

36 Ohio OH 0.8555 0.8986 

37 Oklahoma OK 0.8052 0.8621 
CMS-1498-P 941 

CBSA 

Code Rural Area State 

Proposed 

Wage 

Index 

Proposed 

GAF 

38 Oregon OR 1.0089 1.0061 

39 Pennsylvania PA 0.8521 0.8962 

40 Puerto Rico1 PR ------ ------ 

41 Rhode Island1 RI ------ ------ 

42 South Carolina SC 0.8438 0.8902 

43 South Dakota SD 0.8435 0.8900 

44 Tennessee TN 0.7919 0.8523 

45 Texas TX 0.8018 0.8596 

46 Utah UT 0.8714 0.9100 

47 Vermont VT 0.9465 0.9630 

49 Virginia VA 0.8060 0.8627 

50 Washington WA 1.0107 1.0073 

51 West Virginia WV 0.7536 0.8239 

52 Wisconsin WI 0.9019 0.9317 

53 Wyoming WY 0.9392 0.9580 

1 All counties in the State or Territory are classified as urban. The New Jersey floor is imputed as specified in 

§412.64 (h)(4) and discussed in the FY 2005 IPPS final rule (69 FR 49109) and in section III.B.2. of the preamble of 

the FY 2009 IPPS final rule (73 FR 48567).

TABLE 4C.—PROPOSED WAGE INDEX AND CAPITAL GEOGRAPHIC 

ADJUSTMENT FACTOR (GAF) FOR ACUTE CARE HOSPITALS THAT ARE 

RECLASSIFIED BY CBSA AND BY STATE--FY 2011 

(Wage Index Includes Rural Floor Budget Neutrality Adjustment) 

CBSA 

Code Area State 

Proposed 

Wage 

Index 

Proposed 

GAF 

04 Arkansas AR 0.7517 0.8225 

05 California CA 1.2002 1.1331 

07 Connecticut CT 1.1251 1.0841 

10 Florida FL 0.8458 0.8916 

14 Illinois IL 0.8380 0.8860 

14 Illinois MO 0.8380 0.8860 

17 Kansas KS 0.8027 0.8603 

18 Kentucky KY 0.7992 0.8577 

22 Massachusetts MA 0.9671 0.9774 

23 Michigan MI 0.8605 0.9022 

24 Minnesota IA 0.9142 0.9404 

26 Missouri AR 0.8127 0.8676 

26 Missouri MO 0.8127 0.8676 
CMS-1498-P 942 

CBSA 

Code Area State 

Proposed 

Wage 

Index 

Proposed 

GAF 

28 Nebraska KS 0.8886 0.9223 

33 New York NH 1.0054 1.0037 

33 New York NY 0.8420 0.8889 

34 North Carolina NC 0.8476 0.8929 

34 North Carolina TN 0.8407 0.8880 

36 Ohio OH 0.8555 0.8986 

37 Oklahoma OK 0.8052 0.8621 

38 Oregon OR 1.0089 1.0061 

39 Pennsylvania PA 0.8521 0.8962 

44 Tennessee KY 0.7992 0.8577 

45 Texas LA 0.8022 0.8599 

45 Texas OK 0.8052 0.8621 

45 Texas TX 0.8018 0.8596 

47 Vermont NY 0.9328 0.9535 

49 Virginia KY 0.8060 0.8627 

49 Virginia VA 0.8060 0.8627 

49 Virginia WV 0.8020 0.8598 

50 Washington WA 1.0107 1.0073 

10500 Albany, GA AL 0.8539 0.8975 

10500 Albany, GA GA 0.8547 0.8981 

10580 Albany-Schenectady-Troy, NY NY 0.8708 0.9096 

10740 Albuquerque, NM NM 0.9505 0.9658 

10780 Alexandria, LA LA 0.8164 0.8703 

10900 Allentown-Bethlehem-Easton, PA-NJ PA 0.9418 0.9598 

11100 Amarillo, TX KS 0.8438 0.8902 

11100 Amarillo, TX TX 0.8434 0.8899 

11180 Ames, IA IA 0.9273 0.9496 

11260 Anchorage, AK AK 1.1919 1.1277 

11300 Anderson, IN IN 0.8736 0.9116 

11460 Ann Arbor, MI MI 0.9849 0.9896 

12020 Athens-Clarke County, GA GA 0.9348 0.9549 

12060 Atlanta-Sandy Springs-Marietta, GA AL 0.9563 0.9699 

12060 Atlanta-Sandy Springs-Marietta, GA GA 0.9572 0.9705 

12260 Augusta-Richmond County, GA-SC SC 0.9571 0.9704 

12420 Austin-Round Rock-San Marcos, TX TX 0.9523 0.9671 

12620 Bangor, ME ME 0.9695 0.9790 

12940 Baton Rouge, LA MS 0.8580 0.9004 

12980 Battle Creek, MI MI 0.9759 0.9834 

13020 Bay City, MI MI 0.8891 0.9227 

13644 Bethesda-Rockville-Frederick, MD DC 1.0573 1.0389 

13644 Bethesda-Rockville-Frederick, MD PA 1.0539 1.0366 

13644 Bethesda-Rockville-Frederick, MD VA 1.0571 1.0388 
CMS-1498-P 943 

CBSA 

Code Area State 

Proposed 

Wage 

Index 

Proposed 

GAF 

13780 Binghamton, NY PA 0.8762 0.9135 

13820 Birmingham-Hoover, AL AL 0.8427 0.8894 

13900 Bismarck, ND ND 0.7451 0.8175 

13980 Blacksburg-Christiansburg-Radford, VA WV 0.7746 0.8395 

14260 Boise City-Nampa, ID ID 0.9068 0.9352 

14484 Boston-Quincy, MA MA 1.1613 1.1078 

14484 Boston-Quincy, MA RI 1.1613 1.1078 

14540 Bowling Green, KY KY 0.8347 0.8836 

14740 Bremerton-Silverdale, WA WA 1.0399 1.0272 

15260 Brunswick, GA GA 0.9352 0.9552 

15380 Buffalo-Niagara Falls, NY NY 0.9628 0.9744 

15540 Burlington-South Burlington, VT NY 1.0071 1.0049 

15540 Burlington-South Burlington, VT VT 1.0071 1.0049 

15764 Cambridge-Newton-Framingham, MA NH 1.0990 1.0668 

15940 Canton-Massillon, OH OH 0.8612 0.9027 

16020 Cape Girardeau-Jackson, MO-IL IL 0.8380 0.8860 

16020 Cape Girardeau-Jackson, MO-IL KY 0.8361 0.8846 

16020 Cape Girardeau-Jackson, MO-IL MO 0.8363 0.8848 

16180 Carson City, NV NV 0.9960 0.9973 

16580 Champaign-Urbana, IL IL 0.9154 0.9413 

16620 Charleston, WV WV 0.8093 0.8651 

16700 Charleston-North Charleston-Summerville, SC SC 0.9295 0.9512 

16740 Charlotte-Gastonia-Rock Hill, NC-SC NC 0.9162 0.9418 

16820 Charlottesville, VA VA 0.9243 0.9475 

16860 Chattanooga, TN-GA AL 0.8594 0.9014 

16860 Chattanooga, TN-GA GA 0.8602 0.9020 

16860 Chattanooga, TN-GA TN 0.8531 0.8969 

16974 Chicago-Joliet-Naperville, IL IL 1.0370 1.0252 

16974 Chicago-Joliet-Naperville, IL IN 1.0370 1.0252 

16974 Chicago-Joliet-Naperville, IL WI 1.0370 1.0252 

17140 Cincinnati-Middletown, OH-KY-IN IN 0.9637 0.9750 

17140 Cincinnati-Middletown, OH-KY-IN KY 0.9634 0.9748 

17140 Cincinnati-Middletown, OH-KY-IN OH 0.9624 0.9741 

17300 Clarksville, TN-KY KY 0.7992 0.8577 

17460 Cleveland-Elyria-Mentor, OH OH 0.9082 0.9362 

17780 College Station-Bryan, TX TX 0.9244 0.9476 

17860 Columbia, MO MO 0.8261 0.8774 

17900 Columbia, SC SC 0.8695 0.9087 

17980 Columbus, GA-AL AL 0.8613 0.9028 

17980 Columbus, GA-AL GA 0.8621 0.9034 

18140 Columbus, OH OH 1.0025 1.0017 

18580 Corpus Christi, TX TX 0.8576 0.9001 
CMS-1498-P 944 

CBSA 

Code Area State 

Proposed 

Wage 

Index 

Proposed 

GAF 

18700 Corvallis, OR OR 1.0149 1.0102 

18880 Crestview-Fort Walton Beach-Destin, FL FL 0.8565 0.8994 

19124 Dallas-Plano-Irving, TX TX 0.9584 0.9713 

19340 Davenport-Moline-Rock Island, IA-IL IL 0.8658 0.9060 

19340 Davenport-Moline-Rock Island, IA-IL IA 0.8654 0.9057 

19380 Dayton, OH OH 0.9172 0.9425 

19460 Decatur, AL AL 0.7583 0.8274 

19740 Denver-Aurora-Broomfield, CO CO 1.0303 1.0207 

19780 Des Moines-West Des Moines, IA IA 0.9525 0.9672 

19804 Detroit-Livonia-Dearborn, MI MI 0.9776 0.9846 

20100 Dover, DE DE 1.0090 1.0062 

20500 Durham-Chapel Hill, NC NC 0.9662 0.9767 

20500 Durham-Chapel Hill, NC VA 0.9661 0.9767 

20764 Edison-New Brunswick, NJ NJ 1.1069 1.0720 

21060 Elizabethtown, KY KY 0.8389 0.8867 

21140 Elkhart-Goshen, IN IN 0.9457 0.9625 

21500 Erie, PA NY 0.8420 0.8889 

21500 Erie, PA PA 0.8521 0.8962 

21660 Eugene-Springfield, OR OR 1.1032 1.0696 

22180 Fayetteville, NC NC 0.9238 0.9472 

22220 Fayetteville-Springdale-Rogers, AR-MO OK 0.8646 0.9052 

22420 Flint, MI MI 1.0134 1.0092 

22520 Florence-Muscle Shoals, AL MS 0.8035 0.8609 

22540 Fond du Lac, WI WI 0.9178 0.9430 

22660 Fort Collins-Loveland, CO CO 0.9581 0.9711 

22744 

Fort Lauderdale-Pompano Beach-Deerfield 

Beach, FL FL 1.0364 1.0248 

23060 Fort Wayne, IN IN 0.9245 0.9477 

23104 Fort Worth-Arlington, TX TX 0.9427 0.9604 

23540 Gainesville, FL FL 0.9406 0.9589 

23844 Gary, IN IN 0.9069 0.9353 

24300 Grand Junction, CO CO 1.0051 1.0035 

24340 Grand Rapids-Wyoming, MI MI 0.9315 0.9526 

24500 Great Falls, MT MT 0.8439 0.8903 

24540 Greeley, CO NE 0.9418 0.9598 

24540 Greeley, CO WY 0.9418 0.9598 

24580 Green Bay, WI MI 0.9249 0.9479 

24580 Green Bay, WI WI 0.9249 0.9479 

24660 Greensboro-High Point, NC NC 0.8996 0.9301 

24780 Greenville, NC NC 0.9192 0.9439 

24860 Greenville-Mauldin-Easley, SC NC 0.9127 0.9394 

24860 Greenville-Mauldin-Easley, SC SC 0.9128 0.9394 
CMS-1498-P 945 

CBSA 

Code Area State 

Proposed 

Wage 

Index 

Proposed 

GAF 

25060 Gulfport-Biloxi, MS MS 0.8350 0.8838 

25420 Harrisburg-Carlisle, PA PA 0.9172 0.9425 

25540 Hartford-West Hartford-East Hartford, CT CT 1.1251 1.0841 

25540 Hartford-West Hartford-East Hartford, CT MA 1.1117 1.0752 

25860 Hickory-Lenoir-Morganton, NC NC 0.8537 0.8973 

26300 Hot Springs, AR AR 0.9071 0.9354 

26420 Houston-Sugar Land-Baytown, TX TX 0.9946 0.9963 

26580 Huntington-Ashland, WV-KY-OH KY 0.8767 0.9138 

26580 Huntington-Ashland, WV-KY-OH NC 0.8768 0.9139 

26580 Huntington-Ashland, WV-KY-OH OH 0.8757 0.9131 

26580 Huntington-Ashland, WV-KY-OH WV 0.8723 0.9107 

26620 Huntsville, AL AL 0.8646 0.9052 

26620 Huntsville, AL TN 0.8582 0.9006 

26820 Idaho Falls, ID ID 0.9676 0.9777 

26900 Indianapolis-Carmel, IN IN 0.9555 0.9693 

26980 Iowa City, IA IA 0.9422 0.9600 

27060 Ithaca, NY NY 0.9187 0.9436 

27140 Jackson, MS MS 0.8125 0.8675 

27180 Jackson, TN MS 0.8379 0.8859 

27620 Jefferson City, MO MO 0.8605 0.9022 

27860 Jonesboro, AR AR 0.7833 0.8460 

27900 Joplin, MO KS 0.8448 0.8909 

27900 Joplin, MO OK 0.8446 0.8908 

28020 Kalamazoo-Portage, MI MI 0.9979 0.9986 

28140 Kansas City, MO-KS KS 0.9558 0.9695 

28140 Kansas City, MO-KS MO 0.9558 0.9695 

28420 Kennewick-Pasco-Richland, WA ID 0.9659 0.9765 

28700 Kingsport-Bristol-Bristol, TN-VA KY 0.7992 0.8577 

28700 Kingsport-Bristol-Bristol, TN-VA TN 0.7919 0.8523 

28940 Knoxville, TN KY 0.7992 0.8577 

28940 Knoxville, TN TN 0.7919 0.8523 

29180 Lafayette, LA LA 0.8473 0.8927 

29404 Lake County-Kenosha County, IL-WI IL 1.0515 1.0350 

29460 Lakeland-Winter Haven, FL FL 0.8628 0.9039 

29540 Lancaster, PA PA 0.9760 0.9835 

29620 Lansing-East Lansing, MI MI 1.0144 1.0098 

29700 Laredo, TX TX 0.8312 0.8811 

29740 Las Cruces, NM NM 0.9183 0.9433 

29820 Las Vegas-Paradise, NV AZ 1.1811 1.1207 

30020 Lawton, OK OK 0.8306 0.8806 

30460 Lexington-Fayette, KY KY 0.8798 0.9160 

30620 Lima, OH OH 0.9254 0.9483 
CMS-1498-P 946 

CBSA 

Code Area State 

Proposed 

Wage 

Index 

Proposed 

GAF 

30700 Lincoln, NE NE 0.9490 0.9648 

30780 Little Rock-North Little Rock-Conway, AR AR 0.8490 0.8940 

30980 Longview, TX TX 0.8593 0.9014 

31084 Los Angeles-Long Beach-Glendale, CA CA 1.2002 1.1331 

31140 Louisville-Jefferson County, KY-IN KY 0.8848 0.9196 

31420 Macon, GA GA 0.8970 0.9283 

31540 Madison, WI WI 1.1096 1.0738 

31900 Mansfield, OH OH 0.8917 0.9245 

32780 Medford, OR OR 1.0089 1.0061 

32820 Memphis, TN-MS-AR AR 0.8981 0.9290 

32820 Memphis, TN-MS-AR MS 0.8981 0.9290 

32820 Memphis, TN-MS-AR TN 0.8907 0.9238 

33124 Miami-Miami Beach-Kendall, FL FL 1.0222 1.0151 

33260 Midland, TX TX 0.9554 0.9692 

33340 Milwaukee-Waukesha-West Allis, WI WI 1.0226 1.0154 

33460 Minneapolis-St. Paul-Bloomington, MN-WI MN 1.1027 1.0692 

33460 Minneapolis-St. Paul-Bloomington, MN-WI WI 1.1027 1.0692 

33540 Missoula, MT MT 0.8618 0.9032 

33660 Mobile, AL AL 0.7899 0.8509 

33700 Modesto, CA CA 1.2002 1.1331 

33740 Monroe, LA AR 0.8122 0.8672 

33740 Monroe, LA LA 0.8122 0.8672 

33780 Monroe, MI OH 0.9653 0.9761 

33860 Montgomery, AL AL 0.8506 0.8951 

34060 Morgantown, WV WV 0.8266 0.8777 

34740 Muskegon-Norton Shores, MI MI 0.9386 0.9575 

34820 Myrtle Beach-North Myrtle Beach-Conway, SC NC 0.8680 0.9076 

34980 Nashville-Davidson-Murfreesboro-Franklin, TN KY 0.9320 0.9529 

34980 Nashville-Davidson-Murfreesboro-Franklin, TN TN 0.9246 0.9477 

35004 Nassau-Suffolk, NY CT 1.2234 1.1481 

35084 Newark-Union, NJ-PA NJ 1.1099 1.0740 

35084 Newark-Union, NJ-PA NY 1.1332 1.0894 

35084 Newark-Union, NJ-PA PA 1.1296 1.0870 

35300 New Haven-Milford, CT CT 1.1654 1.1105 

35380 New Orleans-Metairie-Kenner, LA LA 0.9005 0.9307 

35644 New York-White Plains-Wayne, NY-NJ CT 1.2817 1.1853 

35644 New York-White Plains-Wayne, NY-NJ NJ 1.2619 1.1727 

35644 New York-White Plains-Wayne, NY-NJ NY 1.2884 1.1895 

35840 North Port-Bradenton-Sarasota-Venice, FL FL 0.9265 0.9491 

35980 Norwich-New London, CT RI 1.1412 1.0947 

36084 Oakland-Fremont-Hayward, CA CA 1.5428 1.3457 

36140 Ocean City, NJ DE 1.0903 1.0610 
CMS-1498-P 947 

CBSA 

Code Area State 

Proposed 

Wage 

Index 

Proposed 

GAF 

36220 Odessa, TX NM 0.9315 0.9526 

36220 Odessa, TX TX 0.9311 0.9523 

36260 Ogden-Clearfield, UT UT 0.9354 0.9553 

36420 Oklahoma City, OK OK 0.8900 0.9233 

36500 Olympia, WA WA 1.1015 1.0684 

36740 Orlando-Kissimmee-Sanford, FL FL 0.9178 0.9430 

37460 

Panama City-Lynn Haven-Panama City Beach, 

FL AL 0.8002 0.8584 

37764 Peabody, MA NH 1.1021 1.0688 

37860 Pensacola-Ferry Pass-Brent, FL AL 0.8144 0.8688 

37900 Peoria, IL IL 0.9179 0.9430 

37964 Philadelphia, PA NJ 1.1069 1.0720 

37964 Philadelphia, PA PA 1.0663 1.0449 

38060 Phoenix-Mesa-Glendale, AZ AZ 1.0519 1.0353 

38220 Pine Bluff, AR MS 0.8311 0.8810 

38300 Pittsburgh, PA OH 0.8555 0.8986 

38300 Pittsburgh, PA PA 0.8521 0.8962 

38300 Pittsburgh, PA WV 0.8441 0.8904 

38340 Pittsfield, MA NY 1.0158 1.0108 

38340 Pittsfield, MA VT 1.0158 1.0108 

38860 Portland-South Portland-Biddeford, ME ME 0.9509 0.9661 

38900 Portland-Vancouver-Hillsboro, OR-WA OR 1.1221 1.0821 

38900 Portland-Vancouver-Hillsboro, OR-WA WA 1.1212 1.0815 

38940 Port St. Lucie, FL FL 1.0283 1.0193 

39100 Poughkeepsie-Newburgh-Middletown, NY NY 1.1246 1.0837 

39340 Provo-Orem, UT UT 0.9272 0.9496 

39580 Raleigh-Cary, NC NC 0.9713 0.9803 

39740 Reading, PA PA 0.8856 0.9202 

39820 Redding, CA CA 1.3277 1.2142 

39900 Reno-Sparks, NV NV 1.0439 1.0299 

40060 Richmond, VA VA 0.9536 0.9680 

40140 Riverside-San Bernardino-Ontario, CA AZ 1.1429 1.0958 

40220 Roanoke, VA VA 0.8864 0.9207 

40220 Roanoke, VA WV 0.8820 0.9176 

40380 Rochester, NY NY 0.8708 0.9096 

40420 Rockford, IL IL 0.9874 0.9914 

40484 Rockingham County-Strafford County, NH ME 1.0218 1.0149 

40900 Sacramento--Arden-Arcade--Roseville, CA CA 1.3217 1.2105 

40980 Saginaw-Saginaw Township North, MI MI 0.9102 0.9376 

41100 St. George, UT UT 0.9311 0.9523 

41180 St. Louis, MO-IL IL 0.8955 0.9272 

41180 St. Louis, MO-IL MO 0.8955 0.9272 
CMS-1498-P 948 

CBSA 

Code Area State 

Proposed 

Wage 

Index 

Proposed 

GAF 

41620 Salt Lake City, UT UT 0.9362 0.9559 

41700 San Antonio-New Braunfels, TX TX 0.9071 0.9354 

41940 San Jose-Sunnyvale-Santa Clara, CA CA 1.5855 1.3711 

42044 Santa Ana-Anaheim-Irvine, CA CA 1.2002 1.1331 

42100 Santa Cruz-Watsonville, CA CA 1.6059 1.3832 

42140 Santa Fe, NM NM 1.0400 1.0272 

42220 Santa Rosa-Petaluma, CA CA 1.5173 1.3304 

42340 Savannah, GA GA 0.8858 0.9203 

42340 Savannah, GA SC 0.8858 0.9203 

42644 Seattle-Bellevue-Everett, WA WA 1.1272 1.0855 

43300 Sherman-Denison, TX OK 0.8445 0.8907 

43340 Shreveport-Bossier City, LA LA 0.8651 0.9055 

43580 Sioux City, IA-NE-SD NE 0.8968 0.9281 

43620 Sioux Falls, SD SD 0.9388 0.9577 

43780 South Bend-Mishawaka, IN-MI IN 0.9488 0.9646 

43900 Spartanburg, SC SC 0.8970 0.9283 

44060 Spokane, WA ID 1.0384 1.0261 

44100 Springfield, IL IL 0.8948 0.9267 

44140 Springfield, MA NH 1.0258 1.0176 

44180 Springfield, MO AR 0.8413 0.8884 

44180 Springfield, MO MO 0.8413 0.8884 

44940 Sumter, SC SC 0.8438 0.8902 

45060 Syracuse, NY NY 0.9710 0.9800 

45220 Tallahassee, FL GA 0.8795 0.9158 

45300 Tampa-St. Petersburg-Clearwater, FL FL 0.9094 0.9370 

45460 Terre Haute, IN IN 0.8757 0.9131 

45780 Toledo, OH OH 0.9246 0.9477 

45820 Topeka, KS KS 0.8948 0.9267 

46140 Tulsa, OK OK 0.8798 0.9160 

46220 Tuscaloosa, AL AL 0.8015 0.8594 

46220 Tuscaloosa, AL MS 0.8022 0.8599 

46340 Tyler, TX TX 0.8259 0.8772 

46540 Utica-Rome, NY NY 0.8737 0.9117 

46660 Valdosta, GA GA 0.7840 0.8465 

46700 Vallejo-Fairfield, CA CA 1.4010 1.2597 

47260 Virginia Beach-Norfolk-Newport News, VA NC 0.8954 0.9271 

47580 Warner Robins, GA GA 0.8470 0.8925 

47894 Washington-Arlington-Alexandria, DC-VA VA 1.0559 1.0380 

48140 Wausau, WI WI 0.9113 0.9384 

48620 Wichita, KS KS 0.8756 0.9130 

48700 Williamsport, PA PA 0.8521 0.8962 

48864 Wilmington, DE-MD-NJ DE 1.0690 1.0468 
CMS-1498-P 949 

CBSA 

Code Area State 

Proposed 

Wage 

Index 

Proposed 

GAF 

48900 Wilmington, NC SC 0.9265 0.9491 

49180 Winston-Salem, NC NC 0.8974 0.9285 

49180 Winston-Salem, NC VA 0.8973 0.9285 

49660 Youngstown-Warren-Boardman, OH-PA OH 0.8555 0.8986 

49660 Youngstown-Warren-Boardman, OH-PA PA 0.8521 0.8962 
CMS-1498-P 950 

TABLE 4D-1.—PROPOSED RURAL FLOOR BUDGET NEUTRALITY FACTORS FOR 

ACUTE CARE HOSPITALS—FY 2011 

[The rural floor budget neutrality adjustment factor is a 100 percent State-level factor.] 

State 

Proposed Rural Floor 

Budget Neutrality 

Adjustment Factor 

Alabama 0.99910 

Alaska 0.94328 

Arizona 1.00000 

Arkansas 1.00000 

California 0.97557 

Colorado 0.98680 

Connecticut 0.99483 

Delaware 1.00000 

Washington, D.C. 1.00000 

Florida 0.99847 

Georgia 1.00000 

Hawaii 1.00000 

Idaho 1.00000 

Illinois 1.00000 

Indiana 1.00000 

Iowa 0.99954 

Kansas 1.00000 

Kentucky 0.99973 

Louisiana 1.00000 

Maine 1.00000 

Maryland* 1.00000 

Massachusetts 1.00000 

Michigan 1.00000 

Minnesota 1.00000 

Mississippi 1.00000 

Missouri 1.00000 

Montana 0.99988 

Nebraska 1.00000 

Nevada 1.00000 

New Hampshire 1.00000 

New Jersey ** 0.97946 

New Mexico 1.00000 

New York 1.00000 

North Carolina 0.99989 

North Dakota 1.00000 

Ohio 0.99864 

Oklahoma 0.99975 
CMS-1498-P 951 

State 

Proposed Rural Floor 

Budget Neutrality 

Adjustment Factor 

Oregon 0.99974 

Pennsylvania 0.99681 

Puerto Rico 1.00000 

Rhode Island 1.00000 

South Carolina 1.00000 

South Dakota 1.00000 

Tennessee 0.99171 

Texas 0.99956 

Utah 1.00000 

Vermont 1.00000 

Virginia 0.99977 

Washington 0.99891 

West Virginia 0.99479 

Wisconsin 1.00000 

Wyoming 1.00000 

* Maryland hospitals, under section 1814(b)(3) of the Act, are waived from the IPPS 

ratesetting. Therefore, the rural floor budget neutrality adjustment does not apply. 

** The rural floor budget neutrality factor for New Jersey is based on an imputed floor (see TABLE 

4B). 
CMS-1498-P 952 

 

TABLE 4D-2.--URBAN AREAS WITH ACUTE CARE HOSPITALS RECEIVING THE 

PROPOSED STATEWIDE RURAL FLOOR OR IMPUTED FLOOR 

WAGE INDEX--FY 2011 

[*Only hospitals that are geographically located in the specified State receive the State’s rural or 

imputed floor wage index.] 

(Wage Index Includes Rural Floor Budget Neutrality Adjustment) 

CBSA 

Code Urban Area State* 

Proposed 

Rural or 

Imputed 

Floor 

Wage 

Index 

10900 Allentown-Bethlehem-Easton, PA-NJ NJ 1.1069 

11260 Anchorage, AK AK 1.1919 

12100 Atlantic City-Hammonton, NJ NJ 1.1069 

12540 Bakersfield-Delano, CA CA 1.2002 

15804 Camden, NJ NJ 1.1069 

16940 Cheyenne, WY WY 0.9392 

17020 Chico, CA CA 1.2002 

17300 Clarksville, TN-KY KY 0.7992 

17300 Clarksville, TN-KY TN 0.7919 

17420 Cleveland, TN TN 0.7919 

17820 Colorado Springs, CO CO 0.9581 

19060 Cumberland, MD-WV MD 0.9305 

19500 Decatur, IL IL 0.8380 

20100 Dover, DE DE 1.0090 

20764 Edison-New Brunswick, NJ NJ 1.1069 

20940 El Centro, CA CA 1.2002 

21500 Erie, PA PA 0.8521 

21780 Evansville, IN-KY IN 0.8399 

21820 Fairbanks, AK AK 1.1919 

22020 Fargo, ND-MN MN 0.9146 

22140 Farmington, NM NM 0.9030 

22660 Fort Collins-Loveland, CO CO 0.9581 

22900 Fort Smith, AR-OK OK 0.8052 

23420 Fresno, CA CA 1.2002 

23460 Gadsden, AL AL 0.7448 

24220 Grand Forks, ND-MN MN 0.9146 

24500 Great Falls, MT MT 0.8439 

24540 Greeley, CO CO 0.9581 

25260 Hanford-Corcoran, CA CA 1.2002 

25540 Hartford-West Hartford-East Hartford, CT CT 1.1251 

27340 Jacksonville, NC NC 0.8476 

27740 Johnson City, TN TN 0.7919 
CMS-1498-P 953 

 

CBSA 

Code Urban Area State* 

Proposed 

Rural or 

Imputed 

Floor 

Wage 

Index 

27780 Johnstown, PA PA 0.8521 

28420 Kennewick-Pasco-Richland, WA WA 1.0107 

28700 Kingsport-Bristol-Bristol, TN-VA TN 0.7919 

28700 Kingsport-Bristol-Bristol, TN-VA VA 0.8060 

28940 Knoxville, TN TN 0.7919 

30140 Lebanon, PA PA 0.8521 

30300 Lewiston, ID-WA WA 1.0107 

31084 Los Angeles-Long Beach-Glendale, CA CA 1.2002 

31460 Madera-Chowchilla, CA CA 1.2002 

31700 Manchester-Nashua, NH NH 1.0054 

31740 Manhattan, KS KS 0.8027 

32780 Medford, OR OR 1.0089 

32900 Merced, CA CA 1.2002 

33700 Modesto, CA CA 1.2002 

34100 Morristown, TN TN 0.7919 

34580 Mount Vernon-Anacortes, WA WA 1.0107 

34620 Muncie, IN IN 0.8399 

36140 Ocean City, NJ NJ 1.1069 

37380 Palm Coast, FL FL 0.8458 

37460 Panama City-Lynn Haven-Panama City Beach, FL FL 0.8458 

37620 Parkersburg-Marietta-Vienna, WV-OH OH 0.8555 

37620 Parkersburg-Marietta-Vienna, WV-OH WV 0.7536 

37860 Pensacola-Ferry Pass-Brent, FL FL 0.8458 

39380 Pueblo, CO CO 0.9581 

40140 Riverside-San Bernardino-Ontario, CA CA 1.2002 

41540 Salisbury, MD MD 0.9305 

41740 San Diego-Carlsbad-San Marcos, CA CA 1.2002 

42044 Santa Ana-Anaheim-Irvine, CA CA 1.2002 

42060 Santa Barbara-Santa Maria-Goleta, CA CA 1.2002 

42540 Scranton--Wilkes-Barre, PA PA 0.8521 

44600 Steubenville-Weirton, OH-WV OH 0.8555 

44600 Steubenville-Weirton, OH-WV WV 0.7536 

44940 Sumter, SC SC 0.8438 

45500 Texarkana, TX-Texarkana, AR TX 0.8018 

45940 Trenton-Ewing, NJ NJ 1.1069 

47220 Vineland-Millville-Bridgeton, NJ NJ 1.1069 

47300 Visalia-Porterville, CA CA 1.2002 

47940 Waterloo-Cedar Falls, IA IA 0.8533 

48300 Wenatchee-East Wenatchee, WA WA 1.0107 
CMS-1498-P 954 

 

CBSA 

Code Urban Area State* 

Proposed 

Rural or 

Imputed 

Floor 

Wage 

Index 

48540 Wheeling, WV-OH OH 0.8555 

48540 Wheeling, WV-OH WV 0.7536 

48700 Williamsport, PA PA 0.8521 

48864 Wilmington, DE-MD-NJ NJ 1.1069 

49420 Yakima, WA WA 1.0107 

49700 Yuba City, CA CA 1.2002 
CMS-1498-P 955 

TABLE 4E.—URBAN CBSAs AND CONSTITUENT COUNTIES FOR ACUTE CARE 

HOSPITALS—FY 2011 

CBSA Code

Urban Area 

(Constituent Counties) 

10180 Abilene, TX 

Callahan County, TX 

 Jones County, TX 

 Taylor County, TX 

10380 Aguadilla-Isabela-San Sebastián, PR 

 Aguada Municipio, PR 

 Aguadilla Municipio, PR 

 Añasco Municipio, PR 

 Isabela Municipio, PR 

 Lares Municipio, PR 

 Moca Municipio, PR 

 Rincón Municipio, PR 

 San Sebastián Municipio, PR 

10420 Akron, OH 

 Portage County, OH 

 Summit County, OH 

10500 Albany, GA 

 Baker County, GA 

 Dougherty County, GA 

 Lee County, GA 

 Terrell County, GA 

 Worth County, GA 

10580 Albany-Schenectady-Troy, NY 

 Albany County, NY 

 Rensselaer County, NY 

 Saratoga County, NY 

 Schenectady County, NY 

 Schoharie County, NY 

10740 Albuquerque, NM 

 Bernalillo County, NM 

 Sandoval County, NM 

 Torrance County, NM 

 Valencia County, NM 

10780 Alexandria, LA 

 Grant Parish, LA 

 Rapides Parish, LA 

10900 Allentown-Bethlehem-Easton, PA-NJ 

 Warren County, NJ 

 Carbon County, PA 

 Lehigh County, PA 

 Northampton County, PA 
CMS-1498-P 956 

CBSA Code

Urban Area 

(Constituent Counties) 

11020 Altoona, PA 

 Blair County, PA 

11100 Amarillo, TX 

 Armstrong County, TX 

 Carson County, TX 

 Potter County, TX 

 Randall County, TX 

11180 Ames, IA 

 Story County, IA 

11260 Anchorage, AK 

 Anchorage Municipality, AK 

 Matanuska-Susitna Borough, AK 

11300 Anderson, IN 

 Madison County, IN 

11340 Anderson, SC 

 Anderson County, SC 

11460 Ann Arbor, MI 

 Washtenaw County, MI 

11500 Anniston-Oxford, AL 

 Calhoun County, AL 

11540 Appleton, WI 

 Calumet County, WI 

 Outagamie County, WI 

11700 Asheville, NC 

 Buncombe County, NC 

 Haywood County, NC 

 Henderson County, NC 

 Madison County, NC 

12020 Athens-Clarke County, GA 

 Clarke County, GA 

 Madison County, GA 

 Oconee County, GA 

 Oglethorpe County, GA 
CMS-1498-P 957 

CBSA Code

Urban Area 

(Constituent Counties) 

12060 Atlanta-Sandy Springs-Marietta, GA 

 Barrow County, GA 

 Bartow County, GA 

 Butts County, GA 

 Carroll County, GA 

 Cherokee County, GA 

 Clayton County, GA 

 Cobb County, GA 

 Coweta County, GA 

 Dawson County, GA 

 DeKalb County, GA 

 Douglas County, GA 

 Fayette County, GA 

 Forsyth County, GA 

 Fulton County, GA 

 Gwinnett County, GA 

 Haralson County, GA 

 Heard County, GA 

 Henry County, GA 

 Jasper County, GA 

 Lamar County, GA 

 Meriwether County, GA 

 Newton County, GA 

 Paulding County, GA 

 Pickens County, GA 

 Pike County, GA 

 Rockdale County, GA 

 Spalding County, GA 

 Walton County, GA 

12100 

Atlantic City-Hammonton, NJ 

 Atlantic County, NJ 

 Hammonton County, NJ 

12220 Auburn-Opelika, AL 

 Lee County, AL 

12260 Augusta-Richmond County, GA-SC 

 Burke County, GA 

 Columbia County, GA 

 McDuffie County, GA 

 Richmond County, GA 

 Aiken County, SC 

 Edgefield County, SC 
CMS-1498-P 958 

CBSA Code

Urban Area 

(Constituent Counties) 

12420 Austin-Round Rock-San Marcos, TX 

 Bastrop County, TX 

 Caldwell County, TX 

 Hays County, TX 

 Travis County, TX 

 Williamson County, TX 

12540 Bakersfield-Delano, CA 

 Kern County, CA 

12580 Baltimore-Towson, MD 

 Anne Arundel County, MD 

 Baltimore County, MD 

 Carroll County, MD 

 Harford County, MD 

 Howard County, MD 

 Queen Anne's County, MD 

 Baltimore City, MD 

12620 Bangor, ME 

 Penobscot County, ME 

12700 Barnstable Town, MA 

 Barnstable County, MA 

12940 Baton Rouge, LA 

 Ascension Parish, LA 

 East Baton Rouge Parish, LA 

 East Feliciana Parish, LA 

 Iberville Parish, LA 

 Livingston Parish, LA 

 Pointe Coupee Parish, LA 

 St. Helena Parish, LA 

 West Baton Rouge Parish, LA 

 West Feliciana Parish, LA 

12980 Battle Creek, MI 

 Calhoun County, MI 

13020 Bay City, MI 

 Bay County, MI 

13140 Beaumont-Port Arthur, TX 

 Hardin County, TX 

 Jefferson County, TX 

 Orange County, TX 

13380 Bellingham, WA 

 Whatcom County, WA 

13460 Bend, OR 

 Deschutes County, OR 
CMS-1498-P 959 

CBSA Code

Urban Area 

(Constituent Counties) 

13644 Bethesda-Rockville-Frederick, MD 

 Frederick County, MD 

 Montgomery County, MD 

13740 Billings, MT 

 Carbon County, MT 

 Yellowstone County, MT 

13780 Binghamton, NY 

 Broome County, NY 

 Tioga County, NY 

13820 Birmingham-Hoover, AL 

 Bibb County, AL 

 Blount County, AL 

 Chilton County, AL 

 Jefferson County, AL 

 St. Clair County, AL 

 Shelby County, AL 

 Walker County, AL 

13900 Bismarck, ND 

 Burleigh County, ND 

 Morton County, ND 

13980 Blacksburg-Christiansburg-Radford, VA 

 Giles County, VA 

 Montgomery County, VA 

 Pulaski County, VA 

 Radford City, VA 

14020 Bloomington, IN 

 Greene County, IN 

 Monroe County, IN 

 Owen County, IN 

14060 Bloomington-Normal, IL 

 McLean County, IL 

14260 Boise City-Nampa, ID 

 Ada County, ID 

 Boise County, ID 

 Canyon County, ID 

 Gem County, ID 

 Owyhee County, ID 

14484 Boston-Quincy, MA 

 Norfolk County, MA 

 Plymouth County, MA 

 Suffolk County, MA 

14500 Boulder, CO 

 Boulder County, CO 
CMS-1498-P 960 

CBSA Code

Urban Area 

(Constituent Counties) 

14540 Bowling Green, KY 

 Edmonson County, KY 

 Warren County, KY 

14740 Bremerton-Silverdale, WA 

 Kitsap County, WA 

14860 Bridgeport-Stamford-Norwalk, CT 

 Fairfield County, CT 

15180 Brownsville-Harlingen, TX 

 Cameron County, TX 

15260 Brunswick, GA 

 Brantley County, GA 

 Glynn County, GA 

 McIntosh County, GA 

15380 Buffalo-Niagara Falls, NY 

 Erie County, NY 

 Niagara County, NY 

15500 Burlington, NC 

 Alamance County, NC 

15540 Burlington-South Burlington, VT 

 Chittenden County, VT 

 Franklin County, VT 

 Grand Isle County, VT 

15764 Cambridge-Newton-Framingham, MA 

 Middlesex County, MA 

15804 Camden, NJ 

 Burlington County, NJ 

 Camden County, NJ 

 Gloucester County, NJ 

15940 Canton-Massillon, OH 

 Carroll County, OH 

 Stark County, OH 

15980 Cape Coral-Fort Myers, FL 

 Lee County, FL 

16020 Cape Girardeau-Jackson, MO-IL 

 Alexander County, IL 

 Bollinger County, MO 

 Cape Girardeau County, MO 

16180 Carson City, NV 

 Carson City, NV 

16220 Casper, WY 

 Natrona County, WY 
CMS-1498-P 961 

CBSA Code

Urban Area 

(Constituent Counties) 

16300 Cedar Rapids, IA 

 Benton County, IA 

 Jones County, IA 

 Linn County, IA 

16580 Champaign-Urbana, IL 

 Champaign County, IL 

 Ford County, IL 

 Piatt County, IL 

16620 Charleston, WV 

 Boone County, WV 

 Clay County, WV 

 Kanawha County, WV 

 Lincoln County, WV 

 Putnam County, WV 

16700 

Charleston-North Charleston-Summerville, SC 

 Berkeley County, SC 

 Charleston County, SC 

 Dorchester County, SC 

 Summerville County, SC 

16740 Charlotte-Gastonia-Rock Hill, NC-SC 

 Anson County, NC 

 Cabarrus County, NC 

 Gaston County, NC 

 Mecklenburg County, NC 

 Union County, NC 

 York County, SC 

16820 Charlottesville, VA 

 Albemarle County, VA 

 Fluvanna County, VA 

 Greene County, VA 

 Nelson County, VA 

 Charlottesville City, VA 

16860 Chattanooga, TN-GA 

 Catoosa County, GA 

 Dade County, GA 

 Walker County, GA 

 Hamilton County, TN 

 Marion County, TN 

 Sequatchie County, TN 

16940 Cheyenne, WY 

 Laramie County, WY 
CMS-1498-P 962 

CBSA Code

Urban Area 

(Constituent Counties) 

16974 Chicago-Joliet-Naperville, IL 

 Cook County, IL 

 DeKalb County, IL 

 DuPage County, IL 

 Grundy County, IL 

 Kane County, IL 

 Kendall County, IL 

 McHenry County, IL 

 Will County, IL 

17020 Chico, CA 

 Butte County, CA 

17140 Cincinnati-Middletown, OH-KY-IN 

 Dearborn County, IN 

 Franklin County, IN 

 Ohio County, IN 

 Boone County, KY 

 Bracken County, KY 

 Campbell County, KY 

 Gallatin County, KY 

 Grant County, KY 

 Kenton County, KY 

 Pendleton County, KY 

 Brown County, OH 

 Butler County, OH 

 Clermont County, OH 

 Hamilton County, OH 

 Warren County, OH 

17300 Clarksville, TN-KY 

 Christian County, KY 

 Trigg County, KY 

 Montgomery County, TN 

 Stewart County, TN 

17420 Cleveland, TN 

 Bradley County, TN 

 Polk County, TN 

17460 Cleveland-Elyria-Mentor, OH 

 Cuyahoga County, OH 

 Geauga County, OH 

 Lake County, OH 

 Lorain County, OH 

 Medina County, OH 

17660 Coeur d'Alene, ID 

 Kootenai County, ID 
CMS-1498-P 963 

CBSA Code

Urban Area 

(Constituent Counties) 

17780 College Station-Bryan, TX 

 Brazos County, TX 

 Burleson County, TX 

 Robertson County, TX 

17820 Colorado Springs, CO 

 El Paso County, CO 

 Teller County, CO 

17860 Columbia, MO 

 Boone County, MO 

 Howard County, MO 

17900 Columbia, SC 

 Calhoun County, SC 

 Fairfield County, SC 

 Kershaw County, SC 

 Lexington County, SC 

 Richland County, SC 

 Saluda County, SC 

17980 Columbus, GA-AL 

 Russell County, AL 

 Chattahoochee County, GA 

 Harris County, GA 

 Marion County, GA 

 Muscogee County, GA 

18020 Columbus, IN 

 Bartholomew County, IN 

18140 Columbus, OH 

 Delaware County, OH 

 Fairfield County, OH 

 Franklin County, OH 

 Licking County, OH 

 Madison County, OH 

 Morrow County, OH 

 Pickaway County, OH 

 Union County, OH 

18580 Corpus Christi, TX 

 Aransas County, TX 

 Nueces County, TX 

 San Patricio County, TX 

18700 Corvallis, OR 

 Benton County, OR 

18880 Crestview-Fort Walton Beach-Destin, FL 

 Okaloosa County, FL 
CMS-1498-P 964 

CBSA Code

Urban Area 

(Constituent Counties) 

19060 Cumberland, MD-WV 

 Allegany County, MD 

 Mineral County, WV 

19124 Dallas-Plano-Irving, TX 

 Collin County, TX 

 Dallas County, TX 

 Delta County, TX 

 Denton County, TX 

 Ellis County, TX 

 Hunt County, TX 

 Kaufman County, TX 

 Rockwall County, TX 

19140 Dalton, GA 

 Murray County, GA 

 Whitfield County, GA 

19180 Danville, IL 

 Vermilion County, IL 

19260 Danville, VA 

 Pittsylvania County, VA 

 Danville City, VA 

19340 Davenport-Moline-Rock Island, IA-IL 

 Henry County, IL 

 Mercer County, IL 

 Rock Island County, IL 

 Scott County, IA 

19380 Dayton, OH 

 Greene County, OH 

 Miami County, OH 

 Montgomery County, OH 

 Preble County, OH 

19460 Decatur, AL 

 Lawrence County, AL 

 Morgan County, AL 

19500 Decatur, IL 

 Macon County, IL 

19660 Deltona-Daytona Beach-Ormond Beach, FL 

 Volusia County, FL 
CMS-1498-P 965 

CBSA Code

Urban Area 

(Constituent Counties) 

19740 Denver-Aurora-Broomfield, CO 

 Adams County, CO 

 Arapahoe County, CO 

 Broomfield County, CO 

 Clear Creek County, CO 

 Denver County, CO 

 Douglas County, CO 

 Elbert County, CO 

 Gilpin County, CO 

 Jefferson County, CO 

 Park County, CO 

19780 Des Moines-West Des Moines, IA 

 Dallas County, IA 

 Guthrie County, IA 

 Madison County, IA 

 Polk County, IA 

 Warren County, IA 

19804 Detroit-Livonia-Dearborn, MI 

 Wayne County, MI 

20020 Dothan, AL 

 Geneva County, AL 

 Henry County, AL 

 Houston County, AL 

20100 Dover, DE 

 Kent County, DE 

20220 Dubuque, IA 

 Dubuque County, IA 

20260 Duluth, MN-WI 

 Carlton County, MN 

 St. Louis County, MN 

 Douglas County, WI 

20500 Durham-Chapel Hill, NC 

 Chatham County, NC 

 Durham County, NC 

 Orange County, NC 

 Person County, NC 

20740 Eau Claire, WI 

 Chippewa County, WI 

 Eau Claire County, WI 
CMS-1498-P 966 

CBSA Code

Urban Area 

(Constituent Counties) 

20764 

Edison-New Brunswick, NJ 

 Middlesex County, NJ 

 Monmouth County, NJ 

 New Brunswick County, NJ 

 Ocean County, NJ 

 Somerset County, NJ 

20940 El Centro, CA 

 Imperial County, CA 

21060 Elizabethtown, KY 

 Hardin County, KY 

 Larue County, KY 

21140 Elkhart-Goshen, IN 

 Elkhart County, IN 

21300 Elmira, NY 

 Chemung County, NY 

21340 El Paso, TX 

 El Paso County, TX 

21500 Erie, PA 

 Erie County, PA 

21660 Eugene-Springfield, OR 

 Lane County, OR 

21780 Evansville, IN-KY 

 Gibson County, IN 

 Posey County, IN 

 Vanderburgh County, IN 

 Warrick County, IN 

 Henderson County, KY 

 Webster County, KY 

21820 Fairbanks, AK 

 Fairbanks North Star Borough, AK 

21940 Fajardo, PR 

 Ceiba Municipio, PR 

 Fajardo Municipio, PR 

 Luquillo Municipio, PR 

22020 Fargo, ND-MN 

 Clay County, MN 

 Cass County, ND 

22140 Farmington, NM 

 San Juan County, NM 

22180 Fayetteville, NC 

 Cumberland County, NC 

 Hoke County, NC 
CMS-1498-P 967 

CBSA Code

Urban Area 

(Constituent Counties) 

22220 Fayetteville-Springdale-Rogers, AR-MO 

 Benton County, AR 

 Madison County, AR 

 Washington County, AR 

 McDonald County, MO 

22380 Flagstaff, AZ 

 Coconino County, AZ 

22420 Flint, MI 

 Genesee County, MI 

22500 Florence, SC 

 Darlington County, SC 

 Florence County, SC 

22520 Florence-Muscle Shoals, AL 

 Colbert County, AL 

 Lauderdale County, AL 

22540 Fond du Lac, WI 

 Fond du Lac County, WI 

22660 Fort Collins-Loveland, CO 

 Larimer County, CO 

22744 Fort Lauderdale-Pompano Beach-Deerfield Beach, FL 

 Broward County, FL 

22900 Fort Smith, AR-OK 

 Crawford County, AR 

 Franklin County, AR 

 Sebastian County, AR 

 Le Flore County, OK 

 Sequoyah County, OK 

23060 Fort Wayne, IN 

 Allen County, IN 

 Wells County, IN 

 Whitley County, IN 

23104 Fort Worth-Arlington, TX 

 Johnson County, TX 

 Parker County, TX 

 Tarrant County, TX 

 Wise County, TX 

23420 Fresno, CA 

 Fresno County, CA 

23460 Gadsden, AL 

 Etowah County, AL 

23540 Gainesville, FL 

 Alachua County, FL 

 Gilchrist County, FL 
CMS-1498-P 968 

CBSA Code

Urban Area 

(Constituent Counties) 

23580 Gainesville, GA 

 Hall County, GA 

23844 Gary, IN 

 Jasper County, IN 

 Lake County, IN 

 Newton County, IN 

 Porter County, IN 

24020 Glens Falls, NY 

 Warren County, NY 

 Washington County, NY 

24140 Goldsboro, NC 

 Wayne County, NC 

24220 Grand Forks, ND-MN 

 Polk County, MN 

 Grand Forks County, ND 

24300 Grand Junction, CO 

 Mesa County, CO 

24340 Grand Rapids-Wyoming, MI 

 Barry County, MI 

 Ionia County, MI 

 Kent County, MI 

 Newaygo County, MI 

24500 Great Falls, MT 

 Cascade County, MT 

24540 Greeley, CO 

 Weld County, CO 

24580 Green Bay, WI 

 Brown County, WI 

 Kewaunee County, WI 

 Oconto County, WI 

24660 Greensboro-High Point, NC 

 Guilford County, NC 

 Randolph County, NC 

 Rockingham County, NC 

24780 Greenville, NC 

 Greene County, NC 

 Pitt County, NC 

24860 Greenville-Mauldin-Easley, SC 

 Greenville County, SC 

 Laurens County, SC 

 Pickens County, SC 
CMS-1498-P 969 

CBSA Code

Urban Area 

(Constituent Counties) 

25020 Guayama, PR 

 Arroyo Municipio, PR 

 Guayama Municipio, PR 

 Patillas Municipio, PR 

25060 Gulfport-Biloxi, MS 

 Hancock County, MS 

 Harrison County, MS 

 Stone County, MS 

25180 Hagerstown-Martinsburg, MD-WV 

 Washington County, MD 

 Berkeley County, WV 

 Morgan County, WV 

25260 Hanford-Corcoran, CA 

 Kings County, CA 

25420 Harrisburg-Carlisle, PA 

 Cumberland County, PA 

 Dauphin County, PA 

 Perry County, PA 

25500 Harrisonburg, VA 

 Rockingham County, VA 

 Harrisonburg City, VA 

25540 Hartford-West Hartford-East Hartford, CT 

 Hartford County, CT 

 Middlesex County, CT 

 Tolland County, CT 

25620 Hattiesburg, MS 

 Forrest County, MS 

 Lamar County, MS 

 Perry County, MS 

25860 Hickory-Lenoir-Morganton, NC 

 Alexander County, NC 

 Burke County, NC 

 Caldwell County, NC 

 Catawba County, NC 

25980 Hinesville-Fort Stewart, GA 

 Liberty County, GA 

 Long County, GA 

26100 Holland-Grand Haven, MI 

 Ottawa County, MI 

26180 Honolulu, HI 

 Honolulu County, HI 

26300 Hot Springs, AR 

 Garland County, AR 
CMS-1498-P 970 

CBSA Code

Urban Area 

(Constituent Counties) 

26380 Houma-Bayou Cane-Thibodaux, LA 

 Lafourche Parish, LA 

 Terrebonne Parish, LA 

26420 Houston-Sugar Land-Baytown, TX 

 Austin County, TX 

 Brazoria County, TX 

 Chambers County, TX 

 Fort Bend County, TX 

 Galveston County, TX 

 Harris County, TX 

 Liberty County, TX 

 Montgomery County, TX 

 San Jacinto County, TX 

 Waller County, TX 

26580 Huntington-Ashland, WV-KY-OH 

 Boyd County, KY 

 Greenup County, KY 

 Lawrence County, OH 

 Cabell County, WV 

 Wayne County, WV 

26620 Huntsville, AL 

 Limestone County, AL 

 Madison County, AL 

26820 Idaho Falls, ID 

 Bonneville County, ID 

 Jefferson County, ID 

26900 Indianapolis-Carmel, IN 

 Boone County, IN 

 Brown County, IN 

 Hamilton County, IN 

 Hancock County, IN 

 Hendricks County, IN 

 Johnson County, IN 

 Marion County, IN 

 Morgan County, IN 

 Putnam County, IN 

 Shelby County, IN 

26980 Iowa City, IA 

 Johnson County, IA 

 Washington County, IA 

27060 Ithaca, NY 

 Tompkins County, NY 

27100 Jackson, MI 

 Jackson County, MI 
CMS-1498-P 971 

CBSA Code

Urban Area 

(Constituent Counties) 

27140 Jackson, MS 

 Copiah County, MS 

 Hinds County, MS 

 Madison County, MS 

 Rankin County, MS 

 Simpson County, MS 

27180 Jackson, TN 

 Chester County, TN 

 Madison County, TN 

27260 Jacksonville, FL 

 Baker County, FL 

 Clay County, FL 

 Duval County, FL 

 Nassau County, FL 

 St. Johns County, FL 

27340 Jacksonville, NC 

 Onslow County, NC 

27500 Janesville, WI 

 Rock County, WI 

27620 Jefferson City, MO 

 Callaway County, MO 

 Cole County, MO 

 Moniteau County, MO 

 Osage County, MO 

27740 Johnson City, TN 

 Carter County, TN 

 Unicoi County, TN 

 Washington County, TN 

27780 Johnstown, PA 

 Cambria County, PA 

27860 Jonesboro, AR 

 Craighead County, AR 

 Poinsett County, AR 

27900 Joplin, MO 

 Jasper County, MO 

 Newton County, MO 

28020 Kalamazoo-Portage, MI 

 Kalamazoo County, MI 

 Van Buren County, MI 

28100 Kankakee-Bradley, IL 

 Kankakee County, IL 
CMS-1498-P 972 

CBSA Code

Urban Area 

(Constituent Counties) 

28140 Kansas City, MO-KS 

 Franklin County, KS 

 Johnson County, KS 

 Leavenworth County, KS 

 Linn County, KS 

 Miami County, KS 

 Wyandotte County, KS 

 Bates County, MO 

 Caldwell County, MO 

 Cass County, MO 

 Clay County, MO 

 Clinton County, MO 

 Jackson County, MO 

 Lafayette County, MO 

 Platte County, MO 

 Ray County, MO 

28420 Kennewick-Pasco-Richland, WA 

 Benton County, WA 

 Franklin County, WA 

28660 Killeen-Temple-Fort Hood, TX 

 Bell County, TX 

 Coryell County, TX 

 Lampasas County, TX 

28700 Kingsport-Bristol-Bristol, TN-VA 

 Hawkins County, TN 

 Sullivan County, TN 

 Bristol City, VA 

 Scott County, VA 

 Washington County, VA 

28740 Kingston, NY 

 Ulster County, NY 

28940 Knoxville, TN 

 Anderson County, TN 

 Blount County, TN 

 Knox County, TN 

 Loudon County, TN 

 Union County, TN 

29020 Kokomo, IN 

 Howard County, IN 

 Tipton County, IN 

29100 La Crosse, WI-MN 

 Houston County, MN 

 La Crosse County, WI 
CMS-1498-P 973 

CBSA Code

Urban Area 

(Constituent Counties) 

29140 Lafayette, IN 

 Benton County, IN 

 Carroll County, IN 

 Tippecanoe County, IN 

29180 Lafayette, LA 

 Lafayette Parish, LA 

 St. Martin Parish, LA 

29340 Lake Charles, LA 

 Calcasieu Parish, LA 

 Cameron Parish, LA 

29404 Lake County-Kenosha County, IL-WI 

 Lake County, IL 

 Kenosha County, WI 

29420 Lake Havasu City-Kingman, AZ 

Mohave County, AZ 

29460 

Lakeland-Winter Haven, FL 

 Polk County, FL 

 Winter Haven County, FL 

29540 Lancaster, PA 

 Lancaster County, PA 

29620 Lansing-East Lansing, MI 

 Clinton County, MI 

 Eaton County, MI 

 Ingham County, MI 

29700 Laredo, TX 

 Webb County, TX 

29740 Las Cruces, NM 

 Dona Ana County, NM 

29820 Las Vegas-Paradise, NV 

 Clark County, NV 

29940 Lawrence, KS 

 Douglas County, KS 

30020 Lawton, OK 

 Comanche County, OK 

30140 Lebanon, PA 

 Lebanon County, PA 

30300 Lewiston, ID-WA 

 Nez Perce County, ID 

 Asotin County, WA 

30340 Lewiston-Auburn, ME 

 Androscoggin County, ME 
CMS-1498-P 974 

CBSA Code

Urban Area 

(Constituent Counties) 

30460 Lexington-Fayette, KY 

 Bourbon County, KY 

 Clark County, KY 

 Fayette County, KY 

 Jessamine County, KY 

 Scott County, KY 

 Woodford County, KY 

30620 Lima, OH 

 Allen County, OH 

30700 Lincoln, NE 

 Lancaster County, NE 

 Seward County, NE 

30780 Little Rock-North Little Rock-Conway, AR 

 Faulkner County, AR 

 Grant County, AR 

 Lonoke County, AR 

 Perry County, AR 

 Pulaski County, AR 

 Saline County, AR 

30860 Logan, UT-ID 

 Franklin County, ID 

 Cache County, UT 

30980 Longview, TX 

 Gregg County, TX 

 Rusk County, TX 

 Upshur County, TX 

31020 Longview, WA 

 Cowlitz County, WA 

31084 Los Angeles-Long Beach-Glendale, CA 

 Los Angeles County, CA 

31140 Louisville-Jefferson County, KY-IN 

 Clark County, IN 

 Floyd County, IN 

 Harrison County, IN 

 Washington County, IN 

 Bullitt County, KY 

 Henry County, KY 

 Jefferson County, KY 

 Meade County, KY 

 Nelson County, KY 

 Oldham County, KY 

 Shelby County, KY 

 Spencer County, KY 

 Trimble County, KY 
CMS-1498-P 975 

CBSA Code

Urban Area 

(Constituent Counties) 

31180 Lubbock, TX 

 Crosby County, TX 

 Lubbock County, TX 

31340 Lynchburg, VA 

 Amherst County, VA 

 Appomattox County, VA 

 Bedford County, VA 

 Campbell County, VA 

 Bedford City, VA 

 Lynchburg City, VA 

31420 Macon, GA 

 Bibb County, GA 

 Crawford County, GA 

 Jones County, GA 

 Monroe County, GA 

 Twiggs County, GA 

31460 Madera-Chowchilla, CA 

 Madera County, CA 

31540 Madison, WI 

 Columbia County, WI 

 Dane County, WI 

 Iowa County, WI 

31700 Manchester-Nashua, NH 

 Hillsborough County, NH 

31740 Manhattan, KS 

 Geary County, KS 

 Pottawatomie County, KS 

 Riley County, KS 

31860 Mankato-North Mankato, MN 

 Blue Earth County, MN 

 Nicollet County, MN 

31900 Mansfield, OH 

 Richland County, OH 

32420 Mayagüez, PR 

 Hormigueros Municipio, PR 

 Mayagüez Municipio, PR 

32580 McAllen-Edinburg-Mission, TX 

 Hidalgo County, TX 

32780 Medford, OR 

 Jackson County, OR 
CMS-1498-P 976 

CBSA Code

Urban Area 

(Constituent Counties) 

32820 Memphis, TN-MS-AR 

 Crittenden County, AR 

 DeSoto County, MS 

 Marshall County, MS 

 Tate County, MS 

 Tunica County, MS 

 Fayette County, TN 

 Shelby County, TN 

 Tipton County, TN 

32900 Merced, CA 

 Merced County, CA 

33124 Miami-Miami Beach-Kendall, FL 

 Miami-Dade County, FL 

33140 Michigan City-La Porte, IN 

 LaPorte County, IN 

33260 Midland, TX 

 Midland County, TX 

33340 Milwaukee-Waukesha-West Allis, WI 

 Milwaukee County, WI 

 Ozaukee County, WI 

 Washington County, WI 

 Waukesha County, WI 

33460 Minneapolis-St. Paul-Bloomington, MN-WI 

 Anoka County, MN 

 Carver County, MN 

 Chisago County, MN 

 Dakota County, MN 

 Hennepin County, MN 

 Isanti County, MN 

 Ramsey County, MN 

 Scott County, MN 

 Sherburne County, MN 

 Washington County, MN 

 Wright County, MN 

 Pierce County, WI 

 St. Croix County, WI 

33540 Missoula, MT 

 Missoula County, MT 

33660 Mobile, AL 

 Mobile County, AL 

33700 Modesto, CA 

 Stanislaus County, CA 
CMS-1498-P 977 

CBSA Code

Urban Area 

(Constituent Counties) 

33740 Monroe, LA 

 Ouachita Parish, LA 

 Union Parish, LA 

33780 Monroe, MI 

 Monroe County, MI 

33860 Montgomery, AL 

 Autauga County, AL 

 Elmore County, AL 

 Lowndes County, AL 

 Montgomery County, AL 

34060 Morgantown, WV 

 Monongalia County, WV 

 Preston County, WV 

34100 Morristown, TN 

 Grainger County, TN 

 Hamblen County, TN 

 Jefferson County, TN 

34580 Mount Vernon-Anacortes, WA 

 Skagit County, WA 

34620 Muncie, IN 

 Delaware County, IN 

34740 Muskegon-Norton Shores, MI 

 Muskegon County, MI 

34820 Myrtle Beach-North Myrtle Beach-Conway, SC 

 Horry County, SC 

34900 Napa, CA

 Napa County, CA 

34940 Naples-Marco Island, FL 

 Collier County, FL 

34980 Nashville-Davidson-Murfreesboro-Franklin, TN 

 Cannon County, TN 

 Cheatham County, TN 

 Davidson County, TN 

 Dickson County, TN 

 Hickman County, TN 

 Macon County, TN 

 Robertson County, TN 

 Rutherford County, TN 

 Smith County, TN 

 Sumner County, TN 

 Trousdale County, TN 

 Williamson County, TN 

 Wilson County, TN 
CMS-1498-P 978 

CBSA Code

Urban Area 

(Constituent Counties) 

35004 Nassau-Suffolk, NY 

 Nassau County, NY 

 Suffolk County, NY 

35084 Newark-Union, NJ-PA 

 Essex County, NJ 

 Hunterdon County, NJ 

 Morris County, NJ 

 Sussex County, NJ 

 Union County, NJ 

 Pike County, PA 

35300 New Haven-Milford, CT 

 New Haven County, CT 

35380 New Orleans-Metairie-Kenner, LA 

 Jefferson Parish, LA 

 Orleans Parish, LA 

 Plaquemines Parish, LA 

 St. Bernard Parish, LA 

 St. Charles Parish, LA 

 St. John the Baptist Parish, LA 

 St. Tammany Parish, LA 

35644 New York-White Plains-Wayne, NY-NJ 

 Bergen County, NJ 

 Hudson County, NJ 

 Passaic County, NJ 

 Bronx County, NY 

 Kings County, NY 

 New York County, NY 

 Putnam County, NY 

 Queens County, NY 

 Richmond County, NY 

 Rockland County, NY 

 Westchester County, NY 

35660 Niles-Benton Harbor, MI 

 Berrien County, MI 

35840 North Port-Bradenton-Sarasota, FL 

 Manatee County, FL 

 Sarasota County, FL 

35980 Norwich-New London, CT 

 New London County, CT 

36084 Oakland-Fremont-Hayward, CA 

 Alameda County, CA 

 Contra Costa County, CA 

36100 Ocala, FL 

 Marion County, FL 
CMS-1498-P 979 

CBSA Code

Urban Area 

(Constituent Counties) 

36140 Ocean City, NJ 

 Cape May County, NJ 

36220 Odessa, TX 

 Ector County, TX 

36260 Ogden-Clearfield, UT 

 Davis County, UT 

 Morgan County, UT 

 Weber County, UT 

36420 Oklahoma City, OK 

 Canadian County, OK 

 Cleveland County, OK 

 Grady County, OK 

 Lincoln County, OK 

 Logan County, OK 

 McClain County, OK 

 Oklahoma County, OK 

36500 Olympia, WA 

 Thurston County, WA 

36540 Omaha-Council Bluffs, NE-IA 

 Harrison County, IA 

 Mills County, IA 

 Pottawattamie County, IA 

 Cass County, NE 

 Douglas County, NE 

 Sarpy County, NE 

 Saunders County, NE 

 Washington County, NE 

36740 Orlando-Kissimmee-Sanford, FL 

 Lake County, FL 

 Orange County, FL 

 Osceola County, FL 

 Seminole County, FL 

36780 Oshkosh-Neenah, WI 

 Winnebago County, WI 

36980 Owensboro, KY 

 Daviess County, KY 

 Hancock County, KY 

 McLean County, KY 

37100 Oxnard-Thousand Oaks-Ventura, CA 

 Ventura County, CA 

37340 Palm Bay-Melbourne-Titusville, FL 

 Brevard County, FL 

37380 Palm Coast, FL 

 Flager County, FL 
CMS-1498-P 980 

CBSA Code

Urban Area 

(Constituent Counties) 

37460 Panama City-Lynn Haven-Panama City Beach, FL 

 Bay County, FL 

37620 Parkersburg-Marietta-Vienna, WV-OH 

 Washington County, OH 

 Pleasants County, WV 

 Wirt County, WV 

 Wood County, WV 

37700 Pascagoula, MS 

 George County, MS 

 Jackson County, MS 

37764 

Peabody, MA 

 Essex County, MA 

37860 Pensacola-Ferry Pass-Brent, FL 

 Escambia County, FL 

 Santa Rosa County, FL 

37900 Peoria, IL 

 Marshall County, IL 

 Peoria County, IL 

 Stark County, IL 

 Tazewell County, IL 

 Woodford County, IL 

37964 Philadelphia, PA 

 Bucks County, PA 

 Chester County, PA 

 Delaware County, PA 

 Montgomery County, PA 

 Philadelphia County, PA 

38060 Phoenix-Mesa-Glendale, AZ 

 Maricopa County, AZ 

 Pinal County, AZ 

38220 Pine Bluff, AR 

 Cleveland County, AR 

 Jefferson County, AR 

 Lincoln County, AR 

38300 Pittsburgh, PA 

 Allegheny County, PA 

 Armstrong County, PA 

 Beaver County, PA 

 Butler County, PA 

 Fayette County, PA 

 Washington County, PA 

 Westmoreland County, PA 

38340 Pittsfield, MA 

 Berkshire County, MA 
CMS-1498-P 981 

CBSA Code

Urban Area 

(Constituent Counties) 

38540 Pocatello, ID 

 Bannock County, ID 

 Power County, ID 

38660 Ponce, PR 

 Juana Díaz Municipio, PR 

 Ponce Municipio, PR 

 Villalba Municipio, PR 

38860 Portland-South Portland-Biddeford, ME 

 Cumberland County, ME 

 Sagadahoc County, ME 

 York County, ME 

38900 Portland-Vancouver-Hillsboro, OR-WA 

 Clackamas County, OR 

 Columbia County, OR 

 Multnomah County, OR 

 Washington County, OR 

 Yamhill County, OR 

 Clark County, WA 

 Skamania County, WA 

38940 Port St. Lucie, FL 

 Martin County, FL 

 St. Lucie County, FL 

39100 Poughkeepsie-Newburgh-Middletown, NY 

 Dutchess County, NY 

 Orange County, NY 

39140 Prescott, AZ 

 Yavapai County, AZ 

39300 Providence-New Bedford-Fall River, RI-MA 

 Bristol County, MA 

 Bristol County, RI 

 Kent County, RI 

 Newport County, RI 

 Providence County, RI 

 Washington County, RI 

39340 Provo-Orem, UT 

 Juab County, UT 

 Utah County, UT 

39380 Pueblo, CO 

 Pueblo County, CO 

39460 Punta Gorda, FL 

 Charlotte County, FL 

39540 Racine, WI 

 Racine County, WI 
CMS-1498-P 982 

CBSA Code

Urban Area 

(Constituent Counties) 

39580 Raleigh-Cary, NC 

 Franklin County, NC 

 Johnston County, NC 

 Wake County, NC 

39660 Rapid City, SD 

 Meade County, SD 

 Pennington County, SD 

39740 Reading, PA 

 Berks County, PA 

39820 Redding, CA 

 Shasta County, CA 

39900 Reno-Sparks, NV 

 Storey County, NV 

 Washoe County, NV 

40060 Richmond, VA 

 Amelia County, VA 

 Caroline County, VA 

 Charles City County, VA 

 Chesterfield County, VA 

 Cumberland County, VA 

 Dinwiddie County, VA 

 Goochland County, VA 

 Hanover County, VA 

 Henrico County, VA 

 King and Queen County, VA 

 King William County, VA 

 Louisa County, VA 

 New Kent County, VA 

 Powhatan County, VA 

 Prince George County, VA 

 Sussex County, VA 

 Colonial Heights City, VA 

 Hopewell City, VA 

 Petersburg City, VA 

 Richmond City, VA 

40140 Riverside-San Bernardino-Ontario, CA 

 Riverside County, CA 

 San Bernardino County, CA 
CMS-1498-P 983 

CBSA Code

Urban Area 

(Constituent Counties) 

40220 Roanoke, VA 

 Botetourt County, VA 

 Craig County, VA 

 Franklin County, VA 

 Roanoke County, VA 

 Roanoke City, VA 

 Salem City, VA 

40340 Rochester, MN 

 Dodge County, MN 

 Olmsted County, MN 

 Wabasha County, MN 

40380 Rochester, NY 

 Livingston County, NY 

 Monroe County, NY 

 Ontario County, NY 

 Orleans County, NY 

 Wayne County, NY 

40420 Rockford, IL 

 Boone County, IL 

 Winnebago County, IL 

40484 Rockingham County-Strafford County, NH 

 Rockingham County, NH 

 Strafford County, NH 

40580 Rocky Mount, NC 

 Edgecombe County, NC 

 Nash County, NC 

40660 Rome, GA 

 Floyd County, GA 

40900 Sacramento--Arden-Arcade--Roseville, CA 

 El Dorado County, CA 

 Placer County, CA 

 Sacramento County, CA 

 Yolo County, CA 

40980 Saginaw-Saginaw Township North, MI 

 Saginaw County, MI 

41060 St. Cloud, MN 

 Benton County, MN 

 Stearns County, MN 

41100 St. George, UT 

 Washington County, UT 
CMS-1498-P 984 

CBSA Code

Urban Area 

(Constituent Counties) 

41140 St. Joseph, MO-KS 

 Doniphan County, KS 

 Andrew County, MO 

 Buchanan County, MO 

 DeKalb County, MO 

41180 

St. Louis, MO-IL 

 Bond County, IL 

 Calhoun County, IL 

 Clinton County, IL 

 Jersey County, IL 

 Macoupin County, IL 

 Madison County, IL 

 Monroe County, IL 

 St. Clair County, IL 

 Crawford County, MO 

 Franklin County, MO 

 Jefferson County, MO 

 Lincoln County, MO 

 St. Charles County, MO 

 St. Louis County, MO 

 Warren County, MO 

 Washington County, MO 

 St. Louis City, MO 

41420 Salem, OR 

 Marion County, OR 

 Polk County, OR 

41500 Salinas, CA 

 Monterey County, CA 

41540 Salisbury, MD 

 Somerset County, MD 

 Wicomico County, MD 

41620 Salt Lake City, UT 

 Salt Lake County, UT 

 Summit County, UT 

 Tooele County, UT 

41660 San Angelo, TX 

 Irion County, TX 

 Tom Green County, TX 
CMS-1498-P 985 

CBSA Code

Urban Area 

(Constituent Counties) 

41700 San Antonio-New Braunfels, TX 

 Atascosa County, TX 

 Bandera County, TX 

 Bexar County, TX 

 Comal County, TX 

 Guadalupe County, TX 

 Kendall County, TX 

 Medina County, TX 

 Wilson County, TX 

41740 San Diego-Carlsbad-San Marcos, CA 

 San Diego County, CA 

41780 Sandusky, OH 

 Erie County, OH 

41884 San Francisco-San Mateo-Redwood City, CA 

 Marin County, CA 

 San Francisco County, CA 

 San Mateo County, CA 

41900 San Germán-Cabo Rojo, PR 

 Cabo Rojo Municipio, PR 

 Lajas Municipio, PR 

 Sabana Grande Municipio, PR 

 San Germán Municipio, PR 

41940 San Jose-Sunnyvale-Santa Clara, CA 

 San Benito County, CA 

 Santa Clara County, CA 
CMS-1498-P 986 

CBSA Code

Urban Area 

(Constituent Counties) 

41980 

San Juan-Caguas-Guaynabo, PR

 Aguas Buenas Municipio, PR 

 Aibonito Municipio, PR 

 Arecibo Municipio, PR 

 Barceloneta Municipio, PR 

 Barranquitas Municipio, PR 

 Bayamón Municipio, PR 

 Caguas Municipio, PR 

 Camuy Municipio, PR 

 Canóvanas Municipio, PR 

 Carolina Municipio, PR 

 Cataño Municipio, PR 

 Cayey Municipio, PR 

 Ciales Municipio, PR 

 Cidra Municipio, PR 

 Comerío Municipio, PR 

 Corozal Municipio, PR 

 Dorado Municipio, PR 

 Florida Municipio, PR 

 Guaynabo Municipio, PR 

 Gurabo Municipio, PR 

 Hatillo Municipio, PR 

 Humacao Municipio, PR 

 Juncos Municipio, PR 

 Las Piedras Municipio, PR 

 Loíza Municipio, PR 

 Manatí Municipio, PR 

 Maunabo Municipio, PR 

 Morovis Municipio, PR 

 Naguabo Municipio, PR 

 Naranjito Municipio, PR 

 Orocovis Municipio, PR 

 Quebradillas Municipio, PR 

 Río Grande Municipio, PR 

 San Juan Municipio, PR 

 San Lorenzo Municipio, PR 

 Toa Alta Municipio, PR 

 Toa Baja Municipio, PR 

 Trujillo Alto Municipio, PR 

 Vega Alta Municipio, PR 

 Vega Baja Municipio, PR 

 Yabucoa Municipio, PR 

42020 San Luis Obispo-Paso Robles, CA 

 San Luis Obispo County, CA 
CMS-1498-P 987 

CBSA Code

Urban Area 

(Constituent Counties) 

42044 Santa Ana-Anaheim-Irvine, CA 

 Orange County, CA 

42060 Santa Barbara-Santa Maria-Goleta, CA 

 Santa Barbara County, CA 

42100 Santa Cruz-Watsonville, CA 

 Santa Cruz County, CA 

42140 Santa Fe, NM 

 Santa Fe County, NM 

42220 Santa Rosa-Petaluma, CA 

 Sonoma County, CA 

42340 Savannah, GA 

 Bryan County, GA 

 Chatham County, GA 

 Effingham County, GA 

42540 Scranton--Wilkes-Barre, PA 

 Lackawanna County, PA 

 Luzerne County, PA 

 Wyoming County, PA 

42644 Seattle-Bellevue-Everett, WA 

 King County, WA 

 Snohomish County, WA 

42680 Sebastian-Vero Beach, FL 

 Indian River County, FL 

43100 Sheboygan, WI 

 Sheboygan County, WI 

43300 Sherman-Denison, TX 

 Grayson County, TX 

43340 Shreveport-Bossier City, LA 

 Bossier Parish, LA 

 Caddo Parish, LA 

 De Soto Parish, LA 

43580 Sioux City, IA-NE-SD 

 Woodbury County, IA 

 Dakota County, NE 

 Dixon County, NE 

 Union County, SD 

43620 Sioux Falls, SD 

 Lincoln County, SD 

 McCook County, SD 

 Minnehaha County, SD 

 Turner County, SD 

43780 South Bend-Mishawaka, IN-MI 

 St. Joseph County, IN 

 Cass County, MI 
CMS-1498-P 988 

CBSA Code

Urban Area 

(Constituent Counties) 

43900 Spartanburg, SC 

 Spartanburg County, SC 

44060 Spokane, WA 

 Spokane County, WA 

44100 Springfield, IL 

 Menard County, IL 

 Sangamon County, IL 

44140 Springfield, MA 

 Franklin County, MA 

 Hampden County, MA 

 Hampshire County, MA 

44180 Springfield, MO 

 Christian County, MO 

 Dallas County, MO 

 Greene County, MO 

 Polk County, MO 

 Webster County, MO 

44220 Springfield, OH 

 Clark County, OH 

44300 State College, PA 

 Centre County, PA 

44600 Steubenville-Weirton, WV-OH 

 Jefferson County, OH 

 Brooke County, WV 

 Hancock County, WV 

44700 Stockton, CA 

 San Joaquin County, CA 

44940 Sumter, SC 

 Sumter County, SC 

45060 Syracuse, NY 

 Madison County, NY 

 Onondaga County, NY 

 Oswego County, NY 

45104 Tacoma, WA 

 Pierce County, WA 

45220 Tallahassee, FL 

 Gadsden County, FL 

 Jefferson County, FL 

 Leon County, FL 

 Wakulla County, FL 
CMS-1498-P 989 

CBSA Code

Urban Area 

(Constituent Counties) 

45300 Tampa-St. Petersburg-Clearwater, FL 

 Hernando County, FL 

 Hillsborough County, FL 

 Pasco County, FL 

 Pinellas County, FL 

45460 Terre Haute, IN 

 Clay County, IN 

 Sullivan County, IN 

 Vermillion County, IN 

 Vigo County, IN 

45500 Texarkana, TX-Texarkana, AR 

 Miller County, AR 

 Bowie County, TX 

45780 Toledo, OH 

 Fulton County, OH 

 Lucas County, OH 

 Ottawa County, OH 

 Wood County, OH 

45820 Topeka, KS 

 Jackson County, KS 

 Jefferson County, KS 

 Osage County, KS 

 Shawnee County, KS 

 Wabaunsee County, KS 

45940 Trenton-Ewing, NJ 

 Mercer County, NJ 

46060 Tucson, AZ 

 Pima County, AZ 

46140 Tulsa, OK 

 Creek County, OK 

 Okmulgee County, OK 

 Osage County, OK 

 Pawnee County, OK 

 Rogers County, OK 

 Tulsa County, OK 

 Wagoner County, OK 

46220 Tuscaloosa, AL 

 Greene County, AL 

 Hale County, AL 

 Tuscaloosa County, AL 

46340 Tyler, TX 

 Smith County, TX 
CMS-1498-P 990 

CBSA Code

Urban Area 

(Constituent Counties) 

46540 Utica-Rome, NY 

 Herkimer County, NY 

 Oneida County, NY 

46660 Valdosta, GA 

 Brooks County, GA 

 Echols County, GA 

 Lanier County, GA 

 Lowndes County, GA 

46700 Vallejo-Fairfield, CA 

 Solano County, CA 

47020 Victoria, TX 

 Calhoun County, TX 

 Goliad County, TX 

 Victoria County, TX 

47220 Vineland-Millville-Bridgeton, NJ 

 Cumberland County, NJ 

47260 

Virginia Beach-Norfolk-Newport News, VA-NC 

 Currituck County, NC 

 Gloucester County, VA 

 Isle of Wight County, VA 

 James City County, VA 

 Mathews County, VA 

 Surry County, VA 

 York County, VA 

 Chesapeake City, VA 

 Hampton City, VA 

 Newport News City, VA 

 Norfolk City, VA 

 Poquoson City, VA 

 Portsmouth City, VA 

 Suffolk City, VA 

 Virginia Beach City, VA 

 Williamsburg City, VA 

47300 Visalia-Porterville, CA 

 Tulare County, CA 

47380 Waco, TX 

 McLennan County, TX 

47580 Warner Robins, GA 

 Houston County, GA 
CMS-1498-P 991 

CBSA Code

Urban Area 

(Constituent Counties) 

47644 Warren-Troy-Farmington Hills, MI 

 Lapeer County, MI 

 Livingston County, MI 

 Macomb County, MI 

 Oakland County, MI 

 St. Clair County, MI 

47894 Washington-Arlington-Alexandria, DC-VA-MD-WV 

 District of Columbia, DC 

 Calvert County, MD 

 Charles County, MD 

 Prince George's County, MD 

 Arlington County, VA 

 Clarke County, VA 

 Fairfax County, VA 

 Fauquier County, VA 

 Loudoun County, VA 

 Prince William County, VA 

 Spotsylvania County, VA 

 Stafford County, VA 

 Warren County, VA 

 Alexandria City, VA 

 Fairfax City, VA 

 Falls Church City, VA 

 Fredericksburg City, VA 

 Manassas City, VA 

 Manassas Park City, VA 

 Jefferson County, WV 

47940 Waterloo-Cedar Falls, IA 

 Black Hawk County, IA 

 Bremer County, IA 

 Grundy County, IA 

48140 Wausau, WI 

 Marathon County, WI 

48300 Wenatchee-East Wenatchee, WA 

 Chelan County, WA 

 Douglas County, WA 

48424 West Palm Beach-Boca Raton-Boynton Beach, FL 

 Palm Beach County, FL 

48540 Wheeling, WV-OH 

 Belmont County, OH 

 Marshall County, WV 

 Ohio County, WV 
CMS-1498-P 992 

CBSA Code

Urban Area 

(Constituent Counties) 

48620 Wichita, KS 

 Butler County, KS 

 Harvey County, KS 

 Sedgwick County, KS 

 Sumner County, KS 

48660 Wichita Falls, TX 

 Archer County, TX 

 Clay County, TX 

 Wichita County, TX 

48700 Williamsport, PA 

 Lycoming County, PA 

48864 Wilmington, DE-MD-NJ 

 New Castle County, DE 

 Cecil County, MD 

 Salem County, NJ 

48900 Wilmington, NC 

 Brunswick County, NC 

 New Hanover County, NC 

 Pender County, NC 

49020 Winchester, VA-WV 

 Frederick County, VA 

 Winchester City, VA 

 Hampshire County, WV 

49180 Winston-Salem, NC 

 Davie County, NC 

 Forsyth County, NC 

 Stokes County, NC 

 Yadkin County, NC 

49340 Worcester, MA 

 Worcester County, MA 

49420 Yakima, WA 

 Yakima County, WA 

49500 Yauco, PR 

 Guánica Municipio, PR 

 Guayanilla Municipio, PR 

 Peñuelas Municipio, PR 

 Yauco Municipio, PR 

49620 York-Hanover, PA 

 York County, PA 

49660 Youngstown-Warren-Boardman, OH-PA 

 Mahoning County, OH 

 Trumbull County, OH 

 Mercer County, PA 
CMS-1498-P 993 

CBSA Code

Urban Area 

(Constituent Counties) 

49700 Yuba City, CA 

 Sutter County, CA 

 Yuba County, CA 

49740 Yuma, AZ 

 Yuma County, AZ 

TABLE 4F.—PROPOSED PUERTO RICO WAGE INDEX AND CAPITAL 

GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR ACUTE CARE HOSPITALS BY 

CBSA--FY 2011 

(Note: The rural floor budget neutrality adjustment is not applicable to the Puerto Rico specific wage 

index.) 

CBSA 

Code Area 

Proposed 

Wage 

Index 

Proposed 

GAF 

Wage 

Index – 

Reclassified

Hospitals 

GAF – 

Reclassified

Hospitals 

10380 Aguadilla-Isabela-San Sebastián, PR 0.8107 0.8661 ------ ------

21940 Fajardo, PR 0.9207 0.9450 ------ ------

25020 Guayama, PR 0.8570 0.8997 ------ ------

32420 Mayagüez, PR 0.8593 0.9014 ------ ------

38660 Ponce, PR 1.0201 1.0137 ------ ------

41900 San Germán-Cabo Rojo, PR 1.0812 1.0549 ------ ------

41980 San Juan-Caguas-Guaynabo, PR 1.0224 1.0153 ------ ------

49500 Yauco, PR 0.8385 0.8864 ------ ------
CMS-1498-P 994 

TABLE 4J.—PROPOSED OUT-MIGRATION ADJUSTMENT FOR ACUTE CARE 

HOSPITALS--FY 2011 

 The following list represents all hospitals that are eligible to have their wage index 

increased by the out-migration adjustment listed in this table. Hospitals cannot receive the outmigration adjustment if they are reclassified under section 1886(d)(10) of the Act or redesignated 

under section 1886(d)(8)(B) of the Act. Hospitals that have already been reclassified under 

section 1886(d)(10) of the Act or redesignated under section 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)(B) of 

the Act wish to retain their reclassification/redesignation status and waive the application of the 

out-migration adjustment. 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)(B) of the Act will be deemed to have waived the outmigration adjustment, unless they explicitly notified CMS that they elected 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, Attn: Wage Index Adjustment Waivers, Division of 

Acute Care, Room C4-08-06, 7500 Security Boulevard, Baltimore, MD 21244-1850. 

Provider 

Number

Reclassified for 

FY 2011

Proposed 

OutMigration 

Adjustment Qualifying County Name

County 

Code

010005 * 0.0296 MARSHALL 01470

010008 0.0174 CRENSHAW 01200

010010 0.0296 MARSHALL 01470

010012 0.0186 DE KALB 01240

010015 0.0046 CLARKE 01120

010021 0.0123 DALE 01220

010022 * 0.1128 CHEROKEE 01090

010025 * 0.0389 CHAMBERS 01080

010027 0.0062 COFFEE 01150

010029 * 0.0289 LEE 01400

010032 0.0325 RANDOLPH 01550

010035 * 0.0254 CULLMAN 01210

010038 0.0047 CALHOUN 01070

010040 0.0113 ETOWAH 01270

010045 0.0222 FAYETTE 01280

010046 * 0.0113 ETOWAH 01270

010047 0.0127 BUTLER 01060

010049 0.0062 COFFEE 01150

010052 * 0.0245 TALLAPOOSA 01610

010059 * 0.0097 LAWRENCE 01390

010061 * 0.0542 JACKSON 01350
CMS-1498-P 995 

Provider 

Number

Reclassified for 

FY 2011

Proposed 

OutMigration 

Adjustment Qualifying County Name

County 

Code

010065 * 0.0245 TALLAPOOSA 01610

010078 0.0047 CALHOUN 01070

010083 * 0.0134 BALDWIN 01010

010091 0.0046 CLARKE 01120

010100 * 0.0134 BALDWIN 01010

010101 * 0.0211 TALLADEGA 01600

010109 0.0309 PICKENS 01530

010110 0.0215 BULLOCK 01050

010125 0.0476 WINSTON 01660

010128 0.0046 CLARKE 01120

010129 0.0134 BALDWIN 01010

010138 0.0066 SUMTER 01590

010143 * 0.0254 CULLMAN 01210

010146 0.0047 CALHOUN 01070

010150 0.0127 BUTLER 01060

010158 * 0.0023 FRANKLIN 01290

010164 * 0.0211 TALLADEGA 01600

030067 0.0298 LAPAZ 03055

040014 * 0.0199 WHITE 04720

040019 0.0258 ST. FRANCIS 04610

040039 * 0.0172 GREENE 04270

040047 0.0117 RANDOLPH 04600

040067 0.0007 COLUMBIA 04130

040071 * 0.0149 JEFFERSON 04340

040076 * 0.1000 HOT SPRING 04290

040081 0.0357 PIKE 04540

050002 * 0.0010 ALAMEDA 05000

050007 0.0146 SAN MATEO 05510

050009 * 0.0180 NAPA 05380

050013 * 0.0180 NAPA 05380

050014 * 0.0139 AMADOR 05020

050042 * 0.0162 TEHAMA 05620

050043 * 0.0010 ALAMEDA 05000

050070 0.0146 SAN MATEO 05510

050073 * 0.0171 SOLANO 05580

050075 * 0.0010 ALAMEDA 05000

050084 * 0.0132 SAN JOAQUIN 05490

050090 * 0.0058 SONOMA 05590

050101 * 0.0171 SOLANO 05580

050113 0.0146 SAN MATEO 05510

050118 * 0.0132 SAN JOAQUIN 05490

050122 0.0132 SAN JOAQUIN 05490

050133 0.0178 YUBA 05680
CMS-1498-P 996 

Provider 

Number

Reclassified for 

FY 2011

Proposed 

OutMigration 

Adjustment Qualifying County Name

County 

Code

050136 * 0.0058 SONOMA 05590

050150 * 0.0342 NEVADA 05390

050167 0.0132 SAN JOAQUIN 05490

050174 * 0.0058 SONOMA 05590

050195 * 0.0010 ALAMEDA 05000

050197 * 0.0146 SAN MATEO 05510

050211 * 0.0010 ALAMEDA 05000

050264 * 0.0010 ALAMEDA 05000

050283 * 0.0010 ALAMEDA 05000

050289 0.0146 SAN MATEO 05510

050291 * 0.0058 SONOMA 05590

050305 * 0.0010 ALAMEDA 05000

050313 0.0132 SAN JOAQUIN 05490

050320 * 0.0010 ALAMEDA 05000

050325 0.0033 TUOLUMNE 05650

050335 * 0.0033 TUOLUMNE 05650

050336 0.0132 SAN JOAQUIN 05490

050366 * 0.0015 CALAVERAS 05040

050367 * 0.0171 SOLANO 05580

050385 * 0.0058 SONOMA 05590

050444 0.0233 MERCED 05340

050488 * 0.0010 ALAMEDA 05000

050512 * 0.0010 ALAMEDA 05000

050528 * 0.0233 MERCED 05340

050541 * 0.0146 SAN MATEO 05510

050547 * 0.0058 SONOMA 05590

050667 * 0.0180 NAPA 05380

050680 * 0.0171 SOLANO 05580

050690 * 0.0058 SONOMA 05590

050748 * 0.0132 SAN JOAQUIN 05490

050754 0.0146 SAN MATEO 05510

060001 * 0.0042 WELD 06610

060003 * 0.0069 BOULDER 06060

060027 * 0.0069 BOULDER 06060

060103 * 0.0069 BOULDER 06060

060116 * 0.0069 BOULDER 06060

060121 * 0.0042 WELD 06610

070003 * 0.0020 WINDHAM 07070

070004 * 0.0135 LITCHFIELD 07020

070006 * 0.0045 FAIRFIELD 07000

070010 * 0.0045 FAIRFIELD 07000

070011 * 0.0135 LITCHFIELD 07020

070015 * 0.0135 LITCHFIELD 07020

070018 * 0.0045 FAIRFIELD 07000
CMS-1498-P 997 

Provider 

Number

Reclassified for 

FY 2011

Proposed 

OutMigration 

Adjustment Qualifying County Name

County 

Code

070020 0.0101 MIDDLESEX 07030

070021 * 0.0020 WINDHAM 07070

070028 * 0.0045 FAIRFIELD 07000

070033 * 0.0045 FAIRFIELD 07000

070034 * 0.0045 FAIRFIELD 07000

100014 * 0.0047 VOLUSIA 10630

100017 * 0.0047 VOLUSIA 10630

100023 * 0.0031 CITRUS 10080

100045 * 0.0047 VOLUSIA 10630

100047 * 0.0028 CHARLOTTE 10070

100068 * 0.0047 VOLUSIA 10630

100072 * 0.0047 VOLUSIA 10630

100077 * 0.0028 CHARLOTTE 10070

100081 * 0.0097 WALTON 10650

100118 * 0.0177 FLAGLER 10170

100139 * 0.0006 LEVY 10370

100232 * 0.0054 PUTNAM 10530

100236 * 0.0028 CHARLOTTE 10070

100249 * 0.0031 CITRUS 10080

100252 * 0.0151 OKEECHOBEE 10460

100290 * 0.0452 SUMTER 10590

100292 * 0.0097 WALTON 10650

110023 * 0.0416 GORDON 11500

110029 * 0.0052 HALL 11550

110040 * 0.1455 JACKSON 11610

110041 * 0.0623 HABERSHAM 11540

110100 0.0790 JEFFERSON 11620

110101 0.0067 COOK 11311

110142 0.0185 EVANS 11441

110146 * 0.0364 CAMDEN 11170

110150 * 0.0227 BALDWIN 11030

110187 * 0.0643 LUMPKIN 11701

110189 * 0.0066 FANNIN 11450

110190 * 0.0241 MACON 11710

110205 0.0507 GILMER 11471

130003 * 0.0235 NEZ PERCE 13340

130024 0.0675 BONNER 13080

130049 * 0.0319 KOOTENAI 13270

130066 0.0319 KOOTENAI 13270

130067 * 0.0725 BINGHAM 13050

140001 0.0369 FULTON 14370

140026 0.0315 LA SALLE 14580

140043 * 0.0056 WHITESIDE 14988

140058 * 0.0126 MORGAN 14770
CMS-1498-P 998 

Provider 

Number

Reclassified for 

FY 2011

Proposed 

OutMigration 

Adjustment Qualifying County Name

County 

Code

140110 * 0.0315 LA SALLE 14580

140116 * 0.0041 MC HENRY 14640

140160 * 0.0332 STEPHENSON 14970

140161 * 0.0168 LIVINGSTON 14610

140167 * 0.0632 IROQUOIS 14460

140176 * 0.0041 MC HENRY 14640

140234 0.0315 LA SALLE 14580

150022 0.0158 MONTGOMERY 15530

150030 * 0.0192 HENRY 15320

150072 0.0105 CASS 15080

150076 * 0.0215 MARSHALL 15490

150088 * 0.0111 MADISON 15470

150091 * 0.0050 HUNTINGTON 15340

150102 * 0.0108 STARKE 15740

150113 * 0.0111 MADISON 15470

150133 * 0.0193 KOSCIUSKO 15420

150146 * 0.0087 NOBLE 15560

160013 0.0179 MUSCATINE 16690

160032 0.0235 JASPER 16490

160080 * 0.0066 CLINTON 16220

170137 * 0.0402 DOUGLAS 17220

170150 0.0166 COWLEY 17170

180012 * 0.0080 HARDIN 18460

180017 * 0.0035 BARREN 18040

180049 0.0488 MADISON 18750

180064 0.0314 MONTGOMERY 18860

180066 0.0439 LOGAN 18700

180070 0.0240 GRAYSON 18420

180079 0.0259 HARRISON 18480

190003 * 0.0085 IBERIA 19220

190015 * 0.0243 TANGIPAHOA 19520

190017 * 0.0187 ST. LANDRY 19480

190034 0.0189 VERMILION 19560

190044 0.0261 ACADIA 19000

190050 0.0044 BEAUREGARD 19050

190053 0.0101 JEFFRSON DAVIS 19260

190054 0.0085 IBERIA 19220

190078 0.0187 ST. LANDRY 19480

190086 * 0.0061 LINCOLN 19300

190088 0.0387 WEBSTER 19590

190099 0.0189 AVOYELLES 19040

190106 * 0.0102 ALLEN 19010

190116 0.0085 MOREHOUSE 19330
CMS-1498-P 999 

Provider 

Number

Reclassified for 

FY 2011

Proposed 

OutMigration 

Adjustment Qualifying County Name

County 

Code

190133 0.0102 ALLEN 19010

190140 0.0035 FRANKLIN 19200

190144 * 0.0387 WEBSTER 19590

190145 0.0090 LA SALLE 19290

190184 0.0047 CALDWELL 19100

190190 * 0.0047 CALDWELL 19100

190191 0.0187 ST. LANDRY 19480

190246 0.0047 CALDWELL 19100

190257 * 0.0061 LINCOLN 19300

200024 * 0.0094 ANDROSCOGGIN 20000

200032 0.0331 OXFORD 20080

200034 * 0.0094 ANDROSCOGGIN 20000

200050 * 0.0227 HANCOCK 20040

210001 0.0187 WASHINGTON 21210

210023 0.0079 ANNE ARUNDEL 21010

210028 0.0254 ST. MARYS 21180

210043 0.0079 ANNE ARUNDEL 21010

220001 * 0.0064 WORCESTER 22170

220002 * 0.0271 MIDDLESEX 22090

220010 * 0.0355 ESSEX 22040

220011 * 0.0271 MIDDLESEX 22090

220019 * 0.0064 WORCESTER 22170

220025 * 0.0064 WORCESTER 22170

220029 * 0.0355 ESSEX 22040

220033 * 0.0355 ESSEX 22040

220035 * 0.0355 ESSEX 22040

220049 * 0.0271 MIDDLESEX 22090

220058 * 0.0064 WORCESTER 22170

220062 * 0.0064 WORCESTER 22170

220063 * 0.0271 MIDDLESEX 22090

220070 * 0.0271 MIDDLESEX 22090

220080 * 0.0355 ESSEX 22040

220082 * 0.0271 MIDDLESEX 22090

220084 * 0.0271 MIDDLESEX 22090

220090 * 0.0064 WORCESTER 22170

220095 * 0.0064 WORCESTER 22170

220098 * 0.0271 MIDDLESEX 22090

220101 * 0.0271 MIDDLESEX 22090

220105 * 0.0271 MIDDLESEX 22090

220163 * 0.0064 WORCESTER 22170

220171 * 0.0271 MIDDLESEX 22090

220174 * 0.0355 ESSEX 22040

220175 * 0.0271 MIDDLESEX 22090

220176 * 0.0064 WORCESTER 22170
CMS-1498-P 1000 

Provider 

Number

Reclassified for 

FY 2011

Proposed 

OutMigration 

Adjustment Qualifying County Name

County 

Code

230002 * 0.0043 WAYNE 23810

230003 * 0.0220 OTTAWA 23690

230005 0.0473 LENAWEE 23450

230013 * 0.0025 OAKLAND 23620

230015 0.0295 ST. JOSEPH 23740

230019 * 0.0025 OAKLAND 23620

230020 * 0.0043 WAYNE 23810

230021 * 0.0101 BERRIEN 23100

230022 * 0.0212 BRANCH 23110

230024 * 0.0043 WAYNE 23810

230029 * 0.0025 OAKLAND 23620

230035 * 0.0095 MONTCALM 23580

230037 * 0.0210 HILLSDALE 23290

230041 0.0052 BAY 23080

230047 * 0.0021 MACOMB 23490

230053 * 0.0043 WAYNE 23810

230069 * 0.0210 LIVINGSTON 23460

230071 * 0.0025 OAKLAND 23620

230072 * 0.0220 OTTAWA 23690

230075 0.0047 CALHOUN 23120

230078 * 0.0101 BERRIEN 23100

230089 * 0.0043 WAYNE 23810

230092 0.0223 JACKSON 23370

230093 0.0058 MECOSTA 23530

230096 * 0.0295 ST. JOSEPH 23740

230099 * 0.0231 MONROE 23570

230104 * 0.0043 WAYNE 23810

230121 * 0.0678 SHIAWASSEE 23770

230130 * 0.0025 OAKLAND 23620

230135 * 0.0043 WAYNE 23810

230142 * 0.0043 WAYNE 23810

230146 * 0.0043 WAYNE 23810

230151 * 0.0025 OAKLAND 23620

230165 * 0.0043 WAYNE 23810

230174 * 0.0220 OTTAWA 23690

230176 * 0.0043 WAYNE 23810

230195 * 0.0021 MACOMB 23490

230204 * 0.0021 MACOMB 23490

230207 * 0.0025 OAKLAND 23620

230208 * 0.0095 MONTCALM 23580

230217 0.0047 CALHOUN 23120

230222 * 0.0035 MIDLAND 23550

230227 * 0.0021 MACOMB 23490

230244 * 0.0043 WAYNE 23810
CMS-1498-P 1001 

Provider 

Number

Reclassified for 

FY 2011

Proposed 

OutMigration 

Adjustment Qualifying County Name

County 

Code

230254 * 0.0025 OAKLAND 23620

230257 * 0.0021 MACOMB 23490

230264 * 0.0021 MACOMB 23490

230269 * 0.0025 OAKLAND 23620

230270 * 0.0043 WAYNE 23810

230273 * 0.0043 WAYNE 23810

230277 * 0.0025 OAKLAND 23620

230279 * 0.0210 LIVINGSTON 23460

230297 * 0.0043 WAYNE 23810

230301 * 0.0025 OAKLAND 23620

230302 * 0.0025 OAKLAND 23620

240018 0.0805 GOODHUE 24240

240044 0.0625 WINONA 24840

240064 0.0134 ITASCA 24300

240069 * 0.0267 STEELE 24730

240071 * 0.0385 RICE 24650

240117 0.0527 MOWER 24490

240211 0.0812 PINE 24570

250023 * 0.0541 PEARL RIVER 25540

250040 * 0.0021 JACKSON 25290

250117 * 0.0541 PEARL RIVER 25540

250128 0.0446 PANOLA 25530

250162 0.0014 HANCOCK 25220

260059 0.0077 LACLEDE 26520

260064 0.0089 AUDRAIN 26030

260097 0.0300 JOHNSON 26500

260116 * 0.0087 ST. FRANCOIS 26930

260160 0.0144 STODDARD 26985

260163 0.0087 ST. FRANCOIS 26930

280077 * 0.0080 DODGE 28260

290002 * 0.0277 LYON 29090

300011 * 0.0238 HILLSBOROUGH 30050

300012 * 0.0238 HILLSBOROUGH 30050

300017 * 0.0396 ROCKINGHAM 30070

300020 * 0.0238 HILLSBOROUGH 30050

300023 * 0.0396 ROCKINGHAM 30070

300029 * 0.0396 ROCKINGHAM 30070

300034 * 0.0238 HILLSBOROUGH 30050

310002 * 0.0268 ESSEX 31200

310009 * 0.0268 ESSEX 31200

310015 * 0.0254 MORRIS 31300

310017 * 0.0254 MORRIS 31300

310038 * 0.0209 MIDDLESEX 31270

310039 * 0.0209 MIDDLESEX 31270
CMS-1498-P 1002 

Provider 

Number

Reclassified for 

FY 2011

Proposed 

OutMigration 

Adjustment Qualifying County Name

County 

Code

310050 * 0.0254 MORRIS 31300

310054 * 0.0268 ESSEX 31200

310070 * 0.0209 MIDDLESEX 31270

310076 * 0.0268 ESSEX 31200

310083 * 0.0268 ESSEX 31200

310096 * 0.0268 ESSEX 31200

310108 * 0.0209 MIDDLESEX 31270

310119 * 0.0268 ESSEX 31200

320003 * 0.0490 SAN MIGUEL 32230

320011 0.0344 RIO ARRIBA 32190

320018 0.0024 DONA ANA 32060

320085 0.0024 DONA ANA 32060

320088 0.0024 DONA ANA 32060

330004 0.0633 ULSTER 33740

330008 * 0.0126 WYOMING 33900

330010 0.0067 MONTGOMERY 33380

330027 * 0.0123 NASSAU 33400

330033 0.0223 CHENANGO 33080

330047 0.0067 MONTGOMERY 33380

330073 * 0.0151 GENESEE 33290

330094 * 0.0503 COLUMBIA 33200

330103 0.0131 CATTARAUGUS 33040

330106 * 0.0123 NASSAU 33400

330126 * 0.0642 ORANGE 33540

330132 0.0131 CATTARAUGUS 33040

330135 0.0642 ORANGE 33540

330144 0.0034 STEUBEN 33690

330151 0.0034 STEUBEN 33690

330167 * 0.0123 NASSAU 33400

330175 0.0260 CORTLAND 33210

330181 * 0.0123 NASSAU 33400

330182 * 0.0123 NASSAU 33400

330191 * 0.0017 WARREN 33750

330198 * 0.0123 NASSAU 33400

330205 0.0642 ORANGE 33540

330222 0.0016 SARATOGA 33640

330224 * 0.0633 ULSTER 33740

330225 * 0.0123 NASSAU 33400

330235 * 0.0306 CAYUGA 33050

330259 * 0.0123 NASSAU 33400

330264 0.0642 ORANGE 33540

330276 0.0036 FULTON 33280

330277 * 0.0034 STEUBEN 33690
CMS-1498-P 1003 

Provider 

Number

Reclassified for 

FY 2011

Proposed 

OutMigration 

Adjustment Qualifying County Name

County 

Code

330331 * 0.0123 NASSAU 33400

330332 * 0.0123 NASSAU 33400

330372 * 0.0123 NASSAU 33400

330386 * 0.0745 SULLIVAN 33710

340020 0.0156 LEE 34520

340021 * 0.0162 CLEVELAND 34220

340024 0.0177 SAMPSON 34810

340027 * 0.0128 LENOIR 34530

340037 * 0.0162 CLEVELAND 34220

340038 0.0253 BEAUFORT 34060

340039 * 0.0101 IREDELL 34480

340068 * 0.0087 COLUMBUS 34230

340069 * 0.0015 WAKE 34910

340070 * 0.0395 ALAMANCE 34000

340071 * 0.0226 HARNETT 34420

340073 * 0.0015 WAKE 34910

340085 * 0.0250 DAVIDSON 34280

340096 * 0.0250 DAVIDSON 34280

340114 * 0.0015 WAKE 34910

340126 * 0.0100 WILSON 34970

340129 * 0.0101 IREDELL 34480

340133 0.0319 MARTIN 34580

340138 * 0.0015 WAKE 34910

340144 * 0.0101 IREDELL 34480

340145 * 0.0336 LINCOLN 34540

340151 0.0052 HALIFAX 34410

340173 * 0.0015 WAKE 34910

360002 0.0141 ASHLAND 36020

360010 * 0.0074 TUSCARAWAS 36800

360013 * 0.0135 SHELBY 36760

360025 * 0.0077 ERIE 36220

360036 * 0.0126 WAYNE 36860

360040 0.0387 KNOX 36430

360044 0.0127 DARKE 36190

360055 * 0.0011 TRUMBULL 36790

360065 * 0.0075 HURON 36400

360070 0.0038 STARK 36770

360071 0.0035 VAN WERT 36820

360084 0.0038 STARK 36770

360086 * 0.0186 CLARK 36110

360096 0.0071 COLUMBIANA 36140

360107 0.0119 SANDUSKY 36730

360125 * 0.0133 ASHTABULA 36030
CMS-1498-P 1004 

Provider 

Number

Reclassified for 

FY 2011

Proposed 

OutMigration 

Adjustment Qualifying County Name

County 

Code

360131 0.0038 STARK 36770

360151 0.0038 STARK 36770

360156 0.0119 SANDUSKY 36730

360161 0.0011 TRUMBULL 36790

360175 * 0.0183 CLINTON 36130

360185 * 0.0071 COLUMBIANA 36140

360245 * 0.0133 ASHTABULA 36030

360355 0.0186 CLARK 36110

370014 * 0.0361 BRYAN 37060

370015 * 0.0366 MAYES 37480

370023 0.0090 STEPHENS 37680

370065 0.0096 CRAIG 37170

370072 0.0258 LATIMER 37380

370083 0.0051 PUSHMATAHA 37630

370100 0.0100 CHOCTAW 37110

370149 0.0302 POTTAWATOMIE 37620

370156 0.0121 GARVIN 37240

370169 0.0163 MCINTOSH 37450

370172 0.0258 LATIMER 37380

370214 0.0121 GARVIN 37240

380022 * 0.0067 LINN 38210

390008 0.0060 LAWRENCE 39450

390016 * 0.0060 LAWRENCE 39450

390030 * 0.0147 SCHUYLKILL 39650

390031 * 0.0147 SCHUYLKILL 39650

390039 0.0037 SOMERSET 39680

390044 0.0191 BERKS 39110

390052 0.0047 CLEARFIELD 39230

390056 0.0036 HUNTINGDON 39380

390065 * 0.0532 ADAMS 39000

390066 * 0.0372 LEBANON 39460

390079 * 0.0003 BRADFORD 39130

390086 * 0.0047 CLEARFIELD 39230

390096 0.0191 BERKS 39110

390110 * 0.0003 CAMBRIA 39160

390112 0.0037 SOMERSET 39680

390113 * 0.0053 CRAWFORD 39260

390117 0.0002 BEDFORD 39100

390122 0.0053 CRAWFORD 39260

390125 0.0022 WAYNE 39760

390130 * 0.0003 CAMBRIA 39160

390138 * 0.0218 FRANKLIN 39350
CMS-1498-P 1005 

Provider 

Number

Reclassified for 

FY 2011

Proposed 

OutMigration 

Adjustment Qualifying County Name

County 

Code

390146 0.0022 WARREN 39740

390150 0.0031 GREENE 39370

390151 * 0.0218 FRANKLIN 39350

390162 * 0.0215 NORTHAMPTON 39590

390173 0.0037 INDIANA 39390

390183 * 0.0147 SCHUYLKILL 39650

390201 0.1170 MONROE 39550

390236 0.0003 BRADFORD 39130

390313 * 0.0147 SCHUYLKILL 39650

390316 0.0191 BERKS 39110

420005 0.0012 DILLON 42160

420007 * 0.0027 SPARTANBURG 42410

420019 0.0158 CHESTER 42110

420020 * 0.0024 GEORGETOWN 42210

420027 * 0.0108 ANDERSON 42030

420030 * 0.0069 COLLETON 42140

420036 * 0.0064 LANCASTER 42280

420039 * 0.0176 UNION 42430

420043 0.0157 CHEROKEE 42100

420053 0.0035 NEWBERRY 42350

420054 0.0008 MARLBORO 42340

420055 0.0029 MARION 42330

420062 0.0125 CHESTERFIELD 42120

420068 * 0.0027 ORANGEBURG 42370

420069 * 0.0052 CLARENDON 42130

420070 * 0.0051 SUMTER 42420

420083 * 0.0027 SPARTANBURG 42410

420098 0.0024 GEORGETOWN 42210

430008 0.0535 BROOKINGS 43050

430048 0.0129 LAWRENCE 43400

430094 0.0129 LAWRENCE 43400

440007 0.0219 COFFEE 44150

440008 0.0449 HENDERSON 44380

440016 0.0144 CARROLL 44080

440031 0.0019 ROANE 44720

440033 0.0027 CAMPBELL 44060

440035 * 0.0301 MONTGOMERY 44620

440047 0.0338 GIBSON 44260

440051 0.0082 MC NAIRY 44540

440057 0.0021 CLAIBORNE 44120

440060 0.0338 GIBSON 44260

440063 0.0033 WASHINGTON 44890
CMS-1498-P 1006 

Provider 

Number

Reclassified for 

FY 2011

Proposed 

OutMigration 

Adjustment Qualifying County Name

County 

Code

440070 0.0109 DECATUR 44190

440081 0.0052 SEVIER 44770

440084 0.0025 MONROE 44610

440105 0.0033 WASHINGTON 44890

440109 0.0070 HARDIN 44350

440115 0.0338 GIBSON 44260

440137 0.0738 BEDFORD 44010

440144 * 0.0219 COFFEE 44150

440148 0.0296 DE KALB 44200

440174 * 0.0312 HAYWOOD 44370

440180 0.0027 CAMPBELL 44060

440181 0.0365 HARDEMAN 44340

440182 0.0144 CARROLL 44080

440184 0.0033 WASHINGTON 44890

440185 * 0.0230 BRADLEY 44050

450032 * 0.0254 HARRISON 45620

450039 * 0.0024 TARRANT 45910

450052 * 0.0276 BOSQUE 45160

450064 * 0.0024 TARRANT 45910

450087 * 0.0024 TARRANT 45910

450090 0.0650 COOKE 45340

450099 * 0.0145 GRAY 45563

450135 * 0.0024 TARRANT 45910

450137 * 0.0024 TARRANT 45910

450144 * 0.0559 ANDREWS 45010

450163 0.0054 KLEBERG 45743

450192 0.0271 HILL 45651

450194 0.0213 CHEROKEE 45281

450210 0.0151 PANOLA 45842

450224 * 0.0195 WOOD 45974

450236 0.0389 HOPKINS 45654

450270 0.0271 HILL 45651

450283 * 0.0653 VAN ZANDT 45947

450347 * 0.0370 WALKER 45949

450348 * 0.0059 FALLS 45500

450370 * 0.0235 COLORADO 45312

450389 * 0.0618 HENDERSON 45640

450395 0.0441 POLK 45850

450419 * 0.0024 TARRANT 45910

450438 * 0.0235 COLORADO 45312

450451 0.0536 SOMERVELL 45893

450460 0.0053 TYLER 45942

450497 0.0375 MONTAGUE 45800
CMS-1498-P 1007 

Provider 

Number

Reclassified for 

FY 2011

Proposed 

OutMigration 

Adjustment Qualifying County Name

County 

Code

450539 0.0067 HALE 45582

450547 * 0.0195 WOOD 45974

450563 * 0.0024 TARRANT 45910

450565 * 0.0470 PALO PINTO 45841

450573 0.0126 JASPER 45690

450596 * 0.0743 HOOD 45653

450597 0.0003 DE WITT 45420

450639 * 0.0024 TARRANT 45910

450641 0.0375 MONTAGUE 45800

450672 * 0.0024 TARRANT 45910

450675 * 0.0024 TARRANT 45910

450677 * 0.0024 TARRANT 45910

450698 0.0127 LAMB 45751

450747 * 0.0126 ANDERSON 45000

450755 0.0276 HOCKLEY 45652

450770 * 0.0182 MILAM 45795

450779 * 0.0024 TARRANT 45910

450813 0.0126 ANDERSON 45000

450872 * 0.0024 TARRANT 45910

450880 * 0.0024 TARRANT 45910

450884 0.0049 UPSHUR 45943

450886 * 0.0024 TARRANT 45910

450888 0.0024 TARRANT 45910

460001 0.0001 UTAH 46240

460013 0.0001 UTAH 46240

460017 0.0383 BOX ELDER 46010

460023 0.0001 UTAH 46240

460039 * 0.0383 BOX ELDER 46010

460043 0.0001 UTAH 46240

460052 0.0001 UTAH 46240

490002 0.0003 RUSSELL 49830

490019 * 0.1088 CULPEPER 49230

490038 0.0003 SMYTH 49860

490084 0.0187 ESSEX 49280

490105 0.0003 SMYTH 49860

490110 0.0185 MONTGOMERY 49600

500003 * 0.0166 SKAGIT 50280

500007 * 0.0166 SKAGIT 50280

500019 0.0131 LEWIS 50200

500024 0.0065 THURSTON 50330

500039 * 0.0094 KITSAP 50170

500041 * 0.0020 COWLITZ 50070

500139 0.0065 THURSTON 50330
CMS-1498-P 1008 

Provider 

Number

Reclassified for 

FY 2011

Proposed 

OutMigration 

Adjustment Qualifying County Name

County 

Code

500143 0.0065 THURSTON 50330

510012 0.0124 MASON 51260

510018 * 0.0188 JACKSON 51170

510047 * 0.0269 MARION 51240

520009 0.0027 OUTAGAMIE 52430

520028 * 0.0286 GREEN 52220

520035 0.0076 SHEBOYGAN 52580

520044 0.0076 SHEBOYGAN 52580

520045 0.0022 WINNEBAGO 52690

520048 0.0022 WINNEBAGO 52690

520057 0.0193 SAUK 52550

520059 * 0.0195 RACINE 52500

520071 * 0.0161 JEFFERSON 52270

520076 * 0.0146 DODGE 52130

520088 0.0084 FOND DU LAC 52190

520095 * 0.0193 SAUK 52550

520096 * 0.0195 RACINE 52500

520102 * 0.0242 WALWORTH 52630

520116 * 0.0161 JEFFERSON 52270

520160 0.0027 OUTAGAMIE 52430

520198 0.0022 WINNEBAGO 52690
CMS-1498-P 1009 

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MSDRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC 

MEAN LENGTH OF STAY 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

001 No No PRE SURG 

HEART TRANSPLANT OR 

IMPLANT OF HEART ASSIST 

SYSTEM W MCC 26.1241 31.7 41.8 

002 No No PRE SURG 

HEART TRANSPLANT OR 

IMPLANT OF HEART ASSIST 

SYSTEM W/O MCC 13.5332 17.7 22.8 

003 Yes No PRE SURG 

ECMO OR TRACH W MV 96+ HRS 

OR PDX EXC FACE, MOUTH & 

NECK W MAJ O.R. 18.0135 30.0 36.6 

004 Yes No PRE SURG 

TRACH W MV 96+ HRS OR PDX 

EXC FACE, MOUTH & NECK W/O 

MAJ O.R. 11.1832 22.2 27.1 

005 No No PRE SURG 

LIVER TRANSPLANT W MCC OR 

INTESTINAL TRANSPLANT 10.2640 15.0 20.0 

006 No No PRE SURG LIVER TRANSPLANT W/O MCC 4.8067 8.3 9.2 

007 No No PRE SURG LUNG TRANSPLANT 9.3918 15.6 18.7 

008 No No PRE SURG 

SIMULTANEOUS 

PANCREAS/KIDNEY 

TRANSPLANT 4.9951 10.2 11.8 

010 No No PRE SURG PANCREAS TRANSPLANT 3.7220 8.6 9.7 

011 No No PRE SURG 

TRACHEOSTOMY FOR 

FACE,MOUTH & NECK 

DIAGNOSES W MCC 4.7558 12.3 15.6 

012 No No PRE SURG 

TRACHEOSTOMY FOR 

FACE,MOUTH & NECK 

DIAGNOSES W CC 3.1179 8.5 10.1 

013 No No PRE SURG 

TRACHEOSTOMY FOR 

FACE,MOUTH & NECK 

DIAGNOSES W/O CC/MCC 1.9480 5.7 6.7 

014 No No PRE SURG 

ALLOGENEIC BONE MARROW 

TRANSPLANT 11.3961 20.7 27.7 

015 No No PRE SURG 

AUTOLOGOUS BONE MARROW 

TRANSPLANT 5.8721 16.7 19.2 

020 No No 01 SURG 

INTRACRANIAL VASCULAR 

PROCEDURES W PDX 

HEMORRHAGE W MCC 8.2168 14.0 17.2 

021 No No 01 SURG 

INTRACRANIAL VASCULAR 

PROCEDURES W PDX 

HEMORRHAGE W CC 6.2673 12.2 13.9 

022 No No 01 SURG 

INTRACRANIAL VASCULAR 

PROCEDURES W PDX 

HEMORRHAGE W/O CC/MCC 4.1377 6.6 8.4 

023 No No 01 SURG 

CRANIO W MAJOR DEV 

IMPL/ACUTE COMPLEX CNS PDX 5.0829 8.3 11.8 
CMS-1498-P 1010 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

W MCC OR CHEMO IMPLANT 

024 No No 01 SURG 

CRANIO W MAJOR DEV 

IMPL/ACUTE COMPLEX CNS PDX 

W/O MCC 3.4948 5.7 8.1 

025 Yes No 01 SURG 

CRANIOTOMY & 

ENDOVASCULAR 

INTRACRANIAL PROCEDURES W 

MCC 4.7528 8.8 11.5 

026 Yes No 01 SURG 

CRANIOTOMY & 

ENDOVASCULAR 

INTRACRANIAL PROCEDURES W 

CC 2.9804 5.8 7.3 

027 Yes No 01 SURG 

CRANIOTOMY & 

ENDOVASCULAR 

INTRACRANIAL PROCEDURES 

W/O CC/MCC 2.1382 3.0 3.9 

028 Yes Yes 01 SURG SPINAL PROCEDURES W MCC 5.3583 10.1 13.1 

029 Yes Yes 01 SURG 

SPINAL PROCEDURES W CC OR 

SPINAL NEUROSTIMULATORS 2.8798 4.7 6.6 

030 Yes Yes 01 SURG 

SPINAL PROCEDURES W/O 

CC/MCC 1.6452 2.5 3.3 

031 Yes No 01 SURG 

VENTRICULAR SHUNT 

PROCEDURES W MCC 4.1020 8.5 12.2 

032 Yes No 01 SURG 

VENTRICULAR SHUNT 

PROCEDURES W CC 1.9339 3.7 5.4 

033 Yes No 01 SURG 

VENTRICULAR SHUNT 

PROCEDURES W/O CC/MCC 1.3695 2.1 2.7 

034 No No 01 SURG 

CAROTID ARTERY STENT 

PROCEDURE W MCC 3.5290 4.7 7.0 

035 No No 01 SURG 

CAROTID ARTERY STENT 

PROCEDURE W CC 2.1572 2.2 3.2 

036 No No 01 SURG 

CAROTID ARTERY STENT 

PROCEDURE W/O CC/MCC 1.6539 1.3 1.5 

037 No No 01 SURG 

EXTRACRANIAL PROCEDURES 

W MCC 3.1652 5.8 8.4 

038 No No 01 SURG 

EXTRACRANIAL PROCEDURES 

W CC 1.5610 2.4 3.5 

039 No No 01 SURG 

EXTRACRANIAL PROCEDURES 

W/O CC/MCC 1.0278 1.4 1.7 

040 Yes Yes 01 SURG 

PERIPH/CRANIAL NERVE & 

OTHER NERV SYST PROC W MCC 3.9264 9.0 12.2 

041 Yes Yes 01 SURG 

PERIPH/CRANIAL NERVE & 

OTHER NERV SYST PROC W CC 

OR PERIPH NEUROSTIM 2.1447 5.0 6.7 

042 Yes Yes 01 SURG 

PERIPH/CRANIAL NERVE & 

OTHER NERV SYST PROC W/O 

CC/MCC 1.6950 2.3 3.2 

052 No No 01 MED 

SPINAL DISORDERS & INJURIES 

W CC/MCC 1.5964 4.5 6.6 
CMS-1498-P 1011 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

053 No No 01 MED 

SPINAL DISORDERS & INJURIES 

W/O CC/MCC 0.8417 2.9 3.6 

054 Yes No 01 MED 

NERVOUS SYSTEM NEOPLASMS 

W MCC 1.4801 4.6 6.3 

055 Yes No 01 MED 

NERVOUS SYSTEM NEOPLASMS 

W/O MCC 1.0651 3.5 4.6 

056 Yes No 01 MED 

DEGENERATIVE NERVOUS 

SYSTEM DISORDERS W MCC 1.6720 5.5 7.2 

057 Yes No 01 MED 

DEGENERATIVE NERVOUS 

SYSTEM DISORDERS W/O MCC 0.9316 3.7 4.9 

058 No No 01 MED 

MULTIPLE SCLEROSIS & 

CEREBELLAR ATAXIA W MCC 1.5781 5.5 7.3 

059 No No 01 MED 

MULTIPLE SCLEROSIS & 

CEREBELLAR ATAXIA W CC 0.9818 4.1 4.9 

060 No No 01 MED 

MULTIPLE SCLEROSIS & 

CEREBELLAR ATAXIA W/O 

CC/MCC 0.7525 3.2 3.8 

061 No No 01 MED 

ACUTE ISCHEMIC STROKE W 

USE OF THROMBOLYTIC AGENT 

W MCC 2.9397 6.4 8.4 

062 No No 01 MED 

ACUTE ISCHEMIC STROKE W 

USE OF THROMBOLYTIC AGENT 

W CC 1.9450 4.8 5.6 

063 No No 01 MED 

ACUTE ISCHEMIC STROKE W 

USE OF THROMBOLYTIC AGENT 

W/O CC/MCC 1.5296 3.4 3.9 

064 Yes No 01 MED 

INTRACRANIAL HEMORRHAGE 

OR CEREBRAL INFARCTION W 

MCC 1.8601 5.1 6.9 

065 Yes No 01 MED 

INTRACRANIAL HEMORRHAGE 

OR CEREBRAL INFARCTION W 

CC 1.1637 4.0 4.8 

066 Yes No 01 MED 

INTRACRANIAL HEMORRHAGE 

OR CEREBRAL INFARCTION W/O 

CC/MCC 0.8174 2.7 3.3 

067 No No 01 MED 

NONSPECIFIC CVA & 

PRECEREBRAL OCCLUSION W/O 

INFARCT W MCC 1.4176 4.2 5.5 

068 No No 01 MED 

NONSPECIFIC CVA & 

PRECEREBRAL OCCLUSION W/O 

INFARCT W/O MCC 0.8746 2.7 3.3 

069 No No 01 MED TRANSIENT ISCHEMIA 0.7292 2.3 2.8 

070 Yes No 01 MED 

NONSPECIFIC 

CEREBROVASCULAR 

DISORDERS W MCC 1.8345 5.6 7.4 

071 Yes No 01 MED 

NONSPECIFIC 

CEREBROVASCULAR 

DISORDERS W CC 1.1008 4.1 5.1 

072 Yes No 01 MED NONSPECIFIC 0.7468 2.5 3.1 
CMS-1498-P 1012 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

CEREBROVASCULAR 

DISORDERS W/O CC/MCC 

073 No No 01 MED 

CRANIAL & PERIPHERAL NERVE 

DISORDERS W MCC 1.2959 4.2 5.6 

074 No No 01 MED 

CRANIAL & PERIPHERAL NERVE 

DISORDERS W/O MCC 0.8592 3.2 4.1 

075 No No 01 MED VIRAL MENINGITIS W CC/MCC 1.6538 5.5 7.0 

076 No No 01 MED VIRAL MENINGITIS W/O CC/MCC 0.9054 3.3 3.9 

077 No No 01 MED 

HYPERTENSIVE 

ENCEPHALOPATHY W MCC 1.7332 5.1 6.4 

078 No No 01 MED 

HYPERTENSIVE 

ENCEPHALOPATHY W CC 1.0145 3.5 4.4 

079 No No 01 MED 

HYPERTENSIVE 

ENCEPHALOPATHY W/O CC/MCC 0.7500 2.6 3.1 

080 No No 01 MED 

NONTRAUMATIC STUPOR & 

COMA W MCC 1.1831 3.6 4.9 

081 No No 01 MED 

NONTRAUMATIC STUPOR & 

COMA W/O MCC 0.7350 2.7 3.4 

082 No No 01 MED 

TRAUMATIC STUPOR & COMA, 

COMA >1 HR W MCC 2.0028 3.5 6.1 

083 No No 01 MED 

TRAUMATIC STUPOR & COMA, 

COMA >1 HR W CC 1.3194 3.4 4.7 

084 No No 01 MED 

TRAUMATIC STUPOR & COMA, 

COMA >1 HR W/O CC/MCC 0.8899 2.2 2.8 

085 Yes No 01 MED 

TRAUMATIC STUPOR & COMA, 

COMA <1 HR W MCC 2.1345 5.2 7.2 

086 Yes No 01 MED 

TRAUMATIC STUPOR & COMA, 

COMA <1 HR W CC 1.1979 3.7 4.6 

087 Yes No 01 MED 

TRAUMATIC STUPOR & COMA, 

COMA <1 HR W/O CC/MCC 0.7872 2.3 2.9 

088 No No 01 MED CONCUSSION W MCC 1.5102 4.2 5.5 

089 No No 01 MED CONCUSSION W CC 0.9644 2.9 3.7 

090 No No 01 MED CONCUSSION W/O CC/MCC 0.6943 1.9 2.3 

091 Yes No 01 MED 

OTHER DISORDERS OF 

NERVOUS SYSTEM W MCC 1.6299 4.4 6.2 

092 Yes No 01 MED 

OTHER DISORDERS OF 

NERVOUS SYSTEM W CC 0.9372 3.3 4.2 

093 Yes No 01 MED 

OTHER DISORDERS OF 

NERVOUS SYSTEM W/O CC/MCC 0.6800 2.3 2.9 

094 No No 01 MED 

BACTERIAL & TUBERCULOUS 

INFECTIONS OF NERVOUS 

SYSTEM W MCC 3.6910 8.9 11.8 

095 No No 01 MED 

BACTERIAL & TUBERCULOUS 

INFECTIONS OF NERVOUS 

SYSTEM W CC 2.3934 6.6 8.4 

096 No No 01 MED 

BACTERIAL & TUBERCULOUS 

INFECTIONS OF NERVOUS 

SYSTEM W/O CC/MCC 1.9171 4.6 5.7 
CMS-1498-P 1013 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

097 No No 01 MED 

NON-BACTERIAL INFECT OF 

NERVOUS SYS EXC VIRAL 

MENINGITIS W MCC 3.2271 9.0 11.6 

098 No No 01 MED 

NON-BACTERIAL INFECT OF 

NERVOUS SYS EXC VIRAL 

MENINGITIS W CC 1.9053 6.4 7.9 

099 No No 01 MED 

NON-BACTERIAL INFECT OF 

NERVOUS SYS EXC VIRAL 

MENINGITIS W/O CC/MCC 1.2170 4.1 5.2 

100 Yes No 01 MED SEIZURES W MCC 1.5091 4.5 6.0 

101 Yes No 01 MED SEIZURES W/O MCC 0.7588 2.8 3.4 

102 No No 01 MED HEADACHES W MCC 0.9997 3.1 4.3 

103 No No 01 MED HEADACHES W/O MCC 0.6691 2.4 3.0 

113 No No 02 SURG 

ORBITAL PROCEDURES W 

CC/MCC 1.8278 3.9 5.6 

114 No No 02 SURG 

ORBITAL PROCEDURES W/O 

CC/MCC 0.9224 2.0 2.6 

115 No No 02 SURG 

EXTRAOCULAR PROCEDURES 

EXCEPT ORBIT 1.2130 3.4 4.6 

116 No No 02 SURG 

INTRAOCULAR PROCEDURES W 

CC/MCC 1.2920 3.0 4.5 

117 No No 02 SURG 

INTRAOCULAR PROCEDURES 

W/O CC/MCC 0.7393 1.6 2.0 

121 No No 02 MED 

ACUTE MAJOR EYE INFECTIONS 

W CC/MCC 0.9040 4.1 5.1 

122 No No 02 MED 

ACUTE MAJOR EYE INFECTIONS 

W/O CC/MCC 0.6451 3.3 4.0 

123 No No 02 MED 

NEUROLOGICAL EYE 

DISORDERS 0.7135 2.2 2.7 

124 No No 02 MED 

OTHER DISORDERS OF THE EYE 

W MCC 1.1861 3.8 5.3 

125 No No 02 MED 

OTHER DISORDERS OF THE EYE 

W/O MCC 0.6819 2.6 3.4 

129 No No 03 SURG 

MAJOR HEAD & NECK 

PROCEDURES W CC/MCC OR 

MAJOR DEVICE 2.2555 3.7 5.2 

130 No No 03 SURG 

MAJOR HEAD & NECK 

PROCEDURES W/O CC/MCC 1.2316 2.3 2.9 

131 No No 03 SURG 

CRANIAL/FACIAL PROCEDURES 

W CC/MCC 2.0829 4.1 5.6 

132 No No 03 SURG 

CRANIAL/FACIAL PROCEDURES 

W/O CC/MCC 1.2451 2.1 2.7 

133 No No 03 SURG 

OTHER EAR, NOSE, MOUTH & 

THROAT O.R. PROCEDURES W 

CC/MCC 1.6960 3.6 5.4 

134 No No 03 SURG 

OTHER EAR, NOSE, MOUTH & 

THROAT O.R. PROCEDURES W/O 

CC/MCC 0.8518 1.7 2.1 
CMS-1498-P 1014 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

135 No No 03 SURG 

SINUS & MASTOID PROCEDURES 

W CC/MCC 1.9029 4.3 6.3 

136 No No 03 SURG 

SINUS & MASTOID PROCEDURES 

W/O CC/MCC 0.9772 1.7 2.2 

137 No No 03 SURG 

MOUTH PROCEDURES W 

CC/MCC 1.2952 3.6 5.0 

138 No No 03 SURG 

MOUTH PROCEDURES W/O 

CC/MCC 0.7822 1.9 2.5 

139 No No 03 SURG SALIVARY GLAND PROCEDURES 0.8827 1.4 1.8 

146 No No 03 MED 

EAR, NOSE, MOUTH & THROAT 

MALIGNANCY W MCC 2.1722 6.5 9.0 

147 No No 03 MED 

EAR, NOSE, MOUTH & THROAT 

MALIGNANCY W CC 1.2284 4.1 5.7 

148 No No 03 MED 

EAR, NOSE, MOUTH & THROAT 

MALIGNANCY W/O CC/MCC 0.8118 2.4 3.3 

149 No No 03 MED DYSEQUILIBRIUM 0.6363 2.2 2.6 

150 No No 03 MED EPISTAXIS W MCC 1.2811 3.7 5.0 

151 No No 03 MED EPISTAXIS W/O MCC 0.6366 2.3 2.9 

152 No No 03 MED OTITIS MEDIA & URI W MCC 0.9623 3.3 4.3 

153 No No 03 MED OTITIS MEDIA & URI W/O MCC 0.6256 2.5 3.1 

154 No No 03 MED 

OTHER EAR, NOSE, MOUTH & 

THROAT DIAGNOSES W MCC 1.3957 4.3 5.8 

155 No No 03 MED 

OTHER EAR, NOSE, MOUTH & 

THROAT DIAGNOSES W CC 0.9032 3.3 4.2 

156 No No 03 MED 

OTHER EAR, NOSE, MOUTH & 

THROAT DIAGNOSES W/O 

CC/MCC 0.6184 2.4 2.9 

157 No No 03 MED 

DENTAL & ORAL DISEASES W 

MCC 1.5699 4.8 6.7 

158 No No 03 MED 

DENTAL & ORAL DISEASES W 

CC 0.8951 3.3 4.3 

159 No No 03 MED 

DENTAL & ORAL DISEASES W/O 

CC/MCC 0.5858 2.1 2.7 

163 Yes No 04 SURG 

MAJOR CHEST PROCEDURES W 

MCC 5.0701 11.5 14.0 

164 Yes No 04 SURG 

MAJOR CHEST PROCEDURES W 

CC 2.6177 6.2 7.4 

165 Yes No 04 SURG 

MAJOR CHEST PROCEDURES 

W/O CC/MCC 1.7756 3.7 4.4 

166 Yes No 04 SURG 

OTHER RESP SYSTEM O.R. 

PROCEDURES W MCC 3.7415 9.5 12.0 

167 Yes No 04 SURG 

OTHER RESP SYSTEM O.R. 

PROCEDURES W CC 2.0537 5.8 7.4 

168 Yes No 04 SURG 

OTHER RESP SYSTEM O.R. 

PROCEDURES W/O CC/MCC 1.3012 3.3 4.3 

175 Yes No 04 MED PULMONARY EMBOLISM W MCC 1.6088 5.7 6.8 

176 Yes No 04 MED 

PULMONARY EMBOLISM W/O 

MCC 1.0666 4.2 4.9 
CMS-1498-P 1015 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

177 Yes No 04 MED 

RESPIRATORY INFECTIONS & 

INFLAMMATIONS W MCC 2.0651 6.8 8.6 

178 Yes No 04 MED 

RESPIRATORY INFECTIONS & 

INFLAMMATIONS W CC 1.4859 5.6 6.8 

179 Yes No 04 MED 

RESPIRATORY INFECTIONS & 

INFLAMMATIONS W/O CC/MCC 0.9836 4.1 5.0 

180 No No 04 MED 

RESPIRATORY NEOPLASMS W 

MCC 1.7310 5.7 7.5 

181 No No 04 MED 

RESPIRATORY NEOPLASMS W 

CC 1.2155 4.2 5.4 

182 No No 04 MED 

RESPIRATORY NEOPLASMS W/O 

CC/MCC 0.8086 2.8 3.7 

183 No No 04 MED MAJOR CHEST TRAUMA W MCC 1.4874 5.2 6.5 

184 No No 04 MED MAJOR CHEST TRAUMA W CC 0.9670 3.6 4.3 

185 No No 04 MED 

MAJOR CHEST TRAUMA W/O 

CC/MCC 0.6761 2.6 3.0 

186 Yes No 04 MED PLEURAL EFFUSION W MCC 1.5600 5.3 6.7 

187 Yes No 04 MED PLEURAL EFFUSION W CC 1.0991 3.9 4.9 

188 Yes No 04 MED 

PLEURAL EFFUSION W/O 

CC/MCC 0.7628 2.8 3.5 

189 No No 04 MED 

PULMONARY EDEMA & 

RESPIRATORY FAILURE 1.2776 4.3 5.5 

190 Yes No 04 MED 

CHRONIC OBSTRUCTIVE 

PULMONARY DISEASE W MCC 1.1894 4.5 5.5 

191 Yes No 04 MED 

CHRONIC OBSTRUCTIVE 

PULMONARY DISEASE W CC 0.9712 3.8 4.6 

192 Yes No 04 MED 

CHRONIC OBSTRUCTIVE 

PULMONARY DISEASE W/O 

CC/MCC 0.7200 3.1 3.7 

193 Yes No 04 MED 

SIMPLE PNEUMONIA & 

PLEURISY W MCC 1.4753 5.3 6.5 

194 Yes No 04 MED 

SIMPLE PNEUMONIA & 

PLEURISY W CC 1.0124 4.2 5.0 

195 Yes No 04 MED 

SIMPLE PNEUMONIA & 

PLEURISY W/O CC/MCC 0.7073 3.1 3.7 

196 Yes No 04 MED 

INTERSTITIAL LUNG DISEASE W 

MCC 1.6053 5.6 7.0 

197 Yes No 04 MED 

INTERSTITIAL LUNG DISEASE W 

CC 1.1149 4.2 5.1 

198 Yes No 04 MED 

INTERSTITIAL LUNG DISEASE 

W/O CC/MCC 0.8149 3.1 3.8 

199 No No 04 MED PNEUMOTHORAX W MCC 1.7760 6.2 8.0 

200 No No 04 MED PNEUMOTHORAX W CC 1.0198 3.7 4.8 

201 No No 04 MED PNEUMOTHORAX W/O CC/MCC 0.7167 2.8 3.5 

202 No No 04 MED 

BRONCHITIS & ASTHMA W 

CC/MCC 0.8395 3.4 4.1 

203 No No 04 MED 

BRONCHITIS & ASTHMA W/O 

CC/MCC 0.6051 2.6 3.2 
CMS-1498-P 1016 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

204 No No 04 MED 

RESPIRATORY SIGNS & 

SYMPTOMS 0.6705 2.1 2.7 

205 Yes No 04 MED 

OTHER RESPIRATORY SYSTEM 

DIAGNOSES W MCC 1.3018 4.0 5.3 

206 Yes No 04 MED 

OTHER RESPIRATORY SYSTEM 

DIAGNOSES W/O MCC 0.7546 2.6 3.3 

207 Yes No 04 MED 

RESPIRATORY SYSTEM 

DIAGNOSIS W VENTILATOR 

SUPPORT 96+ HOURS 5.1936 12.6 14.8 

208 No No 04 MED 

RESPIRATORY SYSTEM 

DIAGNOSIS W VENTILATOR 

SUPPORT <96 HOURS 2.2522 5.1 7.0 

215 No No 05 SURG 

OTHER HEART ASSIST SYSTEM 

IMPLANT 12.7451 7.0 12.6 

216 Yes No 05 SURG 

CARDIAC VALVE & OTH MAJ 

CARDIOTHORACIC PROC W 

CARD CATH W MCC 10.0309 14.7 17.1 

217 Yes No 05 SURG 

CARDIAC VALVE & OTH MAJ 

CARDIOTHORACIC PROC W 

CARD CATH W CC 6.8081 9.8 11.0 

218 Yes No 05 SURG 

CARDIAC VALVE & OTH MAJ 

CARDIOTHORACIC PROC W 

CARD CATH W/O CC/MCC 5.3407 7.2 8.0 

219 Yes Yes 05 SURG 

CARDIAC VALVE & OTH MAJ 

CARDIOTHORACIC PROC W/O 

CARD CATH W MCC 8.0975 10.8 13.1 

220 Yes Yes 05 SURG 

CARDIAC VALVE & OTH MAJ 

CARDIOTHORACIC PROC W/O 

CARD CATH W CC 5.3923 7.2 8.0 

221 Yes Yes 05 SURG 

CARDIAC VALVE & OTH MAJ 

CARDIOTHORACIC PROC W/O 

CARD CATH W/O CC/MCC 4.4941 5.6 6.0 

222 No No 05 SURG 

CARDIAC DEFIB IMPLANT W 

CARDIAC CATH W 

AMI/HF/SHOCK W MCC 8.5634 9.4 11.9 

223 No No 05 SURG 

CARDIAC DEFIB IMPLANT W 

CARDIAC CATH W 

AMI/HF/SHOCK W/O MCC 6.4649 4.5 6.2 

224 No No 05 SURG 

CARDIAC DEFIB IMPLANT W 

CARDIAC CATH W/O 

AMI/HF/SHOCK W MCC 7.6030 7.7 9.7 

225 No No 05 SURG 

CARDIAC DEFIB IMPLANT W 

CARDIAC CATH W/O 

AMI/HF/SHOCK W/O MCC 6.0613 4.2 5.3 

226 No No 05 SURG 

CARDIAC DEFIBRILLATOR 

IMPLANT W/O CARDIAC CATH W 

MCC 6.4967 5.0 7.8 

227 No No 05 SURG 

CARDIAC DEFIBRILLATOR 

IMPLANT W/O CARDIAC CATH 5.2285 2.0 3.1 
CMS-1498-P 1017 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

W/O MCC 

228 Yes No 05 SURG 

OTHER CARDIOTHORACIC 

PROCEDURES W MCC 7.6151 11.8 14.2 

229 Yes No 05 SURG 

OTHER CARDIOTHORACIC 

PROCEDURES W CC 4.7934 7.3 8.3 

230 Yes No 05 SURG 

OTHER CARDIOTHORACIC 

PROCEDURES W/O CC/MCC 3.5608 4.6 5.5 

231 No No 05 SURG 

CORONARY BYPASS W PTCA W 

MCC 7.8893 10.9 12.9 

232 No No 05 SURG 

CORONARY BYPASS W PTCA 

W/O MCC 5.8492 8.5 9.4 

233 Yes No 05 SURG 

CORONARY BYPASS W CARDIAC 

CATH W MCC 7.2273 12.1 13.7 

234 Yes No 05 SURG 

CORONARY BYPASS W CARDIAC 

CATH W/O MCC 4.8441 8.2 8.9 

235 Yes No 05 SURG 

CORONARY BYPASS W/O 

CARDIAC CATH W MCC 5.8556 9.3 10.8 

236 Yes No 05 SURG 

CORONARY BYPASS W/O 

CARDIAC CATH W/O MCC 3.7839 6.0 6.5 

237 No No 05 SURG 

MAJOR CARDIOVASC 

PROCEDURES W MCC OR 

THORACIC AORTIC ANEURYSM 

REPAIR 5.1927 7.1 10.2 

238 No No 05 SURG 

MAJOR CARDIOVASC 

PROCEDURES W/O MCC 3.1008 2.9 4.2 

239 Yes No 05 SURG 

AMPUTATION FOR CIRC SYS 

DISORDERS EXC UPPER LIMB & 

TOE W MCC 4.5646 11.3 14.3 

240 Yes No 05 SURG 

AMPUTATION FOR CIRC SYS 

DISORDERS EXC UPPER LIMB & 

TOE W CC 2.6639 7.8 9.6 

241 Yes No 05 SURG 

AMPUTATION FOR CIRC SYS 

DISORDERS EXC UPPER LIMB & 

TOE W/O CC/MCC 1.4626 5.0 6.0 

242 Yes No 05 SURG 

PERMANENT CARDIAC 

PACEMAKER IMPLANT W MCC 3.7327 6.3 8.1 

243 Yes No 05 SURG 

PERMANENT CARDIAC 

PACEMAKER IMPLANT W CC 2.6570 3.8 4.9 

244 Yes No 05 SURG 

PERMANENT CARDIAC 

PACEMAKER IMPLANT W/O 

CC/MCC 2.0486 2.2 2.8 

245 No No 05 SURG AICD GENERATOR PROCEDURES 4.2684 2.5 3.8 

246 No No 05 SURG 

PERC CARDIOVASC PROC W 

DRUG-ELUTING STENT W MCC 

OR 4+ VESSELS/STENTS 3.1923 3.5 5.0 

247 No No 05 SURG 

PERC CARDIOVASC PROC W 

DRUG-ELUTING STENT W/O MCC 1.9812 1.8 2.3 

248 No No 05 SURG 

PERC CARDIOVASC PROC W 

NON-DRUG-ELUTING STENT W 2.9295 4.4 6.0 
CMS-1498-P 1018 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

MCC OR 4+ VES/STENTS 

249 No No 05 SURG 

PERC CARDIOVASC PROC W 

NON-DRUG-ELUTING STENT W/O 

MCC 1.7814 2.2 2.8 

250 No No 05 SURG 

PERC CARDIOVASC PROC W/O 

CORONARY ARTERY STENT W 

MCC 2.8844 5.0 7.0 

251 No No 05 SURG 

PERC CARDIOVASC PROC W/O 

CORONARY ARTERY STENT W/O 

MCC 1.8040 2.1 2.9 

252 No No 05 SURG 

OTHER VASCULAR 

PROCEDURES W MCC 2.9853 5.2 7.9 

253 No No 05 SURG 

OTHER VASCULAR 

PROCEDURES W CC 2.4104 4.4 6.0 

254 No No 05 SURG 

OTHER VASCULAR 

PROCEDURES W/O CC/MCC 1.6244 2.0 2.7 

255 Yes No 05 SURG 

UPPER LIMB & TOE 

AMPUTATION FOR CIRC SYSTEM 

DISORDERS W MCC 2.4930 7.0 9.2 

256 Yes No 05 SURG 

UPPER LIMB & TOE 

AMPUTATION FOR CIRC SYSTEM 

DISORDERS W CC 1.5992 5.6 7.0 

257 Yes No 05 SURG 

UPPER LIMB & TOE 

AMPUTATION FOR CIRC SYSTEM 

DISORDERS W/O CC/MCC 0.9629 3.4 4.3 

258 No No 05 SURG 

CARDIAC PACEMAKER DEVICE 

REPLACEMENT W MCC 2.8707 5.2 7.0 

259 No No 05 SURG 

CARDIAC PACEMAKER DEVICE 

REPLACEMENT W/O MCC 1.8381 2.4 3.2 

260 No No 05 SURG 

CARDIAC PACEMAKER 

REVISION EXCEPT DEVICE 

REPLACEMENT W MCC 3.5636 7.7 10.8 

261 No No 05 SURG 

CARDIAC PACEMAKER 

REVISION EXCEPT DEVICE 

REPLACEMENT W CC 1.6515 3.2 4.5 

262 No No 05 SURG 

CARDIAC PACEMAKER 

REVISION EXCEPT DEVICE 

REPLACEMENT W/O CC/MCC 1.1284 2.0 2.6 

263 No No 05 SURG VEIN LIGATION & STRIPPING 1.7560 3.5 5.6 

264 Yes No 05 SURG 

OTHER CIRCULATORY SYSTEM 

O.R. PROCEDURES 2.5446 5.5 8.3 

265 No No 05 SURG AICD LEAD PROCEDURES 2.3205 2.2 3.3 

280 Yes No 05 MED 

ACUTE MYOCARDIAL 

INFARCTION, DISCHARGED 

ALIVE W MCC 1.8435 5.2 6.6 

281 Yes No 05 MED 

ACUTE MYOCARDIAL 

INFARCTION, DISCHARGED 

ALIVE W CC 1.1852 3.6 4.4 
CMS-1498-P 1019 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

282 Yes No 05 MED 

ACUTE MYOCARDIAL 

INFARCTION, DISCHARGED 

ALIVE W/O CC/MCC 0.8042 2.2 2.8 

283 No No 05 MED 

ACUTE MYOCARDIAL 

INFARCTION, EXPIRED W MCC 1.7107 3.2 5.1 

284 No No 05 MED 

ACUTE MYOCARDIAL 

INFARCTION, EXPIRED W CC 0.8884 2.1 3.0 

285 No No 05 MED 

ACUTE MYOCARDIAL 

INFARCTION, EXPIRED W/O 

CC/MCC 0.5717 1.4 1.8 

286 No No 05 MED 

CIRCULATORY DISORDERS 

EXCEPT AMI, W CARD CATH W 

MCC 1.9978 4.8 6.5 

287 No No 05 MED 

CIRCULATORY DISORDERS 

EXCEPT AMI, W CARD CATH W/O 

MCC 1.0876 2.5 3.2 

288 Yes No 05 MED 

ACUTE & SUBACUTE 

ENDOCARDITIS W MCC 2.9607 8.6 10.9 

289 Yes No 05 MED 

ACUTE & SUBACUTE 

ENDOCARDITIS W CC 1.8355 6.4 7.8 

290 Yes No 05 MED 

ACUTE & SUBACUTE 

ENDOCARDITIS W/O CC/MCC 1.2880 4.4 5.6 

291 Yes No 05 MED 

HEART FAILURE & SHOCK W 

MCC 1.4882 4.8 6.2 

292 Yes No 05 MED HEART FAILURE & SHOCK W CC 1.0245 4.0 4.9 

293 Yes No 05 MED 

HEART FAILURE & SHOCK W/O 

CC/MCC 0.6810 2.8 3.3 

294 No No 05 MED 

DEEP VEIN THROMBOPHLEBITIS 

W CC/MCC 1.0394 4.4 5.4 

295 No No 05 MED 

DEEP VEIN THROMBOPHLEBITIS 

W/O CC/MCC 0.6356 3.4 4.0 

296 No No 05 MED 

CARDIAC ARREST, 

UNEXPLAINED W MCC 1.1698 1.8 2.8 

297 No No 05 MED 

CARDIAC ARREST, 

UNEXPLAINED W CC 0.6844 1.4 1.8 

298 No No 05 MED 

CARDIAC ARREST, 

UNEXPLAINED W/O CC/MCC 0.4523 1.1 1.2 

299 Yes No 05 MED 

PERIPHERAL VASCULAR 

DISORDERS W MCC 1.4050 4.7 6.1 

300 Yes No 05 MED 

PERIPHERAL VASCULAR 

DISORDERS W CC 0.9737 3.9 4.9 

301 Yes No 05 MED 

PERIPHERAL VASCULAR 

DISORDERS W/O CC/MCC 0.6579 2.8 3.5 

302 No No 05 MED ATHEROSCLEROSIS W MCC 0.9712 3.0 4.0 

303 No No 05 MED ATHEROSCLEROSIS W/O MCC 0.5804 2.0 2.4 

304 No No 05 MED HYPERTENSION W MCC 1.0182 3.5 4.5 

305 No No 05 MED HYPERTENSION W/O MCC 0.6117 2.2 2.7 

306 No No 05 MED CARDIAC CONGENITAL & 1.4681 4.4 5.9 
CMS-1498-P 1020 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

VALVULAR DISORDERS W MCC 

307 No No 05 MED 

CARDIAC CONGENITAL & 

VALVULAR DISORDERS W/O 

MCC 0.7927 2.7 3.4 

308 No No 05 MED 

CARDIAC ARRHYTHMIA & 

CONDUCTION DISORDERS W 

MCC 1.2270 4.0 5.2 

309 No No 05 MED 

CARDIAC ARRHYTHMIA & 

CONDUCTION DISORDERS W CC 0.8331 3.0 3.7 

310 No No 05 MED 

CARDIAC ARRHYTHMIA & 

CONDUCTION DISORDERS W/O 

CC/MCC 0.5670 2.1 2.5 

311 No No 05 MED ANGINA PECTORIS 0.5038 1.8 2.2 

312 No No 05 MED SYNCOPE & COLLAPSE 0.7136 2.4 2.9 

313 No No 05 MED CHEST PAIN 0.5481 1.7 2.1 

314 Yes No 05 MED 

OTHER CIRCULATORY SYSTEM 

DIAGNOSES W MCC 1.8232 5.0 6.9 

315 Yes No 05 MED 

OTHER CIRCULATORY SYSTEM 

DIAGNOSES W CC 0.9645 3.3 4.2 

316 Yes No 05 MED 

OTHER CIRCULATORY SYSTEM 

DIAGNOSES W/O CC/MCC 0.6124 2.1 2.6 

326 Yes No 06 SURG 

STOMACH, ESOPHAGEAL & 

DUODENAL PROC W MCC 5.8087 12.6 16.3 

327 Yes No 06 SURG 

STOMACH, ESOPHAGEAL & 

DUODENAL PROC W CC 2.7293 6.9 8.8 

328 Yes No 06 SURG 

STOMACH, ESOPHAGEAL & 

DUODENAL PROC W/O CC/MCC 1.4363 2.9 3.8 

329 Yes No 06 SURG 

MAJOR SMALL & LARGE BOWEL 

PROCEDURES W MCC 5.2995 12.5 15.4 

330 Yes No 06 SURG 

MAJOR SMALL & LARGE BOWEL 

PROCEDURES W CC 2.5865 7.8 9.1 

331 Yes No 06 SURG 

MAJOR SMALL & LARGE BOWEL 

PROCEDURES W/O CC/MCC 1.6299 4.8 5.3 

332 Yes No 06 SURG RECTAL RESECTION W MCC 4.8539 11.8 14.2 

333 Yes No 06 SURG RECTAL RESECTION W CC 2.5015 7.1 8.1 

334 Yes No 06 SURG 

RECTAL RESECTION W/O 

CC/MCC 1.5980 4.2 4.9 

335 Yes No 06 SURG 

PERITONEAL ADHESIOLYSIS W 

MCC 4.2742 11.4 13.7 

336 Yes No 06 SURG 

PERITONEAL ADHESIOLYSIS W 

CC 2.3459 7.2 8.8 

337 Yes No 06 SURG 

PERITONEAL ADHESIOLYSIS 

W/O CC/MCC 1.4851 4.0 5.1 

338 No No 06 SURG 

APPENDECTOMY W 

COMPLICATED PRINCIPAL DIAG 

W MCC 3.2121 8.3 10.0 

339 No No 06 SURG 

APPENDECTOMY W 

COMPLICATED PRINCIPAL DIAG 1.8691 5.6 6.5 
CMS-1498-P 1021 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

W CC 

340 No No 06 SURG 

APPENDECTOMY W 

COMPLICATED PRINCIPAL DIAG 

W/O CC/MCC 1.2447 3.2 3.7 

341 No No 06 SURG 

APPENDECTOMY W/O 

COMPLICATED PRINCIPAL DIAG 

W MCC 2.2602 4.9 6.6 

342 No No 06 SURG 

APPENDECTOMY W/O 

COMPLICATED PRINCIPAL DIAG 

W CC 1.3301 3.0 3.8 

343 No No 06 SURG 

APPENDECTOMY W/O 

COMPLICATED PRINCIPAL DIAG 

W/O CC/MCC 0.9636 1.7 2.0 

344 No No 06 SURG 

MINOR SMALL & LARGE BOWEL 

PROCEDURES W MCC 3.1533 8.9 11.2 

345 No No 06 SURG 

MINOR SMALL & LARGE BOWEL 

PROCEDURES W CC 1.6999 6.0 7.0 

346 No No 06 SURG 

MINOR SMALL & LARGE BOWEL 

PROCEDURES W/O CC/MCC 1.1887 4.2 4.6 

347 No No 06 SURG 

ANAL & STOMAL PROCEDURES 

W MCC 2.4021 6.3 8.8 

348 No No 06 SURG 

ANAL & STOMAL PROCEDURES 

W CC 1.3720 4.1 5.4 

349 No No 06 SURG 

ANAL & STOMAL PROCEDURES 

W/O CC/MCC 0.7996 2.3 2.9 

350 No No 06 SURG 

INGUINAL & FEMORAL HERNIA 

PROCEDURES W MCC 2.4467 5.6 7.8 

351 No No 06 SURG 

INGUINAL & FEMORAL HERNIA 

PROCEDURES W CC 1.3581 3.5 4.5 

352 No No 06 SURG 

INGUINAL & FEMORAL HERNIA 

PROCEDURES W/O CC/MCC 0.8651 1.9 2.4 

353 No No 06 SURG 

HERNIA PROCEDURES EXCEPT 

INGUINAL & FEMORAL W MCC 2.7608 6.3 8.4 

354 No No 06 SURG 

HERNIA PROCEDURES EXCEPT 

INGUINAL & FEMORAL W CC 1.5574 4.0 5.0 

355 No No 06 SURG 

HERNIA PROCEDURES EXCEPT 

INGUINAL & FEMORAL W/O 

CC/MCC 1.0383 2.3 2.8 

356 Yes No 06 SURG 

OTHER DIGESTIVE SYSTEM O.R. 

PROCEDURES W MCC 4.0301 9.2 12.7 

357 Yes No 06 SURG 

OTHER DIGESTIVE SYSTEM O.R. 

PROCEDURES W CC 2.1501 5.7 7.4 

358 Yes No 06 SURG 

OTHER DIGESTIVE SYSTEM O.R. 

PROCEDURES W/O CC/MCC 1.3042 3.0 4.0 

368 No No 06 MED 

MAJOR ESOPHAGEAL 

DISORDERS W MCC 1.7585 5.1 6.7 

369 No No 06 MED 

MAJOR ESOPHAGEAL 

DISORDERS W CC 1.0755 3.7 4.5 

370 No No 06 MED MAJOR ESOPHAGEAL 0.7497 2.6 3.1 
CMS-1498-P 1022 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

DISORDERS W/O CC/MCC 

371 Yes No 06 MED 

MAJOR GASTROINTESTINAL 

DISORDERS & PERITONEAL 

INFECTIONS W MCC 2.0998 6.8 8.9 

372 Yes No 06 MED 

MAJOR GASTROINTESTINAL 

DISORDERS & PERITONEAL 

INFECTIONS W CC 1.2891 5.3 6.5 

373 Yes No 06 MED 

MAJOR GASTROINTESTINAL 

DISORDERS & PERITONEAL 

INFECTIONS W/O CC/MCC 0.8543 3.9 4.6 

374 Yes No 06 MED 

DIGESTIVE MALIGNANCY W 

MCC 2.0619 6.3 8.5 

375 Yes No 06 MED DIGESTIVE MALIGNANCY W CC 1.2773 4.4 5.8 

376 Yes No 06 MED 

DIGESTIVE MALIGNANCY W/O 

CC/MCC 0.8405 2.8 3.6 

377 Yes No 06 MED G.I. HEMORRHAGE W MCC 1.7496 5.0 6.4 

378 Yes No 06 MED G.I. HEMORRHAGE W CC 1.0235 3.5 4.2 

379 Yes No 06 MED G.I. HEMORRHAGE W/O CC/MCC 0.7107 2.6 3.0 

380 Yes No 06 MED 

COMPLICATED PEPTIC ULCER W 

MCC 1.9498 5.8 7.5 

381 Yes No 06 MED 

COMPLICATED PEPTIC ULCER W 

CC 1.1172 3.9 4.8 

382 Yes No 06 MED 

COMPLICATED PEPTIC ULCER 

W/O CC/MCC 0.8117 2.9 3.5 

383 No No 06 MED 

UNCOMPLICATED PEPTIC 

ULCER W MCC 1.1936 4.2 5.3 

384 No No 06 MED 

UNCOMPLICATED PEPTIC 

ULCER W/O MCC 0.8308 3.0 3.6 

385 No No 06 MED 

INFLAMMATORY BOWEL 

DISEASE W MCC 1.9145 6.3 8.4 

386 No No 06 MED 

INFLAMMATORY BOWEL 

DISEASE W CC 1.0439 4.2 5.3 

387 No No 06 MED 

INFLAMMATORY BOWEL 

DISEASE W/O CC/MCC 0.7775 3.2 3.9 

388 Yes No 06 MED G.I. OBSTRUCTION W MCC 1.6490 5.5 7.2 

389 Yes No 06 MED G.I. OBSTRUCTION W CC 0.9323 3.9 4.8 

390 Yes No 06 MED G.I. OBSTRUCTION W/O CC/MCC 0.6361 2.8 3.3 

391 No No 06 MED 

ESOPHAGITIS, GASTROENT & 

MISC DIGEST DISORDERS W 

MCC 1.1553 3.9 5.2 

392 No No 06 MED 

ESOPHAGITIS, GASTROENT & 

MISC DIGEST DISORDERS W/O 

MCC 0.7152 2.8 3.4 

393 No No 06 MED 

OTHER DIGESTIVE SYSTEM 

DIAGNOSES W MCC 1.6569 4.9 6.9 

394 No No 06 MED 

OTHER DIGESTIVE SYSTEM 

DIAGNOSES W CC 0.9917 3.7 4.7 

395 No No 06 MED OTHER DIGESTIVE SYSTEM 0.6717 2.5 3.1 
CMS-1498-P 1023 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

DIAGNOSES W/O CC/MCC 

405 Yes No 07 SURG 

PANCREAS, LIVER & SHUNT 

PROCEDURES W MCC 5.6074 12.0 15.9 

406 Yes No 07 SURG 

PANCREAS, LIVER & SHUNT 

PROCEDURES W CC 2.7826 6.5 8.4 

407 Yes No 07 SURG 

PANCREAS, LIVER & SHUNT 

PROCEDURES W/O CC/MCC 1.8691 4.2 5.2 

408 No No 07 SURG 

BILIARY TRACT PROC EXCEPT 

ONLY CHOLECYST W OR W/O 

C.D.E. W MCC 3.9590 11.0 13.5 

409 No No 07 SURG 

BILIARY TRACT PROC EXCEPT 

ONLY CHOLECYST W OR W/O 

C.D.E. W CC 2.4837 7.4 8.9 

410 No No 07 SURG 

BILIARY TRACT PROC EXCEPT 

ONLY CHOLECYST W OR W/O 

C.D.E. W/O CC/MCC 1.6208 4.9 5.8 

411 No No 07 SURG 

CHOLECYSTECTOMY W C.D.E. W 

MCC 3.6953 9.9 11.8 

412 No No 07 SURG 

CHOLECYSTECTOMY W C.D.E. W 

CC 2.5380 7.0 8.3 

413 No No 07 SURG 

CHOLECYSTECTOMY W C.D.E. 

W/O CC/MCC 1.7385 4.5 5.4 

414 Yes No 07 SURG 

CHOLECYSTECTOMY EXCEPT 

BY LAPAROSCOPE W/O C.D.E. W 

MCC 3.6719 9.3 11.4 

415 Yes No 07 SURG 

CHOLECYSTECTOMY EXCEPT 

BY LAPAROSCOPE W/O C.D.E. W 

CC 2.1000 6.2 7.3 

416 Yes No 07 SURG 

CHOLECYSTECTOMY EXCEPT 

BY LAPAROSCOPE W/O C.D.E. 

W/O CC/MCC 1.3123 3.7 4.4 

417 No No 07 SURG 

LAPAROSCOPIC 

CHOLECYSTECTOMY W/O C.D.E. 

W MCC 2.5055 6.2 7.8 

418 No No 07 SURG 

LAPAROSCOPIC 

CHOLECYSTECTOMY W/O C.D.E. 

W CC 1.7047 4.4 5.4 

419 No No 07 SURG 

LAPAROSCOPIC 

CHOLECYSTECTOMY W/O C.D.E. 

W/O CC/MCC 1.1754 2.4 3.0 

420 No No 07 SURG 

HEPATOBILIARY DIAGNOSTIC 

PROCEDURES W MCC 3.6914 9.2 13.1 

421 No No 07 SURG 

HEPATOBILIARY DIAGNOSTIC 

PROCEDURES W CC 1.8890 5.1 7.0 

422 No No 07 SURG 

HEPATOBILIARY DIAGNOSTIC 

PROCEDURES W/O CC/MCC 1.2777 3.1 4.1 

423 No No 07 SURG 

OTHER HEPATOBILIARY OR 

PANCREAS O.R. PROCEDURES W 

MCC 4.4476 10.9 14.4 
CMS-1498-P 1024 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

424 No No 07 SURG 

OTHER HEPATOBILIARY OR 

PANCREAS O.R. PROCEDURES W 

CC 2.4219 7.1 9.1 

425 No No 07 SURG 

OTHER HEPATOBILIARY OR 

PANCREAS O.R. PROCEDURES 

W/O CC/MCC 1.6265 4.5 5.7 

432 No No 07 MED 

CIRRHOSIS & ALCOHOLIC 

HEPATITIS W MCC 1.6939 4.9 6.5 

433 No No 07 MED 

CIRRHOSIS & ALCOHOLIC 

HEPATITIS W CC 0.9487 3.6 4.6 

434 No No 07 MED 

CIRRHOSIS & ALCOHOLIC 

HEPATITIS W/O CC/MCC 0.6116 2.5 3.2 

435 No No 07 MED 

MALIGNANCY OF 

HEPATOBILIARY SYSTEM OR 

PANCREAS W MCC 1.8035 5.6 7.4 

436 No No 07 MED 

MALIGNANCY OF 

HEPATOBILIARY SYSTEM OR 

PANCREAS W CC 1.2175 4.2 5.5 

437 No No 07 MED 

MALIGNANCY OF 

HEPATOBILIARY SYSTEM OR 

PANCREAS W/O CC/MCC 0.8973 2.8 3.7 

438 No No 07 MED 

DISORDERS OF PANCREAS 

EXCEPT MALIGNANCY W MCC 1.8265 5.4 7.5 

439 No No 07 MED 

DISORDERS OF PANCREAS 

EXCEPT MALIGNANCY W CC 1.0081 4.0 5.0 

440 No No 07 MED 

DISORDERS OF PANCREAS 

EXCEPT MALIGNANCY W/O 

CC/MCC 0.6878 2.9 3.5 

441 Yes No 07 MED 

DISORDERS OF LIVER EXCEPT 

MALIG,CIRR,ALC HEPA W MCC 1.8335 5.2 7.1 

442 Yes No 07 MED 

DISORDERS OF LIVER EXCEPT 

MALIG,CIRR,ALC HEPA W CC 0.9843 3.7 4.8 

443 Yes No 07 MED 

DISORDERS OF LIVER EXCEPT 

MALIG,CIRR,ALC HEPA W/O 

CC/MCC 0.6578 2.7 3.3 

444 No No 07 MED 

DISORDERS OF THE BILIARY 

TRACT W MCC 1.5571 4.8 6.2 

445 No No 07 MED 

DISORDERS OF THE BILIARY 

TRACT W CC 1.0681 3.6 4.5 

446 No No 07 MED 

DISORDERS OF THE BILIARY 

TRACT W/O CC/MCC 0.7404 2.5 3.1 

453 No No 08 SURG 

COMBINED 

ANTERIOR/POSTERIOR SPINAL 

FUSION W MCC 10.3048 10.7 13.5 

454 No No 08 SURG 

COMBINED 

ANTERIOR/POSTERIOR SPINAL 

FUSION W CC 7.3001 5.5 6.8 

455 No No 08 SURG 

COMBINED 

ANTERIOR/POSTERIOR SPINAL 5.4796 3.1 3.8 
CMS-1498-P 1025 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

FUSION W/O CC/MCC 

456 No No 08 SURG 

SPINAL FUS EXC CERV W 

SPINAL CURV/MALIG/INFEC OR 

9+ FUS W MCC 9.2948 10.8 13.5 

457 No No 08 SURG 

SPINAL FUS EXC CERV W 

SPINAL CURV/MALIG/INFEC OR 

9+ FUS W CC 6.2478 5.9 7.0 

458 No No 08 SURG 

SPINAL FUS EXC CERV W 

SPINAL CURV/MALIG/INFEC OR 

9+ FUS W/O CC/MCC 4.9778 3.5 4.1 

459 Yes No 08 SURG 

SPINAL FUSION EXCEPT 

CERVICAL W MCC 6.5382 7.4 9.1 

460 Yes No 08 SURG 

SPINAL FUSION EXCEPT 

CERVICAL W/O MCC 3.9004 3.3 3.9 

461 No No 08 SURG 

BILATERAL OR MULTIPLE 

MAJOR JOINT PROCS OF LOWER 

EXTREMITY W MCC 4.9653 6.7 8.3 

462 No No 08 SURG 

BILATERAL OR MULTIPLE 

MAJOR JOINT PROCS OF LOWER 

EXTREMITY W/O MCC 3.3634 3.7 4.1 

463 Yes No 08 SURG 

WND DEBRID & SKN GRFT EXC 

HAND, FOR MUSCULO-CONN 

TISS DIS W MCC 4.9853 11.1 15.1 

464 Yes No 08 SURG 

WND DEBRID & SKN GRFT EXC 

HAND, FOR MUSCULO-CONN 

TISS DIS W CC 2.8664 6.9 8.9 

465 Yes No 08 SURG 

WND DEBRID & SKN GRFT EXC 

HAND, FOR MUSCULO-CONN 

TISS DIS W/O CC/MCC 1.7885 4.1 5.3 

466 Yes No 08 SURG 

REVISION OF HIP OR KNEE 

REPLACEMENT W MCC 4.9381 7.3 9.0 

467 Yes No 08 SURG 

REVISION OF HIP OR KNEE 

REPLACEMENT W CC 3.2568 4.3 5.0 

468 Yes No 08 SURG 

REVISION OF HIP OR KNEE 

REPLACEMENT W/O CC/MCC 2.5912 3.3 3.6 

469 Yes No 08 SURG 

MAJOR JOINT REPLACEMENT OR 

REATTACHMENT OF LOWER 

EXTREMITY W MCC 3.4827 6.7 8.0 

470 Yes No 08 SURG 

MAJOR JOINT REPLACEMENT OR 

REATTACHMENT OF LOWER 

EXTREMITY W/O MCC 2.1173 3.4 3.7 

471 No No 08 SURG 

CERVICAL SPINAL FUSION W 

MCC 4.7410 6.6 9.3 

472 No No 08 SURG CERVICAL SPINAL FUSION W CC 2.7945 2.6 3.8 

473 No No 08 SURG 

CERVICAL SPINAL FUSION W/O 

CC/MCC 2.0987 1.5 1.9 

474 Yes No 08 SURG 

AMPUTATION FOR 

MUSCULOSKELETAL SYS & 

CONN TISSUE DIS W MCC 3.5131 9.2 12.0 
CMS-1498-P 1026 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

475 Yes No 08 SURG 

AMPUTATION FOR 

MUSCULOSKELETAL SYS & 

CONN TISSUE DIS W CC 1.9640 6.1 7.7 

476 Yes No 08 SURG 

AMPUTATION FOR 

MUSCULOSKELETAL SYS & 

CONN TISSUE DIS W/O CC/MCC 0.9985 3.2 4.1 

477 Yes Yes 08 SURG 

BIOPSIES OF 

MUSCULOSKELETAL SYSTEM & 

CONNECTIVE TISSUE W MCC 3.3163 8.9 11.1 

478 Yes Yes 08 SURG 

BIOPSIES OF 

MUSCULOSKELETAL SYSTEM & 

CONNECTIVE TISSUE W CC 2.2598 5.3 6.9 

479 Yes Yes 08 SURG 

BIOPSIES OF 

MUSCULOSKELETAL SYSTEM & 

CONNECTIVE TISSUE W/O 

CC/MCC 1.6417 2.4 3.4 

480 Yes Yes 08 SURG 

HIP & FEMUR PROCEDURES 

EXCEPT MAJOR JOINT W MCC 3.0913 7.7 9.0 

481 Yes Yes 08 SURG 

HIP & FEMUR PROCEDURES 

EXCEPT MAJOR JOINT W CC 1.8944 5.1 5.6 

482 Yes Yes 08 SURG 

HIP & FEMUR PROCEDURES 

EXCEPT MAJOR JOINT W/O 

CC/MCC 1.5431 4.1 4.5 

483 Yes No 08 SURG 

MAJOR JOINT & LIMB 

REATTACHMENT PROC OF 

UPPER EXTREMITY W CC/MCC 2.4235 3.1 3.7 

484 Yes No 08 SURG 

MAJOR JOINT & LIMB 

REATTACHMENT PROC OF 

UPPER EXTREMITY W/O CC/MCC 1.9713 2.0 2.2 

485 No No 08 SURG 

KNEE PROCEDURES W PDX OF 

INFECTION W MCC 3.1808 9.0 10.9 

486 No No 08 SURG 

KNEE PROCEDURES W PDX OF 

INFECTION W CC 2.0450 6.1 7.2 

487 No No 08 SURG 

KNEE PROCEDURES W PDX OF 

INFECTION W/O CC/MCC 1.4752 4.4 5.1 

488 Yes No 08 SURG 

KNEE PROCEDURES W/O PDX OF 

INFECTION W CC/MCC 1.7294 3.8 4.7 

489 Yes No 08 SURG 

KNEE PROCEDURES W/O PDX OF 

INFECTION W/O CC/MCC 1.2220 2.5 2.9 

490 No No 08 SURG 

BACK & NECK PROC EXC 

SPINAL FUSION W CC/MCC OR 

DISC DEVICE/NEUROSTIM 1.7996 3.0 4.3 

491 No No 08 SURG 

BACK & NECK PROC EXC 

SPINAL FUSION W/O CC/MCC 0.9982 1.7 2.1 

492 Yes Yes 08 SURG 

LOWER EXTREM & HUMER 

PROC EXCEPT HIP,FOOT,FEMUR 

W MCC 3.0748 6.8 8.6 

493 Yes Yes 08 SURG 

LOWER EXTREM & HUMER 

PROC EXCEPT HIP,FOOT,FEMUR 1.8573 4.2 5.0 
CMS-1498-P 1027 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

W CC 

494 Yes Yes 08 SURG 

LOWER EXTREM & HUMER 

PROC EXCEPT HIP,FOOT,FEMUR 

W/O CC/MCC 1.3220 2.7 3.1 

495 Yes Yes 08 SURG 

LOCAL EXCISION & REMOVAL 

INT FIX DEVICES EXC HIP & 

FEMUR W MCC 2.8691 7.6 10.2 

496 Yes Yes 08 SURG 

LOCAL EXCISION & REMOVAL 

INT FIX DEVICES EXC HIP & 

FEMUR W CC 1.6275 4.1 5.4 

497 Yes Yes 08 SURG 

LOCAL EXCISION & REMOVAL 

INT FIX DEVICES EXC HIP & 

FEMUR W/O CC/MCC 1.0813 2.0 2.6 

498 No No 08 SURG 

LOCAL EXCISION & REMOVAL 

INT FIX DEVICES OF HIP & 

FEMUR W CC/MCC 1.9968 5.4 7.3 

499 No No 08 SURG 

LOCAL EXCISION & REMOVAL 

INT FIX DEVICES OF HIP & 

FEMUR W/O CC/MCC 0.9936 2.2 3.0 

500 Yes Yes 08 SURG 

SOFT TISSUE PROCEDURES W 

MCC 3.0486 7.7 10.5 

501 Yes Yes 08 SURG SOFT TISSUE PROCEDURES W CC 1.5858 4.6 6.0 

502 Yes Yes 08 SURG 

SOFT TISSUE PROCEDURES W/O 

CC/MCC 1.0354 2.3 2.8 

503 No No 08 SURG FOOT PROCEDURES W MCC 2.2681 6.5 8.4 

504 No No 08 SURG FOOT PROCEDURES W CC 1.5696 5.0 6.2 

505 No No 08 SURG 

FOOT PROCEDURES W/O 

CC/MCC 1.0792 2.5 3.1 

506 No No 08 SURG 

MAJOR THUMB OR JOINT 

PROCEDURES 1.1834 2.7 3.8 

507 No No 08 SURG 

MAJOR SHOULDER OR ELBOW 

JOINT PROCEDURES W CC/MCC 1.8823 3.4 4.5 

508 No No 08 SURG 

MAJOR SHOULDER OR ELBOW 

JOINT PROCEDURES W/O 

CC/MCC 1.4101 1.7 2.1 

509 No No 08 SURG ARTHROSCOPY 1.3044 2.3 3.5 

510 Yes No 08 SURG 

SHOULDER,ELBOW OR 

FOREARM PROC,EXC MAJOR 

JOINT PROC W MCC 2.1698 5.0 6.3 

511 Yes No 08 SURG 

SHOULDER,ELBOW OR 

FOREARM PROC,EXC MAJOR 

JOINT PROC W CC 1.4748 3.2 3.9 

512 Yes No 08 SURG 

SHOULDER,ELBOW OR 

FOREARM PROC,EXC MAJOR 

JOINT PROC W/O CC/MCC 1.0533 1.8 2.1 

513 No No 08 SURG 

HAND OR WRIST PROC, EXCEPT 

MAJOR THUMB OR JOINT PROC 

W CC/MCC 1.3000 3.5 4.8 
CMS-1498-P 1028 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

514 No No 08 SURG 

HAND OR WRIST PROC, EXCEPT 

MAJOR THUMB OR JOINT PROC 

W/O CC/MCC 0.8215 2.1 2.6 

515 Yes Yes 08 SURG 

OTHER MUSCULOSKELET SYS & 

CONN TISS O.R. PROC W MCC 3.1992 7.7 9.9 

516 Yes Yes 08 SURG 

OTHER MUSCULOSKELET SYS & 

CONN TISS O.R. PROC W CC 1.9292 4.7 5.9 

517 Yes Yes 08 SURG 

OTHER MUSCULOSKELET SYS & 

CONN TISS O.R. PROC W/O 

CC/MCC 1.4856 2.6 3.4 

533 Yes No 08 MED FRACTURES OF FEMUR W MCC 1.5545 4.9 6.5 

534 Yes No 08 MED 

FRACTURES OF FEMUR W/O 

MCC 0.7576 3.1 3.9 

535 Yes No 08 MED 

FRACTURES OF HIP & PELVIS W 

MCC 1.3495 4.5 5.8 

536 Yes No 08 MED 

FRACTURES OF HIP & PELVIS 

W/O MCC 0.7175 3.2 3.7 

537 No No 08 MED 

SPRAINS, STRAINS, & 

DISLOCATIONS OF HIP, PELVIS & 

THIGH W CC/MCC 0.8242 3.5 4.1 

538 No No 08 MED 

SPRAINS, STRAINS, & 

DISLOCATIONS OF HIP, PELVIS & 

THIGH W/O CC/MCC 0.6060 2.6 3.0 

539 Yes No 08 MED OSTEOMYELITIS W MCC 2.0525 7.1 9.5 

540 Yes No 08 MED OSTEOMYELITIS W CC 1.3139 5.4 6.8 

541 Yes No 08 MED OSTEOMYELITIS W/O CC/MCC 0.8733 3.7 4.8 

542 Yes No 08 MED 

PATHOLOGICAL FRACTURES & 

MUSCULOSKELET & CONN TISS 

MALIG W MCC 1.9499 6.3 8.3 

543 Yes No 08 MED 

PATHOLOGICAL FRACTURES & 

MUSCULOSKELET & CONN TISS 

MALIG W CC 1.1564 4.5 5.6 

544 Yes No 08 MED 

PATHOLOGICAL FRACTURES & 

MUSCULOSKELET & CONN TISS 

MALIG W/O CC/MCC 0.7753 3.4 4.0 

545 Yes No 08 MED 

CONNECTIVE TISSUE 

DISORDERS W MCC 2.5453 6.3 9.0 

546 Yes No 08 MED 

CONNECTIVE TISSUE 

DISORDERS W CC 1.1596 4.2 5.3 

547 Yes No 08 MED 

CONNECTIVE TISSUE 

DISORDERS W/O CC/MCC 0.7297 2.9 3.5 

548 No No 08 MED SEPTIC ARTHRITIS W MCC 1.9836 6.6 8.7 

549 No No 08 MED SEPTIC ARTHRITIS W CC 1.2003 4.8 6.1 

550 No No 08 MED SEPTIC ARTHRITIS W/O CC/MCC 0.8223 3.3 4.0 

551 Yes No 08 MED 

MEDICAL BACK PROBLEMS W 

MCC 1.6337 5.2 6.8 

552 Yes No 08 MED 

MEDICAL BACK PROBLEMS W/O 

MCC 0.8160 3.3 4.0 
CMS-1498-P 1029 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

553 No No 08 MED 

BONE DISEASES & 

ARTHROPATHIES W MCC 1.1369 4.3 5.6 

554 No No 08 MED 

BONE DISEASES & 

ARTHROPATHIES W/O MCC 0.6774 3.0 3.6 

555 No No 08 MED 

SIGNS & SYMPTOMS OF 

MUSCULOSKELETAL SYSTEM & 

CONN TISSUE W MCC 1.0941 3.6 4.8 

556 No No 08 MED 

SIGNS & SYMPTOMS OF 

MUSCULOSKELETAL SYSTEM & 

CONN TISSUE W/O MCC 0.6536 2.5 3.2 

557 Yes No 08 MED 

TENDONITIS, MYOSITIS & 

BURSITIS W MCC 1.5997 5.4 6.9 

558 Yes No 08 MED 

TENDONITIS, MYOSITIS & 

BURSITIS W/O MCC 0.8796 3.6 4.3 

559 Yes No 08 MED 

AFTERCARE, 

MUSCULOSKELETAL SYSTEM & 

CONNECTIVE TISSUE W MCC 1.7624 5.2 7.1 

560 Yes No 08 MED 

AFTERCARE, 

MUSCULOSKELETAL SYSTEM & 

CONNECTIVE TISSUE W CC 0.9992 3.6 4.6 

561 Yes No 08 MED 

AFTERCARE, 

MUSCULOSKELETAL SYSTEM & 

CONNECTIVE TISSUE W/O 

CC/MCC 0.6201 2.0 2.6 

562 Yes No 08 MED 

FX, SPRN, STRN & DISL EXCEPT 

FEMUR, HIP, PELVIS & THIGH W 

MCC 1.3925 4.5 5.9 

563 Yes No 08 MED 

FX, SPRN, STRN & DISL EXCEPT 

FEMUR, HIP, PELVIS & THIGH 

W/O MCC 0.7120 3.0 3.6 

564 No No 08 MED 

OTHER MUSCULOSKELETAL SYS 

& CONNECTIVE TISSUE 

DIAGNOSES W MCC 1.4686 5.0 6.6 

565 No No 08 MED 

OTHER MUSCULOSKELETAL SYS 

& CONNECTIVE TISSUE 

DIAGNOSES W CC 0.9051 3.7 4.6 

566 No No 08 MED 

OTHER MUSCULOSKELETAL SYS 

& CONNECTIVE TISSUE 

DIAGNOSES W/O CC/MCC 0.6592 2.7 3.4 

573 Yes No 09 SURG 

SKIN GRAFT &/OR DEBRID FOR 

SKN ULCER OR CELLULITIS W 

MCC 3.2654 9.2 12.6 

574 Yes No 09 SURG 

SKIN GRAFT &/OR DEBRID FOR 

SKN ULCER OR CELLULITIS W 

CC 1.8708 6.7 8.5 

575 Yes No 09 SURG 

SKIN GRAFT &/OR DEBRID FOR 

SKN ULCER OR CELLULITIS W/O 

CC/MCC 1.0915 4.2 5.2 

576 No No 09 SURG SKIN GRAFT &/OR DEBRID EXC 3.9309 9.1 13.0 
CMS-1498-P 1030 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

FOR SKIN ULCER OR CELLULITIS 

W MCC 

577 No No 09 SURG 

SKIN GRAFT &/OR DEBRID EXC 

FOR SKIN ULCER OR CELLULITIS 

W CC 1.7025 4.1 6.2 

578 No No 09 SURG 

SKIN GRAFT &/OR DEBRID EXC 

FOR SKIN ULCER OR CELLULITIS 

W/O CC/MCC 1.0505 2.4 3.3 

579 Yes No 09 SURG 

OTHER SKIN, SUBCUT TISS & 

BREAST PROC W MCC 2.9643 7.7 10.5 

580 Yes No 09 SURG 

OTHER SKIN, SUBCUT TISS & 

BREAST PROC W CC 1.4993 3.8 5.4 

581 Yes No 09 SURG 

OTHER SKIN, SUBCUT TISS & 

BREAST PROC W/O CC/MCC 0.9301 1.8 2.4 

582 No No 09 SURG 

MASTECTOMY FOR 

MALIGNANCY W CC/MCC 1.0633 2.0 2.7 

583 No No 09 SURG 

MASTECTOMY FOR 

MALIGNANCY W/O CC/MCC 0.8543 1.5 1.7 

584 No No 09 SURG 

BREAST BIOPSY, LOCAL 

EXCISION & OTHER BREAST 

PROCEDURES W CC/MCC 1.5258 3.5 5.0 

585 No No 09 SURG 

BREAST BIOPSY, LOCAL 

EXCISION & OTHER BREAST 

PROCEDURES W/O CC/MCC 1.0568 1.7 2.1 

592 Yes No 09 MED SKIN ULCERS W MCC 1.7757 6.2 8.3 

593 Yes No 09 MED SKIN ULCERS W CC 1.0631 4.8 5.9 

594 Yes No 09 MED SKIN ULCERS W/O CC/MCC 0.7550 3.6 4.7 

595 No No 09 MED MAJOR SKIN DISORDERS W MCC 1.8752 5.9 7.9 

596 No No 09 MED 

MAJOR SKIN DISORDERS W/O 

MCC 0.8700 3.7 4.6 

597 No No 09 MED 

MALIGNANT BREAST 

DISORDERS W MCC 1.5651 5.5 7.5 

598 No No 09 MED 

MALIGNANT BREAST 

DISORDERS W CC 1.0728 4.1 5.5 

599 No No 09 MED 

MALIGNANT BREAST 

DISORDERS W/O CC/MCC 0.6318 2.5 3.3 

600 No No 09 MED 

NON-MALIGNANT BREAST 

DISORDERS W CC/MCC 0.9639 4.1 4.9 

601 No No 09 MED 

NON-MALIGNANT BREAST 

DISORDERS W/O CC/MCC 0.6731 3.0 3.6 

602 Yes No 09 MED CELLULITIS W MCC 1.4705 5.3 6.7 

603 Yes No 09 MED CELLULITIS W/O MCC 0.8346 3.8 4.5 

604 No No 09 MED 

TRAUMA TO THE SKIN, SUBCUT 

TISS & BREAST W MCC 1.2286 3.9 5.2 

605 No No 09 MED 

TRAUMA TO THE SKIN, SUBCUT 

TISS & BREAST W/O MCC 0.7145 2.7 3.3 

606 No No 09 MED MINOR SKIN DISORDERS W MCC 1.3114 4.3 6.0 

607 No No 09 MED MINOR SKIN DISORDERS W/O 0.6803 2.8 3.6 
CMS-1498-P 1031 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

MCC 

614 No No 10 SURG 

ADRENAL & PITUITARY 

PROCEDURES W CC/MCC 2.4584 4.7 6.5 

615 No No 10 SURG 

ADRENAL & PITUITARY 

PROCEDURES W/O CC/MCC 1.3993 2.5 3.0 

616 Yes No 10 SURG 

AMPUTAT OF LOWER LIMB FOR 

ENDOCRINE,NUTRIT,& 

METABOL DIS W MCC 4.4871 12.5 15.6 

617 Yes No 10 SURG 

AMPUTAT OF LOWER LIMB FOR 

ENDOCRINE,NUTRIT,& 

METABOL DIS W CC 2.0083 6.5 7.9 

618 Yes No 10 SURG 

AMPUTAT OF LOWER LIMB FOR 

ENDOCRINE,NUTRIT,& 

METABOL DIS W/O CC/MCC 1.2176 4.1 5.1 

619 No No 10 SURG 

O.R. PROCEDURES FOR OBESITY 

W MCC 3.6116 4.6 7.7 

620 No No 10 SURG 

O.R. PROCEDURES FOR OBESITY 

W CC 1.8814 2.6 3.4 

621 No No 10 SURG 

O.R. PROCEDURES FOR OBESITY 

W/O CC/MCC 1.4877 1.6 1.9 

622 Yes No 10 SURG 

SKIN GRAFTS & WOUND DEBRID 

FOR ENDOC, NUTRIT & METAB 

DIS W MCC 3.3683 9.4 12.4 

623 Yes No 10 SURG 

SKIN GRAFTS & WOUND DEBRID 

FOR ENDOC, NUTRIT & METAB 

DIS W CC 1.8501 6.1 7.6 

624 Yes No 10 SURG 

SKIN GRAFTS & WOUND DEBRID 

FOR ENDOC, NUTRIT & METAB 

DIS W/O CC/MCC 1.0337 3.9 4.8 

625 No No 10 SURG 

THYROID, PARATHYROID & 

THYROGLOSSAL PROCEDURES 

W MCC 2.2439 4.6 6.9 

626 No No 10 SURG 

THYROID, PARATHYROID & 

THYROGLOSSAL PROCEDURES 

W CC 1.1771 2.1 3.1 

627 No No 10 SURG 

THYROID, PARATHYROID & 

THYROGLOSSAL PROCEDURES 

W/O CC/MCC 0.7884 1.2 1.4 

628 Yes No 10 SURG 

OTHER ENDOCRINE, NUTRIT & 

METAB O.R. PROC W MCC 3.3820 7.2 10.6 

629 Yes No 10 SURG 

OTHER ENDOCRINE, NUTRIT & 

METAB O.R. PROC W CC 2.2645 6.5 8.0 

630 Yes No 10 SURG 

OTHER ENDOCRINE, NUTRIT & 

METAB O.R. PROC W/O CC/MCC 1.4425 3.4 4.5 

637 Yes No 10 MED DIABETES W MCC 1.4431 4.5 6.0 

638 Yes No 10 MED DIABETES W CC 0.8267 3.2 4.0 

639 Yes No 10 MED DIABETES W/O CC/MCC 0.5508 2.3 2.8 

640 Yes No 10 MED NUTRITIONAL & MISC 1.1361 3.6 5.1 
CMS-1498-P 1032 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

METABOLIC DISORDERS W MCC 

641 Yes No 10 MED 

NUTRITIONAL & MISC 

METABOLIC DISORDERS W/O 

MCC 0.6887 2.9 3.6 

642 No No 10 MED 

INBORN ERRORS OF 

METABOLISM 1.0385 3.4 4.7 

643 Yes No 10 MED ENDOCRINE DISORDERS W MCC 1.8172 6.0 7.6 

644 Yes No 10 MED ENDOCRINE DISORDERS W CC 1.0586 4.2 5.2 

645 Yes No 10 MED 

ENDOCRINE DISORDERS W/O 

CC/MCC 0.7169 2.9 3.6 

652 No No 11 SURG KIDNEY TRANSPLANT 3.0630 6.3 7.5 

653 Yes No 11 SURG 

MAJOR BLADDER PROCEDURES 

W MCC 6.0950 13.6 16.6 

654 Yes No 11 SURG 

MAJOR BLADDER PROCEDURES 

W CC 3.0117 8.2 9.3 

655 Yes No 11 SURG 

MAJOR BLADDER PROCEDURES 

W/O CC/MCC 1.9644 4.8 5.7 

656 No No 11 SURG 

KIDNEY & URETER 

PROCEDURES FOR NEOPLASM W 

MCC 3.5861 7.7 10.1 

657 No No 11 SURG 

KIDNEY & URETER 

PROCEDURES FOR NEOPLASM W 

CC 2.0062 4.9 5.9 

658 No No 11 SURG 

KIDNEY & URETER 

PROCEDURES FOR NEOPLASM 

W/O CC/MCC 1.4305 3.0 3.4 

659 Yes No 11 SURG 

KIDNEY & URETER 

PROCEDURES FOR NONNEOPLASM W MCC 3.5110 8.0 10.8 

660 Yes No 11 SURG 

KIDNEY & URETER 

PROCEDURES FOR NONNEOPLASM W CC 1.9077 4.5 6.0 

661 Yes No 11 SURG 

KIDNEY & URETER 

PROCEDURES FOR NONNEOPLASM W/O CC/MCC 1.2709 2.4 2.9 

662 No No 11 SURG 

MINOR BLADDER PROCEDURES 

W MCC 3.0413 7.6 10.8 

663 No No 11 SURG 

MINOR BLADDER PROCEDURES 

W CC 1.4721 3.6 5.2 

664 No No 11 SURG 

MINOR BLADDER PROCEDURES 

W/O CC/MCC 1.1170 1.5 1.9 

665 No No 11 SURG PROSTATECTOMY W MCC 2.8519 8.7 11.3 

666 No No 11 SURG PROSTATECTOMY W CC 1.6440 4.5 6.4 

667 No No 11 SURG PROSTATECTOMY W/O CC/MCC 0.7945 1.8 2.4 

668 No No 11 SURG 

TRANSURETHRAL PROCEDURES 

W MCC 2.5102 6.6 8.9 

669 No No 11 SURG 

TRANSURETHRAL PROCEDURES 

W CC 1.2610 3.2 4.4 
CMS-1498-P 1033 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

670 No No 11 SURG 

TRANSURETHRAL PROCEDURES 

W/O CC/MCC 0.7790 1.8 2.3 

671 No No 11 SURG 

URETHRAL PROCEDURES W 

CC/MCC 1.4360 4.1 5.6 

672 No No 11 SURG 

URETHRAL PROCEDURES W/O 

CC/MCC 0.7921 1.8 2.2 

673 No No 11 SURG 

OTHER KIDNEY & URINARY 

TRACT PROCEDURES W MCC 2.9238 5.9 9.6 

674 No No 11 SURG 

OTHER KIDNEY & URINARY 

TRACT PROCEDURES W CC 2.1004 4.6 6.7 

675 No No 11 SURG 

OTHER KIDNEY & URINARY 

TRACT PROCEDURES W/O 

CC/MCC 1.3469 1.6 2.1 

682 Yes No 11 MED RENAL FAILURE W MCC 1.6383 5.1 6.8 

683 Yes No 11 MED RENAL FAILURE W CC 1.0208 4.0 4.9 

684 Yes No 11 MED RENAL FAILURE W/O CC/MCC 0.6561 2.8 3.3 

685 No No 11 MED ADMIT FOR RENAL DIALYSIS 0.8892 2.5 3.4 

686 No No 11 MED 

KIDNEY & URINARY TRACT 

NEOPLASMS W MCC 1.8264 5.8 7.8 

687 No No 11 MED 

KIDNEY & URINARY TRACT 

NEOPLASMS W CC 1.0822 3.8 5.0 

688 No No 11 MED 

KIDNEY & URINARY TRACT 

NEOPLASMS W/O CC/MCC 0.6447 2.2 2.8 

689 Yes No 11 MED 

KIDNEY & URINARY TRACT 

INFECTIONS W MCC 1.2155 4.6 5.8 

690 Yes No 11 MED 

KIDNEY & URINARY TRACT 

INFECTIONS W/O MCC 0.7838 3.4 4.1 

691 No No 11 MED 

URINARY STONES W ESW 

LITHOTRIPSY W CC/MCC 1.6152 3.3 4.3 

692 No No 11 MED 

URINARY STONES W ESW 

LITHOTRIPSY W/O CC/MCC 1.1211 1.8 2.2 

693 No No 11 MED 

URINARY STONES W/O ESW 

LITHOTRIPSY W MCC 1.3487 3.9 5.2 

694 No No 11 MED 

URINARY STONES W/O ESW 

LITHOTRIPSY W/O MCC 0.7098 2.0 2.6 

695 No No 11 MED 

KIDNEY & URINARY TRACT 

SIGNS & SYMPTOMS W MCC 1.2029 4.3 5.6 

696 No No 11 MED 

KIDNEY & URINARY TRACT 

SIGNS & SYMPTOMS W/O MCC 0.6555 2.6 3.2 

697 No No 11 MED URETHRAL STRICTURE 0.7776 2.4 3.1 

698 Yes No 11 MED 

OTHER KIDNEY & URINARY 

TRACT DIAGNOSES W MCC 1.6033 5.2 6.8 

699 Yes No 11 MED 

OTHER KIDNEY & URINARY 

TRACT DIAGNOSES W CC 0.9988 3.7 4.7 

700 Yes No 11 MED 

OTHER KIDNEY & URINARY 

TRACT DIAGNOSES W/O CC/MCC 0.6703 2.6 3.2 

707 No No 12 SURG 

MAJOR MALE PELVIC 

PROCEDURES W CC/MCC 1.7846 3.2 4.2 
CMS-1498-P 1034 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

708 No No 12 SURG 

MAJOR MALE PELVIC 

PROCEDURES W/O CC/MCC 1.2691 1.6 1.9 

709 No No 12 SURG PENIS PROCEDURES W CC/MCC 1.8781 3.3 5.7 

710 No No 12 SURG 

PENIS PROCEDURES W/O 

CC/MCC 1.2779 1.4 1.7 

711 No No 12 SURG TESTES PROCEDURES W CC/MCC 1.7619 5.1 7.3 

712 No No 12 SURG 

TESTES PROCEDURES W/O 

CC/MCC 0.8121 2.1 2.7 

713 No No 12 SURG 

TRANSURETHRAL 

PROSTATECTOMY W CC/MCC 1.1836 2.9 4.1 

714 No No 12 SURG 

TRANSURETHRAL 

PROSTATECTOMY W/O CC/MCC 0.6583 1.6 1.8 

715 No No 12 SURG 

OTHER MALE REPRODUCTIVE 

SYSTEM O.R. PROC FOR 

MALIGNANCY W CC/MCC 1.7470 4.1 6.1 

716 No No 12 SURG 

OTHER MALE REPRODUCTIVE 

SYSTEM O.R. PROC FOR 

MALIGNANCY W/O CC/MCC 1.0022 1.2 1.4 

717 No No 12 SURG 

OTHER MALE REPRODUCTIVE 

SYSTEM O.R. PROC EXC 

MALIGNANCY W CC/MCC 1.6076 4.6 6.4 

718 No No 12 SURG 

OTHER MALE REPRODUCTIVE 

SYSTEM O.R. PROC EXC 

MALIGNANCY W/O CC/MCC 0.8033 2.0 2.6 

722 No No 12 MED 

MALIGNANCY, MALE 

REPRODUCTIVE SYSTEM W MCC 1.6785 5.4 7.7 

723 No No 12 MED 

MALIGNANCY, MALE 

REPRODUCTIVE SYSTEM W CC 1.0170 3.9 5.1 

724 No No 12 MED 

MALIGNANCY, MALE 

REPRODUCTIVE SYSTEM W/O 

CC/MCC 0.6171 2.0 2.7 

725 No No 12 MED 

BENIGN PROSTATIC 

HYPERTROPHY W MCC 1.2620 4.6 6.1 

726 No No 12 MED 

BENIGN PROSTATIC 

HYPERTROPHY W/O MCC 0.6977 2.8 3.5 

727 No No 12 MED 

INFLAMMATION OF THE MALE 

REPRODUCTIVE SYSTEM W MCC 1.3582 4.9 6.3 

728 No No 12 MED 

INFLAMMATION OF THE MALE 

REPRODUCTIVE SYSTEM W/O 

MCC 0.7599 3.3 4.1 

729 No No 12 MED 

OTHER MALE REPRODUCTIVE 

SYSTEM DIAGNOSES W CC/MCC 0.9802 3.6 4.7 

730 No No 12 MED 

OTHER MALE REPRODUCTIVE 

SYSTEM DIAGNOSES W/O 

CC/MCC 0.6377 2.3 2.8 

734 No No 13 SURG 

PELVIC EVISCERATION, RAD 

HYSTERECTOMY & RAD 

VULVECTOMY W CC/MCC 2.4243 5.1 6.9 
CMS-1498-P 1035 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

735 No No 13 SURG 

PELVIC EVISCERATION, RAD 

HYSTERECTOMY & RAD 

VULVECTOMY W/O CC/MCC 1.1801 2.2 2.7 

736 No No 13 SURG 

UTERINE & ADNEXA PROC FOR 

OVARIAN OR ADNEXAL 

MALIGNANCY W MCC 4.3876 11.5 14.0 

737 No No 13 SURG 

UTERINE & ADNEXA PROC FOR 

OVARIAN OR ADNEXAL 

MALIGNANCY W CC 2.0407 5.7 6.7 

738 No No 13 SURG 

UTERINE & ADNEXA PROC FOR 

OVARIAN OR ADNEXAL 

MALIGNANCY W/O CC/MCC 1.2377 3.2 3.6 

739 No No 13 SURG 

UTERINE,ADNEXA PROC FOR 

NON-OVARIAN/ADNEXAL 

MALIG W MCC 3.4188 7.5 9.9 

740 No No 13 SURG 

UTERINE,ADNEXA PROC FOR 

NON-OVARIAN/ADNEXAL 

MALIG W CC 1.5323 3.8 4.7 

741 No No 13 SURG 

UTERINE,ADNEXA PROC FOR 

NON-OVARIAN/ADNEXAL 

MALIG W/O CC/MCC 1.1068 2.2 2.6 

742 No No 13 SURG 

UTERINE & ADNEXA PROC FOR 

NON-MALIGNANCY W CC/MCC 1.3971 3.2 4.1 

743 No No 13 SURG 

UTERINE & ADNEXA PROC FOR 

NON-MALIGNANCY W/O CC/MCC 0.9150 1.8 2.1 

744 No No 13 SURG 

D&C, CONIZATION, 

LAPAROSCOPY & TUBAL 

INTERRUPTION W CC/MCC 1.5367 4.0 5.6 

745 No No 13 SURG 

D&C, CONIZATION, 

LAPAROSCOPY & TUBAL 

INTERRUPTION W/O CC/MCC 0.8077 1.9 2.4 

746 No No 13 SURG 

VAGINA, CERVIX & VULVA 

PROCEDURES W CC/MCC 1.3373 3.0 4.2 

747 No No 13 SURG 

VAGINA, CERVIX & VULVA 

PROCEDURES W/O CC/MCC 0.8929 1.5 1.8 

748 No No 13 SURG 

FEMALE REPRODUCTIVE 

SYSTEM RECONSTRUCTIVE 

PROCEDURES 0.9231 1.4 1.7 

749 No No 13 SURG 

OTHER FEMALE REPRODUCTIVE 

SYSTEM O.R. PROCEDURES W 

CC/MCC 2.5219 6.2 8.5 

750 No No 13 SURG 

OTHER FEMALE REPRODUCTIVE 

SYSTEM O.R. PROCEDURES W/O 

CC/MCC 0.9389 2.2 2.8 

754 No No 13 MED 

MALIGNANCY, FEMALE 

REPRODUCTIVE SYSTEM W MCC 2.0061 6.4 8.8 

755 No No 13 MED 

MALIGNANCY, FEMALE 

REPRODUCTIVE SYSTEM W CC 1.1371 4.0 5.3 

756 No No 13 MED MALIGNANCY, FEMALE 0.6370 2.3 3.1 
CMS-1498-P 1036 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

REPRODUCTIVE SYSTEM W/O 

CC/MCC 

757 No No 13 MED 

INFECTIONS, FEMALE 

REPRODUCTIVE SYSTEM W MCC 1.6490 6.0 7.8 

758 No No 13 MED 

INFECTIONS, FEMALE 

REPRODUCTIVE SYSTEM W CC 1.0895 4.7 5.7 

759 No No 13 MED 

INFECTIONS, FEMALE 

REPRODUCTIVE SYSTEM W/O 

CC/MCC 0.7344 3.3 4.0 

760 No No 13 MED 

MENSTRUAL & OTHER FEMALE 

REPRODUCTIVE SYSTEM 

DISORDERS W CC/MCC 0.8298 2.9 3.8 

761 No No 13 MED 

MENSTRUAL & OTHER FEMALE 

REPRODUCTIVE SYSTEM 

DISORDERS W/O CC/MCC 0.5246 1.8 2.2 

765 No No 14 SURG CESAREAN SECTION W CC/MCC 1.1316 3.9 4.9 

766 No No 14 SURG 

CESAREAN SECTION W/O 

CC/MCC 0.8063 2.9 3.1 

767 No No 14 SURG 

VAGINAL DELIVERY W 

STERILIZATION &/OR D&C 0.9173 2.4 2.7 

768 No No 14 SURG 

VAGINAL DELIVERY W O.R. 

PROC EXCEPT STERIL &/OR D&C 1.8108 0.0 0.0 

769 No No 14 SURG 

POSTPARTUM & POST 

ABORTION DIAGNOSES W O.R. 

PROCEDURE 2.0588 3.6 5.7 

770 No No 14 SURG 

ABORTION W D&C, ASPIRATION 

CURETTAGE OR HYSTEROTOMY 0.7140 1.6 2.1 

774 No No 14 MED 

VAGINAL DELIVERY W 

COMPLICATING DIAGNOSES 0.6894 2.6 3.2 

775 No No 14 MED 

VAGINAL DELIVERY W/O 

COMPLICATING DIAGNOSES 0.5276 2.1 2.3 

776 No No 14 MED 

POSTPARTUM & POST 

ABORTION DIAGNOSES W/O O.R. 

PROCEDURE 0.6419 2.6 3.3 

777 No No 14 MED ECTOPIC PREGNANCY 0.7401 1.7 2.1 

778 No No 14 MED THREATENED ABORTION 0.4880 2.0 3.2 

779 No No 14 MED ABORTION W/O D&C 0.5637 1.6 2.1 

780 No No 14 MED FALSE LABOR 0.2277 1.2 1.6 

781 No No 14 MED 

OTHER ANTEPARTUM 

DIAGNOSES W MEDICAL 

COMPLICATIONS 0.6807 2.7 3.8 

782 No No 14 MED 

OTHER ANTEPARTUM 

DIAGNOSES W/O MEDICAL 

COMPLICATIONS 0.4731 1.9 2.6 

789 No No 15 MED 

NEONATES, DIED OR 

TRANSFERRED TO ANOTHER 

ACUTE CARE FACILITY 1.4874 0.0 0.0 

790 No No 15 MED EXTREME IMMATURITY OR 4.9049 0.0 0.0 
CMS-1498-P 1037 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

RESPIRATORY DISTRESS 

SYNDROME, NEONATE 

791 No No 15 MED 

PREMATURITY W MAJOR 

PROBLEMS 3.3499 0.0 0.0 

792 No No 15 MED 

PREMATURITY W/O MAJOR 

PROBLEMS 2.0213 0.0 0.0 

793 No No 15 MED 

FULL TERM NEONATE W MAJOR 

PROBLEMS 3.4411 0.0 0.0 

794 No No 15 MED 

NEONATE W OTHER 

SIGNIFICANT PROBLEMS 1.2179 0.0 0.0 

795 No No 15 MED NORMAL NEWBORN 0.1649 0.0 0.0 

799 No No 16 SURG SPLENECTOMY W MCC 4.9483 10.4 13.4 

800 No No 16 SURG SPLENECTOMY W CC 2.6030 5.9 7.5 

801 No No 16 SURG SPLENECTOMY W/O CC/MCC 1.5588 3.1 3.9 

802 No No 16 SURG 

OTHER O.R. PROC OF THE 

BLOOD & BLOOD FORMING 

ORGANS W MCC 3.6327 8.6 12.2 

803 No No 16 SURG 

OTHER O.R. PROC OF THE 

BLOOD & BLOOD FORMING 

ORGANS W CC 1.8899 4.9 6.5 

804 No No 16 SURG 

OTHER O.R. PROC OF THE 

BLOOD & BLOOD FORMING 

ORGANS W/O CC/MCC 1.0419 2.3 3.0 

808 No No 16 MED 

MAJOR HEMATOL/IMMUN DIAG 

EXC SICKLE CELL CRISIS & 

COAGUL W MCC 2.1429 6.3 8.2 

809 No No 16 MED 

MAJOR HEMATOL/IMMUN DIAG 

EXC SICKLE CELL CRISIS & 

COAGUL W CC 1.1935 4.0 5.1 

810 No No 16 MED 

MAJOR HEMATOL/IMMUN DIAG 

EXC SICKLE CELL CRISIS & 

COAGUL W/O CC/MCC 0.9204 3.0 3.7 

811 No No 16 MED 

RED BLOOD CELL DISORDERS W 

MCC 1.2574 3.9 5.3 

812 No No 16 MED 

RED BLOOD CELL DISORDERS 

W/O MCC 0.7996 2.8 3.7 

813 No No 16 MED COAGULATION DISORDERS 1.4355 3.6 5.0 

814 No No 16 MED 

RETICULOENDOTHELIAL & 

IMMUNITY DISORDERS W MCC 1.6466 5.0 6.9 

815 No No 16 MED 

RETICULOENDOTHELIAL & 

IMMUNITY DISORDERS W CC 0.9989 3.6 4.6 

816 No No 16 MED 

RETICULOENDOTHELIAL & 

IMMUNITY DISORDERS W/O 

CC/MCC 0.6826 2.6 3.2 

820 No No 17 SURG 

LYMPHOMA & LEUKEMIA W 

MAJOR O.R. PROCEDURE W MCC 5.7484 13.2 17.5 

821 No No 17 SURG 

LYMPHOMA & LEUKEMIA W 

MAJOR O.R. PROCEDURE W CC 2.3960 5.3 7.4 
CMS-1498-P 1038 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

822 No No 17 SURG 

LYMPHOMA & LEUKEMIA W 

MAJOR O.R. PROCEDURE W/O 

CC/MCC 1.2251 2.3 3.1 

823 No No 17 SURG 

LYMPHOMA & NON-ACUTE 

LEUKEMIA W OTHER O.R. PROC 

W MCC 4.5904 12.2 16.0 

824 No No 17 SURG 

LYMPHOMA & NON-ACUTE 

LEUKEMIA W OTHER O.R. PROC 

W CC 2.3004 6.6 8.7 

825 No No 17 SURG 

LYMPHOMA & NON-ACUTE 

LEUKEMIA W OTHER O.R. PROC 

W/O CC/MCC 1.2439 2.7 3.9 

826 No No 17 SURG 

MYELOPROLIF DISORD OR 

POORLY DIFF NEOPL W MAJ O.R. 

PROC W MCC 4.8575 11.2 14.8 

827 No No 17 SURG 

MYELOPROLIF DISORD OR 

POORLY DIFF NEOPL W MAJ O.R. 

PROC W CC 2.1547 5.3 6.9 

828 No No 17 SURG 

MYELOPROLIF DISORD OR 

POORLY DIFF NEOPL W MAJ O.R. 

PROC W/O CC/MCC 1.3894 3.0 3.8 

829 No No 17 SURG 

MYELOPROLIF DISORD OR 

POORLY DIFF NEOPL W OTHER 

O.R. PROC W CC/MCC 2.7281 6.2 9.3 

830 No No 17 SURG 

MYELOPROLIF DISORD OR 

POORLY DIFF NEOPL W OTHER 

O.R. PROC W/O CC/MCC 1.0911 2.3 3.1 

834 No No 17 MED 

ACUTE LEUKEMIA W/O MAJOR 

O.R. PROCEDURE W MCC 4.9043 10.1 16.2 

835 No No 17 MED 

ACUTE LEUKEMIA W/O MAJOR 

O.R. PROCEDURE W CC 2.4310 5.7 9.3 

836 No No 17 MED 

ACUTE LEUKEMIA W/O MAJOR 

O.R. PROCEDURE W/O CC/MCC 1.1364 3.0 4.4 

837 No No 17 MED 

CHEMO W ACUTE LEUKEMIA AS 

SDX OR W HIGH DOSE CHEMO 

AGENT W MCC 6.6543 17.9 23.6 

838 No No 17 MED 

CHEMO W ACUTE LEUKEMIA AS 

SDX W CC OR HIGH DOSE 

CHEMO AGENT 3.1384 8.1 12.3 

839 No No 17 MED 

CHEMO W ACUTE LEUKEMIA AS 

SDX W/O CC/MCC 1.2874 4.6 5.7 

840 Yes No 17 MED 

LYMPHOMA & NON-ACUTE 

LEUKEMIA W MCC 2.9245 7.8 10.6 

841 Yes No 17 MED 

LYMPHOMA & NON-ACUTE 

LEUKEMIA W CC 1.6376 5.1 6.8 

842 Yes No 17 MED 

LYMPHOMA & NON-ACUTE 

LEUKEMIA W/O CC/MCC 1.0382 3.2 4.2 

843 No No 17 MED 

OTHER MYELOPROLIF DIS OR 

POORLY DIFF NEOPL DIAG W 1.8400 6.0 8.0 
CMS-1498-P 1039 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

MCC 

844 No No 17 MED 

OTHER MYELOPROLIF DIS OR 

POORLY DIFF NEOPL DIAG W CC 1.1895 4.3 5.6 

845 No No 17 MED 

OTHER MYELOPROLIF DIS OR 

POORLY DIFF NEOPL DIAG W/O 

CC/MCC 0.8099 2.9 3.8 

846 No No 17 MED 

CHEMOTHERAPY W/O ACUTE 

LEUKEMIA AS SECONDARY 

DIAGNOSIS W MCC 2.1885 5.4 8.0 

847 No No 17 MED 

CHEMOTHERAPY W/O ACUTE 

LEUKEMIA AS SECONDARY 

DIAGNOSIS W CC 0.9901 2.8 3.4 

848 No No 17 MED 

CHEMOTHERAPY W/O ACUTE 

LEUKEMIA AS SECONDARY 

DIAGNOSIS W/O CC/MCC 0.8070 2.4 3.0 

849 No No 17 MED RADIOTHERAPY 1.2501 4.4 6.0 

853 Yes No 18 SURG 

INFECTIOUS & PARASITIC 

DISEASES W O.R. PROCEDURE W 

MCC 5.5154 12.1 15.7 

854 Yes No 18 SURG 

INFECTIOUS & PARASITIC 

DISEASES W O.R. PROCEDURE W 

CC 2.7976 8.2 10.0 

855 Yes No 18 SURG 

INFECTIOUS & PARASITIC 

DISEASES W O.R. PROCEDURE 

W/O CC/MCC 1.3920 3.9 5.4 

856 Yes No 18 SURG 

POSTOPERATIVE OR POSTTRAUMATIC INFECTIONS W O.R. 

PROC W MCC 5.1335 11.2 15.0 

857 Yes No 18 SURG 

POSTOPERATIVE OR POSTTRAUMATIC INFECTIONS W O.R. 

PROC W CC 2.1011 6.2 7.9 

858 Yes No 18 SURG 

POSTOPERATIVE OR POSTTRAUMATIC INFECTIONS W O.R. 

PROC W/O CC/MCC 1.3079 4.1 5.1 

862 Yes No 18 MED 

POSTOPERATIVE & POSTTRAUMATIC INFECTIONS W 

MCC 1.9553 5.8 7.8 

863 Yes No 18 MED 

POSTOPERATIVE & POSTTRAUMATIC INFECTIONS W/O 

MCC 0.9765 4.0 4.9 

864 No No 18 MED FEVER 0.8255 3.0 3.8 

865 No No 18 MED VIRAL ILLNESS W MCC 1.5524 4.5 6.4 

866 No No 18 MED VIRAL ILLNESS W/O MCC 0.7420 2.8 3.5 

867 Yes No 18 MED 

OTHER INFECTIOUS & 

PARASITIC DISEASES 

DIAGNOSES W MCC 2.4723 6.8 9.2 

868 Yes No 18 MED 

OTHER INFECTIOUS & 

PARASITIC DISEASES 1.1597 4.3 5.4 
CMS-1498-P 1040 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

DIAGNOSES W CC 

869 Yes No 18 MED 

OTHER INFECTIOUS & 

PARASITIC DISEASES 

DIAGNOSES W/O CC/MCC 0.7183 3.0 3.6 

870 Yes No 18 MED 

SEPTICEMIA OR SEVERE SEPSIS 

W MV 96+ HOURS 5.8105 12.8 15.2 

871 Yes No 18 MED 

SEPTICEMIA OR SEVERE SEPSIS 

W/O MV 96+ HOURS W MCC 1.9056 5.4 7.2 

872 Yes No 18 MED 

SEPTICEMIA OR SEVERE SEPSIS 

W/O MV 96+ HOURS W/O MCC 1.1522 4.5 5.4 

876 No No 19 SURG 

O.R. PROCEDURE W PRINCIPAL 

DIAGNOSES OF MENTAL 

ILLNESS 2.8176 8.1 12.7 

880 No No 19 MED 

ACUTE ADJUSTMENT REACTION 

& PSYCHOSOCIAL 

DYSFUNCTION 0.6148 2.3 3.0 

881 No No 19 MED DEPRESSIVE NEUROSES 0.6140 3.1 4.2 

882 No No 19 MED NEUROSES EXCEPT DEPRESSIVE 0.6250 3.1 4.3 

883 No No 19 MED 

DISORDERS OF PERSONALITY & 

IMPULSE CONTROL 1.0741 4.9 7.7 

884 Yes No 19 MED 

ORGANIC DISTURBANCES & 

MENTAL RETARDATION 0.9345 4.0 5.4 

885 No No 19 MED PSYCHOSES 0.8920 5.4 7.4 

886 No No 19 MED 

BEHAVIORAL & 

DEVELOPMENTAL DISORDERS 0.8253 3.9 6.2 

887 No No 19 MED 

OTHER MENTAL DISORDER 

DIAGNOSES 0.7744 2.9 4.0 

894 No No 20 MED 

ALCOHOL/DRUG ABUSE OR 

DEPENDENCE, LEFT AMA 0.4007 2.1 2.9 

895 No No 20 MED 

ALCOHOL/DRUG ABUSE OR 

DEPENDENCE W 

REHABILITATION THERAPY 1.0145 8.5 10.9 

896 Yes No 20 MED 

ALCOHOL/DRUG ABUSE OR 

DEPENDENCE W/O 

REHABILITATION THERAPY W 

MCC 1.4528 4.7 6.5 

897 Yes No 20 MED 

ALCOHOL/DRUG ABUSE OR 

DEPENDENCE W/O 

REHABILITATION THERAPY W/O 

MCC 0.6413 3.2 4.0 

901 No No 21 SURG 

WOUND DEBRIDEMENTS FOR 

INJURIES W MCC 3.9427 9.1 14.1 

902 No No 21 SURG 

WOUND DEBRIDEMENTS FOR 

INJURIES W CC 1.7989 5.4 7.5 

903 No No 21 SURG 

WOUND DEBRIDEMENTS FOR 

INJURIES W/O CC/MCC 1.0616 3.3 4.4 

904 No No 21 SURG 

SKIN GRAFTS FOR INJURIES W 

CC/MCC 3.0388 7.3 11.1 
CMS-1498-P 1041 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

905 No No 21 SURG 

SKIN GRAFTS FOR INJURIES W/O 

CC/MCC 1.1720 3.4 4.5 

906 No No 21 SURG 

HAND PROCEDURES FOR 

INJURIES 1.0393 2.1 3.1 

907 Yes No 21 SURG 

OTHER O.R. PROCEDURES FOR 

INJURIES W MCC 3.8155 7.8 11.1 

908 Yes No 21 SURG 

OTHER O.R. PROCEDURES FOR 

INJURIES W CC 1.9277 4.7 6.3 

909 Yes No 21 SURG 

OTHER O.R. PROCEDURES FOR 

INJURIES W/O CC/MCC 1.1622 2.6 3.4 

913 No No 21 MED TRAUMATIC INJURY W MCC 1.3305 4.0 5.6 

914 No No 21 MED TRAUMATIC INJURY W/O MCC 0.6943 2.5 3.2 

915 No No 21 MED ALLERGIC REACTIONS W MCC 1.4162 3.6 5.1 

916 No No 21 MED ALLERGIC REACTIONS W/O MCC 0.4820 1.7 2.1 

917 Yes No 21 MED 

POISONING & TOXIC EFFECTS 

OF DRUGS W MCC 1.4814 3.7 5.1 

918 Yes No 21 MED 

POISONING & TOXIC EFFECTS 

OF DRUGS W/O MCC 0.6234 2.1 2.7 

919 No No 21 MED 

COMPLICATIONS OF 

TREATMENT W MCC 1.5999 4.4 6.2 

920 No No 21 MED 

COMPLICATIONS OF 

TREATMENT W CC 0.9760 3.2 4.3 

921 No No 21 MED 

COMPLICATIONS OF 

TREATMENT W/O CC/MCC 0.6179 2.2 2.8 

922 No No 21 MED 

OTHER INJURY, POISONING & 

TOXIC EFFECT DIAG W MCC 1.3409 3.8 5.4 

923 No No 21 MED 

OTHER INJURY, POISONING & 

TOXIC EFFECT DIAG W/O MCC 0.6742 2.3 3.2 

927 No No 22 SURG 

EXTENSIVE BURNS OR FULL 

THICKNESS BURNS W MV 96+ 

HRS W SKIN GRAFT 12.6506 21.8 28.2 

928 No No 22 SURG 

FULL THICKNESS BURN W SKIN 

GRAFT OR INHAL INJ W CC/MCC 4.7191 10.8 14.9 

929 No No 22 SURG 

FULL THICKNESS BURN W SKIN 

GRAFT OR INHAL INJ W/O 

CC/MCC 2.0261 5.3 7.7 

933 No No 22 MED 

EXTENSIVE BURNS OR FULL 

THICKNESS BURNS W MV 96+ 

HRS W/O SKIN GRAFT 2.2750 2.3 5.2 

934 No No 22 MED 

FULL THICKNESS BURN W/O 

SKIN GRFT OR INHAL INJ 1.3530 4.1 5.8 

935 No No 22 MED NON-EXTENSIVE BURNS 1.2817 3.5 5.2 

939 No No 23 SURG 

O.R. PROC W DIAGNOSES OF 

OTHER CONTACT W HEALTH 

SERVICES W MCC 2.8683 6.8 10.0 

940 No No 23 SURG 

O.R. PROC W DIAGNOSES OF 

OTHER CONTACT W HEALTH 

SERVICES W CC 1.6847 3.6 5.4 
CMS-1498-P 1042 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

941 No No 23 SURG 

O.R. PROC W DIAGNOSES OF 

OTHER CONTACT W HEALTH 

SERVICES W/O CC/MCC 1.1488 2.0 2.6 

945 Yes No 23 MED REHABILITATION W CC/MCC 1.2883 8.3 10.2 

946 Yes No 23 MED REHABILITATION W/O CC/MCC 1.1140 6.6 7.5 

947 Yes No 23 MED SIGNS & SYMPTOMS W MCC 1.0970 3.7 4.9 

948 Yes No 23 MED SIGNS & SYMPTOMS W/O MCC 0.6840 2.7 3.4 

949 No No 23 MED AFTERCARE W CC/MCC 0.9823 2.6 4.3 

950 No No 23 MED AFTERCARE W/O CC/MCC 0.4983 2.1 2.8 

951 No No 23 MED 

OTHER FACTORS INFLUENCING 

HEALTH STATUS 0.6963 2.2 4.5 

955 No No 24 SURG 

CRANIOTOMY FOR MULTIPLE 

SIGNIFICANT TRAUMA 5.4991 9.0 12.6 

956 Yes No 24 SURG 

LIMB REATTACHMENT, HIP & 

FEMUR PROC FOR MULTIPLE 

SIGNIFICANT TRAUMA 3.3461 7.0 8.4 

957 No No 24 SURG 

OTHER O.R. PROCEDURES FOR 

MULTIPLE SIGNIFICANT 

TRAUMA W MCC 6.3035 10.2 14.3 

958 No No 24 SURG 

OTHER O.R. PROCEDURES FOR 

MULTIPLE SIGNIFICANT 

TRAUMA W CC 3.8041 7.6 9.5 

959 No No 24 SURG 

OTHER O.R. PROCEDURES FOR 

MULTIPLE SIGNIFICANT 

TRAUMA W/O CC/MCC 2.2479 4.5 5.6 

963 No No 24 MED 

OTHER MULTIPLE SIGNIFICANT 

TRAUMA W MCC 2.8145 6.0 8.7 

964 No No 24 MED 

OTHER MULTIPLE SIGNIFICANT 

TRAUMA W CC 1.4818 4.5 5.6 

965 No No 24 MED 

OTHER MULTIPLE SIGNIFICANT 

TRAUMA W/O CC/MCC 0.9316 3.1 3.8 

969 No No 25 SURG 

HIV W EXTENSIVE O.R. 

PROCEDURE W MCC 5.5054 12.1 17.1 

970 No No 25 SURG 

HIV W EXTENSIVE O.R. 

PROCEDURE W/O MCC 2.7380 6.3 8.7 

974 No No 25 MED 

HIV W MAJOR RELATED 

CONDITION W MCC 2.5819 6.9 9.6 

975 No No 25 MED 

HIV W MAJOR RELATED 

CONDITION W CC 1.3551 5.1 6.6 

976 No No 25 MED 

HIV W MAJOR RELATED 

CONDITION W/O CC/MCC 0.9004 3.5 4.4 

977 No No 25 MED 

HIV W OR W/O OTHER RELATED 

CONDITION 1.0398 3.6 4.9 

981 Yes No SURG 

EXTENSIVE O.R. PROCEDURE 

UNRELATED TO PRINCIPAL 

DIAGNOSIS W MCC 5.0726 11.0 14.1 

982 Yes No SURG 

EXTENSIVE O.R. PROCEDURE 

UNRELATED TO PRINCIPAL 2.9434 6.8 8.7 
CMS-1498-P 1043 

MSDRG 

FY 2011 

Proposed 

Rule 

PostAcute 

DRG 

FY 2011 

Proposed 

Rule 

Special 

Pay DRG MDC TYPE MS-DRG Title Weights 

Geometric 

mean 

LOS 

Arithmetic 

mean 

LOS 

DIAGNOSIS W CC 

983 Yes No SURG 

EXTENSIVE O.R. PROCEDURE 

UNRELATED TO PRINCIPAL 

DIAGNOSIS W/O CC/MCC 1.7800 3.1 4.2 

984 No No SURG 

PROSTATIC O.R. PROCEDURE 

UNRELATED TO PRINCIPAL 

DIAGNOSIS W MCC 3.3086 10.5 13.3 

985 No No SURG 

PROSTATIC O.R. PROCEDURE 

UNRELATED TO PRINCIPAL 

DIAGNOSIS W CC 2.1518 6.9 9.0 

986 No No SURG 

PROSTATIC O.R. PROCEDURE 

UNRELATED TO PRINCIPAL 

DIAGNOSIS W/O CC/MCC 1.1129 2.8 4.1 

987 Yes No SURG 

NON-EXTENSIVE O.R. PROC 

UNRELATED TO PRINCIPAL 

DIAGNOSIS W MCC 3.4500 9.3 12.2 

988 Yes No SURG 

NON-EXTENSIVE O.R. PROC 

UNRELATED TO PRINCIPAL 

DIAGNOSIS W CC 1.8721 5.6 7.4 

989 Yes No SURG 

NON-EXTENSIVE O.R. PROC 

UNRELATED TO PRINCIPAL 

DIAGNOSIS W/O CC/MCC 1.0568 2.5 3.5 

998 No No ** 

PRINCIPAL DIAGNOSIS INVALID 

AS DISCHARGE DIAGNOSIS 0.0000 0.0 0.0 

999 No No ** UNGROUPABLE 0.0000 0.0 0.0 

MS-DRGs 998 and 999 contain cases that could not be assigned to valid DRGs. 

Note: If there is no value 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. 
CMS-1498-P 1044 

TABLE 6A.—NEW DIAGNOSIS CODES 

Diagnosis 

Code 

Description CC MDC MS-DRG 

237.73 Schwannomatosis N 01 091,092,093

237.78 Other neurofibromatosis N 01 091,092,093

275.01 Hereditary hemochromatosis N 10 642

275.02 Hemochromatosis due to repeated red blood cell 

transfusions 

N 10 642

275.03 Other hemochromatosis N 10 642

275.09 Other disorders of iron metabolism N 10 642

276.61 Transfusion associated circulatory overload N 10 

15 

640,641

7911,7931

276.69 Other fluid overload N 10 

15 

640,641

7911,7931

278.03 Obesity hypoventilation syndrome N 04 205,206

287.41 Posttransfusion purpura N 15 

16 

25 

7911,7931

813

977

287.49 Other secondary thrombocytopenia N 15 

16 

25 

7911,7931

813

977

447.70 Aortic ectasia, unspecified site N 05 299,300,301

447.71 Thoracic aortic ectasia N 05 299,300,301

447.72 Abdominal aortic ectasia N 05 299,300,301

447.73 Thoracoabdominal aortic ectasia N 05 299,300,301

560.32 Fecal impaction N 06 

15 

388,389,390

7911,7931

724.03 Spinal stenosis, lumbar region, with neurogenic 

claudication 

N 08 551,552

752.31 Agenesis of uterus N 13 742,743,760,761

752.32 Hypoplasia of uterus N 13 742,743,760,761

752.33 Unicornuate uterus N 13 742,743,760,761

752.34 Bicornuate uterus N 13 742,743,760,761

752.35 Septate uterus N 13 742,743,760,761

752.36 Arcuate uterus N 13 742,743,760,761

752.39 Other anomalies of uterus N 13 742,743,760,761

752.43 Cervical agenesis N 13 742,743,760,761

752.44 Cervical duplication N 13 742,743,760,761

752.45 Vaginal agenesis N 13 742,743,760,761
CMS-1498-P 1045 

Diagnosis 

Code 

Description CC MDC MS-DRG 

752.46 Transverse vaginal septum N 13 742,743,760,761

752.47 Longitudinal vaginal septum N 13 742,743,760,761

780.33 Post traumatic seizures N 01 100,101

780.66 Febrile nonhemolytic transfusion reaction N 18 

25 

864

977

784.92 Jaw pain N PRE 

03 

011,012,013

157,158,159

786.30 Hemoptysis, unspecified CC 04 204 

786.31 Acute idiopathic pulmonary hemorrhage in 

infants [AIPHI] 

CC 04 204 

786.39 Other hemoptysis CC 04 204 

787.60 Full incontinence of feces N 06 391,392 

787.61 Incomplete defecation N 06 391,392 

787.62 Fecal smearing N 06 391,392 

787.63 Fecal urgency N 06 391,392 

799.50 Unspecified signs and symptoms involving 

cognition 

N 19 884 

799.51 Attention or concentration deficit N 19 886 

799.52 Cognitive communication deficit N 19 884 

799.53 Visuospatial deficit N 01 091,092,093 

799.54 Psychomotor deficit N 19 884 

799.55 Frontal lobe and executive function deficit N 19 884 

799.59 Other signs and symptoms involving cognition N 19 884 

970.81 Poisoning by cocaine N 21 917,918 

970.89 Poisoning by other central nervous system 

stimulants 

N 21 917,918 

999.60 ABO incompatibility reaction, unspecified CC 15 

16 

7911,7931

811,812 

999.61 ABO incompatibility with hemolytic transfusion 

reaction not specified as acute or delayed 

CC 15 

16 

7911,7931

811,812 

999.62 ABO incompatibility with acute hemolytic 

transfusion reaction 

CC 15 

16 

7911,7931

811,812 

999.63 ABO incompatibility with delayed hemolytic 

transfusion reaction 

CC 15 

16 

7911,7931

811,812 

999.69 Other ABO incompatibility reaction CC 15 

16 

7911,7931

811,812 
CMS-1498-P 1046 

Diagnosis 

Code 

Description CC MDC MS-DRG 

999.70 Rh incompatibility reaction, unspecified CC 15 

16 

7911,7931

811,812 

999.71 Rh incompatibility with hemolytic transfusion 

reaction not specified as acute or delayed 

CC 15 

16 

7911,7931

811,812 

999.72 Rh incompatibility with acute hemolytic 

transfusion reaction 

CC 15 

16 

7911,7931

811,812 

999.73 Rh incompatibility with delayed hemolytic 

transfusion reaction 

CC 15 

16 

7911,7931

811,812 

999.74 Other Rh incompatibility reaction CC 15 

16 

7911,7931

811,812 

999.75 Non-ABO incompatibility reaction, unspecified CC 15 

16 

7911,7931

811,812 

999.76 Non-ABO incompatibility with hemolytic 

transfusion reaction not specified as acute or 

delayed 

CC 15 

16 

7911,7931

811,812 

999.77 Non-ABO incompatibility with acute hemolytic 

transfusion reaction 

CC 15 

16 

7911,7931

811,812 

999.78 Non-ABO incompatibility with delayed 

hemolytic transfusion reaction 

CC 15 

16 

7911,7931

811,812 

999.79 Other non-ABO incompatibility reaction CC 15 

16 

7911,7931

811,812 

999.80 Transfusion reaction, unspecified N 15 

16 

7911,7931

811,812 

999.83 Hemolytic transfusion reaction, incompatibility 

unspecified 

CC 15 

16 

7911,7931

811,812 

999.84 Acute hemolytic transfusion reaction, 

incompatibilty unspecified 

CC 15 

16 

7911,7931

811,812 

999.85 Delayed hemolytic transfusion reaction, 

incompatibility unspecified 

CC 15 

16 

7911,7931

811,812 

V11.4 Personal history of combat and operational stress 

reaction 

N 23 951 
CMS-1498-P 1047 

Diagnosis 

Code 

Description CC MDC MS-DRG 

V13.23 Personal history of vaginal dysplasia N 23 951 

V13.24 Personal history of vulvar dysplasia N 23 951 

V13.62 Personal history of other (corrected) congenital 

malformations of genitourinary system 

N 23 951 

V13.63 Personal history of (corrected) congenital 

malformations of nervous system 

N 23 951 

V13.64 Personal history of (corrected) congenital 

malformations of eye, ear, face and neck 

N 23 951 

V13.65 Personal history of (corrected) congenital 

malformations of heart and circulatory system 

N 23 951 

V13.66 Personal history of (corrected) congenital 

malformations of respiratory system 

N 23 951 

V13.67 Personal history of (corrected) congenital 

malformations of digestive system 

N 23 951 

V13.68 Personal history of (corrected) congenital 

malformations of integument, limbs, and 

musculoskeletal system 

N 23 951 

V15.53 Personal history of retained foreign body fully 

removed 

N 23 951 

V25.11 Encounter for insertion of intrauterine 

contraceptive device 

N 23 951 

V25.12 Encounter for removal of intrauterine 

contraceptive device 

N 23 951 

V25.13 Encounter for removal and reinsertion of 

intrauterine contraceptive device 

N 23 951 

V49.86 Do not resuscitate status N 23 951 

V62.85 Homicidal ideation N 23 951 

V85.41 Body Mass Index 40.0-44.9, adult CC 10 640,641 

V85.42 Body Mass Index 45.0-49.9, adult CC 10 640,641 

V85.43 Body Mass Index 50.0-59.9, adult CC 10 640,641 

V85.44 Body Mass Index 60.0-69.9, adult CC 10 640,641 

V85.45 Body Mass Index 70 and over, adult CC 10 640,641 

V88.11 Acquired total absence of pancreas N 23 951 

V88.12 Acquired partial absence of pancreas N 23 951 

V90.01 Retained depleted uranium fragments N 23 951 

V90.09 Other retained radioactive fragments N 23 951 

V90.10 Retained metal fragments, unspecified N 23 951 

V90.11 Retained magnetic metal fragments N 23 951 

V90.12 Retained nonmagnetic metal fragments N 23 951 

V90.2 Retained plastic fragments N 23 951 

V90.31 Retained animal quills or spines N 23 951 

V90.32 Retained tooth N 23 951 

V90.33 Retained wood fragments N 23 951 
CMS-1498-P 1048 

Diagnosis 

Code 

Description CC MDC MS-DRG 

V90.39 Other retained organic fragments N 23 951 

V90.81 Retained glass fragments N 23 951 

V90.83 Retained stone or crystalline fragments N 23 951 

V90.89 Other specified retained foreign body N 23 951 

V90.9 Retained foreign body, unspecified material N 23 951 

V91.00 Twin gestation, unspecified number of placenta, 

unspecified number of amniotic sacs 

N 23 951 

V91.01 Twin gestation, monochorionic/monoamniotic 

(one placenta, one amniotic sac) 

N 23 951 

V91.02 Twin gestation, monochorionic/diamniotic (one 

placenta, two amniotic sacs) 

N 23 951 

V91.03 Twin gestation, dichorionic/diamniotic (two 

placentae, two amniotic sacs) 

N 23 951 

V91.09 Twin gestation, unable to determine number of 

placenta and number of amniotic sacs 

N 23 951 

V91.10 Triplet gestation, unspecified number of placenta 

and unspecified number of amniotic sacs 

N 23 951 

V91.11 Triplet gestation, with two or more 

monochorionic fetuses 

N 23 951 

V91.12 Triplet gestation, with two or more monoamniotic 

fetuses 

N 23 951 

V91.19 Triplet gestation, unable to determine number of 

placenta and number of amniotic sacs 

N 23 951 

V91.20 Quadruplet gestation, unspecified number of 

placenta and unspecified number of amniotic sacs 

N 23 951 

V91.21 Quadruplet gestation, with two or more 

monochorionic fetuses 

N 23 951 

V91.22 Quadruplet gestation, with two or more 

monoamniotic fetuses 

N 23 951 

V91.29 Quadruplet gestation, unable to determine 

number of placenta and number of amniotic sacs 

N 23 951 

V91.90 Other specified multiple gestation, unspecified 

number of placenta and unspecified number of 

amniotic sacs 

N 23 951 

V91.91 Other specified multiple gestation, with two or 

more monochorionic fetuses 

N 23 951 

V91.92 Other specified multiple gestation, with two or 

more monoamniotic fetuses 

N 23 951 

V91.99 Other specified multiple gestation, unable to 

determine number of placenta and number of 

amniotic sacs 

N 23 951 

Notes: 

1

 Secondary diagnosis of major problem
CMS-1498-P 1049 

TABLE 6B.—NEW PROCEDURE CODES 

Procedure 

Code 

Description O.R. MDC MS-DRG 

00.60 Insertion of drug-eluting stent(s) of superficial 

femoral artery 

N 

32.27 Bronchoscopic bronchial thermoplasty, ablation 

of airway smooth muscle 

Y 04 163,164,165

39.81 Implantation or replacement of carotid sinus 

stimulation device, total system 

Y 05 252,253,254

39.82 Implantation or replacement of carotid sinus 

stimulation lead(s) only 

Y 05 252,253,254

39.83 Implantation or replacement of carotid sinus 

stimulation pulse generator only 

Y 05 252,253,254

39.84 Revision of carotid sinus stimulation lead(s) only Y 05 252,253,254

39.85 Revision of carotid sinus stimulation pulse 

generator 

Y 05 252,253,254

39.86 Removal of carotid sinus stimulation device, total 

system 

Y 05 252,253,254

39.87 Removal of carotid sinus stimulation lead(s) only Y 05 252,253,254

39.88 Removal of carotid sinus stimulation pulse 

generator only 

Y 05 252,253,254

39.89 Other operations on carotid body, carotid sinus 

and other vascular bodies 

Y 05 252,253,254

81.88 Reverse total shoulder replacement Y 08 

21 

24 

483,484 

907,908,909

957,958,959
CMS-1498-P 1050 

TABLE 6C.—INVALID DIAGNOSIS CODES 

Diagnosis 

Code 

Description CC MDC MS-DRG 

275.0 Disorders of iron metabolism N 10 642

276.6 Fluid overload N 10 

15 

640,641

7911,7931

287.4 Secondary thrombocytopenia N 15 

16 

25 

7911,7931

813

977

752.3 Other anomalies of uterus N 13 742,743,760,761

786.3 Hemoptysis CC 04 204

787.6 Incontinence of feces N 06 391,392

970.8 Poisoning by other specified central nervous 

system stimulants 

N 21 917,918

999.6 ABO incompatibility reaction CC 15 

16 

7911,7931

811,812

999.7 Rh incompatibility reaction CC 15 

16 

7911,7931

811,812

V25.1 Encounter for insertion of intrauterine 

contraceptive device 

N 23 951

V85.4 Body Mass Index 40 and over, adult CC 10 640,641

Notes: 

1

 Secondary diagnosis of major problem 

TABLE 6D.—INVALID PROCEDURE CODES 

Procedure 

Code 

Description O.R. MDC MS-DRG 

39.8 Operations on carotid body, carotid sinus and 

other vascular bodies 

Y 01 

04 

05 

037,038,039

166,167,168

252,253,254
CMS-1498-P 1051 

TABLE 6E.—REVISED DIAGNOSIS CODE TITLES 

Diagnosis 

Code 

Description CC MDC MS-DRG 

629.81 Recurrent pregnancy loss without current 

pregnancy 

N 13 742,743,760,761

646.30 Recurrent pregnancy loss, unspecified as to 

episode of care or not applicable 

N 14 998

646.31 Recurrent pregnancy loss, delivered, with 

or without mention of antepartum condition 

CC 14 765,766,767,768,774,

775

646.33 Recurrent pregnancy loss, antepartum 

condition or complication 

N 14 781,782

724.02 Spinal stenosis, lumbar region, without 

neurogenic claudication 

N 08 551,552

781.8 Neurologic neglect syndrome CC 01 091,092,093

V13.61 Personal history of (corrected) hypospadias N 23 951

V13.69 Personal history of other (corrected) 

congenital malformations 

N 23 951

V26.35 Encounter for testing of male partner of 

female with recurrent pregnancy loss 

N 23 951

TABLE 6F.—REVISED PROCEDURE CODE TITLES 

Procedure 

Code 

Description O.R. MDC MS-DRG 

00.55 Insertion of drug-eluting stent(s) of other 

peripheral vessel(s) 

N 

81.80 Other total shoulder replacement Y 08 

21 

24 

483,484

907,908,909

957,958,959

99.14 Injection or infusion of immunoglobulin N 
CMS-1498-P 1052 

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED 

PERCENTILE LENGHTS OF STAY; FY 2009 MedPAR UPDATE – DECEMBER 2009 

GROUPER V27.0 MS-DRGs 

MS-DRG 

Number of 

Discharges 

Arithmetic 

Mean 

LOS 

10th 

Percentile 

25th 

Percentile 

50th 

Percentile 

75th 

Percentile 

90th 

Percentile 

1 1,001 40.5395 12 19 31 50 80

2 239 20.7113 8 11 15 26 39

3 21,956 36.6115 15 21 30 44 63

4 21,395 27.1269 11 16 22 32 46

5 949 19.6185 6 9 14 24 41

6 348 8.3937 5 6 8 10 12

7 469 18.7058 8 11 15 23 31

8 508 11.7835 6 7 9 13 21

9 1,818 21.3311 8 15 19 25 33

10 137 9.7007 5 7 8 11 13

11 1,534 15.5782 6 8 12 19 29

12 1,895 9.9135 4 6 8 12 17

13 1,008 6.7401 3 4 6 8 11

20 1,102 17.1207 6 10 16 23 29

21 448 13.9866 7 10 14 17 22

22 146 8.3767 2 4 8 12 14

23 4,479 11.7948 2 5 9 16 23

24 1,635 7.8526 1 3 6 10 15

25 12,006 11.4943 3 6 9 15 22

26 11,045 7.2149 2 4 6 9 13

27 12,591 3.8861 1 2 3 5 7

28 1,983 13.0479 4 7 11 16 24

29 3,373 6.3409 1 3 5 8 12

30 3,432 3.2797 1 1 3 4 7

31 1,247 12.0938 2 5 9 16 24

32 2,730 5.2289 1 2 4 7 11

33 3,351 2.6640 1 1 2 3 5

34 976 6.9191 1 2 6 9 14

35 2,179 2.9849 1 1 2 4 7

36 5,732 1.5223 1 1 1 1 3

37 5,691 8.2903 2 3 7 11 17

38 13,702 3.3307 1 1 2 4 8

39 43,823 1.6743 1 1 1 2 3

40 5,628 11.7386 3 6 9 15 22

41 6,741 6.3600 1 3 5 8 12

42 3,808 3.2261 1 1 2 4 7

52 1,250 6.6328 2 3 5 7 11

53 487 3.5832 1 2 3 5 6

54 7,691 6.2942 2 3 5 8 12

55 12,545 4.5368 1 2 3 6 9

56 11,620 6.9885 2 3 5 8 13

57 40,900 4.7691 2 3 4 5 8
CMS-1498-P 1053 

MS-DRG 

Number of 

Discharges 

Arithmetic 

Mean 

LOS 

10th 

Percentile 

25th 

Percentile 

50th 

Percentile 

75th 

Percentile 

90th 

Percentile 

58 1,005 7.0537 2 3 5 8 13

59 3,138 4.9143 2 3 4 6 8

60 3,515 3.7713 1 2 3 5 6

61 2,468 8.2265 2 4 7 11 16

62 3,537 5.5785 2 3 5 7 10

63 1,309 3.9152 2 2 3 5 7

64 70,612 6.7735 2 3 5 9 13

65 102,945 4.7452 2 3 4 6 8

66 66,535 3.2734 1 2 3 4 6

67 1,959 5.2409 2 3 4 6 9

68 9,804 3.2279 1 2 3 4 6

69 92,535 2.7913 1 2 2 3 5

70 12,885 7.0182 2 3 5 9 13

71 10,469 4.8679 2 3 4 6 9

72 4,838 3.1174 1 2 2 4 6

73 11,890 5.5112 2 3 4 7 10

74 28,604 3.9747 1 2 3 5 7

75 1,348 6.9733 2 4 5 8 13

76 661 3.9259 1 2 3 5 7

77 1,834 6.4002 2 3 5 8 12

78 1,807 4.0697 1 2 3 5 7

79 774 3.0749 1 2 3 4 5

80 2,027 4.8101 1 2 4 6 9

81 5,465 3.3420 1 2 3 4 6

82 2,546 6.0361 1 1 4 8 13

83 2,422 4.5727 1 2 3 6 9

84 2,542 2.7825 1 1 2 4 5

85 8,441 6.9889 2 3 5 9 14

86 13,175 4.5672 1 2 4 6 8

87 13,012 2.9085 1 1 2 4 5

88 1,078 5.3497 2 3 4 7 10

89 2,947 3.6339 1 2 3 5 7

90 2,481 2.3136 1 1 2 3 4

91 10,887 6.0043 2 3 4 7 12

92 17,603 4.0852 1 2 3 5 7

93 13,215 2.8862 1 1 2 4 5

94 1,527 11.7394 3 6 10 15 21

95 1,085 8.1779 3 5 7 10 15

96 540 5.6667 1 4 5 7 10

97 1,324 11.4373 4 6 9 15 21

98 928 7.6185 3 4 6 10 13

99 423 5.1915 2 3 4 7 10

100 21,435 5.8217 2 3 4 7 11

101 53,878 3.3892 1 2 3 4 6

102 1,501 4.2205 1 2 3 5 9

103 12,310 3.0085 1 1 2 4 6
CMS-1498-P 1054 

MS-DRG 

Number of 

Discharges 

Arithmetic 

Mean 

LOS 

10th 

Percentile 

25th 

Percentile 

50th 

Percentile 

75th 

Percentile 

90th 

Percentile 

113 639 5.5994 1 2 4 7 11

114 431 2.5986 1 1 2 3 5

115 850 4.6082 1 2 4 5 7

116 455 4.4813 1 1 2 5 7

117 549 1.9872 1 1 1 1 2

121 744 5.1022 2 3 4 6 8

122 524 3.9790 1 2 3 5 7

123 2,672 2.7182 1 1 2 3 5

124 975 5.1918 1 2 4 6 10

125 4,038 3.2590 1 2 3 4 6

129 1,508 5.2454 1 2 4 7 11

130 943 2.8908 1 1 2 4 6

131 1,132 5.5998 1 2 4 7 11

132 748 2.7126 1 1 2 3 5

133 2,242 5.3965 1 2 4 7 11

134 2,627 2.0837 1 1 1 2 4

135 466 6.3112 1 2 5 9 13

136 351 2.2422 1 1 1 3 5

137 891 4.9989 1 2 4 6 10

138 747 2.4873 1 1 2 3 5

139 1,363 1.7601 1 1 1 2 3

146 841 8.6992 2 4 7 11 18

147 1,255 5.6805 1 2 4 7 11

148 552 3.3442 1 1 2 4 6

149 33,609 2.6159 1 1 2 3 5

150 1,544 4.7668 1 2 4 6 9

151 5,784 2.7934 1 1 2 4 5

152 2,893 4.1912 1 2 3 5 8

153 10,870 3.0419 1 2 2 4 5

154 3,034 5.6839 1 3 4 7 11

155 5,578 4.1133 1 2 3 5 8

156 3,515 2.8942 1 1 2 4 5

157 1,703 6.3429 2 3 5 8 13

158 3,380 4.2719 1 2 3 5 8

159 1,459 2.7347 1 1 2 3 5

163 14,398 13.8007 5 8 12 18 25

164 17,845 7.2187 3 4 6 9 13

165 10,518 4.3993 2 3 4 6 7

166 25,172 11.8608 4 6 9 15 22

167 17,710 7.0035 2 4 6 9 13

168 4,388 4.2985 1 2 3 6 8

175 16,505 6.7183 3 4 6 8 11

176 34,233 4.8503 2 3 4 6 8

177 79,035 8.4026 3 4 7 11 15

178 60,900 6.6817 3 4 6 8 12

179 16,039 4.9675 2 3 4 6 9
CMS-1498-P 1055 

MS-DRG 

Number of 

Discharges 

Arithmetic 

Mean 

LOS 

10th 

Percentile 

25th 

Percentile 

50th 

Percentile 

75th 

Percentile 

90th 

Percentile 

180 22,329 7.4210 2 4 6 9 14

181 24,506 5.3350 1 2 4 7 10

182 2,840 3.6532 1 2 3 5 7

183 3,042 6.3534 2 3 5 8 12

184 4,806 4.2239 2 3 4 5 7

185 2,187 3.0393 1 2 3 4 5

186 11,691 6.7234 2 3 5 9 13

187 9,939 4.7687 1 2 4 6 9

188 3,293 3.5299 1 2 3 4 7

189 94,058 5.5455 2 3 4 7 10

190 150,776 5.4847 2 3 5 7 10

191 136,438 4.5856 2 3 4 6 8

192 134,412 3.6580 1 2 3 5 6

193 132,433 6.3110 2 3 5 8 11

194 178,528 4.8665 2 3 4 6 8

195 87,008 3.6926 1 2 3 5 6

196 7,608 6.8980 2 4 6 9 13

197 6,141 4.9870 2 3 4 6 9

198 3,047 3.7670 1 2 3 5 7

199 4,146 7.8968 2 4 6 10 15

200 8,319 4.6915 1 2 4 6 9

201 2,745 3.5457 1 2 3 5 7

202 38,888 4.1342 1 2 3 5 7

203 28,980 3.1588 1 2 3 4 6

204 23,390 2.7325 1 1 2 3 5

205 7,730 5.2508 1 2 4 7 10

206 18,931 3.1590 1 1 3 4 6

207 36,288 14.7898 6 9 13 18 25

208 74,965 7.0337 1 3 6 9 14

215 177 12.6215 1 3 8 14 28

216 10,499 16.8419 8 10 15 21 28

217 5,948 10.3763 6 7 9 13 16

218 1,222 7.9869 5 6 7 9 12

219 14,314 12.8291 5 7 10 15 23

220 15,334 7.7011 4 5 7 9 12

221 4,475 5.9678 4 5 6 7 9

222 3,308 11.6403 4 6 10 15 21

223 3,289 5.4472 1 2 5 8 11

224 3,018 9.6156 3 5 8 12 18

225 4,209 5.0663 2 3 4 7 9

226 8,959 7.9386 1 3 6 11 16

227 28,451 2.7800 1 1 1 4 7

228 2,564 13.9961 6 8 12 17 25

229 2,590 7.9672 4 5 7 10 13

230 806 5.5186 2 4 5 7 9

231 1,473 12.8758 6 8 11 16 22
CMS-1498-P 1056 

MS-DRG 

Number of 

Discharges 

Arithmetic 

Mean 

LOS 

10th 

Percentile 

25th 

Percentile 

50th 

Percentile 

75th 

Percentile 

90th 

Percentile 

232 1,098 9.0674 5 6 9 11 14

233 17,629 13.4855 7 9 12 16 22

234 25,101 8.6064 5 6 8 10 13

235 11,045 10.6010 5 6 9 13 18

236 23,925 6.3642 4 5 6 7 10

237 24,161 10.0501 2 4 8 13 20

238 37,998 3.9482 1 1 3 6 8

239 12,154 14.2365 5 7 11 18 27

240 9,506 9.1471 3 5 8 11 16

241 1,552 5.9852 2 3 5 8 11

242 23,571 7.7578 2 4 6 10 14

243 35,573 4.6588 1 2 4 6 9

244 44,828 2.8119 1 1 2 4 6

245 3,970 3.8071 1 1 2 5 8

246 35,016 5.0861 1 2 4 7 10

247 139,869 2.1763 1 1 2 3 4

248 16,308 6.0738 1 3 5 8 12

249 44,453 2.6377 1 1 2 3 5

250 9,062 6.9734 2 3 5 9 14

251 35,031 2.7814 1 1 2 4 6

252 45,083 8.0234 1 3 6 10 17

253 40,080 5.6453 1 2 4 7 11

254 38,370 2.6631 1 1 2 3 6

255 2,897 9.2444 3 5 8 12 17

256 2,782 6.6618 2 3 6 8 12

257 394 4.3046 1 2 4 6 8

258 1,023 6.6970 2 3 5 8 13

259 4,793 2.9994 1 1 2 4 6

260 2,078 10.3725 3 5 8 13 21

261 3,592 4.1779 1 2 3 5 8

262 2,423 2.5815 1 1 2 3 5

263 518 5.6602 1 2 3 7 13

264 22,461 8.2590 1 3 6 11 17

265 1,714 3.3495 1 1 2 4 7

280 81,514 6.5098 2 3 5 8 12

281 41,879 4.0679 1 2 3 5 7

282 34,890 2.7555 1 1 2 4 5

283 14,231 4.9678 1 1 3 6 11

284 2,450 2.6686 1 1 1 3 6

285 1,428 1.7983 1 1 1 2 3

286 32,329 6.5479 2 3 5 8 13

287 127,613 3.0171 1 1 2 4 6

288 2,898 10.8037 4 6 9 13 19

289 979 7.2921 3 4 6 9 12

290 240 5.5792 1 3 5 7 10

291 232,185 6.1498 2 3 5 8 11
CMS-1498-P 1057 

MS-DRG 

Number of 

Discharges 

Arithmetic 

Mean 

LOS 

10th 

Percentile 

25th 

Percentile 

50th 

Percentile 

75th 

Percentile 

90th 

Percentile 

292 192,392 4.4947 2 3 4 6 8

293 118,010 3.3080 1 2 3 4 6

294 1,546 5.3668 2 3 5 7 9

295 874 4.0378 1 2 4 5 7

296 2,059 2.7071 1 1 1 3 6

297 629 1.7266 1 1 1 2 3

298 372 1.2097 1 1 1 1 1

299 26,735 6.0663 2 3 5 7 11

300 42,906 4.7095 1 3 4 6 8

301 28,789 3.4713 1 2 3 5 6

302 10,132 3.9515 1 2 3 5 7

303 50,124 2.3738 1 1 2 3 4

304 3,969 4.5382 1 2 4 6 8

305 32,236 2.6866 1 1 2 3 5

306 3,773 5.8049 2 3 4 7 11

307 5,337 3.1731 1 2 3 4 6

308 71,058 5.0115 2 2 4 6 9

309 93,276 3.6117 1 2 3 5 7

310 127,913 2.5033 1 1 2 3 4

311 15,715 2.2386 1 1 2 3 4

312 165,015 2.9422 1 1 2 4 5

313 169,337 2.0617 1 1 2 2 4

314 66,894 6.7151 2 3 5 8 13

315 25,869 4.0866 1 2 3 5 8

316 10,674 2.5722 1 1 2 3 5

326 11,940 16.0999 5 8 13 20 30

327 9,818 8.5639 2 5 7 11 16

328 8,538 3.7853 1 2 3 5 8

329 50,242 15.1759 6 8 13 19 27

330 56,158 8.8715 4 5 7 11 15

331 24,253 5.3159 3 4 5 6 8

332 1,825 13.8553 6 8 11 17 25

333 5,068 7.9820 4 5 7 10 13

334 3,027 4.9045 2 3 5 6 8

335 8,404 13.3221 5 8 12 17 23

336 12,225 8.4806 3 5 7 11 15

337 7,648 5.0911 1 3 4 7 9

338 1,571 9.6295 4 5 8 12 17

339 2,700 6.4174 3 4 6 8 11

340 3,036 3.7286 1 2 3 5 6

341 1,065 6.4939 2 3 5 9 13

342 2,745 3.6947 1 2 3 5 7

343 6,461 2.0108 1 1 2 2 4

344 1,132 10.8843 4 6 9 13 21

345 2,834 6.7759 3 4 6 8 11

346 2,591 4.6299 2 3 4 6 7
CMS-1498-P 1058 

MS-DRG 

Number of 

Discharges 

Arithmetic 

Mean 

LOS 

10th 

Percentile 

25th 

Percentile 

50th 

Percentile 

75th 

Percentile 

90th 

Percentile 

347 1,798 8.6029 2 4 6 11 17

348 3,935 5.1624 1 2 4 7 10

349 4,039 2.9153 1 1 2 4 6

350 2,080 7.5846 2 3 6 10 15

351 4,131 4.3053 1 2 4 6 8

352 6,456 2.3748 1 1 2 3 4

353 3,824 8.3227 2 4 7 11 16

354 8,960 4.8608 1 3 4 6 9

355 12,947 2.7752 1 1 2 4 5

356 8,909 12.3348 3 6 9 15 24

357 6,591 7.0678 2 4 6 9 13

358 2,045 4.0088 1 2 3 5 8

368 4,134 6.3464 2 3 5 8 12

369 4,797 4.3688 2 2 4 5 8

370 1,777 3.0833 1 2 3 4 5

371 30,894 8.3267 3 4 6 10 16

372 26,332 6.3285 2 4 5 8 11

373 11,202 4.5867 2 3 4 6 8

374 9,912 8.1968 2 4 6 10 16

375 15,328 5.5969 2 3 4 7 10

376 2,537 3.5861 1 2 3 4 6

377 68,239 6.0023 2 3 5 7 11

378 118,605 4.0662 2 2 3 5 7

379 50,778 3.0378 1 2 3 4 5

380 3,797 7.0608 2 3 5 9 13

381 5,326 4.6707 2 3 4 6 8

382 2,708 3.4830 1 2 3 4 6

383 1,656 5.0290 2 3 4 6 9

384 6,876 3.5609 1 2 3 4 6

385 3,198 7.6826 2 4 6 9 15

386 8,050 5.1593 2 3 4 6 9

387 4,132 3.9131 1 2 3 5 7

388 26,490 6.7018 2 3 5 8 13

389 47,015 4.6775 2 3 4 6 8

390 39,806 3.3390 1 2 3 4 6

391 61,486 4.9306 1 2 4 6 9

392 232,434 3.3799 1 2 3 4 6

393 27,251 6.6114 2 3 5 8 13

394 43,392 4.5431 1 2 4 6 8

395 20,065 3.0842 1 2 3 4 6

405 4,575 15.7388 5 8 12 20 31

406 4,893 8.1721 2 5 7 10 15

407 1,927 5.1520 1 3 5 7 8

408 1,640 13.2659 5 7 11 17 24

409 1,299 8.6343 3 5 7 11 15

410 475 5.8400 2 4 5 7 10
CMS-1498-P 1059 

MS-DRG 

Number of 

Discharges 

Arithmetic 

Mean 

LOS 

10th 

Percentile 

25th 

Percentile 

50th 

Percentile 

75th 

Percentile 

90th 

Percentile 

411 840 11.7000 5 7 10 14 21

412 780 8.0923 3 5 7 10 13

413 524 5.4027 2 3 5 7 9

414 5,253 11.1961 4 6 9 14 20

415 5,229 7.0692 3 4 6 9 12

416 3,992 4.3790 2 3 4 5 7

417 20,292 7.7720 3 4 6 10 14

418 24,952 5.1565 2 3 4 7 9

419 28,245 3.0297 1 1 2 4 6

420 774 13.0530 3 6 10 17 26

421 846 6.5910 1 3 5 9 13

422 234 4.1068 1 2 3 5 8

423 1,617 14.1472 4 7 11 18 28

424 672 8.6577 3 4 7 11 16

425 86 5.6860 2 3 4 7 10

432 13,529 6.4975 2 3 5 8 13

433 6,969 4.3401 1 2 4 5 8

434 398 3.1734 1 2 3 4 6

435 13,761 7.2943 2 3 6 9 14

436 11,039 5.3120 2 3 4 7 10

437 2,182 3.6856 1 2 3 5 7

438 19,674 7.0637 2 3 5 9 14

439 23,206 4.8099 2 3 4 6 9

440 20,560 3.4957 1 2 3 4 6

441 18,105 6.8437 2 3 5 8 14

442 14,938 4.5243 1 2 4 6 8

443 4,688 3.3057 1 2 3 4 6

444 14,810 6.1409 2 3 5 8 11

445 16,827 4.3909 1 2 4 6 8

446 12,789 3.0593 1 2 3 4 6

453 1,255 13.0876 5 6 10 16 25

454 2,962 6.6357 3 4 5 8 12

455 2,482 3.7526 1 2 3 5 6

456 1,241 13.1475 5 7 10 16 24

457 3,086 6.8568 3 4 6 8 12

458 1,565 4.0505 2 3 4 5 7

459 4,695 8.6505 3 5 7 10 16

460 60,945 3.8373 2 2 3 5 6

461 947 7.2893 3 4 6 8 13

462 11,067 4.0499 3 3 3 4 6

463 6,113 14.7572 4 7 11 18 29

464 7,907 8.5108 3 4 7 10 16

465 2,708 5.2688 2 3 4 6 9

466 4,780 8.5090 3 4 7 10 15

467 19,097 4.8438 3 3 4 6 8

468 15,812 3.5808 2 3 3 4 5
CMS-1498-P 1060 

MS-DRG 

Number of 

Discharges 

Arithmetic 

Mean 

LOS 

10th 

Percentile 

25th 

Percentile 

50th 

Percentile 

75th 

Percentile 

90th 

Percentile 

469 35,893 7.4293 3 4 6 9 13

470 404,338 3.6454 2 3 3 4 5

471 2,991 9.2207 2 4 7 13 18

472 8,421 3.6774 1 1 2 5 8

473 25,112 1.8500 1 1 1 2 3

474 3,277 11.8758 4 6 9 15 22

475 3,428 7.3629 2 4 6 9 14

476 1,134 4.0908 1 2 3 5 8

477 3,256 10.7457 4 6 9 13 19

478 8,249 6.6555 1 3 6 9 12

479 5,867 3.3936 1 1 2 5 7

480 31,193 8.4968 4 5 7 10 15

481 74,874 5.4504 3 4 5 6 8

482 33,902 4.4797 3 3 4 5 7

483 10,324 3.7260 2 2 3 4 7

484 18,014 2.1959 1 1 2 3 3

485 1,261 10.5147 4 6 8 13 19

486 2,153 7.0060 3 4 6 8 12

487 1,058 5.0888 2 3 4 6 8

488 3,248 4.6918 2 3 3 5 8

489 4,902 2.8499 1 2 3 3 5

490 22,903 4.2505 1 2 3 5 9

491 45,224 2.0655 1 1 1 3 4

492 6,706 8.1353 3 4 7 10 15

493 18,839 4.8463 2 3 4 6 8

494 25,249 3.1465 1 2 3 4 5

495 1,890 9.9476 3 5 8 12 19

496 4,609 5.1833 1 2 4 7 10

497 5,130 2.5558 1 1 2 3 5

498 1,481 7.2552 2 3 6 9 14

499 876 2.9920 1 1 2 3 5

500 2,283 10.1783 3 5 8 13 20

501 4,635 5.7282 2 3 5 7 11

502 5,741 2.8021 1 1 2 3 5

503 1,174 8.4361 3 4 7 11 16

504 2,548 5.9863 2 3 5 8 11

505 2,256 3.1272 1 1 3 4 6

506 717 3.7992 1 1 3 5 8

507 940 4.5160 1 2 3 5 9

508 1,782 2.0561 1 1 2 3 3

509 349 3.4699 1 1 2 4 7

510 1,275 6.1569 2 3 5 8 11

511 4,095 3.8112 1 2 3 5 7

512 8,255 2.1474 1 1 2 3 4

513 1,248 4.8205 1 2 4 6 9

514 921 2.6406 1 1 2 3 5
CMS-1498-P 1061 

MS-DRG 

Number of 

Discharges 

Arithmetic 

Mean 

LOS 

10th 

Percentile 

25th 

Percentile 

50th 

Percentile 

75th 

Percentile 

90th 

Percentile 

515 4,912 9.3950 3 5 8 11 17

516 11,267 5.7698 2 3 5 7 10

517 11,169 3.3660 1 1 3 5 7

533 1,004 6.2490 2 3 5 8 12

534 3,277 3.8145 1 2 3 5 7

535 9,037 5.5860 2 3 4 7 10

536 31,028 3.6752 1 3 3 4 6

537 944 4.0911 2 3 3 5 7

538 708 3.0494 1 2 3 4 5

539 3,683 9.2359 3 5 7 11 16

540 3,800 6.6839 2 4 5 8 11

541 1,124 4.8488 1 2 4 6 8

542 7,101 7.9687 3 4 6 10 15

543 15,205 5.5178 2 3 4 7 10

544 6,624 4.0503 2 3 3 5 7

545 4,543 8.6212 2 4 6 11 18

546 5,210 5.0029 2 3 4 6 9

547 3,348 3.5358 1 2 3 4 6

548 728 8.6181 3 4 7 10 16

549 1,066 5.7645 2 3 5 7 10

550 556 4.0108 1 2 3 5 7

551 14,610 6.4630 2 3 5 8 12

552 73,510 3.8977 1 2 3 5 7

553 4,040 5.3376 2 3 4 6 9

554 15,436 3.4756 1 2 3 4 6

555 3,445 4.7660 1 2 4 6 9

556 16,663 3.1124 1 2 3 4 6

557 6,796 6.2217 2 3 5 7 11

558 14,146 4.1105 2 3 4 5 7

559 2,281 6.9833 2 3 5 9 14

560 4,922 4.5211 1 2 4 6 8

561 5,314 2.6314 1 1 2 3 5

562 7,806 5.6471 2 3 4 7 10

563 30,486 3.4819 1 2 3 4 6

564 2,149 6.4044 2 3 5 8 12

565 3,699 4.5250 1 3 4 6 8

566 1,759 3.4179 1 2 3 4 6

573 5,749 12.2113 4 6 9 14 23

574 9,057 8.3095 3 4 7 10 15

575 3,721 5.1774 2 3 4 7 9

576 780 12.9000 3 5 9 17 26

577 2,280 5.7974 1 2 4 7 12

578 2,530 3.2573 1 1 2 4 6

579 4,595 10.2448 3 5 8 13 19

580 10,731 5.0932 1 2 4 7 10

581 10,753 2.3869 1 1 2 3 5
CMS-1498-P 1062 

MS-DRG 

Number of 

Discharges 

Arithmetic 

Mean 

LOS 

10th 

Percentile 

25th 

Percentile 

50th 

Percentile 

75th 

Percentile 

90th 

Percentile 

582 4,901 2.6566 1 1 2 3 5

583 7,581 1.7392 1 1 1 2 3

584 862 4.9617 1 2 4 7 10

585 1,462 2.1382 1 1 1 3 4

592 4,964 7.9746 2 4 6 9 14

593 10,203 5.7727 2 3 5 7 10

594 1,483 4.6703 1 2 4 6 8

595 1,674 7.2832 2 4 6 9 14

596 4,415 4.4208 1 2 4 5 8

597 695 7.5007 2 3 6 9 13

598 1,384 5.2854 1 2 4 7 10

599 185 3.2757 1 1 3 4 5

600 1,034 4.9207 2 3 4 6 9

601 778 3.6157 1 2 3 5 6

602 33,771 6.4584 2 3 5 8 12

603 127,084 4.4100 2 3 4 5 8

604 3,668 4.9738 1 2 4 6 9

605 19,162 3.2558 1 2 3 4 6

606 2,247 5.6805 1 3 4 7 11

607 6,374 3.4934 1 2 3 4 6

614 1,706 6.5774 2 3 5 8 13

615 1,449 2.9717 1 2 3 4 5

616 1,678 15.5936 6 8 13 19 28

617 6,516 7.8996 3 4 7 10 14

618 148 5.1419 2 3 4 6 9

619 1,009 7.3310 1 2 4 8 15

620 2,993 3.1617 1 2 2 4 6

621 11,368 1.8438 1 1 2 2 3

622 1,232 12.1640 4 6 9 14 22

623 2,455 7.5825 3 4 6 9 13

624 236 4.8347 2 3 4 6 8

625 1,309 7.0963 1 2 5 9 15

626 2,852 2.8159 1 1 2 3 6

627 12,254 1.4115 1 1 1 1 2

628 3,718 10.5662 2 4 8 13 20

629 4,451 7.9232 3 4 7 10 14

630 446 4.4619 1 2 3 6 8

637 26,230 5.4669 2 3 4 7 10

638 46,738 3.9819 1 2 3 5 7

639 24,880 2.8062 1 1 2 3 5

640 79,621 4.7818 1 2 3 6 9

641 164,528 3.5115 1 2 3 4 6

642 1,603 4.7436 1 2 3 6 9

643 7,683 7.2309 2 4 6 9 13

644 11,845 5.0712 2 3 4 6 9

645 6,422 3.5668 1 2 3 4 6
CMS-1498-P 1063 

MS-DRG 

Number of 

Discharges 

Arithmetic 

Mean 

LOS 

10th 

Percentile 

25th 

Percentile 

50th 

Percentile 

75th 

Percentile 

90th 

Percentile 

652 10,211 7.5052 4 5 6 8 13

653 2,013 15.8987 6 8 13 20 29

654 3,404 9.0858 5 6 8 11 15

655 1,275 5.6549 2 4 6 7 9

656 4,888 9.4728 3 5 7 11 18

657 7,350 5.3278 2 3 5 6 9

658 6,807 3.3676 1 2 3 4 5

659 5,503 10.1098 3 4 8 13 20

660 7,095 5.6238 2 3 4 7 11

661 3,862 2.8933 1 2 2 4 5

662 1,015 10.2749 2 4 8 12 21

663 1,820 4.8462 1 2 3 6 10

664 3,282 1.8525 1 1 1 2 3

665 884 10.5271 3 5 9 13 20

666 1,878 5.9361 1 2 4 8 12

667 2,595 2.3680 1 1 2 3 4

668 5,500 7.7095 2 3 6 10 15

669 12,259 4.0007 1 2 3 5 8

670 8,764 2.2913 1 1 2 3 5

671 799 5.5920 1 2 4 7 11

672 635 2.2000 1 1 2 3 4

673 12,494 9.5253 1 3 7 12 20

674 8,802 6.5558 1 2 5 9 14

675 3,252 2.1125 1 1 1 2 5

682 102,211 6.7567 2 3 5 8 13

683 114,329 4.9315 2 3 4 6 9

684 26,729 3.3482 1 2 3 4 6

685 2,513 3.3979 1 1 2 4 7

686 1,940 7.0340 2 3 5 9 14

687 2,618 4.6902 1 2 4 6 8

688 706 2.8031 1 1 2 3 5

689 89,105 5.4897 2 3 4 7 10

690 185,262 3.9692 2 2 3 5 7

691 999 4.3053 1 2 3 5 9

692 380 2.2421 1 1 2 3 4

693 4,313 4.3438 1 2 3 6 8

694 15,245 2.3793 1 1 2 3 4

695 1,361 5.3475 1 3 4 7 10

696 9,992 3.1414 1 2 3 4 6

697 509 3.1100 1 1 2 4 6

698 32,063 6.3485 2 3 5 8 12

699 23,186 4.4403 1 2 4 6 8

700 8,115 3.2223 1 2 3 4 6

707 5,392 4.2381 1 2 3 5 8

708 16,899 1.8647 1 1 2 2 3

709 817 5.6793 1 1 3 7 13
CMS-1498-P 1064 

MS-DRG 

Number of 

Discharges 

Arithmetic 

Mean 

LOS 

10th 

Percentile 

25th 

Percentile 

50th 

Percentile 

75th 

Percentile 

90th 

Percentile 

710 1,504 1.6642 1 1 1 2 3

711 740 7.2986 1 3 5 9 15

712 424 2.6604 1 1 2 3 5

713 9,760 4.0614 1 2 3 5 9

714 22,626 1.8214 1 1 2 2 3

715 505 6.0554 1 2 4 8 13

716 685 1.3518 1 1 1 1 2

717 734 6.4074 1 3 5 8 13

718 446 2.6121 1 1 2 3 5

722 907 6.8655 2 3 5 8 13

723 1,505 4.8213 1 2 4 6 9

724 276 2.6957 1 1 2 3 5

725 1,368 4.8450 2 2 4 6 9

726 3,010 3.2664 1 2 3 4 6

727 2,292 6.0105 2 3 5 7 11

728 5,331 3.9081 1 2 3 5 7

729 838 4.6802 1 2 4 6 9

730 276 2.8442 1 1 2 3 5

734 1,520 6.9493 2 3 5 8 14

735 1,138 2.6951 1 1 2 4 5

736 1,046 13.6434 5 7 11 17 25

737 3,134 6.4467 3 4 6 8 11

738 712 3.5941 2 2 3 4 5

739 1,106 9.4313 3 4 7 11 19

740 4,261 4.5226 2 3 4 5 8

741 5,393 2.5524 1 1 2 3 4

742 10,807 4.1279 1 2 3 5 8

743 27,700 2.0692 1 1 2 3 3

744 1,625 5.5680 1 2 4 7 11

745 1,265 2.4403 1 1 2 3 5

746 2,621 4.1801 1 2 3 5 8

747 7,265 1.7794 1 1 1 2 3

748 17,103 1.6853 1 1 1 2 3

749 1,052 8.4753 2 4 7 11 16

750 362 2.7901 1 1 2 3 5

754 1,471 8.2998 2 4 6 11 16

755 2,959 5.0057 1 2 4 6 9

756 440 3.0750 1 1 2 4 6

757 1,772 7.5056 3 4 6 9 14

758 1,770 5.4650 2 3 5 7 10

759 978 4.0112 2 2 3 5 7

760 2,269 3.7532 1 2 3 5 7

761 1,138 2.2417 1 1 2 3 4

765 3,417 4.8674 2 3 4 5 7

766 2,757 3.0812 2 2 3 4 4

767 169 2.6864 2 2 2 3 4
CMS-1498-P 1065 

MS-DRG 

Number of 

Discharges 

Arithmetic 

Mean 

LOS 

10th 

Percentile 

25th 

Percentile 

50th 

Percentile 

75th 

Percentile 

90th 

Percentile 

768 8 6.7500 1 2 5 6 13

769 122 5.7459 1 2 4 7 13

770 177 2.0904 1 1 1 2 4

774 1,667 3.2190 2 2 2 3 4

775 5,860 2.3258 1 2 2 3 3

776 588 3.3248 1 2 2 4 6

777 198 2.0505 1 1 2 3 4

778 444 3.2050 1 1 2 3 6

779 121 2.1405 1 1 1 2 4

780 42 1.6190 1 1 1 1 2

781 3,387 3.8432 1 1 3 4 7

782 188 2.6117 1 1 2 3 5

793 3 3.6667 1 1 3 7 7

794 1 1.0000 1 1 1 1 1

799 582 13.2405 4 7 11 17 25

800 641 7.2246 2 4 6 9 14

801 357 3.9076 1 2 3 5 7

802 1,095 11.7826 3 5 8 13 21

803 1,004 6.0936 2 3 5 7 11

804 764 2.9686 1 1 2 4 6

808 9,279 8.0600 2 4 6 10 15

809 13,025 4.9646 2 3 4 6 9

810 2,170 3.7392 1 2 3 5 7

811 37,741 5.1436 1 2 4 6 10

812 91,512 3.5555 1 2 3 4 7

813 11,471 4.9750 1 2 4 6 10

814 2,052 6.6774 2 3 5 8 12

815 3,337 4.4489 1 2 4 5 8

816 1,532 3.2428 1 2 3 4 6

820 1,396 17.0659 5 8 13 22 33

821 1,934 7.0817 1 3 5 9 15

822 1,738 3.0984 1 1 2 4 6

823 2,425 14.9126 5 7 12 18 28

824 2,581 8.1395 2 4 7 11 16

825 1,442 3.9286 1 1 3 5 8

826 680 14.2985 5 7 11 18 27

827 1,420 6.6838 2 3 5 8 13

828 696 3.7586 1 2 3 5 7

829 1,398 9.3369 2 3 7 11 20

830 385 3.1247 1 1 2 4 6

834 4,288 15.1749 2 4 9 23 35

835 2,465 9.3513 2 3 5 10 25

836 1,201 4.4388 1 2 3 5 8

837 1,390 22.5914 5 8 22 31 42

838 1,431 12.2697 3 4 6 20 30

839 1,284 5.6830 2 4 5 5 7
CMS-1498-P 1066 

MS-DRG 

Number of 

Discharges 

Arithmetic 

Mean 

LOS 

10th 

Percentile 

25th 

Percentile 

50th 

Percentile 

75th 

Percentile 

90th 

Percentile 

840 9,929 10.0469 3 4 8 13 20

841 8,550 6.3908 2 3 5 8 12

842 3,644 4.1715 1 2 3 5 8

843 1,876 7.7953 2 4 6 10 14

844 2,566 5.4189 2 3 4 7 10

845 667 3.7676 1 2 3 5 7

846 3,055 7.8206 2 3 5 9 17

847 21,591 3.3495 1 2 3 4 6

848 1,107 2.9883 1 1 3 4 5

849 1,163 6.0404 2 3 5 6 11

853 42,325 15.3906 5 8 12 19 28

854 5,584 9.1653 3 5 8 11 16

855 337 5.3976 1 2 4 7 10

856 6,574 14.8006 4 7 11 18 28

857 9,165 7.5920 3 4 6 9 14

858 2,325 5.0533 2 3 4 6 9

862 10,485 7.6788 2 4 6 9 15

863 20,692 4.7970 2 3 4 6 8

864 18,172 3.7732 1 2 3 5 7

865 3,069 6.0336 2 3 4 7 12

866 6,641 3.3212 1 2 3 4 6

867 5,759 8.9976 2 4 7 11 18

868 2,409 5.1582 2 3 4 6 9

869 779 3.6393 1 2 3 4 6

870 25,752 15.1737 6 9 13 18 26

871 280,970 7.0555 2 3 6 9 13

872 75,906 5.1518 2 3 4 6 9

876 656 12.6799 2 4 8 14 29

880 8,144 3.0149 1 1 2 4 6

881 4,536 4.2377 1 2 3 5 8

882 1,797 4.2966 1 2 3 5 8

883 863 7.7034 1 3 5 8 15

884 18,110 5.3720 2 3 4 6 9

885 88,160 7.3601 2 3 6 9 13

886 525 6.1657 1 2 4 6 12

887 466 4.0494 1 2 3 5 7

894 4,520 2.9412 1 1 2 3 4

895 6,273 10.9396 3 4 6 8 9

896 8,621 6.1897 2 3 4 7 11

897 35,167 3.9315 1 2 3 4 6

901 1,074 13.7719 3 5 9 17 29

902 1,753 7.1843 2 3 5 8 14

903 1,027 4.4450 1 2 3 5 8

904 1,895 11.1135 2 4 7 13 23

905 763 4.5242 1 2 4 6 9

906 707 3.0905 1 1 2 3 6
CMS-1498-P 1067 

MS-DRG 

Number of 

Discharges 

Arithmetic 

Mean 

LOS 

10th 

Percentile 

25th 

Percentile 

50th 

Percentile 

75th 

Percentile 

90th 

Percentile 

907 9,288 11.0101 3 5 8 14 22

908 8,383 6.1103 2 3 5 8 12

909 4,760 3.3786 1 1 3 4 7

913 1,159 5.3572 1 2 4 6 10

914 5,171 3.1251 1 1 3 4 6

915 1,808 4.6858 1 2 3 6 9

916 5,255 2.0278 1 1 1 2 4

917 22,772 4.9226 1 2 4 6 10

918 33,100 2.6100 1 1 2 3 5

919 12,011 6.1429 2 3 4 7 12

920 14,002 4.1465 1 2 3 5 8

921 7,314 2.8138 1 1 2 3 5

922 1,467 5.0266 1 2 4 6 10

923 2,780 3.1299 1 1 2 4 5

927 188 28.2128 8 13 23 39 55

928 948 14.8597 3 7 12 20 29

929 366 7.6721 1 3 6 10 15

933 138 5.2319 1 1 1 5 12

934 608 5.8257 1 2 4 7 11

935 2,111 5.2321 1 2 3 6 10

939 816 9.8750 2 4 7 13 20

940 1,539 5.1313 1 2 3 7 11

941 1,455 2.5904 1 1 2 3 5

945 5,971 10.1921 4 6 8 11 15

946 2,809 7.4938 3 5 6 7 8

947 15,418 4.8159 1 2 4 6 9

948 52,323 3.3628 1 2 3 4 6

949 640 4.2969 1 1 2 4 7

950 276 2.7572 1 1 2 3 4

951 1,028 4.5360 1 1 2 3 6

955 443 12.6456 3 5 9 17 24

956 4,421 8.4180 4 5 7 10 15

957 1,516 14.0468 3 7 11 18 27

958 1,134 9.5273 3 5 8 12 16

959 200 5.5800 2 3 5 7 10

963 2,001 8.4983 1 3 7 11 18

964 2,672 5.4963 2 3 5 7 10

965 913 3.7558 1 2 3 5 7

969 638 17.0611 4 7 13 22 35

970 95 8.4526 1 3 7 12 17

974 6,029 9.3641 2 4 7 12 18

975 3,693 6.4075 2 3 5 8 12

976 1,529 4.4173 1 2 3 5 7

977 3,547 4.8765 1 2 4 6 9

981 28,575 13.8055 4 7 11 17 26

982 16,651 8.2634 2 4 7 11 15
CMS-1498-P 1068 

MS-DRG 

Number of 

Discharges 

Arithmetic 

Mean 

LOS 

10th 

Percentile 

25th 

Percentile 

50th 

Percentile 

75th 

Percentile 

90th 

Percentile 

983 4,894 4.2284 1 2 3 6 9

984 747 12.6051 4 7 11 16 22

985 814 8.4017 2 4 7 12 16

986 447 4.0559 1 1 2 6 9

987 9,573 11.8354 3 6 10 15 22

988 9,352 7.0079 2 3 6 9 14

989 3,950 3.5337 1 1 2 5 7

 10,957,307 
CMS-1498-P 1069 

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED 

PERCENTILE LENGHTS OF STAY; FY 2009 MedPAR UPDATE – DECEMBER 2009 

GROUPER V28.0 MS-DRGs 

MSDRG Number of 

Discharges

Arithmetic 

Mean LOS 

10th 

Percentile

25th 

Percentile

50th 

Percentile

75th 

Percentile

90th 

Percentile

1 907 41.8412 12 19 33 53 82

2 333 22.7628 9 12 17 29 42

3 21,956 36.6115 15 21 30 44 63

4 21,395 27.1269 11 16 22 32 46

5 889 19.9944 6 9 14 25 43

6 408 9.2255 5 6 8 11 14

7 469 18.7058 8 11 15 23 31

8 509 11.7741 6 7 9 13 21

10 137 9.7007 5 7 8 11 13

11 1,466 15.5989 6 8 12 19 29

12 1,963 10.0942 4 6 8 13 17

13 1,008 6.7401 3 4 6 8 11

14 446 27.7489 7 19 25 34 50

15 1,372 19.2449 10 15 18 22 28

20 1,081 17.2026 6 10 16 23 29

21 469 13.9382 7 10 14 17 22

22 146 8.3767 2 4 8 12 14

23 4,406 11.7690 2 5 9 16 23

24 1,708 8.0878 1 3 7 11 16

25 11,582 11.5431 3 6 9 15 22

26 11,469 7.3239 2 4 6 9 14

27 12,591 3.8861 1 2 3 5 7

28 1,851 13.1059 4 6 11 16 25

29 3,505 6.5629 1 3 5 9 13

30 3,432 3.2797 1 1 3 4 7

31 1,169 12.2104 2 5 9 16 25

32 2,808 5.3711 1 2 4 7 12

33 3,351 2.6640 1 1 2 3 5

34 819 7.0195 1 2 6 10 15

35 2,336 3.2140 1 1 2 4 8

36 5,732 1.5223 1 1 1 1 3

37 4,944 8.3833 1 3 7 11 18

38 14,449 3.5553 1 1 2 5 8

39 43,823 1.6743 1 1 1 2 3

40 4,817 12.1704 3 6 9 15 23

41 7,552 6.6622 1 3 6 8 13

42 3,808 3.2261 1 1 2 4 7

52 1,250 6.6328 2 3 5 7 11

53 487 3.5832 1 2 3 5 6

54 7,208 6.2757 2 3 5 8 12
CMS-1498-P 1070 

MSDRG Number of 

Discharges

Arithmetic 

Mean LOS 

10th 

Percentile

25th 

Percentile

50th 

Percentile

75th 

Percentile

90th 

Percentile

55 13,028 4.6122 1 2 3 6 9

56 9,289 7.1527 2 3 5 9 14

57 43,231 4.8535 2 3 4 6 8

58 893 7.2878 2 3 5 9 14

59 3,250 4.9237 2 3 4 6 8

60 3,515 3.7713 1 2 3 5 6

61 2,266 8.3530 2 4 7 11 16

62 3,739 5.6448 2 3 5 7 10

63 1,309 3.9152 2 2 3 5 7

64 60,945 6.9291 2 3 5 9 14

65 112,612 4.8351 2 3 4 6 9

66 66,535 3.2734 1 2 3 4 6

67 1,387 5.4737 2 3 4 7 10

68 10,376 3.3077 1 2 3 4 6

69 92,535 2.7913 1 2 2 3 5

70 9,646 7.3534 2 3 6 9 14

71 13,708 5.1401 2 3 4 6 9

72 4,838 3.1174 1 2 2 4 6

73 8,926 5.6255 2 3 4 7 11

74 31,568 4.0866 1 2 3 5 7

75 1,348 6.9733 2 4 5 8 13

76 661 3.9259 1 2 3 5 7

77 1,519 6.4352 2 3 5 8 12

78 2,122 4.3907 1 2 4 5 8

79 774 3.0749 1 2 3 4 5

80 1,625 4.9145 1 2 4 6 10

81 5,867 3.4137 1 2 3 4 6

82 2,372 6.0544 1 1 4 8 13

83 2,596 4.6541 1 2 4 6 9

84 2,542 2.7825 1 1 2 4 5

85 7,305 7.2197 2 3 6 9 14

86 14,311 4.6416 1 2 4 6 8

87 13,012 2.9085 1 1 2 4 5

88 870 5.5345 2 3 4 7 11

89 3,155 3.6960 1 2 3 5 7

90 2,481 2.3136 1 1 2 3 4

91 8,739 6.2049 1 3 4 7 13

92 19,751 4.2052 1 2 3 5 8

93 13,215 2.8862 1 1 2 4 5

94 1,426 11.8296 3 6 10 15 21

95 1,186 8.3727 3 5 7 11 15

96 540 5.6667 1 4 5 7 10

97 1,187 11.6352 4 6 9 15 22

98 1,065 7.8892 3 4 7 10 14

99 423 5.1915 2 3 4 7 10

100 19,259 5.9589 2 3 4 7 11
CMS-1498-P 1071 

MSDRG Number of 

Discharges

Arithmetic 

Mean LOS 

10th 

Percentile

25th 

Percentile

50th 

Percentile

75th 

Percentile

90th 

Percentile

101 56,054 3.4365 1 2 3 4 6

102 1,285 4.2716 1 2 3 5 9

103 12,526 3.0242 1 1 2 4 6

113 639 5.5994 1 2 4 7 11

114 431 2.5986 1 1 2 3 5

115 850 4.6082 1 2 4 5 7

116 455 4.4813 1 1 2 5 7

117 549 1.9872 1 1 1 1 2

121 744 5.1022 2 3 4 6 8

122 524 3.9790 1 2 3 5 7

123 2,672 2.7182 1 1 2 3 5

124 739 5.2612 1 2 4 6 11

125 4,274 3.3538 1 2 3 4 6

129 1,508 5.2454 1 2 4 7 11

130 943 2.8908 1 1 2 4 6

131 1,132 5.5998 1 2 4 7 11

132 748 2.7126 1 1 2 3 5

133 2,242 5.3965 1 2 4 7 11

134 2,627 2.0837 1 1 1 2 4

135 466 6.3112 1 2 5 9 13

136 351 2.2422 1 1 1 3 5

137 891 4.9989 1 2 4 6 10

138 747 2.4873 1 1 2 3 5

139 1,363 1.7601 1 1 1 2 3

146 734 9.0327 2 4 7 11 19

147 1,362 5.7379 1 2 4 7 11

148 552 3.3442 1 1 2 4 6

149 33,609 2.6159 1 1 2 3 5

150 1,162 4.9699 1 2 4 6 10

151 6,166 2.8774 1 1 2 4 5

152 2,298 4.2963 1 2 3 5 8

153 11,465 3.0804 1 2 3 4 5

154 2,458 5.7754 1 3 4 7 12

155 6,154 4.2238 1 2 3 5 8

156 3,515 2.8942 1 1 2 4 5

157 1,374 6.6798 2 3 5 8 14

158 3,709 4.3308 1 2 3 5 8

159 1,459 2.7347 1 1 2 3 5

163 13,439 14.0385 5 8 12 18 25

164 18,804 7.3844 3 4 6 9 13

165 10,518 4.3993 2 3 4 6 7

166 23,100 11.9825 4 6 10 15 22

167 19,782 7.3702 2 4 6 9 14

168 4,388 4.2985 1 2 3 6 8

175 14,080 6.8241 3 4 6 8 12

176 36,658 4.9333 2 3 5 6 8
CMS-1498-P 1072 

MSDRG Number of 

Discharges

Arithmetic 

Mean LOS 

10th 

Percentile

25th 

Percentile

50th 

Percentile

75th 

Percentile

90th 

Percentile

177 68,128 8.5605 3 5 7 11 16

178 71,807 6.7933 3 4 6 8 12

179 16,039 4.9675 2 3 4 6 9

180 20,637 7.4786 2 4 6 10 14

181 26,198 5.4244 1 3 4 7 10

182 2,840 3.6532 1 2 3 5 7

183 2,664 6.4842 2 3 5 8 12

184 5,184 4.3119 2 3 4 5 8

185 2,187 3.0393 1 2 3 4 5

186 10,686 6.7318 2 3 5 9 13

187 10,944 4.9400 1 2 4 6 9

188 3,293 3.5299 1 2 3 4 7

189 94,058 5.5455 2 3 4 7 10

190 136,856 5.5075 2 3 5 7 10

191 150,358 4.6481 2 3 4 6 8

192 134,412 3.6580 1 2 3 5 6

193 103,907 6.4847 2 4 5 8 12

194 207,054 4.9783 2 3 4 6 9

195 87,008 3.6926 1 2 3 5 6

196 6,959 6.9585 2 4 6 9 13

197 6,790 5.1077 2 3 4 6 9

198 3,047 3.7670 1 2 3 5 7

199 3,790 8.0317 2 4 6 10 15

200 8,675 4.7641 1 2 4 6 9

201 2,745 3.5457 1 2 3 5 7

202 38,888 4.1342 1 2 3 5 7

203 28,980 3.1588 1 2 3 4 6

204 23,390 2.7325 1 1 2 3 5

205 6,677 5.3037 1 2 4 7 10

206 19,984 3.2516 1 2 3 4 6

207 36,288 14.7898 6 9 13 18 25

208 74,965 7.0337 1 3 6 9 14

215 177 12.6215 1 3 8 14 28

216 9,532 17.0712 8 11 15 21 29

217 6,915 10.9643 6 7 10 13 18

218 1,222 7.9869 5 6 7 9 12

219 12,766 13.1024 5 7 11 16 24

220 16,882 7.9647 4 6 7 9 13

221 4,475 5.9678 4 5 6 7 9

222 2,754 11.8500 4 6 10 15 22

223 3,843 6.1897 1 2 5 8 12

224 2,738 9.7064 3 5 8 12 18

225 4,489 5.2947 2 3 5 7 10

226 7,266 7.7703 1 2 6 11 16

227 30,144 3.1103 1 1 1 4 7

228 2,305 14.2430 6 8 12 18 25
CMS-1498-P 1073 

MSDRG Number of 

Discharges

Arithmetic 

Mean LOS 

10th 

Percentile

25th 

Percentile

50th 

Percentile

75th 

Percentile

90th 

Percentile

229 2,849 8.3155 4 5 7 10 14

230 806 5.5186 2 4 5 7 9

231 1,351 12.9067 6 8 11 16 22

232 1,220 9.4139 5 7 9 11 14

233 15,293 13.7411 7 9 12 16 23

234 27,437 8.8794 5 6 8 11 13

235 9,468 10.8477 5 6 9 13 19

236 25,502 6.5346 4 5 6 8 10

237 22,101 10.1669 2 4 8 13 20

238 40,058 4.1976 1 1 3 6 9

239 10,869 14.3506 5 7 11 18 27

240 10,791 9.6381 3 5 8 12 18

241 1,552 5.9852 2 3 5 8 11

242 17,882 8.0936 2 4 6 10 15

243 41,262 4.9405 1 2 4 6 9

244 44,828 2.8119 1 1 2 4 6

245 3,970 3.8071 1 1 2 5 8

246 30,909 5.0086 1 2 4 6 10

247 143,976 2.2759 1 1 2 3 4

248 14,361 6.0490 1 3 5 8 12

249 46,400 2.7896 1 1 2 3 5

250 7,652 6.9611 2 3 5 9 14

251 36,441 2.9462 1 1 2 4 6

252 40,567 7.8947 1 3 6 10 17

253 44,596 6.0032 1 2 5 8 12

254 38,370 2.6631 1 1 2 3 6

255 2,483 9.2114 2 4 7 12 17

256 3,196 7.0219 2 4 6 9 13

257 394 4.3046 1 2 4 6 8

258 763 6.9685 2 3 5 9 13

259 5,053 3.1486 1 1 2 4 6

260 1,770 10.7571 2 5 8 14 22

261 3,900 4.4926 1 2 3 6 9

262 2,423 2.5815 1 1 2 3 5

263 518 5.6602 1 2 3 7 13

264 22,461 8.2590 1 3 6 11 17

265 1,714 3.3495 1 1 2 4 7

280 70,000 6.6250 2 3 5 8 12

281 53,393 4.4435 1 2 4 6 8

282 34,890 2.7555 1 1 2 4 5

283 12,651 5.1395 1 1 3 7 12

284 4,030 3.0310 1 1 2 4 7

285 1,428 1.7983 1 1 1 2 3

286 25,188 6.4764 2 3 5 8 13

287 134,754 3.2176 1 1 2 4 6

288 2,679 10.8634 4 6 9 13 19
CMS-1498-P 1074 

MSDRG Number of 

Discharges

Arithmetic 

Mean LOS 

10th 

Percentile

25th 

Percentile

50th 

Percentile

75th 

Percentile

90th 

Percentile

289 1,198 7.8005 3 5 7 10 13

290 240 5.5792 1 3 5 7 10

291 176,332 6.1577 2 3 5 8 12

292 248,245 4.8614 2 3 4 6 9

293 118,010 3.3080 1 2 3 4 6

294 1,546 5.3668 2 3 5 7 9

295 874 4.0378 1 2 4 5 7

296 1,921 2.7673 1 1 1 3 6

297 767 1.7523 1 1 1 2 3

298 372 1.2097 1 1 1 1 1

299 21,223 6.0532 2 3 5 7 11

300 48,418 4.8697 2 3 4 6 8

301 28,789 3.4713 1 2 3 5 6

302 7,760 3.9586 1 2 3 5 7

303 52,496 2.4440 1 1 2 3 4

304 2,867 4.5438 1 2 3 6 8

305 33,338 2.7473 1 1 2 3 5

306 3,079 5.9328 2 3 4 7 11

307 6,031 3.4107 1 2 3 4 6

308 56,626 5.1614 2 3 4 6 10

309 107,708 3.7205 1 2 3 5 7

310 127,913 2.5033 1 1 2 3 4

311 15,715 2.2386 1 1 2 3 4

312 165,015 2.9422 1 1 2 4 5

313 169,337 2.0617 1 1 2 2 4

314 61,174 6.8924 2 3 5 9 13

315 31,589 4.2192 1 2 3 5 8

316 10,674 2.5722 1 1 2 3 5

326 11,327 16.2594 5 8 13 20 30

327 10,431 8.8336 2 5 7 11 16

328 8,538 3.7853 1 2 3 5 8

329 46,072 15.4141 6 8 13 19 28

330 60,328 9.1253 4 6 8 11 16

331 24,253 5.3159 3 4 5 6 8

332 1,602 14.2085 6 8 12 18 26

333 5,291 8.1227 4 5 7 10 14

334 3,027 4.9045 2 3 5 6 8

335 7,054 13.7044 5 8 12 17 24

336 13,575 8.7634 3 5 8 11 15

337 7,648 5.0911 1 3 4 7 9

338 1,283 10.0405 4 6 8 13 17

339 2,988 6.5505 3 4 6 8 11

340 3,036 3.7286 1 2 3 5 6

341 907 6.6185 2 3 5 9 13

342 2,903 3.8081 1 2 3 5 7

343 6,461 2.0108 1 1 2 2 4
CMS-1498-P 1075 

MSDRG Number of 

Discharges

Arithmetic 

Mean LOS 

10th 

Percentile

25th 

Percentile

50th 

Percentile

75th 

Percentile

90th 

Percentile

344 914 11.1838 4 6 9 14 21

345 3,052 6.9797 3 4 6 8 12

346 2,591 4.6299 2 3 4 6 7

347 1,478 8.7794 2 4 6 11 17

348 4,255 5.3598 2 3 4 7 10

349 4,039 2.9153 1 1 2 4 6

350 1,676 7.7739 2 3 6 10 15

351 4,535 4.5275 1 2 4 6 9

352 6,456 2.3748 1 1 2 3 4

353 3,228 8.4365 2 4 7 11 16

354 9,556 5.0383 2 3 4 6 9

355 12,947 2.7752 1 1 2 4 5

356 7,895 12.6730 3 6 10 16 24

357 7,605 7.4191 2 4 6 9 14

358 2,045 4.0088 1 2 3 5 8

368 3,305 6.6865 2 3 5 8 12

369 5,626 4.4604 2 3 4 5 8

370 1,777 3.0833 1 2 3 4 5

371 22,536 8.8666 3 4 7 11 17

372 34,690 6.4592 2 4 5 8 12

373 11,202 4.5867 2 3 4 6 8

374 8,074 8.4488 2 4 7 11 16

375 17,166 5.7567 2 3 4 7 11

376 2,537 3.5861 1 2 3 4 6

377 48,282 6.4252 2 3 5 8 12

378 138,562 4.1977 2 2 4 5 7

379 50,778 3.0378 1 2 3 4 5

380 2,927 7.5364 2 4 6 9 14

381 6,196 4.7816 2 3 4 6 9

382 2,708 3.4830 1 2 3 4 6

383 1,131 5.2856 2 3 4 6 9

384 7,401 3.6259 1 2 3 4 6

385 2,207 8.3715 2 4 6 10 16

386 9,041 5.2677 2 3 4 7 10

387 4,132 3.9131 1 2 3 5 7

388 18,652 7.2489 2 3 6 9 14

389 54,853 4.7808 2 3 4 6 9

390 39,806 3.3390 1 2 3 4 6

391 45,147 5.1526 1 2 4 6 10

392 248,773 3.4414 1 2 3 4 6

393 21,581 6.8656 2 3 5 8 14

394 49,062 4.6703 1 2 4 6 9

395 20,065 3.0842 1 2 3 4 6

405 4,357 15.8947 5 8 12 20 31

406 5,111 8.3620 2 5 7 10 15

407 1,927 5.1520 1 3 5 7 8
CMS-1498-P 1076 

MSDRG Number of 

Discharges

Arithmetic 

Mean LOS 

10th 

Percentile

25th 

Percentile

50th 

Percentile

75th 

Percentile

90th 

Percentile

408 1,493 13.4662 5 7 11 17 24

409 1,446 8.8983 4 5 8 11 16

410 475 5.8400 2 4 5 7 10

411 782 11.7852 5 7 10 14 21

412 838 8.2625 3 5 7 10 14

413 524 5.4027 2 3 5 7 9

414 4,700 11.3732 4 6 9 14 20

415 5,782 7.3200 3 4 6 9 12

416 3,992 4.3790 2 3 4 5 7

417 17,753 7.8448 3 4 6 10 15

418 27,491 5.3511 2 3 5 7 10

419 28,245 3.0297 1 1 2 4 6

420 712 13.1110 3 6 10 17 27

421 908 6.9868 2 3 5 9 14

422 234 4.1068 1 2 3 5 8

423 1,487 14.3658 4 7 11 18 28

424 802 9.1421 3 5 7 11 17

425 86 5.6860 2 3 4 7 10

432 12,413 6.5409 2 3 5 8 13

433 8,085 4.5713 1 2 4 6 8

434 398 3.1734 1 2 3 4 6

435 12,205 7.3902 2 3 6 9 14

436 12,595 5.4640 2 3 4 7 10

437 2,182 3.6856 1 2 3 5 7

438 14,979 7.4713 2 3 5 9 15

439 27,901 4.9703 2 3 4 6 9

440 20,560 3.4957 1 2 3 4 6

441 14,431 7.1160 2 3 5 9 14

442 18,612 4.7711 2 2 4 6 9

443 4,688 3.3057 1 2 3 4 6

444 12,611 6.2323 2 3 5 8 12

445 19,026 4.5326 1 2 4 6 8

446 12,789 3.0593 1 2 3 4 6

453 1,133 13.4704 5 7 10 17 26

454 3,084 6.7503 3 4 5 8 13

455 2,482 3.7526 1 2 3 5 6

456 1,130 13.4611 5 7 10 17 25

457 3,197 6.9643 3 4 6 8 12

458 1,565 4.0505 2 3 4 5 7

459 3,823 9.0876 4 5 7 11 17

460 61,817 3.8782 2 3 3 5 6

461 638 8.3103 3 4 7 9 15

462 11,376 4.0806 3 3 3 4 6

463 5,302 15.1032 4 7 11 18 30

464 8,718 8.8815 3 4 7 11 17

465 2,708 5.2688 2 3 4 6 9
CMS-1498-P 1077 

MSDRG Number of 

Discharges

Arithmetic 

Mean LOS 

10th 

Percentile

25th 

Percentile

50th 

Percentile

75th 

Percentile

90th 

Percentile

466 3,705 8.9744 3 5 7 11 16

467 20,172 4.9536 3 3 4 6 8

468 15,812 3.5808 2 3 3 4 5

469 27,090 7.9945 3 5 7 9 14

470 413,141 3.6890 2 3 3 4 5

471 2,812 9.2649 2 4 7 13 18

472 8,600 3.7783 1 1 2 5 8

473 25,112 1.8500 1 1 1 2 3

474 2,922 11.9521 4 6 9 15 22

475 3,783 7.7275 3 4 6 10 14

476 1,134 4.0908 1 2 3 5 8

477 2,596 11.0882 4 6 9 14 20

478 8,909 6.8587 2 3 6 9 13

479 5,867 3.3936 1 1 2 5 7

480 24,275 9.0228 4 5 7 11 16

481 81,792 5.5520 3 4 5 6 8

482 33,902 4.4797 3 3 4 5 7

483 10,324 3.7260 2 2 3 4 7

484 18,014 2.1959 1 1 2 3 3

485 1,023 10.9101 4 6 9 13 19

486 2,391 7.1861 3 4 6 8 12

487 1,058 5.0888 2 3 4 6 8

488 3,248 4.6918 2 3 3 5 8

489 4,902 2.8499 1 2 3 3 5

490 22,903 4.2505 1 2 3 5 9

491 45,224 2.0655 1 1 1 3 4

492 5,167 8.5982 3 5 7 11 16

493 20,378 4.9773 2 3 4 6 9

494 25,249 3.1465 1 2 3 4 5

495 1,614 10.1691 3 5 8 13 19

496 4,885 5.3793 1 3 4 7 10

497 5,130 2.5558 1 1 2 3 5

498 1,481 7.2552 2 3 6 9 14

499 876 2.9920 1 1 2 3 5

500 1,850 10.4573 3 5 8 13 21

501 5,068 6.0065 2 3 5 8 11

502 5,741 2.8021 1 1 2 3 5

503 914 8.4344 2 4 7 11 16

504 2,808 6.2137 2 3 5 8 11

505 2,256 3.1272 1 1 3 4 6

506 717 3.7992 1 1 3 5 8

507 940 4.5160 1 2 3 5 9

508 1,782 2.0561 1 1 2 3 3

509 349 3.4699 1 1 2 4 7

510 1,058 6.2968 2 3 5 8 12

511 4,312 3.8949 1 2 3 5 7
CMS-1498-P 1078 

MSDRG Number of 

Discharges

Arithmetic 

Mean LOS 

10th 

Percentile

25th 

Percentile

50th 

Percentile

75th 

Percentile

90th 

Percentile

512 8,255 2.1474 1 1 2 3 4

513 1,248 4.8205 1 2 4 6 9

514 921 2.6406 1 1 2 3 5

515 3,952 9.8641 3 5 8 12 18

516 12,227 5.9028 2 3 5 8 11

517 11,169 3.3660 1 1 3 5 7

533 818 6.4792 2 3 5 8 12

534 3,463 3.8908 1 2 3 5 7

535 7,263 5.7939 2 3 4 7 11

536 32,802 3.7325 1 3 3 4 6

537 944 4.0911 2 3 3 5 7

538 708 3.0494 1 2 3 4 5

539 3,238 9.4632 3 5 7 11 17

540 4,245 6.7781 2 4 5 8 11

541 1,124 4.8488 1 2 4 6 8

542 5,511 8.3028 3 4 6 10 16

543 16,795 5.6402 2 3 5 7 10

544 6,624 4.0503 2 3 3 5 7

545 3,605 9.0019 2 4 6 11 18

546 6,148 5.3317 2 3 4 7 10

547 3,348 3.5358 1 2 3 4 6

548 579 8.7323 3 4 7 11 17

549 1,215 6.0601 2 3 5 7 11

550 556 4.0108 1 2 3 5 7

551 10,908 6.7836 2 3 5 8 13

552 77,212 3.9754 1 2 3 5 7

553 2,162 5.6300 2 3 4 7 10

554 17,314 3.6410 1 2 3 4 6

555 2,593 4.8481 1 2 4 6 9

556 17,515 3.1807 1 2 3 4 6

557 3,723 6.8571 2 4 5 8 12

558 17,219 4.3499 2 3 4 5 7

559 1,902 7.1420 2 3 5 9 14

560 5,301 4.6403 1 2 4 6 8

561 5,314 2.6314 1 1 2 3 5

562 5,861 5.8555 2 3 5 7 11

563 32,431 3.5741 1 2 3 4 6

564 1,779 6.5509 2 3 5 8 13

565 4,069 4.6319 1 3 4 6 8

566 1,759 3.4179 1 2 3 4 6

573 4,789 12.5780 4 6 9 15 24

574 10,017 8.5081 3 4 7 10 15

575 3,721 5.1774 2 3 4 7 9

576 646 13.0294 3 5 9 17 26

577 2,414 6.1570 1 2 4 8 13

578 2,530 3.2573 1 1 2 4 6
CMS-1498-P 1079 

MSDRG Number of 

Discharges

Arithmetic 

Mean LOS 

10th 

Percentile

25th 

Percentile

50th 

Percentile

75th 

Percentile

90th 

Percentile

579 3,778 10.4611 3 5 8 13 20

580 11,548 5.3869 1 2 4 7 11

581 10,753 2.3869 1 1 2 3 5

582 4,901 2.6566 1 1 2 3 5

583 7,581 1.7392 1 1 1 2 3

584 862 4.9617 1 2 4 7 10

585 1,462 2.1382 1 1 1 3 4

592 3,956 8.2786 2 4 6 10 15

593 11,211 5.8634 2 3 5 7 10

594 1,483 4.6703 1 2 4 6 8

595 1,117 7.8809 2 4 6 10 15

596 4,972 4.6072 1 2 4 6 8

597 559 7.5277 2 3 6 9 14

598 1,520 5.4737 1 3 4 7 10

599 185 3.2757 1 1 3 4 5

600 1,034 4.9207 2 3 4 6 9

601 778 3.6157 1 2 3 5 6

602 22,955 6.6712 2 3 5 8 12

603 137,900 4.5353 2 3 4 6 8

604 2,660 5.1549 1 2 4 6 10

605 20,170 3.3178 1 2 3 4 6

606 1,532 6.0091 1 2 4 7 12

607 7,089 3.6430 1 2 3 4 7

614 1,566 6.5447 2 3 5 8 13

615 1,351 2.9704 1 2 3 4 5

616 1,632 15.6746 6 8 13 19 28

617 6,562 7.9334 3 4 7 10 14

618 148 5.1419 2 3 4 6 9

619 840 7.7405 1 2 4 8 17

620 3,287 3.3998 1 2 3 4 6

621 11,451 1.8512 1 1 2 2 3

622 1,161 12.4358 4 6 9 15 23

623 2,541 7.6025 3 4 6 9 13

624 251 4.7649 2 3 4 6 8

625 1,200 6.9017 1 2 5 8 15

626 2,961 3.0523 1 1 2 3 7

627 12,254 1.4115 1 1 1 1 2

628 3,451 10.6140 2 4 8 14 21

629 4,718 8.0377 3 4 7 10 14

630 446 4.4619 1 2 3 6 8

637 18,691 5.9589 2 3 4 7 11

638 54,277 4.0187 1 2 3 5 7

639 24,880 2.8062 1 1 2 3 5

640 56,552 5.0713 1 2 4 6 10

641 187,597 3.5804 1 2 3 4 6

642 1,603 4.7436 1 2 3 6 9
CMS-1498-P 1080 

MSDRG Number of 

Discharges

Arithmetic 

Mean LOS 

10th 

Percentile

25th 

Percentile

50th 

Percentile

75th 

Percentile

90th 

Percentile

643 5,944 7.6445 3 4 6 9 14

644 13,584 5.1667 2 3 4 7 9

645 6,422 3.5668 1 2 3 4 6

652 10,210 7.5053 4 5 6 8 13

653 1,695 16.6053 7 9 14 21 30

654 3,722 9.3461 5 6 8 11 15

655 1,275 5.6549 2 4 6 7 9

656 3,223 10.0583 3 5 8 12 20

657 9,015 5.8840 2 3 5 7 10

658 6,807 3.3676 1 2 3 4 5

659 4,058 10.8544 3 5 8 14 21

660 8,540 6.0290 2 3 5 8 12

661 3,862 2.8933 1 2 2 4 5

662 794 10.8363 2 4 8 13 22

663 2,041 5.2156 1 2 4 7 11

664 3,282 1.8525 1 1 1 2 3

665 571 11.3345 3 6 10 14 21

666 2,191 6.3816 1 2 5 9 13

667 2,595 2.3680 1 1 2 3 4

668 3,076 8.9451 2 4 7 12 18

669 14,683 4.3541 1 2 3 6 9

670 8,764 2.2913 1 1 2 3 5

671 799 5.5920 1 2 4 7 11

672 635 2.2000 1 1 2 3 4

673 11,751 9.5646 1 3 7 12 20

674 9,545 6.7385 1 2 5 9 14

675 3,252 2.1125 1 1 1 2 5

682 99,106 6.8064 2 3 5 9 13

683 117,434 4.9378 2 3 4 6 9

684 26,729 3.3482 1 2 3 4 6

685 2,513 3.3979 1 1 2 4 7

686 1,144 7.7736 2 4 6 10 15

687 3,414 4.9889 1 2 4 6 9

688 706 2.8031 1 1 2 3 5

689 60,772 5.7814 2 3 5 7 10

690 213,595 4.0879 2 2 3 5 7

691 999 4.3053 1 2 3 5 9

692 380 2.2421 1 1 2 3 4

693 1,779 5.1793 1 2 4 7 10

694 17,779 2.5757 1 1 2 3 5

695 1,094 5.6307 2 3 4 7 11

696 10,259 3.1686 1 2 3 4 6

697 509 3.1100 1 1 2 4 6

698 23,432 6.7565 2 3 5 8 13

699 31,817 4.6574 1 2 4 6 8

700 8,115 3.2223 1 2 3 4 6
CMS-1498-P 1081 

MSDRG Number of 

Discharges

Arithmetic 

Mean LOS 

10th 

Percentile

25th 

Percentile

50th 

Percentile

75th 

Percentile

90th 

Percentile

707 5,392 4.2381 1 2 3 5 8

708 16,899 1.8647 1 1 2 2 3

709 817 5.6793 1 1 3 7 13

710 1,504 1.6642 1 1 1 2 3

711 740 7.2986 1 3 5 9 15

712 424 2.6604 1 1 2 3 5

713 9,760 4.0614 1 2 3 5 9

714 22,626 1.8214 1 1 2 2 3

715 505 6.0554 1 2 4 8 13

716 685 1.3518 1 1 1 1 2

717 734 6.4074 1 3 5 8 13

718 446 2.6121 1 1 2 3 5

722 477 7.7191 2 3 6 10 15

723 1,935 5.0651 1 2 4 6 9

724 276 2.6957 1 1 2 3 5

725 469 6.0874 2 3 4 8 11

726 3,909 3.4804 1 2 3 4 6

727 1,530 6.3399 2 3 5 8 11

728 6,093 4.0883 1 2 3 5 7

729 838 4.6802 1 2 4 6 9

730 276 2.8442 1 1 2 3 5

734 1,520 6.9493 2 3 5 8 14

735 1,138 2.6951 1 1 2 4 5

736 903 13.9989 5 8 11 17 25

737 3,277 6.6628 3 4 6 8 11

738 712 3.5941 2 2 3 4 5

739 905 9.8663 3 5 7 12 20

740 4,462 4.6555 2 3 4 5 8

741 5,393 2.5524 1 1 2 3 4

742 10,807 4.1279 1 2 3 5 8

743 27,700 2.0692 1 1 2 3 3

744 1,625 5.5680 1 2 4 7 11

745 1,265 2.4403 1 1 2 3 5

746 2,621 4.1801 1 2 3 5 8

747 7,265 1.7794 1 1 1 2 3

748 17,103 1.6853 1 1 1 2 3

749 1,052 8.4753 2 4 7 11 16

750 362 2.7901 1 1 2 3 5

754 1,024 8.7656 2 4 7 11 17

755 3,406 5.2980 1 2 4 7 10

756 440 3.0750 1 1 2 4 6

757 1,322 7.7526 3 4 6 9 14

758 2,220 5.7315 2 3 5 7 10

759 978 4.0112 2 2 3 5 7

760 2,269 3.7532 1 2 3 5 7

761 1,138 2.2417 1 1 2 3 4
CMS-1498-P 1082 

MSDRG Number of 

Discharges

Arithmetic 

Mean LOS 

10th 

Percentile

25th 

Percentile

50th 

Percentile

75th 

Percentile

90th 

Percentile

765 3,417 4.8674 2 3 4 5 7

766 2,757 3.0812 2 2 3 4 4

767 169 2.6864 2 2 2 3 4

768 8 6.7500 1 2 5 6 13

769 122 5.7459 1 2 4 7 13

770 177 2.0904 1 1 1 2 4

774 1,667 3.2190 2 2 2 3 4

775 5,860 2.3258 1 2 2 3 3

776 588 3.3248 1 2 2 4 6

777 198 2.0505 1 1 2 3 4

778 444 3.2050 1 1 2 3 6

779 121 2.1405 1 1 1 2 4

780 42 1.6190 1 1 1 1 2

781 3,387 3.8432 1 1 3 4 7

782 188 2.6117 1 1 2 3 5

793 3 3.6667 1 1 3 7 7

794 1 1.0000 1 1 1 1 1

799 537 13.3762 4 7 11 17 25

800 686 7.5131 2 4 6 9 15

801 357 3.9076 1 2 3 5 7

802 936 12.1891 3 5 9 14 22

803 1,163 6.5443 2 3 5 8 13

804 764 2.9686 1 1 2 4 6

808 7,983 8.2525 3 4 6 10 16

809 14,321 5.1374 2 3 4 6 9

810 2,170 3.7392 1 2 3 5 7

811 29,074 5.2696 1 2 4 6 10

812 100,179 3.6564 1 2 3 5 7

813 11,471 4.9750 1 2 4 6 10

814 1,597 6.9080 2 3 5 8 13

815 3,792 4.6192 1 2 4 6 8

816 1,532 3.2428 1 2 3 4 6

820 1,269 17.4704 5 8 14 22 34

821 2,061 7.4478 2 3 6 10 15

822 1,738 3.0984 1 1 2 4 6

823 1,872 15.9583 5 8 12 20 30

824 3,134 8.7100 2 4 7 12 17

825 1,442 3.9286 1 1 3 5 8

826 602 14.7741 5 7 11 18 27

827 1,498 6.8892 2 3 6 8 13

828 696 3.7586 1 2 3 5 7

829 1,398 9.3369 2 3 7 11 20

830 385 3.1247 1 1 2 4 6

834 3,703 16.1674 2 5 11 24 37

835 3,050 9.2633 2 3 5 10 25

836 1,201 4.4388 1 2 3 5 8
CMS-1498-P 1083 

MSDRG Number of 

Discharges

Arithmetic 

Mean LOS 

10th 

Percentile

25th 

Percentile

50th 

Percentile

75th 

Percentile

90th 

Percentile

837 1,268 23.5733 5 9 23 32 43

838 1,553 12.2788 3 4 6 20 30

839 1,284 5.6830 2 4 5 5 7

840 7,561 10.6359 3 5 8 14 21

841 10,918 6.7759 2 3 5 8 13

842 3,644 4.1715 1 2 3 5 8

843 1,480 8.0122 2 4 6 10 15

844 2,962 5.6283 2 3 4 7 11

845 667 3.7676 1 2 3 5 7

846 2,614 7.9591 2 3 5 9 18

847 22,032 3.4226 1 2 3 4 6

848 1,107 2.9883 1 1 3 4 5

849 1,163 6.0404 2 3 5 6 11

853 39,169 15.7007 5 8 13 19 29

854 8,740 10.0237 4 6 8 12 18

855 337 5.3976 1 2 4 7 10

856 5,929 15.0469 4 7 11 18 29

857 9,810 7.9171 3 4 6 9 15

858 2,325 5.0533 2 3 4 6 9

862 9,500 7.7561 2 4 6 9 15

863 21,677 4.8940 2 3 4 6 8

864 18,172 3.7732 1 2 3 5 7

865 2,269 6.4293 2 3 4 8 13

866 7,441 3.4921 1 2 3 4 6

867 5,314 9.1929 2 4 7 11 18

868 2,854 5.3931 2 3 4 7 10

869 779 3.6393 1 2 3 4 6

870 25,752 15.1737 6 9 13 18 26

871 246,509 7.1936 2 3 6 9 14

872 110,367 5.4377 2 3 5 7 10

876 656 12.6799 2 4 8 14 29

880 8,144 3.0149 1 1 2 4 6

881 4,536 4.2377 1 2 3 5 8

882 1,797 4.2966 1 2 3 5 8

883 863 7.7034 1 3 5 8 15

884 18,110 5.3720 2 3 4 6 9

885 88,160 7.3601 2 3 6 9 13

886 525 6.1657 1 2 4 6 12

887 466 4.0494 1 2 3 5 7

894 4,520 2.9412 1 1 2 3 4

895 6,273 10.9396 3 4 6 8 9

896 6,925 6.5217 2 3 5 8 12

897 36,863 3.9730 1 2 3 4 6

901 937 14.1206 3 5 9 17 30

902 1,890 7.4889 2 3 6 9 14

903 1,027 4.4450 1 2 3 5 8
CMS-1498-P 1084 

MSDRG Number of 

Discharges

Arithmetic 

Mean LOS 

10th 

Percentile

25th 

Percentile

50th 

Percentile

75th 

Percentile

90th 

Percentile

904 1,895 11.1135 2 4 7 13 23

905 763 4.5242 1 2 4 6 9

906 707 3.0905 1 1 2 3 6

907 8,654 11.1347 2 5 8 14 22

908 9,017 6.3353 2 3 5 8 12

909 4,760 3.3786 1 1 3 4 7

913 872 5.6239 1 3 4 6 11

914 5,458 3.1999 1 2 3 4 6

915 1,429 5.0539 1 2 4 6 10

916 5,634 2.1132 1 1 2 3 4

917 19,117 5.1092 1 2 4 6 10

918 36,755 2.7429 1 1 2 3 5

919 10,767 6.2020 2 3 4 8 12

920 15,246 4.2676 1 2 3 5 8

921 7,314 2.8138 1 1 2 3 5

922 1,046 5.4312 1 2 4 7 10

923 3,201 3.2471 1 1 2 4 6

927 188 28.2128 8 13 23 39 55

928 948 14.8597 3 7 12 20 29

929 366 7.6721 1 3 6 10 15

933 138 5.2319 1 1 1 5 12

934 608 5.8257 1 2 4 7 11

935 2,111 5.2321 1 2 3 6 10

939 718 9.9624 2 4 7 13 21

940 1,637 5.3769 1 2 4 7 12

941 1,455 2.5904 1 1 2 3 5

945 5,971 10.1921 4 6 8 11 15

946 2,809 7.4938 3 5 6 7 8

947 12,298 4.9270 1 2 4 6 9

948 55,443 3.4200 1 2 3 4 6

949 640 4.2969 1 1 2 4 7

950 276 2.7572 1 1 2 3 4

951 1,028 4.5360 1 1 2 3 6

955 443 12.6456 3 5 9 17 24

956 4,421 8.4180 4 5 7 10 15

957 1,436 14.2806 3 7 12 19 27

958 1,214 9.5486 3 5 8 12 16

959 200 5.5800 2 3 5 7 10

963 1,769 8.6733 1 3 7 12 18

964 2,904 5.6295 2 3 5 7 10

965 913 3.7558 1 2 3 5 7

969 631 17.1236 4 7 13 22 35

970 102 8.6569 1 4 7 12 17

974 5,213 9.6277 2 4 7 12 19

975 4,509 6.6378 2 3 5 8 12

976 1,529 4.4173 1 2 3 5 7
CMS-1498-P 1085 

MSDRG Number of 

Discharges

Arithmetic 

Mean LOS 

10th 

Percentile

25th 

Percentile

50th 

Percentile

75th 

Percentile

90th 

Percentile

977 3,547 4.8765 1 2 4 6 9

981 25,561 14.1288 4 7 11 18 26

982 19,665 8.6927 3 4 7 11 16

983 4,894 4.2284 1 2 3 6 9

984 505 13.2911 4 7 12 17 24

985 1,056 9.0369 2 4 8 12 17

986 447 4.0559 1 1 2 6 9

987 7,986 12.1990 3 6 10 15 23

988 10,939 7.4428 2 3 6 10 14

989 3,950 3.5337 1 1 2 5 7

 10,957,307 
CMS-1498-P 1086 

TABLE 8A.—PROPOSED STATEWIDE AVERAGE OPERATING 

COST-TO-CHARGE RATIOS (CCRs) 

FOR ACUTE CARE HOSPITALS—MARCH 2010 

State Urban Rural 

Alabama 0.247 0.318

Alaska 0.342 0.654

Arizona 0.27 0.357

Arkansas 0.313 0.328

California 0.218 0.277

Colorado 0.279 0.413

Connecticut 0.39 0.517

Delaware 0.483 0.447

District of Columbia* 0.325 ----

Florida 0.222 0.251

Georgia 0.311 0.374

Hawaii 0.375 0.48

Idaho 0.454 0.546

Illinois 0.293 0.363

Indiana 0.37 0.429

Iowa 0.338 0.418

Kansas 0.28 0.408

Kentucky 0.368 0.353

Louisiana 0.295 0.334

Maine 0.487 0.478

Maryland 0.719 0.767

Massachusetts 0.468 0.963

Michigan 0.371 0.441

Minnesota 0.383 0.509

Mississippi 0.285 0.336

Missouri 0.317 0.34

Montana 0.401 0.461

Nebraska 0.334 0.44

Nevada 0.202 0.432

New Hampshire 0.422 0.42

New Jersey* 0.175 ----

New Mexico 0.341 0.357

New York 0.344 0.51

North Carolina 0.374 0.38

North Dakota 0.445 0.343

Ohio 0.317 0.486

Oklahoma 0.294 0.366
CMS-1498-P 1087 

State Urban Rural 

Oregon 0.432 0.397

Pennsylvania 0.254 0.409

Puerto Rico* 0.489 ----

Rhode Island* 0.373 ----

South Carolina 0.274 0.303

South Dakota 0.322 0.398

Tennessee 0.282 0.346

Texas 0.245 0.328

Utah 0.396 0.586

Vermont 0.558 0.632

Virginia 0.341 0.346

Washington 0.343 0.445

West Virginia 0.438 0.465

Wisconsin 0.391 0.441

Wyoming 0.393 0.523

*All counties in the State or Territory are classified as urban. 
CMS-1498-P 1088 

TABLE 8B.—PROPOSED STATEWIDE AVERAGE CAPITAL 

COST-TO-CHARGE RATIOS (CCRs) 

FOR ACUTE CARE HOSPITALS—MARCH 2010 

State Ratio 

Alabama 0.024

Alaska 0.039

Arizona 0.027

Arkansas 0.024

California 0.015

Colorado 0.029

Connecticut 0.026

Delaware 0.035

District of Columbia 0.018

Florida 0.022

Georgia 0.027

Hawaii 0.029

Idaho 0.038

Illinois 0.025

Indiana 0.037

Iowa 0.028

Kansas 0.03

Kentucky 0.03

Louisiana 0.025

Maine 0.03

Maryland 0.059

Massachusetts 0.033

Michigan 0.031

Minnesota 0.031

Mississippi 0.026

Missouri 0.028

Montana 0.034

Nebraska 0.034

Nevada 0.023

New Hampshire 0.034

New Jersey 0.013

New Mexico 0.034

New York 0.026

North Carolina 0.032

North Dakota 0.029

Ohio 0.028

Oklahoma 0.025

Oregon 0.037
CMS-1498-P 1089 

State Ratio 

Pennsylvania 0.021

Puerto Rico 0.041

Rhode Island 0.02

South Carolina 0.026

South Dakota 0.027

Tennessee 0.025

Texas 0.025

Utah 0.037

Vermont 0.045

Virginia 0.033

Washington 0.028

West Virginia 0.031

Wisconsin 0.038

Wyoming 0.04
CMS-1498-P 1090 

 TABLE 8C.—PROPOSED STATEWIDE AVERAGE TOTAL 

COST-TO-CHARGE RATIOS (CCRs) FOR LTCHs—DECEMBER 2009 

State Urban Rural 

Alabama 0.268 0.347

Alaska 0.373 0.745

Arizona 0.296 0.389

Arkansas 0.334 0.357

California 0.232 0.298

Colorado 0.306 0.46

Connecticut 0.41 0.566

Delaware 0.517 0.483

District of Columbia* 0.343 ----

Florida 0.243 0.308

Georgia 0.335 0.409

Hawaii 0.399 0.511

Idaho 0.491 0.585

Illinois 0.317 0.392

Indiana 0.404 0.48

Iowa 0.364 0.462

Kansas 0.307 0.446

Kentucky 0.397 0.386

Louisiana 0.32 0.362

Maine 0.519 0.505

Maryland** 0.327 0.42

Massachusetts 0.498 1.06

Michigan 0.402 0.478

Minnesota 0.412 0.554

Mississippi 0.312 0.364

Missouri 0.341 0.373

Montana 0.431 0.503

Nebraska 0.367 0.479

Nevada 0.224 0.503

New Hampshire 0.456 0.449

New Jersey* 0.189 ----

New Mexico 0.375 0.393

New York 0.368 0.544

North Carolina 0.405 0.408

North Dakota 0.459 0.371

Ohio 0.344 0.528

Oklahoma 0.303 0.396

Oregon 0.458 0.433

Pennsylvania 0.273 0.443
CMS-1498-P 1091 

State Urban Rural 

Puerto Rico* 0.531 ----

Rhode Island* 0.393 ----

South Carolina 0.3 0.325

South Dakota 0.346 0.431

Tennessee 0.305 0.382

Texas 0.267 0.372

Utah 0.435 0.637

Vermont 0.608 0.67

Virginia 0.373 0.378

Washington 0.374 0.476

West Virginia 0.462 0.5

Wisconsin 0.42 0.481

Wyoming 0.429 0.568

 *All counties in the State or Territory are classified as urban. However, no short-term acute care 

 IPPS hospitals or LTCHs are located in those areas as of July 2010. 

 **National average IPPS total CCRs, as discussed in section V.C.2. of this Addendum. 
CMS-1498-P 1092 

TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND 

REDESIGNATIONS--FY 2011 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

010001 20020 10500

010005 01 13820

010009 19460 26620

010022 01 12060

010025 01 17980

010029 12220 17980

010035 01 13820

010046 23460 13820

010052 01 33860

010054 19460 26620

010055 20020 37460

010059 19460 26620

010061 01 16860

010065 01 13820

010083 01 33660

010085 19460 26620

010100 01 37860

010101 01 13820

010102 01 33860

010118 01 46220

010126 01 33860

010143 01 26620

010158 01 19460

010164 01 13820

020008 02 11260

030033 03 38060

030069 29420 40140

030101 29420 29820

040014 04 30780

040017 04 26

040027 04 44180

040039 04 26

040041 04 30780

040069 04 26

040071 38220 30780

040076 04 26300 LUGAR 

040080 04 27860
CMS-1498-P 1093 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

040085 04 32820

040088 04 33740

040119 04 30780

050002 36084 41940

050006 05 39820

050009 34900 42220

050013 34900 42220

050014 05 40900

050022 40140 42044

050038 41940 42100

050042 05 39820

050043 36084 41940

050046 37100 31084

050054 40140 42044

050069 42044 31084

050071 41940 42100

050073 46700 36084

050075 36084 41940

050082 37100 31084

050084 44700 40900

050089 40140 31084

050090 42220 36084

050095 36084 41940

050099 40140 31084

050101 46700 36084

050102 40140 42044

050118 44700 33700

050125 41940 42100

050129 40140 31084

050131 41884 36084

050136 42220 36084

050140 40140 31084

050150 05 40900

050152 41884 36084

050153 41940 42100

050159 37100 31084

050168 42044 31084

050173 42044 31084

050174 42220 36084
CMS-1498-P 1094 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

050188 41940 42100

050193 42044 31084

050195 36084 41940

050197 41884 41940

050211 36084 41940

050224 42044 31084

050226 42044 31084

050230 42044 31084

050236 37100 31084

050243 40140 42044

050245 40140 31084

050264 36084 41940

050272 40140 31084

050279 40140 31084

050283 36084 41940

050291 42220 36084

050292 40140 42044

050300 40140 31084

050305 36084 41940

050308 41940 42100

050320 36084 41940

050327 40140 31084

050329 40140 42044

050334 41500 41940

050335 05 33700

050348 42044 31084

050360 41884 36084

050366 05 40900

050367 46700 36084

050380 41940 42100

050385 42220 36084

050390 40140 42044

050394 37100 31084

050423 40140 42044

050426 42044 31084

050441 41940 42100

050488 36084 41940

050510 41884 36084

050512 36084 41940
CMS-1498-P 1095 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

050517 40140 31084

050526 42044 31084

050534 40140 42044

050541 41884 41940

050543 42044 31084

050547 42220 36084

050548 42044 31084

050549 37100 31084

050551 42044 31084

050567 42044 31084

050570 42044 31084

050573 40140 42044

050580 42044 31084

050586 40140 31084

050589 42044 31084

050603 42044 31084

050604 41940 42100

050609 42044 31084

050616 37100 31084

050662 41940 42100

050667 34900 46700

050668 41884 36084

050678 42044 31084

050680 46700 36084

050684 40140 42044

050686 40140 42044

050688 41940 42100

050690 42220 36084

050693 42044 31084

050694 40140 42044

050701 40140 42044

050709 40140 31084

050720 42044 31084

050744 42044 31084

050745 42044 31084

050746 42044 31084

050747 42044 31084

050748 44700 33700

050749 37100 31084
CMS-1498-P 1096 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

050758 40140 31084

060001 24540 19740

060003 14500 19740

060023 24300 19740

060027 14500 19740

060031 17820 19740

060049 06 22660

060075 06 24300

060096 06 19740

060103 14500 19740

060116 14500 19740

060118 06 19740

060121 24540 19740

070001 35300 35004

070003 07 25540 LUGAR 

070005 35300 35004

070006 14860 35644

070010 14860 35644

070011 07 25540 LUGAR 

070015 07 35644

070016 35300 35004

070017 35300 35004

070018 14860 35644

070019 35300 35004

070021 07 25540 LUGAR 

070022 35300 35004

070028 14860 35644

070031 35300 35004

070033 14860 35644

070034 14860 35644

070036 25540 35300

070038 35300 35004

070039 35300 35004

080004 20100 48864

080006 08 20100

080007 08 36140

090004 47894 13644

100002 48424 22744

100014 19660 36740
CMS-1498-P 1097 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

100017 19660 36740

100022 33124 22744

100023 10 45300

100024 10 33124

100045 19660 36740

100047 39460 35840

100049 10 29460

100068 19660 36740

100072 19660 36740

100077 39460 35840

100080 48424 22744

100081 10 18880 LUGAR 

100105 42680 38940

100109 10 36740

100130 48424 22744

100139 10 23540 LUGAR 

100150 10 33124

100157 29460 45300

100160 10 33124

100168 48424 22744

100176 48424 22744

100217 42680 38940

100232 10 23540

100234 48424 22744

100236 39460 35840

100249 10 45300

100252 10 38940

100253 48424 22744

100258 48424 22744

100268 48424 22744

100269 48424 22744

100275 48424 22744

100287 48424 22744

100288 48424 22744

100290 10 36740

100292 10 18880 LUGAR 

110001 19140 16860

110002 11 31420

110016 11 17980
CMS-1498-P 1098 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

110023 11 12060

110029 23580 12060

110038 11 46660

110040 11 12060 LUGAR 

110041 11 12060

110054 40660 12060

110069 47580 31420

110075 11 42340

110095 11 10500

110105 11 10500

110112 11 10500

110122 46660 45220

110125 11 31420

110146 11 15260

110150 11 31420

110153 47580 31420

110168 40660 12060

110187 11 12060 LUGAR 

110189 11 12060

110190 11 47580

130002 13 14260

130003 30300 28420

130049 17660 44060

130067 13 26820 LUGAR 

140008 16974 29404

140010 16974 29404

140012 14 16974

140015 14 41180

140018 16974 29404

140032 14 41180

140034 14 41180

140040 14 37900

140043 14 19340

140046 14 41180

140048 16974 29404

140049 16974 29404

140051 16974 29404

140054 16974 29404

140058 14 44100
CMS-1498-P 1099 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

140062 16974 29404

140063 16974 29404

140064 14 37900

140065 16974 29404

140068 16974 29404

140075 16974 29404

140080 16974 29404

140082 16974 29404

140083 16974 29404

140088 16974 29404

140094 16974 29404

140095 16974 29404

140103 16974 29404

140110 14 16974

140114 16974 29404

140115 16974 29404

140116 16974 29404

140117 16974 29404

140118 16974 29404

140119 16974 29404

140124 16974 29404

140133 16974 29404

140135 19500 16580

140150 16974 29404

140151 16974 29404

140155 28100 16974

140158 16974 29404

140160 14 40420

140161 14 16974

140164 14 16020

140166 19500 16580

140172 16974 29404

140176 16974 29404

140177 16974 29404

140179 16974 29404

140180 16974 29404

140181 16974 29404

140182 16974 29404

140186 28100 16974
CMS-1498-P 1100 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

140191 16974 29404

140197 16974 29404

140206 16974 29404

140207 16974 29404

140208 16974 29404

140223 16974 29404

140224 16974 29404

140240 16974 29404

140250 16974 29404

140251 16974 29404

140252 16974 29404

140258 16974 29404

140276 16974 29404

140281 16974 29404

140290 16974 29404

140300 16974 29404

140301 16974 29404

140303 16974 29404

150002 23844 16974

150004 23844 16974

150006 33140 43780

150008 23844 16974

150011 15 26900

150015 33140 23844

150018 21140 43780

150023 45460 26900

150030 15 26900 LUGAR 

150034 23844 16974

150042 15 45460

150048 15 17140

150051 14020 26900

150064 15 26900

150065 15 26900

150069 15 17140

150076 15 43780

150088 11300 26900

150089 34620 11300

150090 23844 16974

150091 15 23060
CMS-1498-P 1101 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

150102 15 23844 LUGAR 

150112 18020 26900

150113 11300 26900

150125 23844 16974

150126 23844 16974

150133 15 43780

150146 15 21140

150165 23844 16974

150166 23844 16974

150170 23844 16974

160001 16 19780

160016 16 11180

160057 16 26980

160064 16 24

160080 16 19340

160147 16 11180

170006 17 27900

170013 17 28

170020 17 48620

170033 17 48620

170058 17 28140

170068 17 11100

170142 31740 45820

170175 17 48620

180002 18 49

180011 18 30460

180012 21060 31140

180013 14540 34980

180017 18 14540

180020 18 49

180024 18 21060

180027 18 17300

180029 18 30460

180043 18 44

180044 18 26580

180048 18 31140

180050 18 28700

180069 18 26580

180078 18 26580
CMS-1498-P 1102 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

180080 18 28940

180102 18 16020

180104 18 16020

180116 18 16020

180124 14540 34980

180127 18 17140

180132 18 30460

190003 19 29180

190015 19 35380

190017 19 29180

190086 19 33740

190106 19 10780

190144 19 43340

190164 19 45

190167 19 29180

190190 19 33740

190218 19 43340

190257 19 33740

200002 20 38860

200020 38860 40484

200024 30340 38860

200034 30340 38860

200039 20 38860

200050 20 12620

220001 49340 14484

220002 15764 14484

220008 39300 14484

220010 37764 14484

220011 15764 14484

220019 49340 14484

220020 39300 14484

220025 49340 14484

220029 37764 14484

220033 37764 14484

220035 37764 14484

220049 15764 14484

220058 49340 14484

220062 49340 14484

220063 15764 14484
CMS-1498-P 1103 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

220070 15764 14484

220073 39300 14484

220074 39300 14484

220077 44140 25540

220080 37764 14484

220082 15764 14484

220084 15764 14484

220090 49340 14484

220095 49340 14484

220098 15764 14484

220101 15764 14484

220105 15764 14484

220163 49340 14484

220171 15764 14484

220174 37764 14484

220175 15764 14484

220176 49340 14484

230002 19804 11460

230003 26100 34740

230013 47644 22420

230019 47644 22420

230020 19804 11460

230021 35660 28020

230022 23 12980

230024 19804 11460

230029 47644 22420

230030 23 40980

230035 23 24340 LUGAR 

230036 23 13020

230037 23 11460

230038 24340 34740

230047 47644 19804

230053 19804 11460

230054 23 24580

230059 24340 34740

230069 47644 11460

230071 47644 22420

230072 26100 34740

230077 40980 22420
CMS-1498-P 1104 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

230089 19804 11460

230095 23 13020

230096 23 28020

230097 23 24340

230099 33780 11460

230104 19804 11460

230105 23 24340

230106 24340 34740

230121 23 29620 LUGAR 

230130 47644 22420

230135 19804 11460

230142 19804 11460

230146 19804 11460

230151 47644 22420

230165 19804 11460

230174 26100 34740

230176 19804 11460

230195 47644 19804

230204 47644 19804

230207 47644 22420

230208 23 24340 LUGAR 

230222 23 13020

230227 47644 19804

230236 24340 34740

230244 19804 11460

230254 47644 22420

230257 47644 19804

230264 47644 19804

230269 47644 22420

230270 19804 11460

230273 19804 11460

230277 47644 22420

230279 47644 11460

230297 19804 11460

230301 47644 22420

230302 47644 22420

230B04 47644 22420

230B95 19804 11460 . 

240036 41060 33460
CMS-1498-P 1105 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

240069 24 33460

240071 24 33460

240187 24 33460

250002 25 22520

250004 25 32820

250006 25 32820

250009 25 27180

250023 25 25060 LUGAR 

250031 25 27140

250034 25 32820

250040 37700 25060

250042 25 32820

250069 25 46220

250078 25620 25060

250079 25 27140

250081 25 46220

250082 25 38220

250094 25620 25060

250095 25 27140

250097 25 12940

250099 25 27140

250100 25 46220

250104 25 46220

250117 25 25060 LUGAR 

260009 26 27620

260017 26 27620

260022 26 17860

260025 26 41180

260074 26 17860

260094 26 44180

260113 26 14

260116 26 14

260119 26 16020

260175 26 28140

260186 26 27620

270003 27 24500

270012 24500 33540

270017 27 33540

270051 27 33540
CMS-1498-P 1106 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

280009 28 30700

280023 28 30700

280065 28 24540

280077 28 30700

280125 28 43580

290002 29 16180 LUGAR 

290006 29 39900

290019 16180 39900

300011 31700 15764

300012 31700 15764

300017 40484 37764

300019 30 44140

300020 31700 15764

300029 40484 37764

300034 31700 15764

310002 35084 35644

310009 35084 35644

310014 15804 37964

310015 35084 35644

310017 35084 35644

310018 35084 35644

310022 15804 37964

310029 15804 37964

310031 15804 20764

310038 20764 35644

310039 20764 35644

310048 20764 35084

310050 35084 35644

310054 35084 35644

310070 20764 35644

310076 35084 35644

310081 15804 37964

310083 35084 35644

310086 15804 37964

310093 35084 35644

310096 35084 35644

310108 20764 35644

310119 35084 35644

320003 32 42140
CMS-1498-P 1107 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

320005 22140 10740

320006 32 10740

320013 32 42140

320014 32 29740

320033 32 42140 LUGAR 

320063 32 36220

330008 33 15380 LUGAR 

330023 39100 35644

330027 35004 35644

330073 33 40380 LUGAR 

330079 33 47

330090 21300 27060

330094 33 38340

330106 35004 35644

330126 39100 35644

330136 33 10580

330157 33 45060

330167 35004 35644

330181 35004 35644

330182 35004 35644

330191 24020 10580

330198 35004 35644

330213 33 46540

330224 28740 39100

330225 35004 35644

330229 33 21500

330239 33 21500

330250 33 15540

330259 35004 35644

330277 33 27060

330331 35004 35644

330332 35004 35644

330372 35004 35644

330386 33 35084

340004 24660 49180

340008 34 26580

340013 34 16740

340015 34 16740

340021 34 16740
CMS-1498-P 1108 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

340023 11700 24860

340027 34 24780

340037 34 16740

340039 34 49180

340050 34 22180

340051 34 25860

340068 34 34820

340069 39580 20500

340070 15500 24660

340071 34 39580 LUGAR 

340073 39580 20500

340085 34 24660 LUGAR 

340091 24660 49180

340096 34 24660 LUGAR 

340109 34 47260

340114 39580 20500

340115 34 20500

340126 34 39580

340127 34 20500 LUGAR 

340129 34 16740

340131 34 24780

340138 39580 20500

340144 34 16740

340145 34 16740 LUGAR 

340147 40580 39580

340173 39580 20500

350006 35 13900

360010 36 15940

360011 36 18140

360013 36 30620

360014 36 18140

360019 10420 17460

360020 10420 17460

360025 41780 45780

360027 10420 17460

360036 36 31900

360054 36 26580

360055 49660 17460

360065 36 17460
CMS-1498-P 1109 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

360078 10420 17460

360086 44220 19380

360095 36 45780

360109 36 18140

360112 45780 33780

360121 36 45780

360133 19380 17140

360150 10420 17460

360159 36 18140

360175 36 18140

360185 36 49660 LUGAR 

360187 44220 19380

360211 44600 38300

360241 10420 17460

360245 36 17460 LUGAR 

370004 37 27900

370006 37 46140

370014 37 43300

370015 37 46140

370016 37 36420

370018 37 46140

370019 37 45

370020 37 36420

370022 37 30020

370025 37 46140

370026 37 36420

370030 37 46140

370047 37 36420

370099 37 36420

370113 37 22220

380001 38 38900

380022 38 18700 LUGAR 

380027 38 21660

380047 13460 21660

380050 38 32780

380051 41420 38900

380090 38 21660

390006 39 25420

390013 39 25420
CMS-1498-P 1110 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

390016 39 38300

390030 39 39740 LUGAR 

390031 39 39740 LUGAR 

390046 49620 29540

390048 39 25420

390065 39 13644

390066 30140 25420

390067 25420 29540

390071 39 48700 LUGAR 

390079 39 13780

390086 39 38300

390091 39 49660

390093 39 49660

390110 27780 38300

390113 39 21500

390133 10900 37964

390138 39 25420

390151 39 13644

390162 10900 35084

390185 42540 10900

390313 39 39740 LUGAR 

410001 39300 14484

410004 39300 14484

410005 39300 14484

410007 39300 14484

410010 39300 14484

410011 39300 14484

410012 39300 14484

410013 39300 35980

420007 43900 24860

420009 42 24860 LUGAR 

420020 42 16700

420027 11340 24860

420030 42 16700

420036 42 17900

420039 42 43900 LUGAR 

420067 42 42340

420068 42 12260

420069 42 44940 LUGAR 
CMS-1498-P 1111 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

420070 44940 17900

420071 42 24860

420080 42 42340

420083 43900 24860

420085 34820 48900

420101 42 42340

430012 43 43620

440002 27180 32820

440018 27740 28700

440025 44 34

440035 17300 34980

440056 34100 28940

440058 44 26620

440059 44 34980

440067 34100 28700

440068 44 16860

440073 44 34980

440144 44 34980

440151 44 34980

440174 44 32820

440185 17420 16860

440192 44 34980

450007 45 41700

450032 45 30980 LUGAR 

450039 23104 19124

450064 23104 19124

450080 45 19124

450087 23104 19124

450092 45 29700

450099 45 11100

450135 23104 19124

450137 23104 19124

450144 45 33260

450147 47020 18580

450148 23104 19124

450178 45 36220

450187 45 26420

450211 45 30980

450214 45 26420
CMS-1498-P 1112 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

450224 45 46340

450283 45 19124 LUGAR 

450324 43300 19124

450347 45 26420

450351 45 23104

450370 45 26420

450389 45 19124 LUGAR 

450400 45 17780

450419 23104 19124

450438 45 26420

450447 45 19124

450465 45 26420

450469 43300 19124

450484 45 30980

450508 45 30980

450547 45 19124

450563 23104 19124

450565 45 23104

450596 45 23104

450604 45 41700

450639 23104 19124

450656 45 30980

450672 23104 19124

450675 23104 19124

450677 23104 19124

450747 45 46340

450770 45 12420 LUGAR 

450779 23104 19124

450872 23104 19124

450880 23104 19124

450886 23104 19124

460004 36260 41620

460005 36260 41620

460007 46 41100

460026 46 39340

460039 46 36260

460041 36260 41620

460042 36260 41620

470001 47 15540
CMS-1498-P 1113 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

470012 47 38340

490004 25500 16820

490005 49020 47894

490013 49 20500

490018 49 16820

490019 49 16820

490042 13980 40220

490043 47894 13644

490063 47894 13644

490066 47260 40060

490079 49 49180

490101 47894 13644

490107 47894 13644

490122 47894 13644

500003 34580 42644

500007 34580 42644

500016 48300 42644

500021 45104 42644

500031 50 36500

500039 14740 42644

500041 31020 38900

500072 50 14740

500079 45104 42644

500108 45104 42644

500129 45104 42644

510002 51 40220

510006 51 34060

510018 51 16620 LUGAR 

510046 51 49

510047 51 34060

510050 48540 38300

510062 51 16620

510070 51 16620

510071 51 13980

510077 51 26580

520002 52 48140

520013 20740 33460

520021 29404 16974

520028 52 31540 LUGAR 
CMS-1498-P 1114 

Provider 

Number 

Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

520037 52 48140

520059 39540 33340

520071 52 33340 LUGAR 

520076 52 33340

520095 52 31540

520096 39540 33340

520102 52 33340 LUGAR 

520107 52 22540

520113 52 24580

520116 52 33340 LUGAR 

520189 29404 16974

530014 16940 24540
CMS-1498-P 1115 

TABLE 9C.--HOSPITALS REDESIGNATED AS RURAL 

UNDER SECTION 1886(d)(8)(E) OF THE ACT--FY 2011 

Provider No. 

Geographic 

CBSA 

Redesignated 

Rural Area 

040118 27860 04

050192 23420 05

050528 32900 05

050618 40140 05

070004 07 07

100048 37860 10

100118 37380 10

100134 27260 10

140167 14 14

170074 31740 17

170137 29940 17

180016 31140 18

180038 36980 18

220051 38340 22

230078 35660 23

250017 25 25

260006 41140 26

260034 28140 26

260047 27620 26

260195 44180 26

300023 40484 33

330215 46540 33

330235 33 33

330268 10580 33

340010 24140 34

340121 48900 34

360125 36 36

370054 36420 37

380040 13460 38

390130 27780 39

390183 39 39

390233 49620 39

450052 45 45

450078 10180 45

450243 10180 45

450348 45 45

490116 13980 49
CMS-1498-P 1116 

Provider No. 

Geographic 

CBSA 

Redesignated 

Rural Area 

500148 48300 50
CMS-1498-P 1117 

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 MEDICARE SEVERITY 

DIAGNOSIS-RELATED GROUP (MS-DRG)—MARCH 20101 

MS-DRG 

Number of 

Cases Threshold 

1 907 $434,245

2 333 $240,232

3 21,932 $280,834

4 21,377 $171,837

5 889 $181,631

6 408 $106,603

7 469 $180,685

8 508 $111,800

10 137 $87,191

11 1,465 $84,611

12 1,963 $62,285

13 1,008 $44,014

14 446 $173,221

15 1,371 $110,828

20 1,081 $161,767

21 468 $124,259

22 146 $85,874

23 4,406 $96,764

24 1,708 $70,333

25 11,578 $86,631

26 11,464 $61,699

27 12,575 $49,489

28 1,850 $90,885

29 3,505 $55,101

30 3,432 $35,818

31 1,169 $69,659

32 2,808 $42,884

33 3,346 $35,451

34 818 $71,961

35 2,329 $51,071

36 5,711 $43,574

37 4,943 $62,277

38 14,446 $39,441

39 43,741 $29,380

40 4,815 $69,423

41 7,549 $46,033
CMS-1498-P 1118 

MS-DRG 

Number of 

Cases Threshold 

42 3,807 $39,316

52 1,250 $35,010

53 487 $24,212

54 7,203 $33,761

55 13,021 $29,356

56 9,282 $33,807

57 43,183 $23,053

58 893 $33,327

59 3,245 $26,683

60 3,512 $20,846

61 2,265 $63,317

62 3,736 $49,373

63 1,306 $43,140

64 60,920 $39,190

65 112,506 $31,542

66 66,435 $23,769

67 1,387 $35,073

68 10,359 $26,739

69 92,456 $21,784

70 9,641 $38,473

71 13,705 $29,897

72 4,836 $21,740

73 8,924 $30,863

74 31,535 $24,268

75 1,345 $38,691

76 660 $26,901

77 1,517 $38,495

78 2,120 $29,153

79 773 $21,987

80 1,625 $29,586

81 5,863 $20,738

82 2,372 $40,097

83 2,594 $32,688

84 2,540 $25,202

85 7,305 $40,772

86 14,305 $30,370

87 13,004 $21,699

88 870 $35,610

89 3,155 $27,526

90 2,481 $20,786

91 8,734 $34,747

92 19,740 $25,249
CMS-1498-P 1119 

MS-DRG 

Number of 

Cases Threshold 

93 13,201 $19,449

94 1,426 $65,792

95 1,185 $49,565

96 540 $42,502

97 1,186 $61,456

98 1,063 $42,348

99 422 $33,115

100 19,251 $33,637

101 56,024 $21,484

102 1,284 $27,641

103 12,514 $20,151

113 639 $40,406

114 431 $26,196

115 849 $31,885

116 455 $31,888

117 549 $21,050

121 744 $23,633

122 523 $15,971

123 2,670 $21,955

124 738 $28,841

125 4,273 $18,988

129 1,508 $48,976

130 939 $34,737

131 1,132 $46,345

132 745 $33,424

133 2,242 $36,924

134 2,622 $24,387

135 466 $42,963

136 351 $28,285

137 890 $31,653

138 746 $22,447

139 1,361 $25,472

146 734 $41,764

147 1,362 $29,480

148 552 $23,055

149 33,589 $18,807

150 1,162 $29,226

151 6,159 $16,053

152 2,298 $25,939

153 11,461 $17,571

154 2,458 $32,534

155 6,150 $25,001
CMS-1498-P 1120 

MS-DRG 

Number of 

Cases Threshold 

156 3,513 $17,470

157 1,374 $33,896

158 3,705 $24,494

159 1,458 $16,289

163 13,429 $92,474

164 18,789 $56,614

165 10,516 $43,737

166 23,092 $68,109

167 19,774 $46,238

168 4,387 $34,990

175 14,073 $38,408

176 36,633 $29,043

177 68,096 $42,241

178 71,786 $34,277

179 16,033 $25,958

180 20,621 $38,793

181 26,178 $31,187

182 2,834 $23,827

183 2,662 $35,329

184 5,183 $26,627

185 2,185 $18,859

186 10,686 $35,963

187 10,940 $29,659

188 3,291 $21,555

189 94,000 $32,121

190 136,797 $30,807

191 150,301 $26,417

192 134,340 $19,737

193 103,862 $34,826

194 206,953 $27,354

195 86,964 $19,374

196 6,956 $36,218

197 6,785 $29,750

198 3,045 $22,571

199 3,790 $38,729

200 8,673 $27,771

201 2,745 $19,061

202 38,878 $23,055

203 28,973 $16,710

204 23,374 $19,911

205 6,673 $30,904

206 19,971 $21,524
CMS-1498-P 1121 

MS-DRG 

Number of 

Cases Threshold 

207 36,206 $96,662

208 74,943 $48,685

215 177 $197,565

216 9,531 $182,613

217 6,914 $133,364

218 1,220 $112,405

219 12,757 $149,444

220 16,859 $110,276

221 4,462 $96,359

222 2,753 $167,255

223 3,841 $131,602

224 2,736 $152,310

225 4,479 $125,719

226 7,259 $124,233

227 30,034 $103,955

228 2,305 $142,545

229 2,844 $101,007

230 806 $79,269

231 1,350 $165,608

232 1,219 $131,481

233 15,280 $140,586

234 27,390 $106,146

235 9,464 $111,951

236 25,454 $83,813

237 22,095 $98,558

238 40,046 $66,101

239 10,860 $70,090

240 10,778 $47,663

241 1,549 $34,093

242 17,876 $73,344

243 41,219 $58,653

244 44,714 $48,782

245 3,963 $84,900

246 30,895 $74,642

247 143,690 $54,799

248 14,355 $69,420

249 46,331 $51,231

250 7,651 $64,700

251 36,366 $49,826

252 40,559 $57,835

253 44,579 $53,429

254 38,311 $41,802
CMS-1498-P 1122 

MS-DRG 

Number of 

Cases Threshold 

255 2,482 $45,768

256 3,195 $35,494

257 394 $25,161

258 762 $59,622

259 5,040 $43,543

260 1,769 $63,839

261 3,898 $37,685

262 2,417 $30,338

263 517 $35,655

264 22,458 $46,679

265 1,714 $47,659

280 69,980 $39,490

281 53,379 $31,733

282 34,872 $24,367

283 12,645 $36,266

284 4,028 $25,976

285 1,426 $17,208

286 25,184 $47,068

287 134,625 $34,930

288 2,679 $54,285

289 1,196 $39,615

290 240 $31,203

291 176,278 $33,680

292 248,137 $26,745

293 117,949 $18,319

294 1,546 $26,111

295 874 $15,647

296 1,917 $31,226

297 762 $21,036

298 370 $13,581

299 21,212 $32,155

300 48,392 $24,880

301 28,761 $17,012

302 7,755 $26,119

303 52,448 $17,051

304 2,864 $28,173

305 33,320 $17,776

306 3,078 $32,067

307 6,028 $21,707

308 56,608 $30,569

309 107,651 $22,974

310 127,822 $16,117
CMS-1498-P 1123 

MS-DRG 

Number of 

Cases Threshold 

311 15,707 $15,028

312 164,947 $20,561

313 169,249 $17,054

314 61,143 $36,453

315 31,566 $26,084

316 10,661 $17,666

326 11,323 $100,038

327 10,427 $56,127

328 8,536 $37,088

329 46,053 $93,370

330 60,286 $55,007

331 24,223 $40,753

332 1,602 $86,827

333 5,288 $53,532

334 3,027 $39,164

335 7,048 $80,849

336 13,571 $51,477

337 7,645 $38,166

338 1,283 $66,771

339 2,986 $46,480

340 3,035 $35,170

341 906 $51,011

342 2,901 $37,261

343 6,446 $28,320

344 914 $61,169

345 3,050 $40,209

346 2,589 $30,770

347 1,477 $46,158

348 4,253 $33,994

349 4,036 $22,321

350 1,676 $49,482

351 4,531 $35,490

352 6,446 $24,273

353 3,228 $54,617

354 9,551 $38,734

355 12,936 $28,045

356 7,893 $69,691

357 7,603 $47,181

358 2,044 $35,035

368 3,304 $38,781

369 5,624 $29,781

370 1,776 $21,455
CMS-1498-P 1124 

MS-DRG 

Number of 

Cases Threshold 

371 22,527 $40,135

372 34,664 $31,161

373 11,188 $22,331

374 8,067 $41,336

375 17,153 $31,518

376 2,535 $24,404

377 48,249 $37,454

378 138,450 $27,315

379 50,738 $19,552

380 2,926 $41,150

381 6,193 $30,795

382 2,706 $23,160

383 1,129 $32,602

384 7,393 $25,019

385 2,206 $39,912

386 9,038 $29,099

387 4,129 $22,146

388 18,643 $35,848

389 54,825 $25,881

390 39,776 $18,232

391 45,134 $29,680

392 248,631 $20,958

393 21,573 $35,248

394 49,036 $27,559

395 20,047 $19,463

405 4,356 $94,902

406 5,109 $57,667

407 1,925 $43,571

408 1,492 $76,268

409 1,446 $53,357

410 474 $40,046

411 782 $75,017

412 838 $57,460

413 524 $44,552

414 4,697 $69,885

415 5,774 $48,153

416 3,984 $35,009

417 17,747 $55,518

418 27,480 $43,966

419 28,223 $34,296

420 711 $69,211

421 908 $43,258
CMS-1498-P 1125 

MS-DRG 

Number of 

Cases Threshold 

422 234 $34,441

423 1,486 $78,374

424 802 $51,529

425 86 $39,079

432 12,406 $36,533

433 8,081 $26,786

434 398 $17,634

435 12,193 $39,619

436 12,588 $31,248

437 2,181 $27,130

438 14,974 $38,269

439 27,894 $28,968

440 20,546 $20,564

441 14,420 $36,621

442 18,594 $26,589

443 4,681 $18,613

444 12,604 $36,356

445 19,019 $30,426

446 12,775 $22,512

453 1,132 $182,692

454 3,077 $132,948

455 2,469 $102,744

456 1,130 $164,516

457 3,192 $114,426

458 1,561 $93,166

459 3,821 $114,004

460 61,691 $76,529

461 636 $95,750

462 11,335 $71,162

463 5,297 $72,652

464 8,717 $52,913

465 2,706 $39,867

466 3,703 $87,195

467 20,146 $65,733

468 15,777 $55,334

469 27,068 $67,299

470 412,246 $49,549

471 2,809 $88,964

472 8,590 $59,484

473 25,031 $49,259

474 2,921 $58,249

475 3,780 $40,794
CMS-1498-P 1126 

MS-DRG 

Number of 

Cases Threshold 

476 1,133 $26,002

477 2,596 $65,108

478 8,906 $51,186

479 5,865 $41,443

480 24,261 $61,969

481 81,675 $45,348

482 33,813 $39,284

483 10,312 $54,770

484 17,960 $47,483

485 1,022 $63,293

486 2,389 $47,100

487 1,056 $38,013

488 3,242 $39,904

489 4,891 $31,977

490 22,896 $41,626

491 45,102 $27,812

492 5,163 $60,846

493 20,358 $43,967

494 25,195 $34,948

495 1,614 $54,469

496 4,879 $38,810

497 5,123 $29,492

498 1,480 $43,377

499 875 $26,447

500 1,848 $55,259

501 5,063 $37,568

502 5,734 $27,688

503 914 $46,218

504 2,807 $37,301

505 2,256 $29,136

506 716 $31,618

507 940 $43,481

508 1,782 $35,680

509 349 $34,621

510 1,057 $48,362

511 4,310 $38,156

512 8,239 $28,922

513 1,248 $33,152

514 920 $22,905

515 3,952 $61,716

516 12,225 $45,041

517 11,158 $37,652
CMS-1498-P 1127 

MS-DRG 

Number of 

Cases Threshold 

533 818 $32,358

534 3,460 $18,488

535 7,260 $30,780

536 32,783 $17,853

537 944 $21,930

538 707 $16,133

539 3,237 $38,638

540 4,242 $31,087

541 1,124 $22,751

542 5,508 $39,262

543 16,786 $29,624

544 6,621 $20,148

545 3,601 $42,580

546 6,143 $28,738

547 3,344 $20,085

548 578 $39,621

549 1,215 $29,575

550 555 $20,310

551 10,903 $35,750

552 77,153 $22,274

553 2,150 $28,226

554 17,287 $17,720

555 2,590 $27,936

556 17,502 $18,051

557 3,722 $35,286

558 17,209 $23,595

559 1,899 $34,415

560 5,300 $24,964

561 5,307 $16,072

562 5,857 $31,319

563 32,421 $18,265

564 1,779 $32,772

565 4,064 $24,269

566 1,758 $17,800

573 4,788 $50,542

574 10,014 $37,184

575 3,719 $27,509

576 644 $63,202

577 2,414 $37,754

578 2,529 $28,880

579 3,776 $52,443

580 11,546 $35,468
CMS-1498-P 1128 

MS-DRG 

Number of 

Cases Threshold 

581 10,745 $26,778

582 4,896 $29,747

583 7,560 $24,267

584 862 $36,952

585 1,459 $30,205

592 3,953 $34,195

593 11,208 $25,280

594 1,482 $17,532

595 1,114 $35,853

596 4,967 $22,362

597 559 $34,968

598 1,519 $28,537

599 185 $18,944

600 1,034 $25,106

601 778 $17,823

602 22,941 $32,031

603 137,791 $21,037

604 2,660 $30,594

605 20,161 $19,580

606 1,531 $28,668

607 7,082 $17,523

614 1,566 $52,876

615 1,350 $38,331

616 1,630 $73,334

617 6,557 $41,763

618 148 $31,392

619 840 $66,833

620 3,281 $45,226

621 11,420 $39,418

622 1,161 $51,332

623 2,540 $37,658

624 251 $27,170

625 1,200 $47,825

626 2,958 $33,033

627 12,193 $22,852

628 3,450 $60,959

629 4,714 $46,582

630 446 $36,422

637 18,690 $32,234

638 54,251 $21,744

639 24,864 $14,934

640 56,538 $27,789
CMS-1498-P 1129 

MS-DRG 

Number of 

Cases Threshold 

641 187,502 $18,502

642 1,603 $26,187

643 5,943 $37,831

644 13,581 $28,528

645 6,414 $20,136

652 10,206 $69,446

653 1,695 $103,526

654 3,717 $62,937

655 1,275 $45,981

656 3,219 $69,622

657 9,011 $47,214

658 6,794 $38,290

659 4,057 $62,116

660 8,536 $42,838

661 3,858 $35,296

662 794 $54,224

663 2,041 $35,553

664 3,279 $30,167

665 571 $54,953

666 2,190 $37,500

667 2,593 $21,648

668 3,075 $50,865

669 14,675 $33,924

670 8,752 $21,741

671 799 $34,868

672 633 $21,959

673 11,749 $52,536

674 9,543 $45,904

675 3,249 $37,269

682 99,060 $34,669

683 117,393 $26,883

684 26,713 $17,930

685 2,509 $22,911

686 1,144 $38,658

687 3,412 $28,835

688 705 $18,931

689 60,753 $29,890

690 213,524 $20,821

691 997 $39,723

692 380 $29,377

693 1,778 $34,011
CMS-1498-P 1130 

MS-DRG 

Number of 

Cases Threshold 

694 17,760 $21,450

695 1,093 $29,370

696 10,252 $17,381

697 509 $21,088

698 23,414 $34,055

699 31,796 $26,373

700 8,108 $18,232

707 5,391 $43,551

708 16,866 $36,159

709 817 $38,918

710 1,503 $32,486

711 739 $38,867

712 424 $23,105

713 9,757 $30,924

714 22,569 $17,966

715 505 $39,925

716 685 $32,503

717 734 $35,429

718 446 $22,030

722 477 $34,256

723 1,933 $27,779

724 276 $17,297

725 468 $30,772

726 3,907 $18,897

727 1,529 $31,681

728 6,091 $20,560

729 836 $25,783

730 276 $17,460

734 1,520 $49,324

735 1,137 $33,179

736 903 $83,470

737 3,274 $47,200

738 711 $34,082

739 905 $63,570

740 4,458 $39,308

741 5,381 $30,656

742 10,803 $35,874

743 27,629 $25,402

744 1,623 $35,398

745 1,263 $24,085

746 2,619 $34,032
CMS-1498-P 1131 

MS-DRG 

Number of 

Cases Threshold 

747 7,244 $24,914

748 17,063 $25,408

749 1,052 $49,175

750 362 $25,774

754 1,022 $40,025

755 3,404 $28,901

756 440 $18,265

757 1,322 $36,079

758 2,220 $29,154

759 978 $20,075

760 2,268 $22,173

761 1,135 $15,266

765 3,416 $23,396

766 2,753 $15,950

767 168 $18,876

769 122 $36,289

770 177 $19,526

774 1,665 $13,966

775 5,850 $10,155

776 588 $17,142

777 197 $22,190

778 444 $10,944

779 121 $14,296

780 42 $5,027

781 3,387 $16,074

782 188 $10,992

799 537 $93,801

800 686 $56,226

801 356 $39,392

802 935 $61,181

803 1,162 $41,905

804 764 $30,381

808 7,976 $42,063

809 14,309 $29,974

810 2,165 $25,051

811 29,067 $29,896

812 100,121 $21,370

813 11,434 $30,788

814 1,595 $35,777

815 3,792 $27,743

816 1,528 $19,965
CMS-1498-P 1132 

MS-DRG 

Number of 

Cases Threshold 

820 1,268 $101,585

821 2,060 $50,233

822 1,736 $33,712

823 1,872 $83,644

824 3,132 $50,598

825 1,442 $33,753

826 602 $86,073

827 1,497 $47,782

828 694 $36,506

829 1,398 $51,566

830 384 $31,420

834 3,700 $70,199

835 3,043 $39,872

836 1,199 $26,518

837 1,266 $106,271

838 1,553 $53,954

839 1,282 $31,359

840 7,556 $51,514

841 10,908 $36,242

842 3,637 $28,006

843 1,480 $38,892

844 2,961 $30,255

845 666 $23,011

846 2,613 $42,088

847 22,015 $29,252

848 1,106 $24,344

849 1,161 $32,275

853 39,157 $91,531

854 8,734 $55,845

855 337 $34,562

856 5,924 $76,601

857 9,805 $41,686

858 2,324 $32,633

862 9,495 $38,011

863 21,662 $24,948

864 18,165 $22,959

865 2,268 $32,370

866 7,434 $20,691

867 5,312 $44,169

868 2,854 $28,484

869 778 $18,946
CMS-1498-P 1133 

MS-DRG 

Number of 

Cases Threshold 

870 25,704 $106,185

871 246,469 $39,940

872 110,301 $29,921

876 656 $47,281

880 8,141 $17,733

881 4,536 $13,825

882 1,797 $13,928

883 863 $21,336

884 18,103 $22,036

885 88,143 $17,427

886 525 $16,974

887 466 $20,752

894 4,519 $9,250

895 6,272 $18,826

896 6,916 $31,320

897 36,847 $15,672

901 937 $59,770

902 1,889 $36,330

903 1,026 $27,622

904 1,894 $50,605

905 763 $30,023

906 706 $27,779

907 8,651 $64,343

908 9,015 $41,044

909 4,756 $30,985

913 871 $31,045

914 5,457 $19,215

915 1,429 $32,069

916 5,627 $12,701

917 19,110 $33,847

918 36,704 $17,074

919 10,760 $34,206

920 15,239 $25,970

921 7,309 $16,831

922 1,046 $31,696

923 3,197 $18,119

927 188 $191,332

928 947 $70,439

929 366 $39,682

933 138 $35,364

934 608 $27,112
CMS-1498-P 1134 

MS-DRG 

Number of 

Cases Threshold 

935 2,111 $25,585

939 718 $53,737

940 1,636 $38,331

941 1,454 $31,143

945 5,962 $22,482

946 2,808 $19,520

947 12,288 $28,163

948 55,407 $18,688

949 639 $24,011

950 276 $12,574

951 1,027 $17,059

955 443 $101,419

956 4,421 $63,509

957 1,436 $116,430

958 1,214 $76,277

959 200 $50,235

963 1,769 $55,015

964 2,904 $35,973

965 911 $25,761

969 631 $88,018

970 102 $55,798

974 5,213 $46,839

975 4,509 $31,862

976 1,528 $24,990

977 3,545 $27,392

981 25,552 $87,682

982 19,654 $58,273

983 4,889 $41,091

984 505 $63,106

985 1,056 $46,172

986 447 $30,153

987 7,984 $61,556

988 10,936 $41,576

989 3,945 $29,355

999 17 $24,638

1

Cases taken from the FY 2009 MedPAR file; MS-DRGs are from GROUPER Version 28.0.
CMS-1498-P 1135 

TABLE 11.—PROPOSED MS-LTC-DRGS, RELATIVE WEIGHTS, GEOMETRIC 

AVERAGE LENGTH OF STAY, AND SHORT-STAY OUTLIER (SSO) THRESHOLD 

FOR DISCHARGES OCCURRING FROM OCTOBER 1, 2010 THROUGH 

SEPTEMBER 30, 2011 UNDER THE LTCH PPS 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

1 1 HEART TRANSPLANT OR IMPLANT OF 

HEART ASSIST SYSTEM W MCC 0 0.0000 0.0 0.0 

2 1 HEART TRANSPLANT OR IMPLANT OF 

HEART ASSIST SYSTEM W/O MCC 0 0.0000 0.0 0.0 

3 3 ECMO OR TRACH W MV 96+ HRS OR PDX EXC 

FACE, MOUTH & NECK W MAJ O.R. 270 4.6420 65.4 54.5 

4 4 TRACH W MV 96+ HRS OR PDX EXC FACE, 

MOUTH & NECK W/O MAJ O.R. 1,536 2.9398 43.7 36.4 

5 5 LIVER TRANSPLANT W MCC OR INTESTINAL 

TRANSPLANT 0 0.0000 0.0 0.0 

6 5 LIVER TRANSPLANT W/O MCC 0 0.0000 0.0 0.0 

7 7 LUNG TRANSPLANT 0 0.0000 0.0 0.0 

8 8 SIMULTANEOUS PANCREAS/KIDNEY 

TRANSPLANT 0 0.0000 0.0 0.0 

10 10 PANCREAS TRANSPLANT 0 0.0000 0.0 0.0 

11 11 TRACHEOSTOMY FOR FACE,MOUTH & NECK 

DIAGNOSES W MCC 1 1.0834 28.9 24.1 

12 11 TRACHEOSTOMY FOR FACE,MOUTH & NECK 

DIAGNOSES W CC 0 0.8745 23.3 19.4 

13 11 TRACHEOSTOMY FOR FACE,MOUTH & NECK 

DIAGNOSES W/O CC/MCC 0 0.4878 18.1 15.1 

14 14 ALLOGENEIC BONE MARROW TRANSPLANT 0 0.5578 19.4 16.2 

15 15 AUTOLOGOUS BONE MARROW TRANSPLANT 0 0.5578 19.4 16.2 

20 20 INTRACRANIAL VASCULAR PROCEDURES W 

PDX HEMORRHAGE W MCC 1 1.6495 36.4 30.3 

21 20 INTRACRANIAL VASCULAR PROCEDURES W 

PDX HEMORRHAGE W CC 0 0.6040 22.1 18.4 

22 20 INTRACRANIAL VASCULAR PROCEDURES W 

PDX HEMORRHAGE W/O CC/MCC 0 0.4878 18.1 15.1 

23 23 CRANIO W MAJOR DEV IMPL/ACUTE 

COMPLEX CNS PDX W MCC OR CHEMO 

IMPLANT 0 1.0834 28.9 24.1 

24 23 CRANIO W MAJOR DEV IMPL/ACUTE 

COMPLEX CNS PDX W/O MCC 0 0.4878 18.1 15.1 

25 25 CRANIOTOMY & ENDOVASCULAR 

INTRACRANIAL PROCEDURES W MCC 2 1.0834 28.9 24.1 

26 25 CRANIOTOMY & ENDOVASCULAR 

INTRACRANIAL PROCEDURES W CC 1 0.4878 18.1 15.1 

27 25 CRANIOTOMY & ENDOVASCULAR 

INTRACRANIAL PROCEDURES W/O CC/MCC 0 0.4878 18.1 15.1 

28 28 SPINAL PROCEDURES W MCC 11 1.0834 28.9 24.1 

29 28 SPINAL PROCEDURES W CC OR SPINAL 

NEUROSTIMULATORS 16 0.8667 24.6 20.5 
CMS-1498-P 1136 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

30 28 SPINAL PROCEDURES W/O CC/MCC 0 0.8667 24.6 20.5 

31 31 VENTRICULAR SHUNT PROCEDURES W MCC 1 1.0834 28.9 24.1 

32 31 VENTRICULAR SHUNT PROCEDURES W CC 0 1.0834 28.9 24.1 

33 31 VENTRICULAR SHUNT PROCEDURES W/O 

CC/MCC 0 1.0834 28.9 24.1 

34 34 CAROTID ARTERY STENT PROCEDURE W 

MCC 0 1.6495 36.4 30.3 

35 34 CAROTID ARTERY STENT PROCEDURE W CC 0 1.6495 36.4 30.3 

36 34 CAROTID ARTERY STENT PROCEDURE W/O 

CC/MCC 0 1.6495 36.4 30.3 

37 37 EXTRACRANIAL PROCEDURES W MCC* 13 1.6495 36.4 30.3 

38 37 EXTRACRANIAL PROCEDURES W CC 4 1.6495 36.4 30.3 

39 37 EXTRACRANIAL PROCEDURES W/O CC/MCC 0 1.6495 36.4 30.3 

40 40 PERIPH/CRANIAL NERVE & OTHER NERV 

SYST PROC W MCC 116 1.2680 34.0 28.3 

41 40 PERIPH/CRANIAL NERVE & OTHER NERV 

SYST PROC W CC OR PERIPH NEUROSTIM 82 0.8898 29.0 24.2 

42 40 PERIPH/CRANIAL NERVE & OTHER NERV 

SYST PROC W/O CC/MCC 3 0.4878 18.1 15.1 

52 52 SPINAL DISORDERS & INJURIES W CC/MCC* 64 1.1123 41.2 34.3 

53 52 SPINAL DISORDERS & INJURIES W/O CC/MCC 6 1.1123 41.2 34.3 

54 54 NERVOUS SYSTEM NEOPLASMS W MCC 32 0.7988 27.3 22.8 

55 54 NERVOUS SYSTEM NEOPLASMS W/O MCC 35 0.5857 19.2 16.0 

56 56 DEGENERATIVE NERVOUS SYSTEM 

DISORDERS W MCC 1,122 0.8046 25.6 21.3 

57 56 DEGENERATIVE NERVOUS SYSTEM 

DISORDERS W/O MCC 1,142 0.5744 23.7 19.8 

58 58 MULTIPLE SCLEROSIS & CEREBELLAR 

ATAXIA W MCC 11 1.6495 36.4 30.3 

59 58 MULTIPLE SCLEROSIS & CEREBELLAR 

ATAXIA W CC 14 0.6280 20.9 17.4 

60 58 MULTIPLE SCLEROSIS & CEREBELLAR 

ATAXIA W/O CC/MCC 4 0.4878 18.1 15.1 

61 61 ACUTE ISCHEMIC STROKE W USE OF 

THROMBOLYTIC AGENT W MCC 0 0.9204 23.3 19.4 

62 61 ACUTE ISCHEMIC STROKE W USE OF 

THROMBOLYTIC AGENT W CC 0 0.6172 22.1 18.4 

63 61 ACUTE ISCHEMIC STROKE W USE OF 

THROMBOLYTIC AGENT W/O CC/MCC 0 0.6172 22.1 18.4 

64 64 INTRACRANIAL HEMORRHAGE OR 

CEREBRAL INFARCTION W MCC 145 0.8377 24.2 20.2 

65 64 INTRACRANIAL HEMORRHAGE OR 

CEREBRAL INFARCTION W CC 52 0.6040 22.1 18.4 

66 64 INTRACRANIAL HEMORRHAGE OR 

CEREBRAL INFARCTION W/O CC/MCC 9 0.4878 18.1 15.1 

67 67 NONSPECIFIC CVA & PRECEREBRAL 

OCCLUSION W/O INFARCT W MCC 0 0.4878 18.1 15.1 
CMS-1498-P 1137 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

68 67 NONSPECIFIC CVA & PRECEREBRAL 

OCCLUSION W/O INFARCT W/O MCC 3 0.4878 18.1 15.1 

69 69 TRANSIENT ISCHEMIA 2 1.0834 28.9 24.1 

70 70 NONSPECIFIC CEREBROVASCULAR 

DISORDERS W MCC 182 0.9204 23.3 19.4 

71 70 NONSPECIFIC CEREBROVASCULAR 

DISORDERS W CC* 92 0.6172 22.1 18.4 

72 70 NONSPECIFIC CEREBROVASCULAR 

DISORDERS W/O CC/MCC 9 0.6172 22.1 18.4 

73 73 CRANIAL & PERIPHERAL NERVE DISORDERS 

W MCC 112 0.8684 24.9 20.8 

74 73 CRANIAL & PERIPHERAL NERVE DISORDERS 

W/O MCC 111 0.6375 21.9 18.3 

75 75 VIRAL MENINGITIS W CC/MCC 9 0.8667 24.6 20.5 

76 75 VIRAL MENINGITIS W/O CC/MCC 0 0.8667 24.6 20.5 

77 77 HYPERTENSIVE ENCEPHALOPATHY W MCC 2 0.8667 24.6 20.5 

78 77 HYPERTENSIVE ENCEPHALOPATHY W CC 2 0.8667 24.6 20.5 

79 77 HYPERTENSIVE ENCEPHALOPATHY W/O 

CC/MCC 0 0.6280 20.9 17.4 

80 80 NONTRAUMATIC STUPOR & COMA W MCC 8 1.0834 28.9 24.1 

81 80 NONTRAUMATIC STUPOR & COMA W/O MCC 6 0.4878 18.1 15.1 

82 82 TRAUMATIC STUPOR & COMA, COMA >1 HR 

W MCC 15 0.8667 24.6 20.5 

83 82 TRAUMATIC STUPOR & COMA, COMA >1 HR 

W CC 9 0.6280 20.9 17.4 

84 82 TRAUMATIC STUPOR & COMA, COMA >1 HR 

W/O CC/MCC 1 0.4878 18.1 15.1 

85 85 TRAUMATIC STUPOR & COMA, COMA <1 HR 

W MCC 92 0.9280 25.1 20.9 

86 85 TRAUMATIC STUPOR & COMA, COMA <1 HR 

W CC 56 0.6865 23.9 19.9 

87 85 TRAUMATIC STUPOR & COMA, COMA <1 HR 

W/O CC/MCC 8 0.4878 18.1 15.1 

88 88 CONCUSSION W MCC 0 1.0834 28.9 24.1 

89 88 CONCUSSION W CC 1 1.0834 28.9 24.1 

90 88 CONCUSSION W/O CC/MCC 1 0.8667 24.6 20.5 

91 91 OTHER DISORDERS OF NERVOUS SYSTEM W 

MCC 264 0.8775 24.3 20.3 

92 91 OTHER DISORDERS OF NERVOUS SYSTEM W 

CC 98 0.7482 24.2 20.2 

93 91 OTHER DISORDERS OF NERVOUS SYSTEM 

W/O CC/MCC 7 0.4878 18.1 15.1 

94 94 BACTERIAL & TUBERCULOUS INFECTIONS 

OF NERVOUS SYSTEM W MCC 247 1.1110 29.4 24.5 

95 94 BACTERIAL & TUBERCULOUS INFECTIONS 

OF NERVOUS SYSTEM W CC* 99 0.8203 25.3 21.1 

96 94 BACTERIAL & TUBERCULOUS INFECTIONS 

OF NERVOUS SYSTEM W/O CC/MCC 22 0.8203 25.3 21.1 
CMS-1498-P 1138 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

97 97 NON-BACTERIAL INFECT OF NERVOUS SYS 

EXC VIRAL MENINGITIS W MCC 70 0.9186 24.6 20.5 

98 97 NON-BACTERIAL INFECT OF NERVOUS SYS 

EXC VIRAL MENINGITIS W CC 23 0.6280 20.9 17.4 

99 97 NON-BACTERIAL INFECT OF NERVOUS SYS 

EXC VIRAL MENINGITIS W/O CC/MCC 4 0.4878 18.1 15.1 

100 100 SEIZURES W MCC 32 0.7248 21.5 17.9 

101 100 SEIZURES W/O MCC 36 0.6180 21.8 18.2 

102 102 HEADACHES W MCC 2 0.8667 24.6 20.5 

103 102 HEADACHES W/O MCC 0 0.4878 18.1 15.1 

113 113 ORBITAL PROCEDURES W CC/MCC 1 1.0834 28.9 24.1 

114 113 ORBITAL PROCEDURES W/O CC/MCC 0 1.0834 28.9 24.1 

115 115 EXTRAOCULAR PROCEDURES EXCEPT 

ORBIT 0 1.0834 28.9 24.1 

116 116 INTRAOCULAR PROCEDURES W CC/MCC 0 1.0834 28.9 24.1 

117 116 INTRAOCULAR PROCEDURES W/O CC/MCC 0 1.0834 28.9 24.1 

121 121 ACUTE MAJOR EYE INFECTIONS W CC/MCC 9 0.6280 20.9 17.4 

122 121 ACUTE MAJOR EYE INFECTIONS W/O 

CC/MCC 3 0.4878 18.1 15.1 

123 123 NEUROLOGICAL EYE DISORDERS 0 1.0834 28.9 24.1 

124 124 OTHER DISORDERS OF THE EYE W MCC* 6 1.0834 28.9 24.1 

125 124 OTHER DISORDERS OF THE EYE W/O MCC 3 1.0834 28.9 24.1 

129 129 MAJOR HEAD & NECK PROCEDURES W 

CC/MCC OR MAJOR DEVICE 0 1.2634 27.1 22.6 

130 129 MAJOR HEAD & NECK PROCEDURES W/O 

CC/MCC 0 0.4878 18.1 15.1 

131 131 CRANIAL/FACIAL PROCEDURES W CC/MCC 1 1.6495 36.4 30.3 

132 131 CRANIAL/FACIAL PROCEDURES W/O CC/MCC 0 0.8203 25.3 21.1 

133 133 OTHER EAR, NOSE, MOUTH & THROAT O.R. 

PROCEDURES W CC/MCC 9 1.6495 36.4 30.3 

134 133 OTHER EAR, NOSE, MOUTH & THROAT O.R. 

PROCEDURES W/O CC/MCC 0 0.4878 18.1 15.1 

135 135 SINUS & MASTOID PROCEDURES W CC/MCC 0 1.6495 36.4 30.3 

136 135 SINUS & MASTOID PROCEDURES W/O 

CC/MCC 0 0.4878 18.1 15.1 

137 137 MOUTH PROCEDURES W CC/MCC 0 0.6280 20.9 17.4 

138 137 MOUTH PROCEDURES W/O CC/MCC 0 0.6280 20.9 17.4 

139 139 SALIVARY GLAND PROCEDURES 0 0.6280 20.9 17.4 

146 146 EAR, NOSE, MOUTH & THROAT 

MALIGNANCY W MCC 39 1.2634 27.1 22.6 

147 146 EAR, NOSE, MOUTH & THROAT 

MALIGNANCY W CC 31 0.8745 23.3 19.4 

148 146 EAR, NOSE, MOUTH & THROAT 

MALIGNANCY W/O CC/MCC 3 0.4878 18.1 15.1 

149 149 DYSEQUILIBRIUM 2 0.4878 18.1 15.1 

150 150 EPISTAXIS W MCC 0 0.8587 25.4 21.2 

151 150 EPISTAXIS W/O MCC 1 0.4878 18.1 15.1 

152 152 OTITIS MEDIA & URI W MCC 31 0.8587 25.4 21.2 
CMS-1498-P 1139 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

153 152 OTITIS MEDIA & URI W/O MCC 28 0.5982 19.9 16.6 

154 154 OTHER EAR, NOSE, MOUTH & THROAT 

DIAGNOSES W MCC 49 1.0726 26.3 21.9 

155 154 OTHER EAR, NOSE, MOUTH & THROAT 

DIAGNOSES W CC* 42 0.8203 25.3 21.1 

156 154 OTHER EAR, NOSE, MOUTH & THROAT 

DIAGNOSES W/O CC/MCC 8 0.8203 25.3 21.1 

157 157 DENTAL & ORAL DISEASES W MCC 9 1.0834 28.9 24.1 

158 157 DENTAL & ORAL DISEASES W CC 24 0.6280 20.9 17.4 

159 157 DENTAL & ORAL DISEASES W/O CC/MCC 4 0.6280 20.9 17.4 

163 163 MAJOR CHEST PROCEDURES W MCC 28 2.4302 42.0 35.0 

164 163 MAJOR CHEST PROCEDURES W CC 5 1.6495 36.4 30.3 

165 163 MAJOR CHEST PROCEDURES W/O CC/MCC 0 1.5463 31.4 26.2 

166 166 OTHER RESP SYSTEM O.R. PROCEDURES W 

MCC 1,742 2.5489 42.0 35.0 

167 166 OTHER RESP SYSTEM O.R. PROCEDURES W 

CC* 174 1.5463 31.4 26.2 

168 166 OTHER RESP SYSTEM O.R. PROCEDURES W/O 

CC/MCC 8 1.5463 31.4 26.2 

175 175 PULMONARY EMBOLISM W MCC 105 0.7521 22.7 18.9 

176 175 PULMONARY EMBOLISM W/O MCC 72 0.5489 18.8 15.7 

177 177 RESPIRATORY INFECTIONS & 

INFLAMMATIONS W MCC 4,071 0.8895 22.9 19.1 

178 177 RESPIRATORY INFECTIONS & 

INFLAMMATIONS W CC 1,912 0.7193 20.8 17.3 

179 177 RESPIRATORY INFECTIONS & 

INFLAMMATIONS W/O CC/MCC 143 0.6009 17.1 14.3 

180 180 RESPIRATORY NEOPLASMS W MCC 117 0.7510 20.1 16.8 

181 180 RESPIRATORY NEOPLASMS W CC 64 0.6640 19.9 16.6 

182 180 RESPIRATORY NEOPLASMS W/O CC/MCC 2 0.6280 20.9 17.4 

183 183 MAJOR CHEST TRAUMA W MCC 0 2.4302 42.0 35.0 

184 183 MAJOR CHEST TRAUMA W CC 0 1.6495 36.4 30.3 

185 183 MAJOR CHEST TRAUMA W/O CC/MCC 0 1.5463 31.4 26.2 

186 186 PLEURAL EFFUSION W MCC 147 0.7405 20.7 17.3 

187 186 PLEURAL EFFUSION W CC 41 0.5699 18.8 15.7 

188 186 PLEURAL EFFUSION W/O CC/MCC 3 0.4878 18.1 15.1 

189 189 PULMONARY EDEMA & RESPIRATORY 

FAILURE 8,376 0.9737 23.5 19.6 

190 190 CHRONIC OBSTRUCTIVE PULMONARY 

DISEASE W MCC 2,365 0.7421 20.2 16.8 

191 190 CHRONIC OBSTRUCTIVE PULMONARY 

DISEASE W CC 1,129 0.6316 18.4 15.3 

192 190 CHRONIC OBSTRUCTIVE PULMONARY 

DISEASE W/O CC/MCC 286 0.5081 16.4 13.7 

193 193 SIMPLE PNEUMONIA & PLEURISY W MCC 2,120 0.7644 20.9 17.4 

194 193 SIMPLE PNEUMONIA & PLEURISY W CC 1,554 0.6152 18.9 15.8 

195 193 SIMPLE PNEUMONIA & PLEURISY W/O 

CC/MCC 162 0.4881 16.7 13.9 
CMS-1498-P 1140 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

196 196 INTERSTITIAL LUNG DISEASE W MCC 96 0.7048 20.4 17.0 

197 196 INTERSTITIAL LUNG DISEASE W CC 71 0.6056 18.6 15.5 

198 196 INTERSTITIAL LUNG DISEASE W/O CC/MCC 20 0.4878 18.1 15.1 

199 199 PNEUMOTHORAX W MCC 80 0.7749 21.5 17.9 

200 199 PNEUMOTHORAX W CC 15 0.6280 20.9 17.4 

201 199 PNEUMOTHORAX W/O CC/MCC 4 0.4878 18.1 15.1 

202 202 BRONCHITIS & ASTHMA W CC/MCC 114 0.7236 20.9 17.4 

203 202 BRONCHITIS & ASTHMA W/O CC/MCC 10 0.6280 20.9 17.4 

204 204 RESPIRATORY SIGNS & SYMPTOMS 144 0.7769 21.1 17.6 

205 205 OTHER RESPIRATORY SYSTEM DIAGNOSES 

W MCC 376 0.8291 22.1 18.4 

206 205 OTHER RESPIRATORY SYSTEM DIAGNOSES 

W/O MCC 145 0.7030 20.7 17.3 

207 207 RESPIRATORY SYSTEM DIAGNOSIS W 

VENTILATOR SUPPORT 96+ HOURS 14,744 2.0241 33.3 27.8 

208 208 RESPIRATORY SYSTEM DIAGNOSIS W 

VENTILATOR SUPPORT <96 HOURS 1,828 1.0948 22.2 18.5 

215 215 OTHER HEART ASSIST SYSTEM IMPLANT 0 0.6280 20.9 17.4 

216 216 CARDIAC VALVE & OTH MAJ 

CARDIOTHORACIC PROC W CARD CATH W 

MCC 0 1.6495 36.4 30.3 

217 216 CARDIAC VALVE & OTH MAJ 

CARDIOTHORACIC PROC W CARD CATH W 

CC 0 1.2501 30.4 25.3 

218 216 CARDIAC VALVE & OTH MAJ 

CARDIOTHORACIC PROC W CARD CATH W/O 

CC/MCC 0 0.6280 20.9 17.4 

219 219 CARDIAC VALVE & OTH MAJ 

CARDIOTHORACIC PROC W/O CARD CATH W 

MCC 0 1.6495 36.4 30.3 

220 219 CARDIAC VALVE & OTH MAJ 

CARDIOTHORACIC PROC W/O CARD CATH W 

CC 1 1.6495 36.4 30.3 

221 219 CARDIAC VALVE & OTH MAJ 

CARDIOTHORACIC PROC W/O CARD CATH 

W/O CC/MCC 0 0.6280 20.9 17.4 

222 222 CARDIAC DEFIB IMPLANT W CARDIAC CATH 

W AMI/HF/SHOCK W MCC 0 1.6495 36.4 30.3 

223 222 CARDIAC DEFIB IMPLANT W CARDIAC CATH 

W AMI/HF/SHOCK W/O MCC 0 0.8667 24.6 20.5 

224 224 CARDIAC DEFIB IMPLANT W CARDIAC CATH 

W/O AMI/HF/SHOCK W MCC 0 1.6495 36.4 30.3 

225 224 CARDIAC DEFIB IMPLANT W CARDIAC CATH 

W/O AMI/HF/SHOCK W/O MCC 1 0.6280 20.9 17.4 

226 226 CARDIAC DEFIBRILLATOR IMPLANT W/O 

CARDIAC CATH W MCC 6 1.6495 36.4 30.3 

227 226 CARDIAC DEFIBRILLATOR IMPLANT W/O 

CARDIAC CATH W/O MCC 2 1.6495 36.4 30.3 
CMS-1498-P 1141 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

228 228 OTHER CARDIOTHORACIC PROCEDURES W 

MCC 0 1.3830 30.1 25.1 

229 228 OTHER CARDIOTHORACIC PROCEDURES W 

CC 0 1.2501 30.4 25.3 

230 228 OTHER CARDIOTHORACIC PROCEDURES 

W/O CC/MCC 0 0.6280 20.9 17.4 

231 231 CORONARY BYPASS W PTCA W MCC 0 1.6495 36.4 30.3 

232 231 CORONARY BYPASS W PTCA W/O MCC 0 0.6280 20.9 17.4 

233 233 CORONARY BYPASS W CARDIAC CATH W 

MCC 0 1.6495 36.4 30.3 

234 233 CORONARY BYPASS W CARDIAC CATH W/O 

MCC 0 0.6280 20.9 17.4 

235 235 CORONARY BYPASS W/O CARDIAC CATH W 

MCC 0 1.6495 36.4 30.3 

236 235 CORONARY BYPASS W/O CARDIAC CATH 

W/O MCC 1 0.6280 20.9 17.4 

237 237 MAJOR CARDIOVASC PROCEDURES W MCC 

OR THORACIC AORTIC ANEURYSM REPAIR 6 1.6495 36.4 30.3 

238 237 MAJOR CARDIOVASC PROCEDURES W/O 

MCC 0 0.6280 20.9 17.4 

239 239 AMPUTATION FOR CIRC SYS DISORDERS 

EXC UPPER LIMB & TOE W MCC 142 1.5508 36.9 30.8 

240 239 AMPUTATION FOR CIRC SYS DISORDERS 

EXC UPPER LIMB & TOE W CC 55 1.3458 35.0 29.2 

241 239 AMPUTATION FOR CIRC SYS DISORDERS 

EXC UPPER LIMB & TOE W/O CC/MCC 0 0.6280 20.9 17.4 

242 242 PERMANENT CARDIAC PACEMAKER 

IMPLANT W MCC 3 1.6495 36.4 30.3 

243 242 PERMANENT CARDIAC PACEMAKER 

IMPLANT W CC 6 0.8667 24.6 20.5 

244 242 PERMANENT CARDIAC PACEMAKER 

IMPLANT W/O CC/MCC 1 0.4878 18.1 15.1 

245 245 AICD GENERATOR PROCEDURES 0 0.4878 18.1 15.1 

246 246 PERC CARDIOVASC PROC W DRUG-ELUTING 

STENT W MCC OR 4+ VESSELS/STENTS 0 1.3830 30.1 25.1 

247 246 PERC CARDIOVASC PROC W DRUG-ELUTING 

STENT W/O MCC 2 0.8667 24.6 20.5 

248 248 PERC CARDIOVASC PROC W NON-DRUGELUTING STENT W MCC OR 4+ VES/STENTS 1 1.6495 36.4 30.3 

249 248 PERC CARDIOVASC PROC W NON-DRUGELUTING STENT W/O MCC 1 0.6280 20.9 17.4 

250 250 PERC CARDIOVASC PROC W/O CORONARY 

ARTERY STENT W MCC 3 1.0834 28.9 24.1 

251 250 PERC CARDIOVASC PROC W/O CORONARY 

ARTERY STENT W/O MCC 0 1.0834 28.9 24.1 

252 252 OTHER VASCULAR PROCEDURES W MCC 110 1.3830 30.1 25.1 

253 252 OTHER VASCULAR PROCEDURES W CC 46 1.2501 30.4 25.3 

254 252 OTHER VASCULAR PROCEDURES W/O 

CC/MCC 2 0.6280 20.9 17.4 
CMS-1498-P 1142 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

255 255 UPPER LIMB & TOE AMPUTATION FOR CIRC 

SYSTEM DISORDERS W MCC 37 1.2192 33.9 28.3 

256 255 UPPER LIMB & TOE AMPUTATION FOR CIRC 

SYSTEM DISORDERS W CC 22 1.0834 28.9 24.1 

257 255 UPPER LIMB & TOE AMPUTATION FOR CIRC 

SYSTEM DISORDERS W/O CC/MCC 0 0.6280 20.9 17.4 

258 258 CARDIAC PACEMAKER DEVICE 

REPLACEMENT W MCC 1 0.8667 24.6 20.5 

259 258 CARDIAC PACEMAKER DEVICE 

REPLACEMENT W/O MCC 0 0.6280 20.9 17.4 

260 260 CARDIAC PACEMAKER REVISION EXCEPT 

DEVICE REPLACEMENT W MCC 2 1.6495 36.4 30.3 

261 260 CARDIAC PACEMAKER REVISION EXCEPT 

DEVICE REPLACEMENT W CC 3 1.0834 28.9 24.1 

262 260 CARDIAC PACEMAKER REVISION EXCEPT 

DEVICE REPLACEMENT W/O CC/MCC 1 0.6280 20.9 17.4 

263 263 VEIN LIGATION & STRIPPING 2 1.6495 36.4 30.3 

264 264 OTHER CIRCULATORY SYSTEM O.R. 

PROCEDURES 594 1.0441 30.6 25.5 

265 265 AICD LEAD PROCEDURES 0 1.0441 30.6 25.5 

280 280 ACUTE MYOCARDIAL INFARCTION, 

DISCHARGED ALIVE W MCC 271 0.7702 22.2 18.5 

281 280 ACUTE MYOCARDIAL INFARCTION, 

DISCHARGED ALIVE W CC 105 0.6663 20.9 17.4 

282 280 ACUTE MYOCARDIAL INFARCTION, 

DISCHARGED ALIVE W/O CC/MCC 12 0.4878 18.1 15.1 

283 283 ACUTE MYOCARDIAL INFARCTION, EXPIRED 

W MCC 46 0.9091 17.2 14.3 

284 283 ACUTE MYOCARDIAL INFARCTION, EXPIRED 

W CC 6 0.6280 20.9 17.4 

285 283 ACUTE MYOCARDIAL INFARCTION, EXPIRED 

W/O CC/MCC 0 0.6280 20.9 17.4 

286 286 CIRCULATORY DISORDERS EXCEPT AMI, W 

CARD CATH W MCC 11 1.6495 36.4 30.3 

287 286 CIRCULATORY DISORDERS EXCEPT AMI, W 

CARD CATH W/O MCC 5 0.8667 24.6 20.5 

288 288 ACUTE & SUBACUTE ENDOCARDITIS W MCC 646 1.0263 26.3 21.9 

289 288 ACUTE & SUBACUTE ENDOCARDITIS W CC 240 0.8452 26.2 21.8 

290 288 ACUTE & SUBACUTE ENDOCARDITIS W/O 

CC/MCC 25 0.7600 27.8 23.2 

291 291 HEART FAILURE & SHOCK W MCC 1,436 0.7773 21.5 17.9 

292 291 HEART FAILURE & SHOCK W CC 872 0.6120 19.5 16.3 

293 291 HEART FAILURE & SHOCK W/O CC/MCC 83 0.4418 16.9 14.1 

294 294 DEEP VEIN THROMBOPHLEBITIS W CC/MCC 8 1.6495 36.4 30.3 

295 294 DEEP VEIN THROMBOPHLEBITIS W/O 

CC/MCC 0 0.5156 20.0 16.7 

296 296 CARDIAC ARREST, UNEXPLAINED W MCC 0 0.7773 21.5 17.9 

297 296 CARDIAC ARREST, UNEXPLAINED W CC 0 0.6120 19.5 16.3 
CMS-1498-P 1143 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

298 296 CARDIAC ARREST, UNEXPLAINED W/O 

CC/MCC 0 0.4418 16.9 14.1 

299 299 PERIPHERAL VASCULAR DISORDERS W MCC 735 0.7976 23.7 19.8 

300 299 PERIPHERAL VASCULAR DISORDERS W CC 696 0.5845 21.6 18.0 

301 299 PERIPHERAL VASCULAR DISORDERS W/O 

CC/MCC 39 0.5156 20.0 16.7 

302 302 ATHEROSCLEROSIS W MCC 49 0.8801 22.6 18.8 

303 302 ATHEROSCLEROSIS W/O MCC 38 0.5651 21.5 17.9 

304 304 HYPERTENSION W MCC 3 1.6495 36.4 30.3 

305 304 HYPERTENSION W/O MCC 14 0.6280 20.9 17.4 

306 306 CARDIAC CONGENITAL & VALVULAR 

DISORDERS W MCC 58 0.8633 24.3 20.3 

307 306 CARDIAC CONGENITAL & VALVULAR 

DISORDERS W/O MCC 37 0.8144 24.4 20.3 

308 308 CARDIAC ARRHYTHMIA & CONDUCTION 

DISORDERS W MCC 131 0.7120 20.7 17.3 

309 308 CARDIAC ARRHYTHMIA & CONDUCTION 

DISORDERS W CC 55 0.5307 19.3 16.1 

310 308 CARDIAC ARRHYTHMIA & CONDUCTION 

DISORDERS W/O CC/MCC 11 0.4878 18.1 15.1 

311 311 ANGINA PECTORIS 1 0.8667 24.6 20.5 

312 312 SYNCOPE & COLLAPSE 29 0.4995 17.3 14.4 

313 313 CHEST PAIN 3 0.8667 24.6 20.5 

314 314 OTHER CIRCULATORY SYSTEM DIAGNOSES 

W MCC 1,566 0.9068 23.1 19.3 

315 314 OTHER CIRCULATORY SYSTEM DIAGNOSES 

W CC 314 0.6812 21.5 17.9 

316 314 OTHER CIRCULATORY SYSTEM DIAGNOSES 

W/O CC/MCC 26 0.5394 19.2 16.0 

326 326 STOMACH, ESOPHAGEAL & DUODENAL 

PROC W MCC 24 1.6495 36.4 30.3 

327 326 STOMACH, ESOPHAGEAL & DUODENAL 

PROC W CC 3 0.8667 24.6 20.5 

328 326 STOMACH, ESOPHAGEAL & DUODENAL 

PROC W/O CC/MCC 1 0.8667 24.6 20.5 

329 329 MAJOR SMALL & LARGE BOWEL 

PROCEDURES W MCC 28 1.7888 41.2 34.3 

330 329 MAJOR SMALL & LARGE BOWEL 

PROCEDURES W CC 8 1.6495 36.4 30.3 

331 329 MAJOR SMALL & LARGE BOWEL 

PROCEDURES W/O CC/MCC 0 1.0834 28.9 24.1 

332 332 RECTAL RESECTION W MCC 0 1.0834 28.9 24.1 

333 332 RECTAL RESECTION W CC 0 0.8667 24.6 20.5 

334 332 RECTAL RESECTION W/O CC/MCC 0 0.8667 24.6 20.5 

335 335 PERITONEAL ADHESIOLYSIS W MCC 10 1.6495 36.4 30.3 

336 335 PERITONEAL ADHESIOLYSIS W CC 1 1.0834 28.9 24.1 

337 335 PERITONEAL ADHESIOLYSIS W/O CC/MCC 0 1.0834 28.9 24.1 
CMS-1498-P 1144 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

338 338 APPENDECTOMY W COMPLICATED 

PRINCIPAL DIAG W MCC 0 0.7254 22.0 18.3 

339 338 APPENDECTOMY W COMPLICATED 

PRINCIPAL DIAG W CC 0 0.7254 22.0 18.3 

340 338 APPENDECTOMY W COMPLICATED 

PRINCIPAL DIAG W/O CC/MCC 0 0.5065 17.1 14.3 

341 341 APPENDECTOMY W/O COMPLICATED 

PRINCIPAL DIAG W MCC 0 0.9536 24.3 20.3 

342 341 APPENDECTOMY W/O COMPLICATED 

PRINCIPAL DIAG W CC 0 0.7254 22.0 18.3 

343 341 APPENDECTOMY W/O COMPLICATED 

PRINCIPAL DIAG W/O CC/MCC 0 0.5065 17.1 14.3 

344 344 MINOR SMALL & LARGE BOWEL 

PROCEDURES W MCC* 1 1.0834 28.9 24.1 

345 344 MINOR SMALL & LARGE BOWEL 

PROCEDURES W CC* 1 1.0834 28.9 24.1 

346 344 MINOR SMALL & LARGE BOWEL 

PROCEDURES W/O CC/MCC 0 1.0834 28.9 24.1 

347 347 ANAL & STOMAL PROCEDURES W MCC 3 1.0834 28.9 24.1 

348 347 ANAL & STOMAL PROCEDURES W CC 2 0.8667 24.6 20.5 

349 347 ANAL & STOMAL PROCEDURES W/O CC/MCC 0 0.8667 24.6 20.5 

350 350 INGUINAL & FEMORAL HERNIA 

PROCEDURES W MCC 1 1.6495 36.4 30.3 

351 350 INGUINAL & FEMORAL HERNIA 

PROCEDURES W CC 0 0.4878 18.1 15.1 

352 350 INGUINAL & FEMORAL HERNIA 

PROCEDURES W/O CC/MCC 0 0.4878 18.1 15.1 

353 353 HERNIA PROCEDURES EXCEPT INGUINAL & 

FEMORAL W MCC 3 1.0834 28.9 24.1 

354 353 HERNIA PROCEDURES EXCEPT INGUINAL & 

FEMORAL W CC 1 0.4878 18.1 15.1 

355 353 HERNIA PROCEDURES EXCEPT INGUINAL & 

FEMORAL W/O CC/MCC 0 0.4878 18.1 15.1 

356 356 OTHER DIGESTIVE SYSTEM O.R. 

PROCEDURES W MCC 141 1.7106 35.6 29.7 

357 356 OTHER DIGESTIVE SYSTEM O.R. 

PROCEDURES W CC 26 1.1300 29.0 24.2 

358 356 OTHER DIGESTIVE SYSTEM O.R. 

PROCEDURES W/O CC/MCC 3 1.0834 28.9 24.1 

368 368 MAJOR ESOPHAGEAL DISORDERS W MCC 34 1.0400 22.4 18.7 

369 368 MAJOR ESOPHAGEAL DISORDERS W CC 12 0.6280 20.9 17.4 

370 368 MAJOR ESOPHAGEAL DISORDERS W/O 

CC/MCC* 1 0.6280 20.9 17.4 

371 371 MAJOR GASTROINTESTINAL DISORDERS & 

PERITONEAL INFECTIONS W MCC 949 0.9536 24.3 20.3 

372 371 MAJOR GASTROINTESTINAL DISORDERS & 

PERITONEAL INFECTIONS W CC 342 0.7254 22.0 18.3 

373 371 MAJOR GASTROINTESTINAL DISORDERS & 

PERITONEAL INFECTIONS W/O CC/MCC 31 0.5065 17.1 14.3 
CMS-1498-P 1145 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

374 374 DIGESTIVE MALIGNANCY W MCC 101 0.8268 21.0 17.5 

375 374 DIGESTIVE MALIGNANCY W CC 56 0.6770 21.3 17.8 

376 374 DIGESTIVE MALIGNANCY W/O CC/MCC 3 0.4878 18.1 15.1 

377 377 G.I. HEMORRHAGE W MCC 88 0.7978 22.5 18.8 

378 377 G.I. HEMORRHAGE W CC 43 0.6163 21.3 17.8 

379 377 G.I. HEMORRHAGE W/O CC/MCC 8 0.4878 18.1 15.1 

380 380 COMPLICATED PEPTIC ULCER W MCC 22 1.0834 28.9 24.1 

381 380 COMPLICATED PEPTIC ULCER W CC 17 0.8667 24.6 20.5 

382 380 COMPLICATED PEPTIC ULCER W/O CC/MCC 1 0.8667 24.6 20.5 

383 383 UNCOMPLICATED PEPTIC ULCER W MCC 9 0.4878 18.1 15.1 

384 383 UNCOMPLICATED PEPTIC ULCER W/O MCC* 5 0.4878 18.1 15.1 

385 385 INFLAMMATORY BOWEL DISEASE W MCC 32 0.9126 23.3 19.4 

386 385 INFLAMMATORY BOWEL DISEASE W CC 26 0.7394 25.5 21.3 

387 385 INFLAMMATORY BOWEL DISEASE W/O 

CC/MCC 2 0.4878 18.1 15.1 

388 388 G.I. OBSTRUCTION W MCC 218 0.9443 23.4 19.5 

389 388 G.I. OBSTRUCTION W CC 83 0.6325 19.8 16.5 

390 388 G.I. OBSTRUCTION W/O CC/MCC 10 0.4878 18.1 15.1 

391 391 ESOPHAGITIS, GASTROENT & MISC DIGEST 

DISORDERS W MCC 342 0.9298 23.1 19.3 

392 391 ESOPHAGITIS, GASTROENT & MISC DIGEST 

DISORDERS W/O MCC 194 0.6310 19.9 16.6 

393 393 OTHER DIGESTIVE SYSTEM DIAGNOSES W 

MCC 970 1.0710 25.8 21.5 

394 393 OTHER DIGESTIVE SYSTEM DIAGNOSES W 

CC 389 0.7560 21.8 18.2 

395 393 OTHER DIGESTIVE SYSTEM DIAGNOSES W/O 

CC/MCC 17 0.6280 20.9 17.4 

405 405 PANCREAS, LIVER & SHUNT PROCEDURES W 

MCC 17 1.6495 36.4 30.3 

406 405 PANCREAS, LIVER & SHUNT PROCEDURES W 

CC 2 1.0834 28.9 24.1 

407 405 PANCREAS, LIVER & SHUNT PROCEDURES 

W/O CC/MCC 0 0.6280 20.9 17.4 

408 408 BILIARY TRACT PROC EXCEPT ONLY 

CHOLECYST W OR W/O C.D.E. W MCC 1 1.6495 36.4 30.3 

409 408 BILIARY TRACT PROC EXCEPT ONLY 

CHOLECYST W OR W/O C.D.E. W CC 1 1.0834 28.9 24.1 

410 408 BILIARY TRACT PROC EXCEPT ONLY 

CHOLECYST W OR W/O C.D.E. W/O CC/MCC 0 0.6280 20.9 17.4 

411 411 CHOLECYSTECTOMY W C.D.E. W MCC 1 1.6495 36.4 30.3 

412 411 CHOLECYSTECTOMY W C.D.E. W CC 0 1.6495 36.4 30.3 

413 411 CHOLECYSTECTOMY W C.D.E. W/O CC/MCC 0 0.6280 20.9 17.4 

414 414 CHOLECYSTECTOMY EXCEPT BY 

LAPAROSCOPE W/O C.D.E. W MCC 0 1.6495 36.4 30.3 

415 414 CHOLECYSTECTOMY EXCEPT BY 

LAPAROSCOPE W/O C.D.E. W CC 0 1.6495 36.4 30.3 
CMS-1498-P 1146 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

416 414 CHOLECYSTECTOMY EXCEPT BY 

LAPAROSCOPE W/O C.D.E. W/O CC/MCC 1 1.6495 36.4 30.3 

417 417 LAPAROSCOPIC CHOLECYSTECTOMY W/O 

C.D.E. W MCC 10 1.6495 36.4 30.3 

418 417 LAPAROSCOPIC CHOLECYSTECTOMY W/O 

C.D.E. W CC 2 1.6495 36.4 30.3 

419 417 LAPAROSCOPIC CHOLECYSTECTOMY W/O 

C.D.E. W/O CC/MCC 1 0.6280 20.9 17.4 

420 420 HEPATOBILIARY DIAGNOSTIC PROCEDURES 

W MCC 0 1.6495 36.4 30.3 

421 420 HEPATOBILIARY DIAGNOSTIC PROCEDURES 

W CC 0 1.6495 36.4 30.3 

422 420 HEPATOBILIARY DIAGNOSTIC PROCEDURES 

W/O CC/MCC 0 1.6495 36.4 30.3 

423 423 OTHER HEPATOBILIARY OR PANCREAS O.R. 

PROCEDURES W MCC 17 1.6495 36.4 30.3 

424 423 OTHER HEPATOBILIARY OR PANCREAS O.R. 

PROCEDURES W CC 3 1.6495 36.4 30.3 

425 423 OTHER HEPATOBILIARY OR PANCREAS O.R. 

PROCEDURES W/O CC/MCC 0 1.6495 36.4 30.3 

432 432 CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC 80 0.6674 20.3 16.9 

433 432 CIRRHOSIS & ALCOHOLIC HEPATITIS W CC 11 0.6280 20.9 17.4 

434 432 CIRRHOSIS & ALCOHOLIC HEPATITIS W/O 

CC/MCC 0 0.6280 20.9 17.4 

435 435 MALIGNANCY OF HEPATOBILIARY SYSTEM 

OR PANCREAS W MCC 41 0.8842 20.1 16.8 

436 435 MALIGNANCY OF HEPATOBILIARY SYSTEM 

OR PANCREAS W CC 11 0.6280 20.9 17.4 

437 435 MALIGNANCY OF HEPATOBILIARY SYSTEM 

OR PANCREAS W/O CC/MCC 1 0.4878 18.1 15.1 

438 438 DISORDERS OF PANCREAS EXCEPT 

MALIGNANCY W MCC 310 1.0513 23.8 19.8 

439 438 DISORDERS OF PANCREAS EXCEPT 

MALIGNANCY W CC 122 0.7550 21.1 17.6 

440 438 DISORDERS OF PANCREAS EXCEPT 

MALIGNANCY W/O CC/MCC 13 0.4878 18.1 15.1 

441 441 DISORDERS OF LIVER EXCEPT 

MALIG,CIRR,ALC HEPA W MCC 228 0.8011 22.2 18.5 

442 441 DISORDERS OF LIVER EXCEPT 

MALIG,CIRR,ALC HEPA W CC* 72 0.7091 23.1 19.3 

443 441 DISORDERS OF LIVER EXCEPT 

MALIG,CIRR,ALC HEPA W/O CC/MCC 8 0.7091 23.1 19.3 

444 444 DISORDERS OF THE BILIARY TRACT W MCC 127 0.7728 21.5 17.9 

445 444 DISORDERS OF THE BILIARY TRACT W CC* 47 0.5847 20.7 17.3 

446 444 DISORDERS OF THE BILIARY TRACT W/O 

CC/MCC 12 0.5847 20.7 17.3 

453 453 COMBINED ANTERIOR/POSTERIOR SPINAL 

FUSION W MCC 0 1.6495 36.4 30.3 
CMS-1498-P 1147 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

454 453 COMBINED ANTERIOR/POSTERIOR SPINAL 

FUSION W CC 0 1.6495 36.4 30.3 

455 453 COMBINED ANTERIOR/POSTERIOR SPINAL 

FUSION W/O CC/MCC 0 1.0834 28.9 24.1 

456 456 SPINAL FUS EXC CERV W SPINAL 

CURV/MALIG/INFEC OR 9+ FUS W MCC 2 1.6495 36.4 30.3 

457 456 SPINAL FUS EXC CERV W SPINAL 

CURV/MALIG/INFEC OR 9+ FUS W CC 0 1.6495 36.4 30.3 

458 456 SPINAL FUS EXC CERV W SPINAL 

CURV/MALIG/INFEC OR 9+ FUS W/O CC/MCC 0 1.0834 28.9 24.1 

459 459 SPINAL FUSION EXCEPT CERVICAL W MCC 2 1.6495 36.4 30.3 

460 459 SPINAL FUSION EXCEPT CERVICAL W/O MCC 1 1.0834 28.9 24.1 

461 461 BILATERAL OR MULTIPLE MAJOR JOINT 

PROCS OF LOWER EXTREMITY W MCC 0 1.6495 36.4 30.3 

462 461 BILATERAL OR MULTIPLE MAJOR JOINT 

PROCS OF LOWER EXTREMITY W/O MCC 0 1.6495 36.4 30.3 

463 463 WND DEBRID & SKN GRFT EXC HAND, FOR 

MUSCULO-CONN TISS DIS W MCC 845 1.4194 39.1 32.6 

464 463 WND DEBRID & SKN GRFT EXC HAND, FOR 

MUSCULO-CONN TISS DIS W CC 306 1.0953 34.3 28.6 

465 463 WND DEBRID & SKN GRFT EXC HAND, FOR 

MUSCULO-CONN TISS DIS W/O CC/MCC 23 0.8667 24.6 20.5 

466 466 REVISION OF HIP OR KNEE REPLACEMENT W 

MCC 4 1.6495 36.4 30.3 

467 466 REVISION OF HIP OR KNEE REPLACEMENT W 

CC 1 0.8667 24.6 20.5 

468 466 REVISION OF HIP OR KNEE REPLACEMENT 

W/O CC/MCC* 0 0.8667 24.6 20.5 

469 469 MAJOR JOINT REPLACEMENT OR 

REATTACHMENT OF LOWER EXTREMITY W 

MCC 2 1.6495 36.4 30.3 

470 469 MAJOR JOINT REPLACEMENT OR 

REATTACHMENT OF LOWER EXTREMITY 

W/O MCC 2 1.6495 36.4 30.3 

471 471 CERVICAL SPINAL FUSION W MCC 0 1.0834 28.9 24.1 

472 471 CERVICAL SPINAL FUSION W CC 1 1.0834 28.9 24.1 

473 471 CERVICAL SPINAL FUSION W/O CC/MCC 0 1.0834 28.9 24.1 

474 474 AMPUTATION FOR MUSCULOSKELETAL SYS 

& CONN TISSUE DIS W MCC 140 1.3860 36.9 30.8 

475 474 AMPUTATION FOR MUSCULOSKELETAL SYS 

& CONN TISSUE DIS W CC 51 1.0993 34.1 28.4 

476 474 AMPUTATION FOR MUSCULOSKELETAL SYS 

& CONN TISSUE DIS W/O CC/MCC 4 0.6280 20.9 17.4 

477 477 BIOPSIES OF MUSCULOSKELETAL SYSTEM & 

CONNECTIVE TISSUE W MCC 32 1.3916 38.2 31.8 

478 477 BIOPSIES OF MUSCULOSKELETAL SYSTEM & 

CONNECTIVE TISSUE W CC 13 1.0834 28.9 24.1 

479 477 BIOPSIES OF MUSCULOSKELETAL SYSTEM & 

CONNECTIVE TISSUE W/O CC/MCC* 1 1.0834 28.9 24.1 
CMS-1498-P 1148 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

480 480 HIP & FEMUR PROCEDURES EXCEPT MAJOR 

JOINT W MCC* 13 1.6495 36.4 30.3 

481 480 HIP & FEMUR PROCEDURES EXCEPT MAJOR 

JOINT W CC 6 1.6495 36.4 30.3 

482 480 HIP & FEMUR PROCEDURES EXCEPT MAJOR 

JOINT W/O CC/MCC 1 1.6495 36.4 30.3 

483 483 MAJOR JOINT & LIMB REATTACHMENT 

PROC OF UPPER EXTREMITY W CC/MCC 0 1.6495 36.4 30.3 

484 483 MAJOR JOINT & LIMB REATTACHMENT 

PROC OF UPPER EXTREMITY W/O CC/MCC 0 1.6495 36.4 30.3 

485 485 KNEE PROCEDURES W PDX OF INFECTION W 

MCC 11 1.0834 28.9 24.1 

486 485 KNEE PROCEDURES W PDX OF INFECTION W 

CC 9 1.0834 28.9 24.1 

487 485 KNEE PROCEDURES W PDX OF INFECTION 

W/O CC/MCC 2 0.6280 20.9 17.4 

488 488 KNEE PROCEDURES W/O PDX OF INFECTION 

W CC/MCC 0 1.0834 28.9 24.1 

489 488 KNEE PROCEDURES W/O PDX OF INFECTION 

W/O CC/MCC 0 0.6280 20.9 17.4 

490 490 BACK & NECK PROC EXC SPINAL FUSION W 

CC/MCC OR DISC DEVICE/NEUROSTIM 9 1.0834 28.9 24.1 

491 490 BACK & NECK PROC EXC SPINAL FUSION 

W/O CC/MCC 2 0.4878 18.1 15.1 

492 492 LOWER EXTREM & HUMER PROC EXCEPT 

HIP,FOOT,FEMUR W MCC 11 1.6495 36.4 30.3 

493 492 LOWER EXTREM & HUMER PROC EXCEPT 

HIP,FOOT,FEMUR W CC 17 1.6495 36.4 30.3 

494 492 LOWER EXTREM & HUMER PROC EXCEPT 

HIP,FOOT,FEMUR W/O CC/MCC 1 0.8667 24.6 20.5 

495 495 LOCAL EXCISION & REMOVAL INT FIX 

DEVICES EXC HIP & FEMUR W MCC 81 1.4624 37.6 31.3 

496 495 LOCAL EXCISION & REMOVAL INT FIX 

DEVICES EXC HIP & FEMUR W CC 22 1.0834 28.9 24.1 

497 495 LOCAL EXCISION & REMOVAL INT FIX 

DEVICES EXC HIP & FEMUR W/O CC/MCC 1 1.0834 28.9 24.1 

498 498 LOCAL EXCISION & REMOVAL INT FIX 

DEVICES OF HIP & FEMUR W CC/MCC 18 1.6495 36.4 30.3 

499 498 LOCAL EXCISION & REMOVAL INT FIX 

DEVICES OF HIP & FEMUR W/O CC/MCC 1 0.8667 24.6 20.5 

500 500 SOFT TISSUE PROCEDURES W MCC 129 1.3544 36.4 30.3 

501 500 SOFT TISSUE PROCEDURES W CC 38 0.9664 30.7 25.6 

502 500 SOFT TISSUE PROCEDURES W/O CC/MCC 5 0.6280 20.9 17.4 

503 503 FOOT PROCEDURES W MCC* 33 1.0106 31.5 26.3 

504 503 FOOT PROCEDURES W CC 22 1.0106 31.5 26.3 

505 503 FOOT PROCEDURES W/O CC/MCC 2 1.0106 31.5 26.3 

506 506 MAJOR THUMB OR JOINT PROCEDURES 1 0.8667 24.6 20.5 

507 507 MAJOR SHOULDER OR ELBOW JOINT 

PROCEDURES W CC/MCC 2 1.6495 36.4 30.3 
CMS-1498-P 1149 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

508 507 MAJOR SHOULDER OR ELBOW JOINT 

PROCEDURES W/O CC/MCC 0 0.8667 24.6 20.5 

509 509 ARTHROSCOPY 2 1.6495 36.4 30.3 

510 510 SHOULDER,ELBOW OR FOREARM PROC,EXC 

MAJOR JOINT PROC W MCC 0 1.3468 31.7 26.4 

511 510 SHOULDER,ELBOW OR FOREARM PROC,EXC 

MAJOR JOINT PROC W CC 0 0.8667 24.6 20.5 

512 510 SHOULDER,ELBOW OR FOREARM PROC,EXC 

MAJOR JOINT PROC W/O CC/MCC 0 0.8667 24.6 20.5 

513 513 HAND OR WRIST PROC, EXCEPT MAJOR 

THUMB OR JOINT PROC W CC/MCC 8 1.0834 28.9 24.1 

514 513 HAND OR WRIST PROC, EXCEPT MAJOR 

THUMB OR JOINT PROC W/O CC/MCC 0 0.8667 24.6 20.5 

515 515 OTHER MUSCULOSKELET SYS & CONN TISS 

O.R. PROC W MCC 83 1.3468 31.7 26.4 

516 515 OTHER MUSCULOSKELET SYS & CONN TISS 

O.R. PROC W CC 23 0.8667 24.6 20.5 

517 515 OTHER MUSCULOSKELET SYS & CONN TISS 

O.R. PROC W/O CC/MCC* 5 0.8667 24.6 20.5 

533 533 FRACTURES OF FEMUR W MCC 3 1.0834 28.9 24.1 

534 533 FRACTURES OF FEMUR W/O MCC 1 1.0834 28.9 24.1 

535 535 FRACTURES OF HIP & PELVIS W MCC 26 0.7420 25.4 21.2 

536 535 FRACTURES OF HIP & PELVIS W/O MCC 13 0.6280 20.9 17.4 

537 537 SPRAINS, STRAINS, & DISLOCATIONS OF HIP, 

PELVIS & THIGH W CC/MCC 1 0.4878 18.1 15.1 

538 537 SPRAINS, STRAINS, & DISLOCATIONS OF HIP, 

PELVIS & THIGH W/O CC/MCC 0 0.4878 18.1 15.1 

539 539 OSTEOMYELITIS W MCC 1,932 1.0093 30.7 25.6 

540 539 OSTEOMYELITIS W CC 962 0.7936 27.5 22.9 

541 539 OSTEOMYELITIS W/O CC/MCC 148 0.6821 24.4 20.3 

542 542 PATHOLOGICAL FRACTURES & 

MUSCULOSKELET & CONN TISS MALIG W 

MCC 37 0.9292 21.9 18.3 

543 542 PATHOLOGICAL FRACTURES & 

MUSCULOSKELET & CONN TISS MALIG W CC 25 0.6938 22.1 18.4 

544 542 PATHOLOGICAL FRACTURES & 

MUSCULOSKELET & CONN TISS MALIG W/O 

CC/MCC 4 0.6280 20.9 17.4 

545 545 CONNECTIVE TISSUE DISORDERS W MCC 61 0.8812 21.8 18.2 

546 545 CONNECTIVE TISSUE DISORDERS W CC 47 0.7162 24.1 20.1 

547 545 CONNECTIVE TISSUE DISORDERS W/O 

CC/MCC 2 0.4878 18.1 15.1 

548 548 SEPTIC ARTHRITIS W MCC 260 0.9215 27.2 22.7 

549 548 SEPTIC ARTHRITIS W CC 214 0.7472 26.6 22.2 

550 548 SEPTIC ARTHRITIS W/O CC/MCC 39 0.5739 25.1 20.9 

551 551 MEDICAL BACK PROBLEMS W MCC 130 0.9177 26.4 22.0 

552 551 MEDICAL BACK PROBLEMS W/O MCC 116 0.5946 21.7 18.1 

553 553 BONE DISEASES & ARTHROPATHIES W MCC 6 0.4878 18.1 15.1 
CMS-1498-P 1150 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

554 553 BONE DISEASES & ARTHROPATHIES W/O 

MCC* 17 0.4878 18.1 15.1 

555 555 SIGNS & SYMPTOMS OF MUSCULOSKELETAL 

SYSTEM & CONN TISSUE W MCC* 15 0.6280 20.9 17.4 

556 555 SIGNS & SYMPTOMS OF MUSCULOSKELETAL 

SYSTEM & CONN TISSUE W/O MCC 12 0.6280 20.9 17.4 

557 557 TENDONITIS, MYOSITIS & BURSITIS W MCC 114 0.8794 26.1 21.8 

558 557 TENDONITIS, MYOSITIS & BURSITIS W/O 

MCC 109 0.6295 21.9 18.3 

559 559 AFTERCARE, MUSCULOSKELETAL SYSTEM 

& CONNECTIVE TISSUE W MCC 1,722 0.8472 25.6 21.3 

560 559 AFTERCARE, MUSCULOSKELETAL SYSTEM 

& CONNECTIVE TISSUE W CC 1,411 0.6950 24.9 20.8 

561 559 AFTERCARE, MUSCULOSKELETAL SYSTEM 

& CONNECTIVE TISSUE W/O CC/MCC 243 0.5788 23.0 19.2 

562 562 FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, 

PELVIS & THIGH W MCC 13 0.8667 24.6 20.5 

563 562 FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, 

PELVIS & THIGH W/O MCC 14 0.8667 24.6 20.5 

564 564 OTHER MUSCULOSKELETAL SYS & 

CONNECTIVE TISSUE DIAGNOSES W MCC 384 0.8675 23.5 19.6 

565 564 OTHER MUSCULOSKELETAL SYS & 

CONNECTIVE TISSUE DIAGNOSES W CC 207 0.6727 22.6 18.8 

566 564 OTHER MUSCULOSKELETAL SYS & 

CONNECTIVE TISSUE DIAGNOSES W/O 

CC/MCC 25 0.5464 19.5 16.3 

573 573 SKIN GRAFT &/OR DEBRID FOR SKN ULCER 

OR CELLULITIS W MCC 1,862 1.3702 38.2 31.8 

574 573 SKIN GRAFT &/OR DEBRID FOR SKN ULCER 

OR CELLULITIS W CC 1,163 1.0312 34.5 28.8 

575 573 SKIN GRAFT &/OR DEBRID FOR SKN ULCER 

OR CELLULITIS W/O CC/MCC 77 0.7628 28.0 23.3 

576 576 SKIN GRAFT &/OR DEBRID EXC FOR SKIN 

ULCER OR CELLULITIS W MCC 44 1.4531 38.4 32.0 

577 576 SKIN GRAFT &/OR DEBRID EXC FOR SKIN 

ULCER OR CELLULITIS W CC 26 0.9545 30.8 25.7 

578 576 SKIN GRAFT &/OR DEBRID EXC FOR SKIN 

ULCER OR CELLULITIS W/O CC/MCC 3 0.4878 18.1 15.1 

579 579 OTHER SKIN, SUBCUT TISS & BREAST PROC 

W MCC 626 1.3095 35.4 29.5 

580 579 OTHER SKIN, SUBCUT TISS & BREAST PROC 

W CC 315 0.9380 31.5 26.3 

581 579 OTHER SKIN, SUBCUT TISS & BREAST PROC 

W/O CC/MCC 12 0.8667 24.6 20.5 

582 582 MASTECTOMY FOR MALIGNANCY W 

CC/MCC 0 1.6495 36.4 30.3 

583 582 MASTECTOMY FOR MALIGNANCY W/O 

CC/MCC 0 0.5998 20.1 16.8 
CMS-1498-P 1151 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

584 584 BREAST BIOPSY, LOCAL EXCISION & OTHER 

BREAST PROCEDURES W CC/MCC 4 0.6280 20.9 17.4 

585 584 BREAST BIOPSY, LOCAL EXCISION & OTHER 

BREAST PROCEDURES W/O CC/MCC 0 0.6016 22.3 18.6 

592 592 SKIN ULCERS W MCC 3,450 0.9187 26.5 22.1 

593 592 SKIN ULCERS W CC 2,181 0.6858 25.1 20.9 

594 592 SKIN ULCERS W/O CC/MCC 151 0.5644 23.1 19.3 

595 595 MAJOR SKIN DISORDERS W MCC 48 0.9095 24.7 20.6 

596 595 MAJOR SKIN DISORDERS W/O MCC 33 0.5998 20.1 16.8 

597 597 MALIGNANT BREAST DISORDERS W MCC 15 1.6495 36.4 30.3 

598 597 MALIGNANT BREAST DISORDERS W CC 11 0.6280 20.9 17.4 

599 597 MALIGNANT BREAST DISORDERS W/O 

CC/MCC 0 0.4878 18.1 15.1 

600 600 NON-MALIGNANT BREAST DISORDERS W 

CC/MCC 29 0.6625 24.0 20.0 

601 600 NON-MALIGNANT BREAST DISORDERS W/O 

CC/MCC 5 0.4878 18.1 15.1 

602 602 CELLULITIS W MCC 1,133 0.7276 22.1 18.4 

603 602 CELLULITIS W/O MCC 1,519 0.5291 19.1 15.9 

604 604 TRAUMA TO THE SKIN, SUBCUT TISS & 

BREAST W MCC 37 0.6494 23.4 19.5 

605 604 TRAUMA TO THE SKIN, SUBCUT TISS & 

BREAST W/O MCC 50 0.6016 22.3 18.6 

606 606 MINOR SKIN DISORDERS W MCC 94 0.8380 22.8 19.0 

607 606 MINOR SKIN DISORDERS W/O MCC 98 0.5684 20.2 16.8 

614 614 ADRENAL & PITUITARY PROCEDURES W 

CC/MCC 0 0.9743 28.6 23.8 

615 614 ADRENAL & PITUITARY PROCEDURES W/O 

CC/MCC 0 0.8667 24.6 20.5 

616 616 AMPUTAT OF LOWER LIMB FOR 

ENDOCRINE,NUTRIT,& METABOL DIS W MCC 104 1.5785 39.7 33.1 

617 616 AMPUTAT OF LOWER LIMB FOR 

ENDOCRINE,NUTRIT,& METABOL DIS W CC 115 1.0153 31.1 25.9 

618 616 AMPUTAT OF LOWER LIMB FOR 

ENDOCRINE,NUTRIT,& METABOL DIS W/O 

CC/MCC 0 1.0153 31.1 25.9 

619 619 O.R. PROCEDURES FOR OBESITY W MCC 3 1.0834 28.9 24.1 

620 619 O.R. PROCEDURES FOR OBESITY W CC 0 1.0834 28.9 24.1 

621 619 O.R. PROCEDURES FOR OBESITY W/O 

CC/MCC 0 1.0834 28.9 24.1 

622 622 SKIN GRAFTS & WOUND DEBRID FOR 

ENDOC, NUTRIT & METAB DIS W MCC 261 1.2544 35.9 29.9 

623 622 SKIN GRAFTS & WOUND DEBRID FOR 

ENDOC, NUTRIT & METAB DIS W CC 352 0.9977 30.8 25.7 

624 622 SKIN GRAFTS & WOUND DEBRID FOR 

ENDOC, NUTRIT & METAB DIS W/O CC/MCC 9 0.6280 20.9 17.4 

625 625 THYROID, PARATHYROID & THYROGLOSSAL 

PROCEDURES W MCC 1 0.6280 20.9 17.4 
CMS-1498-P 1152 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

626 625 THYROID, PARATHYROID & THYROGLOSSAL 

PROCEDURES W CC* 0 0.6280 20.9 17.4 

627 625 THYROID, PARATHYROID & THYROGLOSSAL 

PROCEDURES W/O CC/MCC* 0 0.6280 20.9 17.4 

628 628 OTHER ENDOCRINE, NUTRIT & METAB O.R. 

PROC W MCC 68 1.2313 32.7 27.3 

629 628 OTHER ENDOCRINE, NUTRIT & METAB O.R. 

PROC W CC 108 0.9743 28.6 23.8 

630 628 OTHER ENDOCRINE, NUTRIT & METAB O.R. 

PROC W/O CC/MCC 3 0.8667 24.6 20.5 

637 637 DIABETES W MCC 687 0.8949 26.2 21.8 

638 637 DIABETES W CC 1,035 0.7071 23.4 19.5 

639 637 DIABETES W/O CC/MCC 32 0.4679 20.0 16.7 

640 640 NUTRITIONAL & MISC METABOLIC 

DISORDERS W MCC 678 0.8741 23.1 19.3 

641 640 NUTRITIONAL & MISC METABOLIC 

DISORDERS W/O MCC 465 0.6222 20.6 17.2 

642 642 INBORN ERRORS OF METABOLISM 5 1.0834 28.9 24.1 

643 643 ENDOCRINE DISORDERS W MCC 17 0.6280 20.9 17.4 

644 643 ENDOCRINE DISORDERS W CC 18 0.6280 20.9 17.4 

645 643 ENDOCRINE DISORDERS W/O CC/MCC 4 0.4878 18.1 15.1 

652 652 KIDNEY TRANSPLANT 0 0.0000 0.0 0.0 

653 653 MAJOR BLADDER PROCEDURES W MCC 1 1.6495 36.4 30.3 

654 653 MAJOR BLADDER PROCEDURES W CC 0 1.0834 28.9 24.1 

655 653 MAJOR BLADDER PROCEDURES W/O CC/MCC 0 1.0834 28.9 24.1 

656 656 KIDNEY & URETER PROCEDURES FOR 

NEOPLASM W MCC 1 0.4878 18.1 15.1 

657 656 KIDNEY & URETER PROCEDURES FOR 

NEOPLASM W CC 0 0.4878 18.1 15.1 

658 656 KIDNEY & URETER PROCEDURES FOR 

NEOPLASM W/O CC/MCC 0 0.4878 18.1 15.1 

659 659 KIDNEY & URETER PROCEDURES FOR NONNEOPLASM W MCC* 4 1.0834 28.9 24.1 

660 659 KIDNEY & URETER PROCEDURES FOR NONNEOPLASM W CC 4 1.0834 28.9 24.1 

661 659 KIDNEY & URETER PROCEDURES FOR NONNEOPLASM W/O CC/MCC 0 1.0834 28.9 24.1 

662 662 MINOR BLADDER PROCEDURES W MCC 0 1.0834 28.9 24.1 

663 662 MINOR BLADDER PROCEDURES W CC 1 1.0834 28.9 24.1 

664 662 MINOR BLADDER PROCEDURES W/O CC/MCC 0 1.0834 28.9 24.1 

665 665 PROSTATECTOMY W MCC 2 1.0834 28.9 24.1 

666 665 PROSTATECTOMY W CC 0 1.0834 28.9 24.1 

667 665 PROSTATECTOMY W/O CC/MCC 0 1.0834 28.9 24.1 

668 668 TRANSURETHRAL PROCEDURES W MCC 9 1.0834 28.9 24.1 

669 668 TRANSURETHRAL PROCEDURES W CC 1 0.6280 20.9 17.4 

670 668 TRANSURETHRAL PROCEDURES W/O 

CC/MCC 0 0.6280 20.9 17.4 

671 671 URETHRAL PROCEDURES W CC/MCC 3 0.8667 24.6 20.5 
CMS-1498-P 1153 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

672 671 URETHRAL PROCEDURES W/O CC/MCC 0 0.8667 24.6 20.5 

673 673 OTHER KIDNEY & URINARY TRACT 

PROCEDURES W MCC 212 1.3836 32.9 27.4 

674 673 OTHER KIDNEY & URINARY TRACT 

PROCEDURES W CC 44 0.9783 27.9 23.3 

675 673 OTHER KIDNEY & URINARY TRACT 

PROCEDURES W/O CC/MCC 3 0.8667 24.6 20.5 

682 682 RENAL FAILURE W MCC 1,584 0.9085 23.1 19.3 

683 682 RENAL FAILURE W CC 538 0.6892 21.0 17.5 

684 682 RENAL FAILURE W/O CC/MCC 28 0.6199 17.1 14.3 

685 685 ADMIT FOR RENAL DIALYSIS 1 1.0834 28.9 24.1 

686 686 KIDNEY & URINARY TRACT NEOPLASMS W 

MCC 15 0.8667 24.6 20.5 

687 686 KIDNEY & URINARY TRACT NEOPLASMS W 

CC 14 0.6280 20.9 17.4 

688 686 KIDNEY & URINARY TRACT NEOPLASMS 

W/O CC/MCC 0 0.6280 20.9 17.4 

689 689 KIDNEY & URINARY TRACT INFECTIONS W 

MCC 942 0.6715 21.7 18.1 

690 689 KIDNEY & URINARY TRACT INFECTIONS 

W/O MCC 682 0.5198 19.3 16.1 

691 691 URINARY STONES W ESW LITHOTRIPSY W 

CC/MCC 0 0.8667 24.6 20.5 

692 691 URINARY STONES W ESW LITHOTRIPSY W/O 

CC/MCC 0 0.4878 18.1 15.1 

693 693 URINARY STONES W/O ESW LITHOTRIPSY W 

MCC 11 0.8667 24.6 20.5 

694 693 URINARY STONES W/O ESW LITHOTRIPSY 

W/O MCC 1 0.4878 18.1 15.1 

695 695 KIDNEY & URINARY TRACT SIGNS & 

SYMPTOMS W MCC 5 0.8667 24.6 20.5 

696 695 KIDNEY & URINARY TRACT SIGNS & 

SYMPTOMS W/O MCC 4 0.4878 18.1 15.1 

697 697 URETHRAL STRICTURE 1 0.8667 24.6 20.5 

698 698 OTHER KIDNEY & URINARY TRACT 

DIAGNOSES W MCC 345 0.8846 22.9 19.1 

699 698 OTHER KIDNEY & URINARY TRACT 

DIAGNOSES W CC 134 0.6313 20.2 16.8 

700 698 OTHER KIDNEY & URINARY TRACT 

DIAGNOSES W/O CC/MCC 11 0.6280 20.9 17.4 

707 707 MAJOR MALE PELVIC PROCEDURES W 

CC/MCC 0 1.0834 28.9 24.1 

708 707 MAJOR MALE PELVIC PROCEDURES W/O 

CC/MCC 0 1.0834 28.9 24.1 

709 709 PENIS PROCEDURES W CC/MCC 5 1.0834 28.9 24.1 

710 709 PENIS PROCEDURES W/O CC/MCC 1 0.6280 20.9 17.4 

711 711 TESTES PROCEDURES W CC/MCC 5 1.0834 28.9 24.1 

712 711 TESTES PROCEDURES W/O CC/MCC 0 1.0834 28.9 24.1 
CMS-1498-P 1154 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

713 713 TRANSURETHRAL PROSTATECTOMY W 

CC/MCC 4 0.8667 24.6 20.5 

714 713 TRANSURETHRAL PROSTATECTOMY W/O 

CC/MCC 0 0.6280 20.9 17.4 

715 715 OTHER MALE REPRODUCTIVE SYSTEM O.R. 

PROC FOR MALIGNANCY W CC/MCC 0 1.6495 36.4 30.3 

716 715 OTHER MALE REPRODUCTIVE SYSTEM O.R. 

PROC FOR MALIGNANCY W/O CC/MCC 0 1.0834 28.9 24.1 

717 717 OTHER MALE REPRODUCTIVE SYSTEM O.R. 

PROC EXC MALIGNANCY W CC/MCC 11 1.6495 36.4 30.3 

718 717 OTHER MALE REPRODUCTIVE SYSTEM O.R. 

PROC EXC MALIGNANCY W/O CC/MCC 1 1.0834 28.9 24.1 

722 722 MALIGNANCY, MALE REPRODUCTIVE 

SYSTEM W MCC 8 1.0834 28.9 24.1 

723 722 MALIGNANCY, MALE REPRODUCTIVE 

SYSTEM W CC 9 0.6280 20.9 17.4 

724 722 MALIGNANCY, MALE REPRODUCTIVE 

SYSTEM W/O CC/MCC 0 0.6280 20.9 17.4 

725 725 BENIGN PROSTATIC HYPERTROPHY W MCC 2 1.6495 36.4 30.3 

726 725 BENIGN PROSTATIC HYPERTROPHY W/O 

MCC 1 0.8667 24.6 20.5 

727 727 INFLAMMATION OF THE MALE 

REPRODUCTIVE SYSTEM W MCC 75 0.8106 22.6 18.8 

728 727 INFLAMMATION OF THE MALE 

REPRODUCTIVE SYSTEM W/O MCC 57 0.5026 17.3 14.4 

729 729 OTHER MALE REPRODUCTIVE SYSTEM 

DIAGNOSES W CC/MCC 68 0.8981 26.5 22.1 

730 729 OTHER MALE REPRODUCTIVE SYSTEM 

DIAGNOSES W/O CC/MCC 3 0.4878 18.1 15.1 

734 734 PELVIC EVISCERATION, RAD 

HYSTERECTOMY & RAD VULVECTOMY W 

CC/MCC 0 1.0834 28.9 24.1 

735 734 PELVIC EVISCERATION, RAD 

HYSTERECTOMY & RAD VULVECTOMY W/O 

CC/MCC 0 1.0834 28.9 24.1 

736 736 UTERINE & ADNEXA PROC FOR OVARIAN OR 

ADNEXAL MALIGNANCY W MCC 0 1.0834 28.9 24.1 

737 736 UTERINE & ADNEXA PROC FOR OVARIAN OR 

ADNEXAL MALIGNANCY W CC 0 0.6280 20.9 17.4 

738 736 UTERINE & ADNEXA PROC FOR OVARIAN OR 

ADNEXAL MALIGNANCY W/O CC/MCC 0 0.6280 20.9 17.4 

739 739 UTERINE,ADNEXA PROC FOR NONOVARIAN/ADNEXAL MALIG W MCC 0 1.2313 32.7 27.3 

740 739 UTERINE,ADNEXA PROC FOR NONOVARIAN/ADNEXAL MALIG W CC* 0 0.9743 28.6 23.8 

741 739 UTERINE,ADNEXA PROC FOR NONOVARIAN/ADNEXAL MALIG W/O CC/MCC 0 0.8667 24.6 20.5 

742 742 UTERINE & ADNEXA PROC FOR NONMALIGNANCY W CC/MCC* 0 0.9743 28.6 23.8 
CMS-1498-P 1155 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

743 742 UTERINE & ADNEXA PROC FOR NONMALIGNANCY W/O CC/MCC 0 0.8667 24.6 20.5 

744 744 D&C, CONIZATION, LAPAROSCOPY & TUBAL 

INTERRUPTION W CC/MCC 0 1.0834 28.9 24.1 

745 744 D&C, CONIZATION, LAPAROSCOPY & TUBAL 

INTERRUPTION W/O CC/MCC 0 1.0834 28.9 24.1 

746 746 VAGINA, CERVIX & VULVA PROCEDURES W 

CC/MCC 4 1.0834 28.9 24.1 

747 746 VAGINA, CERVIX & VULVA PROCEDURES 

W/O CC/MCC 0 1.0834 28.9 24.1 

748 748 FEMALE REPRODUCTIVE SYSTEM 

RECONSTRUCTIVE PROCEDURES 0 1.0834 28.9 24.1 

749 749 OTHER FEMALE REPRODUCTIVE SYSTEM 

O.R. PROCEDURES W CC/MCC 7 1.0834 28.9 24.1 

750 749 OTHER FEMALE REPRODUCTIVE SYSTEM 

O.R. PROCEDURES W/O CC/MCC 0 1.0834 28.9 24.1 

754 754 MALIGNANCY, FEMALE REPRODUCTIVE 

SYSTEM W MCC 17 1.0834 28.9 24.1 

755 754 MALIGNANCY, FEMALE REPRODUCTIVE 

SYSTEM W CC 11 0.6280 20.9 17.4 

756 754 MALIGNANCY, FEMALE REPRODUCTIVE 

SYSTEM W/O CC/MCC* 0 0.6279 20.9 17.4 

757 757 INFECTIONS, FEMALE REPRODUCTIVE 

SYSTEM W MCC 72 0.7744 24.6 20.5 

758 757 INFECTIONS, FEMALE REPRODUCTIVE 

SYSTEM W CC 40 0.6839 23.9 19.9 

759 757 INFECTIONS, FEMALE REPRODUCTIVE 

SYSTEM W/O CC/MCC 7 0.4878 18.1 15.1 

760 760 MENSTRUAL & OTHER FEMALE 

REPRODUCTIVE SYSTEM DISORDERS W 

CC/MCC* 4 0.8667 24.6 20.5 

761 760 MENSTRUAL & OTHER FEMALE 

REPRODUCTIVE SYSTEM DISORDERS W/O 

CC/MCC* 2 0.8667 24.6 20.5 

765 765 CESAREAN SECTION W CC/MCC 0 1.0834 28.9 24.1 

766 765 CESAREAN SECTION W/O CC/MCC 0 1.0834 28.9 24.1 

767 767 VAGINAL DELIVERY W STERILIZATION &/OR 

D&C 0 1.0834 28.9 24.1 

768 768 VAGINAL DELIVERY W O.R. PROC EXCEPT 

STERIL &/OR D&C 0 1.0834 28.9 24.1 

769 769 POSTPARTUM & POST ABORTION 

DIAGNOSES W O.R. PROCEDURE 2 1.6495 36.4 30.3 

770 770 ABORTION W D&C, ASPIRATION CURETTAGE 

OR HYSTEROTOMY 0 1.0834 28.9 24.1 

774 774 VAGINAL DELIVERY W COMPLICATING 

DIAGNOSES 0 1.0834 28.9 24.1 

775 775 VAGINAL DELIVERY W/O COMPLICATING 

DIAGNOSES 0 1.0834 28.9 24.1 
CMS-1498-P 1156 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

776 776 POSTPARTUM & POST ABORTION 

DIAGNOSES W/O O.R. PROCEDURE 1 0.6280 20.9 17.4 

777 777 ECTOPIC PREGNANCY 0 0.6280 20.9 17.4 

778 778 THREATENED ABORTION 0 0.6280 20.9 17.4 

779 779 ABORTION W/O D&C 0 0.6280 20.9 17.4 

780 780 FALSE LABOR 0 0.6280 20.9 17.4 

781 781 OTHER ANTEPARTUM DIAGNOSES W 

MEDICAL COMPLICATIONS 3 0.4878 18.1 15.1 

782 782 OTHER ANTEPARTUM DIAGNOSES W/O 

MEDICAL COMPLICATIONS 0 0.4878 18.1 15.1 

789 789 NEONATES, DIED OR TRANSFERRED TO 

ANOTHER ACUTE CARE FACILITY 0 0.4878 18.1 15.1 

790 790 EXTREME IMMATURITY OR RESPIRATORY 

DISTRESS SYNDROME, NEONATE 0 0.4878 18.1 15.1 

791 791 PREMATURITY W MAJOR PROBLEMS 0 0.4878 18.1 15.1 

792 792 PREMATURITY W/O MAJOR PROBLEMS 0 0.4878 18.1 15.1 

793 793 FULL TERM NEONATE W MAJOR PROBLEMS 0 0.4878 18.1 15.1 

794 794 NEONATE W OTHER SIGNIFICANT 

PROBLEMS 0 0.4878 18.1 15.1 

795 795 NORMAL NEWBORN 0 0.4878 18.1 15.1 

799 799 SPLENECTOMY W MCC 0 1.0834 28.9 24.1 

800 799 SPLENECTOMY W CC 0 1.0834 28.9 24.1 

801 799 SPLENECTOMY W/O CC/MCC 0 1.0834 28.9 24.1 

802 802 OTHER O.R. PROC OF THE BLOOD & BLOOD 

FORMING ORGANS W MCC 1 1.0834 28.9 24.1 

803 802 OTHER O.R. PROC OF THE BLOOD & BLOOD 

FORMING ORGANS W CC 0 1.0834 28.9 24.1 

804 802 OTHER O.R. PROC OF THE BLOOD & BLOOD 

FORMING ORGANS W/O CC/MCC 0 1.0834 28.9 24.1 

808 808 MAJOR HEMATOL/IMMUN DIAG EXC SICKLE 

CELL CRISIS & COAGUL W MCC 12 0.8667 24.6 20.5 

809 808 MAJOR HEMATOL/IMMUN DIAG EXC SICKLE 

CELL CRISIS & COAGUL W CC 14 0.6280 20.9 17.4 

810 808 MAJOR HEMATOL/IMMUN DIAG EXC SICKLE 

CELL CRISIS & COAGUL W/O CC/MCC 0 0.5578 19.4 16.2 

811 811 RED BLOOD CELL DISORDERS W MCC 65 0.8441 21.1 17.6 

812 811 RED BLOOD CELL DISORDERS W/O MCC 38 0.5578 19.4 16.2 

813 813 COAGULATION DISORDERS 35 0.7443 20.8 17.3 

814 814 RETICULOENDOTHELIAL & IMMUNITY 

DISORDERS W MCC 29 0.8803 24.8 20.7 

815 814 RETICULOENDOTHELIAL & IMMUNITY 

DISORDERS W CC 14 0.6280 20.9 17.4 

816 814 RETICULOENDOTHELIAL & IMMUNITY 

DISORDERS W/O CC/MCC 0 0.6280 20.9 17.4 

820 820 LYMPHOMA & LEUKEMIA W MAJOR O.R. 

PROCEDURE W MCC 0 0.4878 18.1 15.1 

821 820 LYMPHOMA & LEUKEMIA W MAJOR O.R. 

PROCEDURE W CC 1 0.4878 18.1 15.1 
CMS-1498-P 1157 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

822 820 LYMPHOMA & LEUKEMIA W MAJOR O.R. 

PROCEDURE W/O CC/MCC 0 0.4878 18.1 15.1 

823 823 LYMPHOMA & NON-ACUTE LEUKEMIA W 

OTHER O.R. PROC W MCC 3 1.6495 36.4 30.3 

824 823 LYMPHOMA & NON-ACUTE LEUKEMIA W 

OTHER O.R. PROC W CC 1 0.4878 18.1 15.1 

825 823 LYMPHOMA & NON-ACUTE LEUKEMIA W 

OTHER O.R. PROC W/O CC/MCC 0 0.4878 18.1 15.1 

826 826 MYELOPROLIF DISORD OR POORLY DIFF 

NEOPL W MAJ O.R. PROC W MCC 0 0.8667 24.6 20.5 

827 826 MYELOPROLIF DISORD OR POORLY DIFF 

NEOPL W MAJ O.R. PROC W CC 1 0.8667 24.6 20.5 

828 826 MYELOPROLIF DISORD OR POORLY DIFF 

NEOPL W MAJ O.R. PROC W/O CC/MCC 0 0.8667 24.6 20.5 

829 829 MYELOPROLIF DISORD OR POORLY DIFF 

NEOPL W OTHER O.R. PROC W CC/MCC 7 1.6495 36.4 30.3 

830 829 MYELOPROLIF DISORD OR POORLY DIFF 

NEOPL W OTHER O.R. PROC W/O CC/MCC 0 1.6495 36.4 30.3 

834 834 ACUTE LEUKEMIA W/O MAJOR O.R. 

PROCEDURE W MCC 22 0.8667 24.6 20.5 

835 834 ACUTE LEUKEMIA W/O MAJOR O.R. 

PROCEDURE W CC 12 0.8667 24.6 20.5 

836 834 ACUTE LEUKEMIA W/O MAJOR O.R. 

PROCEDURE W/O CC/MCC 1 0.6280 20.9 17.4 

837 837 CHEMO W ACUTE LEUKEMIA AS SDX OR W 

HIGH DOSE CHEMO AGENT W MCC 0 1.3820 29.1 24.3 

838 837 CHEMO W ACUTE LEUKEMIA AS SDX W CC 

OR HIGH DOSE CHEMO AGENT 0 1.3026 28.6 23.8 

839 837 CHEMO W ACUTE LEUKEMIA AS SDX W/O 

CC/MCC 0 1.3026 28.6 23.8 

840 840 LYMPHOMA & NON-ACUTE LEUKEMIA W 

MCC 91 0.8901 22.1 18.4 

841 840 LYMPHOMA & NON-ACUTE LEUKEMIA W CC 38 0.6737 18.8 15.7 

842 840 LYMPHOMA & NON-ACUTE LEUKEMIA W/O 

CC/MCC 4 0.4878 18.1 15.1 

843 843 OTHER MYELOPROLIF DIS OR POORLY DIFF 

NEOPL DIAG W MCC 7 0.8667 24.6 20.5 

844 843 OTHER MYELOPROLIF DIS OR POORLY DIFF 

NEOPL DIAG W CC 7 0.8667 24.6 20.5 

845 843 OTHER MYELOPROLIF DIS OR POORLY DIFF 

NEOPL DIAG W/O CC/MCC 1 0.4878 18.1 15.1 

846 846 CHEMOTHERAPY W/O ACUTE LEUKEMIA AS 

SECONDARY DIAGNOSIS W MCC 57 1.3820 29.1 24.3 

847 846 CHEMOTHERAPY W/O ACUTE LEUKEMIA AS 

SECONDARY DIAGNOSIS W CC 54 1.3026 28.6 23.8 

848 846 CHEMOTHERAPY W/O ACUTE LEUKEMIA AS 

SECONDARY DIAGNOSIS W/O CC/MCC 0 1.3026 28.6 23.8 

849 849 RADIOTHERAPY 119 0.7730 22.7 18.9 
CMS-1498-P 1158 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

853 853 INFECTIOUS & PARASITIC DISEASES W O.R. 

PROCEDURE W MCC 1,059 1.7413 37.6 31.3 

854 853 INFECTIOUS & PARASITIC DISEASES W O.R. 

PROCEDURE W CC 96 1.1085 30.2 25.2 

855 853 INFECTIOUS & PARASITIC DISEASES W O.R. 

PROCEDURE W/O CC/MCC 2 0.8667 24.6 20.5 

856 856 POSTOPERATIVE OR POST-TRAUMATIC 

INFECTIONS W O.R. PROC W MCC 361 1.4571 34.1 28.4 

857 856 POSTOPERATIVE OR POST-TRAUMATIC 

INFECTIONS W O.R. PROC W CC 194 1.0415 30.5 25.4 

858 856 POSTOPERATIVE OR POST-TRAUMATIC 

INFECTIONS W O.R. PROC W/O CC/MCC 10 0.8667 24.6 20.5 

862 862 POSTOPERATIVE & POST-TRAUMATIC 

INFECTIONS W MCC 1,722 0.9661 25.3 21.1 

863 862 POSTOPERATIVE & POST-TRAUMATIC 

INFECTIONS W/O MCC 1,019 0.6984 23.0 19.2 

864 864 FEVER 3 0.4878 18.1 15.1 

865 865 VIRAL ILLNESS W MCC 26 0.8013 21.3 17.8 

866 865 VIRAL ILLNESS W/O MCC* 13 0.8013 21.3 17.8 

867 867 OTHER INFECTIOUS & PARASITIC DISEASES 

DIAGNOSES W MCC 450 1.0443 23.7 19.8 

868 867 OTHER INFECTIOUS & PARASITIC DISEASES 

DIAGNOSES W CC 64 0.6882 19.5 16.3 

869 867 OTHER INFECTIOUS & PARASITIC DISEASES 

DIAGNOSES W/O CC/MCC 2 0.4878 18.1 15.1 

870 870 SEPTICEMIA OR SEVERE SEPSIS W MV 96+ 

HOURS 1,282 2.1404 31.7 26.4 

871 871 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ 

HOURS W MCC 5,885 0.8725 23.1 19.3 

872 871 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ 

HOURS W/O MCC 1,275 0.6255 20.3 16.9 

876 876 O.R. PROCEDURE W PRINCIPAL DIAGNOSES 

OF MENTAL ILLNESS 3 1.6495 36.4 30.3 

880 880 ACUTE ADJUSTMENT REACTION & 

PSYCHOSOCIAL DYSFUNCTION 9 0.6280 20.9 17.4 

881 881 DEPRESSIVE NEUROSES 34 0.3912 21.9 18.3 

882 882 NEUROSES EXCEPT DEPRESSIVE 10 0.4878 18.1 15.1 

883 883 DISORDERS OF PERSONALITY & IMPULSE 

CONTROL 7 0.6280 20.9 17.4 

884 884 ORGANIC DISTURBANCES & MENTAL 

RETARDATION 76 0.5153 25.7 21.4 

885 885 PSYCHOSES 877 0.3977 24.2 20.2 

886 886 BEHAVIORAL & DEVELOPMENTAL 

DISORDERS 38 0.4205 24.7 20.6 

887 887 OTHER MENTAL DISORDER DIAGNOSES 2 0.4878 18.1 15.1 

894 894 ALCOHOL/DRUG ABUSE OR DEPENDENCE, 

LEFT AMA 0 0.4878 18.1 15.1 

895 895 ALCOHOL/DRUG ABUSE OR DEPENDENCE W 

REHABILITATION THERAPY 0 0.4878 18.1 15.1 
CMS-1498-P 1159 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

896 896 ALCOHOL/DRUG ABUSE OR DEPENDENCE 

W/O REHABILITATION THERAPY W MCC 12 0.8667 24.6 20.5 

897 896 ALCOHOL/DRUG ABUSE OR DEPENDENCE 

W/O REHABILITATION THERAPY W/O MCC 8 0.4878 18.1 15.1 

901 901 WOUND DEBRIDEMENTS FOR INJURIES W 

MCC 292 1.3896 34.4 28.7 

902 901 WOUND DEBRIDEMENTS FOR INJURIES W CC 138 1.0410 29.9 24.9 

903 901 WOUND DEBRIDEMENTS FOR INJURIES W/O 

CC/MCC 6 0.6280 20.9 17.4 

904 904 SKIN GRAFTS FOR INJURIES W CC/MCC 100 1.3723 38.3 31.9 

905 904 SKIN GRAFTS FOR INJURIES W/O CC/MCC 2 0.8667 24.6 20.5 

906 906 HAND PROCEDURES FOR INJURIES 3 0.6280 20.9 17.4 

907 907 OTHER O.R. PROCEDURES FOR INJURIES W 

MCC 135 1.4580 34.3 28.6 

908 907 OTHER O.R. PROCEDURES FOR INJURIES W 

CC 57 0.9544 28.7 23.9 

909 907 OTHER O.R. PROCEDURES FOR INJURIES W/O 

CC/MCC 4 0.6280 20.9 17.4 

913 913 TRAUMATIC INJURY W MCC 49 0.7653 24.3 20.3 

914 913 TRAUMATIC INJURY W/O MCC 79 0.5687 20.1 16.8 

915 915 ALLERGIC REACTIONS W MCC 1 0.4878 18.1 15.1 

916 915 ALLERGIC REACTIONS W/O MCC 0 0.4878 18.1 15.1 

917 917 POISONING & TOXIC EFFECTS OF DRUGS W 

MCC 8 1.0834 28.9 24.1 

918 917 POISONING & TOXIC EFFECTS OF DRUGS 

W/O MCC 3 0.4878 18.1 15.1 

919 919 COMPLICATIONS OF TREATMENT W MCC 1,547 1.0957 26.7 22.3 

920 919 COMPLICATIONS OF TREATMENT W CC 888 0.8190 24.9 20.8 

921 919 COMPLICATIONS OF TREATMENT W/O 

CC/MCC 53 0.5150 18.4 15.3 

922 922 OTHER INJURY, POISONING & TOXIC EFFECT 

DIAG W MCC 7 0.8667 24.6 20.5 

923 922 OTHER INJURY, POISONING & TOXIC EFFECT 

DIAG W/O MCC 11 0.4878 18.1 15.1 

927 927 EXTENSIVE BURNS OR FULL THICKNESS 

BURNS W MV 96+ HRS W SKIN GRAFT 0 1.0834 28.9 24.1 

928 928 FULL THICKNESS BURN W SKIN GRAFT OR 

INHAL INJ W CC/MCC 11 1.0834 28.9 24.1 

929 928 FULL THICKNESS BURN W SKIN GRAFT OR 

INHAL INJ W/O CC/MCC 1 1.0834 28.9 24.1 

933 933 EXTENSIVE BURNS OR FULL THICKNESS 

BURNS W MV 96+ HRS W/O SKIN GRAFT 11 0.6280 20.9 17.4 

934 934 FULL THICKNESS BURN W/O SKIN GRFT OR 

INHAL INJ 31 0.6455 23.9 19.9 

935 935 NON-EXTENSIVE BURNS 64 0.6800 22.2 18.5 

939 939 O.R. PROC W DIAGNOSES OF OTHER 

CONTACT W HEALTH SERVICES W MCC 225 1.4032 33.6 28.0 
CMS-1498-P 1160 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

940 939 O.R. PROC W DIAGNOSES OF OTHER 

CONTACT W HEALTH SERVICES W CC 98 1.0076 31.1 25.9 

941 939 O.R. PROC W DIAGNOSES OF OTHER 

CONTACT W HEALTH SERVICES W/O CC/MCC 9 0.6280 20.9 17.4 

945 945 REHABILITATION W CC/MCC 1,338 0.6482 21.1 17.6 

946 945 REHABILITATION W/O CC/MCC 89 0.4068 17.2 14.3 

947 947 SIGNS & SYMPTOMS W MCC 41 0.8225 23.5 19.6 

948 947 SIGNS & SYMPTOMS W/O MCC 51 0.4846 19.9 16.6 

949 949 AFTERCARE W CC/MCC 3,264 0.7151 22.1 18.4 

950 949 AFTERCARE W/O CC/MCC 194 0.4499 17.1 14.3 

951 951 OTHER FACTORS INFLUENCING HEALTH 

STATUS 66 1.5229 27.2 22.7 

955 955 CRANIOTOMY FOR MULTIPLE SIGNIFICANT 

TRAUMA 0 1.0834 28.9 24.1 

956 956 LIMB REATTACHMENT, HIP & FEMUR PROC 

FOR MULTIPLE SIGNIFICANT TRAUMA 0 1.6495 36.4 30.3 

957 957 OTHER O.R. PROCEDURES FOR MULTIPLE 

SIGNIFICANT TRAUMA W MCC 1 0.6280 20.9 17.4 

958 957 OTHER O.R. PROCEDURES FOR MULTIPLE 

SIGNIFICANT TRAUMA W CC* 0 0.6280 20.9 17.4 

959 957 OTHER O.R. PROCEDURES FOR MULTIPLE 

SIGNIFICANT TRAUMA W/O CC/MCC* 0 0.6280 20.9 17.4 

963 963 OTHER MULTIPLE SIGNIFICANT TRAUMA W 

MCC* 8 1.0834 28.9 24.1 

964 963 OTHER MULTIPLE SIGNIFICANT TRAUMA W 

CC 8 1.0834 28.9 24.1 

965 963 OTHER MULTIPLE SIGNIFICANT TRAUMA 

W/O CC/MCC 1 0.4878 18.1 15.1 

969 969 HIV W EXTENSIVE O.R. PROCEDURE W MCC 12 1.6495 36.4 30.3 

970 969 HIV W EXTENSIVE O.R. PROCEDURE W/O 

MCC 2 0.8667 24.6 20.5 

974 974 HIV W MAJOR RELATED CONDITION W MCC 210 1.0512 23.2 19.3 

975 974 HIV W MAJOR RELATED CONDITION W CC 58 0.6394 18.6 15.5 

976 974 HIV W MAJOR RELATED CONDITION W/O 

CC/MCC 7 0.4878 18.1 15.1 

977 977 HIV W OR W/O OTHER RELATED CONDITION 30 0.6746 19.9 16.6 

981 981 EXTENSIVE O.R. PROCEDURE UNRELATED 

TO PRINCIPAL DIAGNOSIS W MCC 1,045 2.1787 41.6 34.7 

982 981 EXTENSIVE O.R. PROCEDURE UNRELATED 

TO PRINCIPAL DIAGNOSIS W CC 219 1.1314 30.7 25.6 

983 981 EXTENSIVE O.R. PROCEDURE UNRELATED 

TO PRINCIPAL DIAGNOSIS W/O CC/MCC 6 0.6280 20.9 17.4 

984 984 PROSTATIC O.R. PROCEDURE UNRELATED 

TO PRINCIPAL DIAGNOSIS W MCC 19 1.6495 36.4 30.3 

985 984 PROSTATIC O.R. PROCEDURE UNRELATED 

TO PRINCIPAL DIAGNOSIS W CC 8 1.0834 28.9 24.1 

986 984 PROSTATIC O.R. PROCEDURE UNRELATED 

TO PRINCIPAL DIAGNOSIS W/O CC/MCC 0 1.0834 28.9 24.1 
CMS-1498-P 1161 

MSLTCDRG 

Base 

MSLTCDRG MS-LTC-DRG Title 

FY 

2009 

LTCH 

Cases 

Proposed 

Relative 

Weight 

Proposed 

Geometric 

Average 

Length of 

Stay 

Proposed 

Short-Stay 

Outlier 

(SSO) 

Threshold1

987 987 NON-EXTENSIVE O.R. PROC UNRELATED TO 

PRINCIPAL DIAGNOSIS W MCC 467 1.8330 38.5 32.1 

988 987 NON-EXTENSIVE O.R. PROC UNRELATED TO 

PRINCIPAL DIAGNOSIS W CC 172 1.0342 30.2 25.2 

989 987 NON-EXTENSIVE O.R. PROC UNRELATED TO 

PRINCIPAL DIAGNOSIS W/O CC/MCC 4 0.6280 20.9 17.4 

998 998 PRINCIPAL DIAGNOSIS INVALID AS 

DISCHARGE DIAGNOSIS 0 0.0000 0.0 0.0 

999 999 UNGROUPABLE 0 0.0000 0.0 0.0 

1

 The SSO Threshold is calculated as 5/6th of the geometric average length of stay of the MS-LTC-DRG (as specified in §412.529(a) 

in conjunction with §412.503). 

* In determining the proposed MS-LTC-DRG relative weights for FY 2011, these MS-LTC-DRGs were adjusted for 

nonmonotonicity as discussed in section VIII.B.3.g. (step 6) of the preamble of this proposed rule. 
CMS-1498-P 1162 

TABLE 12A.—PROPOSED LTCH PPS WAGE INDEX FOR URBAN AREAS FOR 

DISCHARGES OCCURRING FROM 

OCTOBER 1, 2010 THROUGH SEPTEMBER 30, 2011 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

10180 Abilene, TX 

 Callahan County, TX 

 Jones County, TX 

 Taylor County, TX 0.8016

10380 Aguadilla-Isabela-San Sebastián, PR 

 Aguada Municipio, PR 

 Aguadilla Municipio, PR 

 Añasco Municipio, PR 

 Isabela Municipio, PR 

 Lares Municipio, PR 

 Moca Municipio, PR 

 Rincón Municipio, PR 

 San Sebastián Municipio, PR 0.3476

10420 Akron, OH 

 Portage County, OH 

 Summit County, OH 0.8857

10500 Albany, GA 

 Baker County, GA 

 Dougherty County, GA 

 Lee County, GA 

 Terrell County, GA 

 Worth County, GA 0.9050

10580 Albany-Schenectady-Troy, NY 

 Albany County, NY 

 Rensselaer County, NY 

 Saratoga County, NY 

 Schenectady County, NY 

 Schoharie County, NY 0.8667

10740 Albuquerque, NM 

 Bernalillo County, NM 

 Sandoval County, NM 

 Torrance County, NM 

 Valencia County, NM 0.9454

10780 Alexandria, LA 

 Grant Parish, LA 

 Rapides Parish, LA 0.8008
CMS-1498-P 1163 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

10900 Allentown-Bethlehem-Easton, PA-NJ 

 Warren County, NJ 

 Carbon County, PA 

 Lehigh County, PA 

 Northampton County, PA 0.9178

11020 Altoona, PA 

 Blair County, PA 0.8634

11100 Amarillo, TX 

 Armstrong County, TX 

 Carson County, TX 

 Potter County, TX 

 Randall County, TX 0.8658

11180 Ames, IA 

 Story County, IA 0.9986

11260 Anchorage, AK 

 Anchorage Municipality, AK 

 Matanuska-Susitna Borough, AK 1.1984

11300 Anderson, IN 

 Madison County, IN 0.9207

11340 Anderson, SC 

 Anderson County, SC 0.8969

11460 Ann Arbor, MI 

 Washtenaw County, MI 1.0140

11500 Anniston-Oxford, AL 

 Calhoun County, AL 0.7931

11540 Appleton, WI 

 Calumet County, WI 

 Outagamie County, WI 0.9376

11700 Asheville, NC 

 Buncombe County, NC 

 Haywood County, NC 

 Henderson County, NC 

 Madison County, NC 0.9016

12020 Athens-Clarke County, GA 

 Clarke County, GA 

 Madison County, GA 

 Oconee County, GA 

 Oglethorpe County, GA 0.9546
CMS-1498-P 1164 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

12060 Atlanta-Sandy Springs-Marietta, GA 

 Barrow County, GA 

 Bartow County, GA 

 Butts County, GA 

 Carroll County, GA 

 Cherokee County, GA 

 Clayton County, GA 

 Cobb County, GA 

 Coweta County, GA 

 Dawson County, GA 

 DeKalb County, GA 

 Douglas County, GA 

 Fayette County, GA 

 Forsyth County, GA 

 Fulton County, GA 

 Gwinnett County, GA 

 Haralson County, GA 

 Heard County, GA 

 Henry County, GA 

 Jasper County, GA 

 Lamar County, GA 

 Meriwether County, GA 

 Newton County, GA 

 Paulding County, GA 

 Pickens County, GA 

 Pike County, GA 

 Rockdale County, GA 

 Spalding County, GA 

 Walton County, GA 0.9566

12100 Atlantic City, NJ- Hammonton, New Jersey 

 Atlantic County, NJ 1.1147

12220 Auburn-Opelika, AL 

 Lee County, AL 0.7255

12260 Augusta-Richmond County, GA-SC 

 Burke County, GA 

 Columbia County, GA 

 McDuffie County, GA 

 Richmond County, GA 

 Aiken County, SC 

 Edgefield County, SC 0.9522
CMS-1498-P 1165 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

12420 Austin-Round Rock-San Marcos, TX 

 Bastrop County, TX 

 Caldwell County, TX 

 Hays County, TX 

 Travis County, TX 

 Williamson County, TX 0.9529

12540 Bakersfield-Delano, CA 

 Kern County, CA 1.1655

12580 Baltimore-Towson, MD 

 Anne Arundel County, MD 

 Baltimore County, MD 

 Carroll County, MD 

 Harford County, MD 

 Howard County, MD 

 Queen Anne's County, MD 

 Baltimore City, MD 1.0267

12620 Bangor, ME 

 Penobscot County, ME 0.9793

12700 Barnstable Town, MA 

 Barnstable County, MA 1.2844

12940 Baton Rouge, LA 

 Ascension Parish, LA 

 East Baton Rouge Parish, LA 

 East Feliciana Parish, LA 

 Iberville Parish, LA 

 Livingston Parish, LA 

 Pointe Coupee Parish, LA 

 St. Helena Parish, LA 

 West Baton Rouge Parish, LA 

 West Feliciana Parish, LA 0.8597

12980 Battle Creek, MI 

 Calhoun County, MI 0.9671

13020 Bay City, MI 

 Bay County, MI 0.9235

13140 Beaumont-Port Arthur, TX 

 Hardin County, TX 

 Jefferson County, TX 

 Orange County, TX 0.8502

13380 Bellingham, WA 

 Whatcom County, WA 1.1408

13460 Bend, OR 

 Deschutes County, OR 1.1388
CMS-1498-P 1166 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

13644 Bethesda- - Rockville-Frederick, MD 

 Frederick County, MD 

 Montgomery County, MD 1.0542

13740 Billings, MT 

 Carbon County, MT 

 Yellowstone County, MT 0.8688

13780 Binghamton, NY 

 Broome County, NY 

 Tioga County, NY 0.8733

13820 Birmingham-Hoover, AL 

 Bibb County, AL 

 Blount County, AL 

 Chilton County, AL 

 Jefferson County, AL 

 St. Clair County, AL 

 Shelby County, AL 

 Walker County, AL 0.8616

13900 Bismarck, ND 

 Burleigh County, ND 

 Morton County, ND 0.7360

13980 Blacksburg-Christiansburg-Radford, VA 

 Giles County, VA 

 Montgomery County, VA 

 Pulaski County, VA 

 Radford City, VA 0.8328

14020 Bloomington, IN 

 Greene County, IN 

 Monroe County, IN 

 Owen County, IN 0.9004

14060 Bloomington-Normal, IL 

 McLean County, IL 0.9455

14260 Boise City-Nampa, ID 

 Ada County, ID 

 Boise County, ID 

 Canyon County, ID 

 Gem County, ID 

 Owyhee County, ID 0.9288

14484 Boston-Quincy, MA 

 Norfolk County, MA 

 Plymouth County, MA 

 Suffolk County, MA 1.2215

14500 Boulder, CO 

 Boulder County, CO 1.0081
CMS-1498-P 1167 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

14540 Bowling Green, KY 

 Edmonson County, KY 

 Warren County, KY 0.8680

14740 Bremerton-Silverdale, WA 

 Kitsap County, WA 1.0684

14860 Bridgeport-Stamford-Norwalk, CT 

 Fairfield County, CT 1.2567

15180 Brownsville-Harlingen, TX 

 Cameron County, TX 0.9188

15260 Brunswick, GA 

 Brantley County, GA 

 Glynn County, GA 

 McIntosh County, GA 0.9224

15380 Buffalo-Niagara Falls, NY 

 Erie County, NY 

 Niagara County, NY 0.9545

15500 Burlington, NC 

 Alamance County, NC 0.8878

15540 Burlington-South Burlington, VT 

 Chittenden County, VT 

 Franklin County, VT 

 Grand Isle County, VT 0.9963

15764 Cambridge-Newton-Framingham, MA 

 Middlesex County, MA 1.1268

15804 Camden, NJ 

 Burlington County, NJ 

 Camden County, NJ 

 Gloucester County, NJ 1.0403

15940 Canton-Massillon, OH 

 Carroll County, OH 

 Stark County, OH 0.8761

15980 Cape Coral-Fort Myers, FL 

 Lee County, FL 0.9191

16020 Cape Girardeau-Jackson, MO-IL 

Alexander County, IL 

Bollinger County, MO 

 Cape Girardeau County, MO 0.8905

16180 Carson City, NV 

 Carson City, NV 1.0482

16220 Casper, WY 

 Natrona County, WY 0.9670
CMS-1498-P 1168 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

16300 Cedar Rapids, IA 

 Benton County, IA 

 Jones County, IA 

 Linn County, IA 0.8858

16580 Champaign-Urbana, IL 

 Champaign County, IL 

 Ford County, IL 

 Piatt County, IL 1.0251

16620 Charleston, WV 

 Boone County, WV 

 Clay County, WV 

 Kanawha County, WV 

 Lincoln County, WV 

 Putnam County, WV 0.7908

16700 Charleston-North CharlestonSummerville, SC 

 Berkeley County, SC 

 Charleston County, SC 

 Dorchester County, SC 0.9345

16740 Charlotte-Gastonia-Rock Hill, NC-SC 

 Anson County, NC 

 Cabarrus County, NC 

 Gaston County, NC 

 Mecklenburg County, NC 

 Union County, NC 

 York County, SC 0.9435

16820 Charlottesville, VA 

 Albemarle County, VA 

 Fluvanna County, VA 

 Greene County, VA 

 Nelson County, VA 

 Charlottesville City, VA 0.9358

16860 Chattanooga, TN-GA 

 Catoosa County, GA 

 Dade County, GA 

 Walker County, GA 

 Hamilton County, TN 

 Marion County, TN 

 Sequatchie County, TN 0.8755

16940 Cheyenne, WY 

 Laramie County, WY 0.9408
CMS-1498-P 1169 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

16974 Chicago- Joliet-Naperville, IL 

 Cook County, IL 

 DeKalb County, IL 

 DuPage County, IL 

 Grundy County, IL 

 Kane County, IL 

 Kendall County, IL 

 McHenry County, IL 

 Will County, IL 1.0573

17020 Chico, CA 

 Butte County, CA 1.1572

17140 Cincinnati-Middletown, OH-KY-IN 

 Dearborn County, IN 

 Franklin County, IN 

 Ohio County, IN 

 Boone County, KY 

 Bracken County, KY 

 Campbell County, KY 

 Gallatin County, KY 

 Grant County, KY 

 Kenton County, KY 

 Pendleton County, KY 

 Brown County, OH 

 Butler County, OH 

 Clermont County, OH 

 Hamilton County, OH 

 Warren County, OH 0.9714

17300 Clarksville, TN-KY 

 Christian County, KY 

 Trigg County, KY 

 Montgomery County, TN 

 Stewart County, TN 0.7898

17420 Cleveland, TN 

 Bradley County, TN 

 Polk County, TN 0.7744

17460 Cleveland-Elyria-Mentor, OH 

 Cuyahoga County, OH 

 Geauga County, OH 

 Lake County, OH 

 Lorain County, OH 

 Medina County, OH 0.9052

17660 Coeur d'Alene, ID 

 Kootenai County, ID 0.9379
CMS-1498-P 1170 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

17780 College Station-Bryan, TX 

 Brazos County, TX 

 Burleson County, TX 

 Robertson County, TX 0.9604

17820 Colorado Springs, CO 

 El Paso County, CO 

 Teller County, CO 0.9497

17860 Columbia, MO 

 Boone County, MO 

 Howard County, MO 0.8295

17900 Columbia, SC 

 Calhoun County, SC 

 Fairfield County, SC 

 Kershaw County, SC 

 Lexington County, SC 

 Richland County, SC 

 Saluda County, SC 0.8721

17980 Columbus, GA-AL 

 Russell County, AL 

 Chattahoochee County, GA 

 Harris County, GA 

 Marion County, GA 

 Muscogee County, GA 0.9042

18020 Columbus, IN 

 Bartholomew County, IN 0.9449

18140 Columbus, OH 

 Delaware County, OH 

 Fairfield County, OH 

 Franklin County, OH 

 Licking County, OH 

 Madison County, OH 

 Morrow County, OH 

 Pickaway County, OH 

 Union County, OH 1.0157

18580 Corpus Christi, TX 

 Aransas County, TX 

 Nueces County, TX 

 San Patricio County, TX 0.8599

18700 Corvallis, OR 

 Benton County, OR 1.0472

18880 Crestview-Fort Walton Beach- Destin, FL 

 Okaloosa County, FL 0.8856
CMS-1498-P 1171 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

19060 Cumberland, MD-WV 

 Allegany County, MD 

 Mineral County, WV 0.8199

19124 Dallas-Plano-Irving, TX 

 Collin County, TX 

 Dallas County, TX 

 Delta County, TX 

 Denton County, TX 

 Ellis County, TX 

 Hunt County, TX 

 Kaufman County, TX 

 Rockwall County, TX 0.9848

19140 Dalton, GA 

 Murray County, GA 

 Whitfield County, GA 0.8610

19180 Danville, IL 

 Vermilion County, IL 0.9708

19260 Danville, VA 

 Pittsylvania County, VA 

 Danville City, VA 0.8182

19340 Davenport-Moline-Rock Island, IA-IL 

 Henry County, IL 

 Mercer County, IL 

 Rock Island County, IL 

 Scott County, IA 0.8414

19380 Dayton, OH 

 Greene County, OH 

 Miami County, OH 

 Montgomery County, OH 

 Preble County, OH 0.9155

19460 Decatur, AL 

 Lawrence County, AL 

 Morgan County, AL 0.7618

19500 Decatur, IL 

 Macon County, IL 0.7929

19660 Deltona-Daytona Beach-Ormond Beach, FL 

 Volusia County, FL 0.8750
CMS-1498-P 1172 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

19740 Denver-Aurora-Broomfield, CO 

 Adams County, CO 

 Arapahoe County, CO 

 Broomfield County, CO 

 Clear Creek County, CO 

 Denver County, CO 

 Douglas County, CO 

 Elbert County, CO 

 Gilpin County, CO 

 Jefferson County, CO 

 Park County, CO 1.0735

19780 Des Moines,-West Des Moines, IA 

 Dallas County, IA 

 Guthrie County, IA 

 Madison County, IA 

 Polk County, IA 

 Warren County, IA 0.9637

19804 Detroit-Livonia-Dearborn, MI 

 Wayne County, MI 0.9702

20020 Dothan, AL 

 Geneva County, AL 

 Henry County, AL 

 Houston County, AL 0.7635

20100 Dover, DE 

 Kent County, DE 0.9937

20220 Dubuque, IA 

 Dubuque County, IA 0.8788

20260 Duluth, MN-WI 

 Carlton County, MN 

 St. Louis County, MN 

 Douglas County, WI 1.0469

20500 Durham-Chapel Hill, NC 

 Chatham County, NC 

 Durham County, NC 

 Orange County, NC 

 Person County, NC 0.9680

20740 Eau Claire, WI 

 Chippewa County, WI 

 Eau Claire County, WI 0.9655
CMS-1498-P 1173 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

20764 Edison-New Brunswick, NJ 

 Middlesex County, NJ 

 Monmouth County, NJ 

 Ocean County, NJ 

 Somerset County, NJ 1.1022

20940 El Centro, CA 

 Imperial County, CA 0.9273

21060 Elizabethtown, KY 

 Hardin County, KY 

 Larue County, KY 0.8463

21140 Elkhart-Goshen, IN 

 Elkhart County, IN 0.9480

21300 Elmira, NY 

 Chemung County, NY 0.8459

21340 El Paso, TX 

 El Paso County, TX 0.8489

21500 Erie, PA 

 Erie County, PA 0.8371

21660 Eugene-Springfield, OR 

 Lane County, OR 1.1402

21780 Evansville, IN-KY 

 Gibson County, IN 

 Posey County, IN 

 Vanderburgh County, IN 

 Warrick County, IN 

 Henderson County, KY 

 Webster County, KY 0.8446

21820 Fairbanks, AK 

 Fairbanks North Star Borough, AK 1.1098

21940 Fajardo, PR 

 Ceiba Municipio, PR 

 Fajardo Municipio, PR 

 Luquillo Municipio, PR 0.3889

22020 

Fargo, ND-MN 

 Cass County, ND 

 Clay County, MN 0.8049

22140 Farmington, NM 

 San Juan County, NM 0.8000

22180 Fayetteville, NC 

 Cumberland County, NC 

 Hoke County, NC 0.9339
CMS-1498-P 1174 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

22220 Fayetteville-Springdale-Rogers, AR-MO 

 Benton County, AR 

 Madison County, AR 

 Washington County, AR 

 McDonald County, MO 0.8630

22380 Flagstaff, AZ 

 Coconino County, AZ 1.2463

22420 Flint, MI 

 Genesee County, MI 1.1515

22500 Florence, SC 

 Darlington County, SC 

 Florence County, SC 0.8264

22520 Florence-Muscle Shoals, AL 

 Colbert County, AL 

 Lauderdale County, AL 0.8058

22540 Fond du Lac, WI 

 Fond du Lac County, WI 0.9238

22660 Fort Collins-Loveland, CO 

 Larimer County, CO 0.9908

22744 

Fort Lauderdale-Pompano Beach-Deerfield Beach, 

FL 

 Broward County, FL 1.0170

22900 Fort Smith, AR-OK 

 Crawford County, AR 

 Franklin County, AR 

 Sebastian County, AR 

 Le Flore County, OK 

 Sequoyah County, OK 0.7601

23060 Fort Wayne, IN 

 Allen County, IN 

 Wells County, IN 

 Whitley County, IN 0.9322

23104 Fort Worth-Arlington, TX 

 Johnson County, TX 

 Parker County, TX 

 Tarrant County, TX 

 Wise County, TX 0.9490

23420 Fresno, CA 

 Fresno County, CA 1.1439

23460 Gadsden, AL 

 Etowah County, AL 0.7028
CMS-1498-P 1175 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

23540 Gainesville, FL 

 Alachua County, FL 

 Gilchrist County, FL 0.9175

23580 Gainesville, GA 

 Hall County, GA 0.9386

23844 Gary, IN 

 Jasper County, IN 

 Lake County, IN 

 Newton County, IN 

 Porter County, IN 0.9099

24020 Glens Falls, NY 

 Warren County, NY 

 Washington County, NY 0.8521

24140 Goldsboro, NC 

 Wayne County, NC 0.9081

24220 Grand Forks, ND-MN 

 Polk County, MN 

 Grand Forks County, ND 0.7729

24300 Grand Junction, CO 

 Mesa County, CO 0.9866

24340 Grand Rapids-Wyoming, MI 

 Barry County, MI 

 Ionia County, MI 

 Kent County, MI 

 Newaygo County, MI 0.9183

24500 Great Falls, MT 

 Cascade County, MT 0.8303

24540 Greeley, CO 

 Weld County, CO 0.9511

24580 Green Bay, WI 

 Brown County, WI 

 Kewaunee County, WI 

 Oconto County, WI 0.9601

24660 Greensboro-High Point, NC 

 Guilford County, NC 

 Randolph County, NC 

 Rockingham County, NC 0.8897

24780 Greenville, NC 

 Greene County, NC 

 Pitt County, NC 0.9385
CMS-1498-P 1176 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

24860 Greenville-Mauldin-Easley, SC 

 Greenville County, SC 

 Laurens County, SC 

 Pickens County, SC 0.9563

25020 Guayama, PR 

 Arroyo Municipio, PR 

 Guayama Municipio, PR 

 Patillas Municipio, PR 0.3692

25060 Gulfport-Biloxi, MS 

 Hancock County, MS 

 Harrison County, MS 

 Stone County, MS 0.8990

25180 Hagerstown-Martinsburg, MD-WV 

 Washington County, MD 

 Berkeley County, WV 

 Morgan County, WV 0.9269

25260 Hanford-Corcoran, CA 

 Kings County, CA 1.1223

25420 Harrisburg-Carlisle, PA 

 Cumberland County, PA 

 Dauphin County, PA 

 Perry County, PA 0.9311

25500 Harrisonburg, VA 

 Rockingham County, VA 

 Harrisonburg City, VA 0.9173

25540 Hartford-West Hartford-East Hartford, CT 

 Hartford County, CT 

 Middlesex County, CT 

 Tolland County, CT 1.0936

25620 Hattiesburg, MS 

 Forrest County, MS 

 Lamar County, MS 

 Perry County, MS 0.7727

25860 Hickory-Lenoir-Morganton, NC 

 Alexander County, NC 

 Burke County, NC 

 Caldwell County, NC 

 Catawba County, NC 0.8707

25980 Hinesville-Fort Stewart, GA 

 Liberty County, GA 

 Long County, GA 0.8955

26100 Holland-Grand Haven, MI 

 Ottawa County, MI 0.8646
CMS-1498-P 1177 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

26180 Honolulu, HI 

 Honolulu County, HI 1.1801

26300 Hot Springs, AR 

 Garland County, AR 0.9166

26380 Houma-Bayou Cane-Thibodaux, LA 

 Lafourche Parish, LA 

 Terrebonne Parish, LA 0.7865

26420 Houston-Sugar Land-Baytown, TX 

 Austin County, TX 

 Brazoria County, TX 

 Chambers County, TX 

 Fort Bend County, TX 

 Galveston County, TX 

 Harris County, TX 

 Liberty County, TX 

 Montgomery County, TX 

 San Jacinto County, TX 

 Waller County, TX 0.9838

26580 Huntington-Ashland, WV-KY-OH 

 Boyd County, KY 

 Greenup County, KY 

 Lawrence County, OH 

 Cabell County, WV 

 Wayne County, WV 0.8967

26620 Huntsville, AL 

 Limestone County, AL 

 Madison County, AL 0.9130

26820 Idaho Falls, ID 

 Bonneville County, ID 

 Jefferson County, ID 0.9678

26900 Indianapolis-Carmel, IN 

 Boone County, IN 

 Brown County, IN 

 Hamilton County, IN 

 Hancock County, IN 

 Hendricks County, IN 

 Johnson County, IN 

 Marion County, IN 

 Morgan County, IN 

 Putnam County, IN 

 Shelby County, IN 0.9687
CMS-1498-P 1178 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

26980 Iowa City, IA 

 Johnson County, IA 

 Washington County, IA 0.9672

27060 Ithaca, NY 

 Tompkins County, NY 0.9858

27100 Jackson, MI 

 Jackson County, MI 0.9170

27140 Jackson, MS 

 Copiah County, MS 

 Hinds County, MS 

 Madison County, MS 

 Rankin County, MS 

 Simpson County, MS 0.8105

27180 Jackson, TN 

 Chester County, TN 

 Madison County, TN 0.8418

27260 Jacksonville, FL 

 Baker County, FL 

 Clay County, FL 

 Duval County, FL 

 Nassau County, FL 

 St. Johns County, FL 0.8899

27340 Jacksonville, NC 

 Onslow County, NC 0.7819

27500 Janesville, WI 

 Rock County, WI 0.9430

27620 Jefferson City, MO 

 Callaway County, MO 

 Cole County, MO 

 Moniteau County, MO 

 Osage County, MO 0.8448

27740 Johnson City, TN 

 Carter County, TN 

 Unicoi County, TN 

 Washington County, TN 0.7269

27780 Johnstown, PA 

 Cambria County, PA 0.8103

27860 Jonesboro, AR 

 Craighead County, AR 

 Poinsett County, AR 0.7770

27900 Joplin, MO 

 Jasper County, MO 

 Newton County, MO 0.8227
CMS-1498-P 1179 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

28020 Kalamazoo-Portage, MI 

 Kalamazoo County, MI 

 Van Buren County, MI 1.0309

28100 Kankakee-Bradley, IL 

 Kankakee County, IL 1.0636

28140 Kansas City, MO-KS 

 Franklin County, KS 

 Johnson County, KS 

 Leavenworth County, KS 

 Linn County, KS 

 Miami County, KS 

 Wyandotte County, KS 

 Bates County, MO 

 Caldwell County, MO 

 Cass County, MO 

 Clay County, MO 

 Clinton County, MO 

 Jackson County, MO 

 Lafayette County, MO 

 Platte County, MO 

 Ray County, MO 0.9667

28420 Kennewick- Pasco-Richland, WA 

 Benton County, WA 

 Franklin County, WA 0.9992

28660 Killeen-Temple-Fort Hood, TX 

 Bell County, TX 

 Coryell County, TX 

 Lampasas County, TX 0.8711

28700 Kingsport-Bristol-Bristol, TN-VA 

 Hawkins County, TN 

 Sullivan County, TN 

 Bristol City, VA 

 Scott County, VA 

 Washington County, VA 0.7596

28740 Kingston, NY 

 Ulster County, NY 0.9089

28940 Knoxville, TN 

 Anderson County, TN 

 Blount County, TN 

 Knox County, TN 

 Loudon County, TN 

 Union County, TN 0.7856
CMS-1498-P 1180 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

29020 Kokomo, IN 

 Howard County, IN 

 Tipton County, IN 0.9134

29100 La Crosse, WI-MN 

 Houston County, MN 

 La Crosse County, WI 0.9819

29140 Lafayette, IN 

 Benton County, IN 

 Carroll County, IN 

 Tippecanoe County, IN 0.9304

29180 Lafayette, LA 

 Lafayette Parish, LA 

 St. Martin Parish, LA 0.8499

29340 Lake Charles, LA 

 Calcasieu Parish, LA 

 Cameron Parish, LA 0.8209

29404 Lake County-Kenosha County, IL-WI 

 Lake County, IL 

 Kenosha County, WI 1.0799

29420 

Lake Havasu City-Kingman, AZ 

 Mohave County, AZ 1.0252

29460 Lakeland-Winter Haven, FL 

 Polk County, FL 0.8461

29540 Lancaster, PA 

 Lancaster County, PA 0.9359

29620 Lansing-East Lansing, MI 

 Clinton County, MI 

 Eaton County, MI 

 Ingham County, MI 1.0315

29700 Laredo, TX 

 Webb County, TX 0.7927

29740 Las Cruces, NM 

 Dona Ana County, NM 0.9311

29820 Las Vegas-Paradise, NV 

 Clark County, NV 1.2119

29940 Lawrence, KS 

 Douglas County, KS 0.8547

30020 Lawton, OK 

 Comanche County, OK 0.8298

30140 Lebanon, PA 

 Lebanon County, PA 0.7820
CMS-1498-P 1181 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

30300 Lewiston, ID-WA 

 Nez Perce County, ID 

 Asotin County, WA 0.9373

30340 Lewiston-Auburn, ME 

 Androscoggin County, ME 0.8917

30460 Lexington-Fayette, KY 

 Bourbon County, KY 

 Clark County, KY 

 Fayette County, KY 

 Jessamine County, KY 

 Scott County, KY 

 Woodford County, KY 0.8832

30620 Lima, OH 

 Allen County, OH 0.9285

30700 Lincoln, NE 

 Lancaster County, NE 

 Seward County, NE 0.9633

30780 Little Rock-North Little Rock-Conway, AR 

 Faulkner County, AR 

 Grant County, AR 

 Lonoke County, AR 

 Perry County, AR 

 Pulaski County, AR 

 Saline County, AR 0.8542

30860 Logan, UT-ID 

 Franklin County, ID 

 Cache County, UT 0.8808

30980 Longview, TX 

 Gregg County, TX 

 Rusk County, TX 

 Upshur County, TX 0.8582

31020 Longview, WA 

 Cowlitz County, WA 1.0313

31084 Los Angeles-Long Beach-Glendale, CA 

 Los Angeles County, CA 1.2054
CMS-1498-P 1182 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

31140 Louisville-Jefferson County, KY-IN 

 Clark County, IN 

 Floyd County, IN 

 Harrison County, IN 

 Washington County, IN 

 Bullitt County, KY 

 Henry County, KY 

 Jefferson County, KY 

 Meade County, KY 

 Nelson County, KY 

 Oldham County, KY 

 Shelby County, KY 

 Spencer County, KY 

 Trimble County, KY 0.8898

31180 Lubbock, TX 

 Crosby County, TX 

 Lubbock County, TX 0.8862

31340 Lynchburg, VA 

 Amherst County, VA 

 Appomattox County, VA 

 Bedford County, VA 

 Campbell County, VA 

 Bedford City, VA 

 Lynchburg City, VA 0.8679

31420 Macon, GA 

 Bibb County, GA 

 Crawford County, GA 

 Jones County, GA 

 Monroe County, GA 

 Twiggs County, GA 0.9044

31460 Madera-Chowchilla, CA 

 Madera County, CA 0.7999

31540 Madison, WI 

 Columbia County, WI 

 Dane County, WI 

 Iowa County, WI 1.1307

31700 Manchester-Nashua, NH 

 Hillsborough County, NH 0.9885

31740 Mahattan, KS 

 Geary County, KS 

 Pottawatomie County, KS 

 Riley County; KS 0.7860
CMS-1498-P 1183 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

31860 Mankato-North Mankato, MN 

 Blue Earth County, MN 

 Nicollet County, MN 0.9098

31900 Mansfield, OH 

 Richland County, OH 0.8932

32420 Mayagüez, PR 

 Hormigueros Municipio, PR 

 Mayagüez Municipio, PR 0.3646

32580 McAllen-Edinburg-Mission, TX 

 Hidalgo County, TX 0.8852

32780 Medford, OR 

 Jackson County, OR 1.0077

32820 Memphis, TN-MS-AR 

 Crittenden County, AR 

 DeSoto County, MS 

 Marshall County, MS 

 Tate County, MS 

 Tunica County, MS 

 Fayette County, TN 

 Shelby County, TN 

 Tipton County, TN 0.9205

32900 Merced, CA 

 Merced County, CA 1.2241

33124 Miami-Miami Beach-Kendall, FL 

 Miami-Dade County, FL 1.0144

33140 Michigan City-La Porte, IN 

 LaPorte County, IN 0.9485

33260 Midland, TX 

 Midland County, TX 0.9727

33340 Milwaukee-Waukesha-West Allis, WI 

 Milwaukee County, WI 

 Ozaukee County, WI 

 Washington County, WI 

 Waukesha County, WI 1.0200
CMS-1498-P 1184 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

33460 Minneapolis-St. Paul-Bloomington, MN-WI 

 Anoka County, MN 

 Carver County, MN 

 Chisago County, MN 

 Dakota County, MN 

 Hennepin County, MN 

 Isanti County, MN 

 Ramsey County, MN 

 Scott County, MN 

 Sherburne County, MN 

 Washington County, MN 

 Wright County, MN 

 Pierce County, WI 

 St. Croix County, WI 1.1161

33540 Missoula, MT 

 Missoula County, MT 0.8935

33660 Mobile, AL 

 Mobile County, AL 0.7949

33700 Modesto, CA 

 Stanislaus County, CA 1.2123

33740 Monroe, LA 

 Ouachita Parish, LA 

 Union Parish, LA 0.8008

33780 Monroe, MI 

 Monroe County, MI 0.8698

33860 Montgomery, AL 

 Autauga County, AL 

 Elmore County, AL 

 Lowndes County, AL 

 Montgomery County, AL 0.8346

34060 Morgantown, WV 

 Monongalia County, WV 

 Preston County, WV 0.8150

34100 Morristown, TN 

 Grainger County, TN 

 Hamblen County, TN 

 Jefferson County, TN 0.7046

34580 Mount Vernon-Anacortes, WA 

 Skagit County, WA 1.0379

34620 Muncie, IN 

 Delaware County, IN 0.8219

34740 Muskegon-Norton Shores, MI 

 Muskegon County, MI 0.9805
CMS-1498-P 1185 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

34820 Myrtle Beach- North Myrtle Beach-Conway, SC 

 Horry County, SC 0.8726

34900 Napa, CA

 Napa County, CA 1.4628

34940 Naples-Marco Island, FL 

 Collier County, FL 0.9714

34980 Nashville-Davidson-Murfreesboro-Franklin, TN 

 Cannon County, TN 

 Cheatham County, TN 

 Davidson County, TN 

 Dickson County, TN 

 Hickman County, TN 

 Macon County, TN 

 Robertson County, TN 

 Rutherford County, TN 

 Smith County, TN 

 Sumner County, TN 

 Trousdale County, TN 

 Williamson County, TN 

 Wilson County, TN 0.9390

35004 Nassau-Suffolk, NY 

 Nassau County, NY 

 Suffolk County, NY 1.2333

35084 Newark-Union, NJ-PA 

 Essex County, NJ 

 Hunterdon County, NJ 

 Morris County, NJ 

 Sussex County, NJ 

 Union County, NJ 

 Pike County, PA 1.1461

35300 New Haven-Milford, CT 

 New Haven County, CT 1.1534

35380 New Orleans-Metairie-Kenner, LA 

 Jefferson Parish, LA 

 Orleans Parish, LA 

 Plaquemines Parish, LA 

 St. Bernard Parish, LA 

 St. Charles Parish, LA 

 St. John the Baptist Parish, LA 

 St. Tammany Parish, LA 0.9085
CMS-1498-P 1186 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

35644 New York-White Plains-Wayne, NY-NJ 

 Bergen County, NJ 

 Hudson County, NJ 

 Passaic County, NJ 

 Bronx County, NY 

 Kings County, NY 

 New York County, NY 

 Putnam County, NY 

 Queens County, NY 

 Richmond County, NY 

 Rockland County, NY 

 Westchester County, NY 1.2949

35660 Niles-Benton Harbor, MI 

 Berrien County, MI 0.8887

35840 North Port-Bradenton-Sarasota, FL 

 Manatee County, FL 

 Sarasota County, FL 0.9495

35980 Norwich-New London, CT 

 New London County, CT 1.1234

36084 Oakland-Fremont-Hayward, CA 

 Alameda County, CA 

 Contra Costa County, CA 1.6374

36100 Ocala, FL 

 Marion County, FL 0.8482

36140 Ocean City, NJ 

 Cape May County, NJ 1.0896

36220 Odessa, TX 

 Ector County, TX 0.9451

36260 Ogden-Clearfield, UT 

 Davis County, UT 

 Morgan County, UT 

 Weber County, UT 0.9282

36420 Oklahoma City, OK 

 Canadian County, OK 

 Cleveland County, OK 

 Grady County, OK 

 Lincoln County, OK 

 Logan County, OK 

 McClain County, OK 

 Oklahoma County, OK 0.8892

36500 Olympia, WA 

 Thurston County, WA 1.1287
CMS-1498-P 1187 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

36540 Omaha-Council Bluffs, NE-IA 

 Harrison County, IA 

 Mills County, IA 

 Pottawattamie County, IA 

 Cass County, NE 

 Douglas County, NE 

 Sarpy County, NE 

 Saunders County, NE 

 Washington County, NE 0.9599

36740 Orlando-Kissimmee-Sanford, FL 

 Lake County, FL 

 Orange County, FL 

 Osceola County, FL 

 Seminole County, FL 0.9159

36780 Oshkosh-Neenah, WI 

 Winnebago County, WI 0.9582

36980 Owensboro, KY 

 Daviess County, KY 

 Hancock County, KY 

 McLean County, KY 0.8384

37100 Oxnard-Thousand Oaks-Ventura, CA 

 Ventura County, CA 1.2397

37340 Palm Bay-Melbourne-Titusville, FL 

 Brevard County, FL 0.9226

37380 

Palm Coast, FL 

 Flager County, FL 0.8419

37460 Panama City-Lynn Haven-Panama City Beach, FL 

 Bay County, FL 0.7967

37620 Parkersburg-Marietta-Vienna, WV-OH 

 Washington County, OH 

 Pleasants County, WV 

 Wirt County, WV 

 Wood County, WV 0.7467

37700 Pascagoula, MS 

 George County, MS 

 Jackson County, MS 0.8312

37764 

Peabody, MA 

 Essex County, MA 1.0996

37860 Pensacola-Ferry Pass-Brent, FL 

 Escambia County, FL 

 Santa Rosa County, FL 0.8267
CMS-1498-P 1188 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

37900 Peoria, IL 

 Marshall County, IL 

 Peoria County, IL 

 Stark County, IL 

 Tazewell County, IL 

 Woodford County, IL 0.9163

37964 Philadelphia, PA 

 Bucks County, PA 

 Chester County, PA 

 Delaware County, PA 

 Montgomery County, PA 

 Philadelphia County, PA 1.0818

38060 Phoenix-Mesa-Glendale, AZ 

 Maricopa County, AZ 

 Pinal County, AZ 1.0662

38220 Pine Bluff, AR 

 Cleveland County, AR 

 Jefferson County, AR 

 Lincoln County, AR 0.8025

38300 Pittsburgh, PA 

 Allegheny County, PA 

 Armstrong County, PA 

 Beaver County, PA 

 Butler County, PA 

 Fayette County, PA 

 Washington County, PA 

 Westmoreland County, PA 0.8619

38340 Pittsfield, MA 

 Berkshire County, MA 1.0388

38540 Pocatello, ID 

 Bannock County, ID 

 Power County, ID 0.9523

38660 Ponce, PR 

 Juana Díaz Municipio, PR 

 Ponce Municipio, PR 

 Villalba Municipio, PR 0.4320

38860 Portland-South Portland-Biddeford, ME 

 Cumberland County, ME 

 Sagadahoc County, ME 

 York County, ME 0.9905
CMS-1498-P 1189 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

38900 Portland-Vancouver-Hillsboro, OR-WA 

 Clackamas County, OR 

 Columbia County, OR 

 Multnomah County, OR 

 Washington County, OR 

 Yamhill County, OR 

 Clark County, WA 

 Skamania County, WA 1.1495

38940 Port St. Lucie, FL 

 Martin County, FL 

 St. Lucie County, FL 1.0740

39100 Poughkeepsie-Newburgh-Middletown, NY 

 Dutchess County, NY 

 Orange County, NY 1.1350

39140 Prescott, AZ 

 Yavapai County, AZ 1.2253

39300 Providence-New Bedford-Fall River, RI-MA 

 Bristol County, MA 

 Bristol County, RI 

 Kent County, RI 

 Newport County, RI 

 Providence County, RI 

 Washington County, RI 1.0731

39340 Provo-Orem, UT 

 Juab County, UT 

 Utah County, UT 0.9336

39380 Pueblo, CO 

 Pueblo County, CO 0.8735

39460 Punta Gorda, FL 

 Charlotte County, FL 0.8773

39540 Racine, WI 

 Racine County, WI 1.0597

39580 Raleigh-Cary, NC 

 Franklin County, NC 

 Johnston County, NC 

 Wake County, NC 0.9827

39660 Rapid City, SD 

 Meade County, SD 

 Pennington County, SD 1.0459

39740 Reading, PA 

 Berks County, PA 0.8918

39820 Redding, CA 

 Shasta County, CA 1.4146
CMS-1498-P 1190 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

39900 Reno-Sparks, NV 

 Storey County, NV 

 Washoe County, NV 1.0436

40060 Richmond, VA 

 Amelia County, VA 

 Caroline County, VA 

 Charles City County, VA 

 Chesterfield County, VA 

 Cumberland County, VA 

 Dinwiddie County, VA 

 Goochland County, VA 

 Hanover County, VA 

 Henrico County, VA 

 King and Queen County, VA 

 King William County, VA 

 Louisa County, VA 

 New Kent County, VA 

 Powhatan County, VA 

 Prince George County, VA 

 Sussex County, VA 

 Colonial Heights City, VA 

 Hopewell City, VA 

 Petersburg City, VA 

 Richmond City, VA 0.9677

40140 Riverside-San Bernardino-Ontario, CA 

 Riverside County, CA 

 San Bernardino County, CA 1.1553

40220 Roanoke, VA 

 Botetourt County, VA 

 Craig County, VA 

 Franklin County, VA 

 Roanoke County, VA 

 Roanoke City, VA 

 Salem City, VA 0.8841

40340 Rochester, MN 

 Dodge County, MN 

 Olmsted County, MN 

 Wabasha County, MN 1.0960
CMS-1498-P 1191 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

40380 Rochester, NY 

 Livingston County, NY 

 Monroe County, NY 

 Ontario County, NY 

 Orleans County, NY 

 Wayne County, NY 0.8609

40420 Rockford, IL 

 Boone County, IL 

 Winnebago County, IL 1.0049

40484 Rockingham County-Strafford County, NH 

 Rockingham County, NH 

 Strafford County, NH 1.0042

40580 Rocky Mount, NC 

 Edgecombe County, NC 

 Nash County, NC 0.9049

40660 Rome, GA 

 Floyd County, GA 0.8817

40900 Sacramento--Arden-Arcade--Roseville, CA 

 El Dorado County, CA 

 Placer County, CA 

 Sacramento County, CA 

 Yolo County, CA 1.3949

40980 Saginaw-Saginaw Township North, MI 

 Saginaw County, MI 0.8742

41060 St. Cloud, MN 

 Benton County, MN 

 Stearns County, MN 1.1060

41100 St. George, UT 

 Washington County, UT 0.9148

41140 St. Joseph, MO-KS 

 Doniphan County, KS 

 Andrew County, MO 

 Buchanan County, MO 

 DeKalb County, MO 1.0318
CMS-1498-P 1192 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

41180 St. Louis, MO-IL 

 Bond County, IL 

 Calhoun County, IL 

 Clinton County, IL 

 Jersey County, IL 

 Macoupin County, IL 

 Madison County, IL 

 Monroe County, IL 

 St. Clair County, IL 

 Crawford County, MO 

 Franklin County, MO 

 Jefferson County, MO 

 Lincoln County, MO 

 St. Charles County, MO 

 St. Louis County, MO 

 Warren County, MO 

 Washington County, MO 

 St. Louis City, MO 0.9105

41420 Salem, OR 

 Marion County, OR 

 Polk County, OR 1.1151

41500 Salinas, CA 

 Monterey County, CA 1.5711

41540 Salisbury, MD 

 Somerset County, MD 

 Wicomico County, MD 0.9020

41620 Salt Lake City, UT 

 Salt Lake County, UT 

 Summit County, UT 

 Tooele County, UT 0.9281

41660 San Angelo, TX 

 Irion County, TX 

 Tom Green County, TX 0.8317

41700 San Antonio-New Braunfels, TX 

 Atascosa County, TX 

 Bandera County, TX 

 Bexar County, TX 

 Comal County, TX 

 Guadalupe County, TX 

 Kendall County, TX 

 Medina County, TX 

 Wilson County, TX 0.9013
CMS-1498-P 1193 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

41740 San Diego-Carlsbad-San Marcos, CA 

 San Diego County, CA 1.1858

41780 Sandusky, OH 

 Erie County, OH 0.8700

41884 San Francisco-San Mateo-Redwood City, CA 

 Marin County, CA 

 San Francisco County, CA 

 San Mateo County, CA 1.5740

41900 San Germán-Cabo Rojo, PR 

 Cabo Rojo Municipio, PR 

 Lajas Municipio, PR 

 Sabana Grande Municipio, PR 

 San Germán Municipio, PR 0.4567

41940 San Jose-Sunnyvale-Santa Clara, CA 

 San Benito County, CA 

 Santa Clara County, CA 1.6730
CMS-1498-P 1194 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

41980 San Juan-Caguas-Guaynabo, PR

 Aguas Buenas Municipio, PR 

 Aibonito Municipio, PR 

 Arecibo Municipio, PR 

 Barceloneta Municipio, PR 

 Barranquitas Municipio, PR 

 Bayamón Municipio, PR 

 Caguas Municipio, PR 

 Camuy Municipio, PR 

 Canóvanas Municipio, PR 

 Carolina Municipio, PR 

 Cataño Municipio, PR 

 Cayey Municipio, PR 

 Ciales Municipio, PR 

 Cidra Municipio, PR 

 Comerío Municipio, PR 

 Corozal Municipio, PR 

 Dorado Municipio, PR 

 Florida Municipio, PR 

 Guaynabo Municipio, PR 

 Gurabo Municipio, PR 

 Hatillo Municipio, PR 

 Humacao Municipio, PR 

 Juncos Municipio, PR 

 Las Piedras Municipio, PR 

 Loíza Municipio, PR 

 Manatí Municipio, PR 

 Maunabo Municipio, PR 

 Morovis Municipio, PR 

 Naguabo Municipio, PR 

 Naranjito Municipio, PR 

 Orocovis Municipio, PR 

 Quebradillas Municipio, PR 

 Río Grande Municipio, PR 

 San Juan Municipio, PR 

 San Lorenzo Municipio, PR 

 Toa Alta Municipio, PR 

 Toa Baja Municipio, PR 

 Trujillo Alto Municipio, PR 

 Vega Alta Municipio, PR 

 Vega Baja Municipio, PR 

 Yabucoa Municipio, PR 0.4303
CMS-1498-P 1195 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

42020 San Luis Obispo-Paso Robles, CA 

 San Luis Obispo County, CA 1.2927

42044 Santa Ana-Anaheim-Irvine, CA 

 Orange County, CA 1.2181

42060 Santa Barbara-Santa Maria-Goleta, CA 

 Santa Barbara County, CA 1.1986

42100 Santa Cruz-Watsonville, CA 

 Santa Cruz County, CA 1.6768

42140 Santa Fe, NM 

 Santa Fe County, NM 1.0864

42220 Santa Rosa-Petaluma, CA 

 Sonoma County, CA 1.6167

42340 Savannah, GA 

 Bryan County, GA 

 Chatham County, GA 

 Effingham County, GA 0.8918

42540 Scranton--Wilkes-Barre, PA 

 Lackawanna County, PA 

 Luzerne County, PA 

 Wyoming County, PA 0.8252

42644 Seattle-Tacoma-Bellevue, WA 

 King County, WA 

 Snohomish County, WA 1.1574

42680 Sebastian-Vero Beach, FL 

 Indian River County, FL 0.9111

43100 Sheboygan, WI 

 Sheboygan County, WI 0.9248

43300 Sherman-Denison, TX 

 Grayson County, TX 0.8292

43340 Shreveport-Bossier City, LA 

 Bossier Parish, LA 

 Caddo Parish, LA 

 De Soto Parish, LA 0.8550

43580 Sioux City, IA-NE-SD 

 Woodbury County, IA 

 Dakota County, NE 

 Dixon County, NE 

 Union County, SD 0.9106

43620 Sioux Falls, SD 

 Lincoln County, SD 

 McCook County, SD 

 Minnehaha County, SD 

 Turner County, SD 0.9314
CMS-1498-P 1196 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

43780 South Bend-Mishawaka, IN-MI 

 St. Joseph County, IN 

 Cass County, MI 0.9964

43900 Spartanburg, SC 

 Spartanburg County, SC 0.9268

44060 Spokane, WA 

 Spokane County, WA 1.0588

44100 Springfield, IL 

 Menard County, IL 

 Sangamon County, IL 0.9145

44140 Springfield, MA 

 Franklin County, MA 

 Hampden County, MA 

 Hampshire County, MA 1.0236

44180 Springfield, MO 

 Christian County, MO 

 Dallas County, MO 

 Greene County, MO 

 Polk County, MO 

 Webster County, MO 0.8271

44220 Springfield, OH 

 Clark County, OH 0.9249

44300 State College, PA 

 Centre County, PA 0.8793

44600 SteubenvilleWeirton-, WV-OH 

 Jefferson County, OH 

 Brooke County, WV 

 Hancock County, WV 0.7326

44700 Stockton, CA 

 San Joaquin County, CA 1.2576

44940 Sumter, SC 

 Sumter County, SC 0.7873

45060 Syracuse, NY 

 Madison County, NY 

 Onondaga County, NY 

 Oswego County, NY 0.9631

45104 Tacoma, WA 

 Pierce County, WA 1.1362

45220 Tallahassee, FL 

 Gadsden County, FL 

 Jefferson County, FL 

 Leon County, FL 

 Wakulla County, FL 0.8820
CMS-1498-P 1197 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

45300 Tampa-St. Petersburg-Clearwater, FL 

 Hernando County, FL 

 Hillsborough County, FL 

 Pasco County, FL 

 Pinellas County, FL 0.9068

45460 Terre Haute, IN 

 Clay County, IN 

 Sullivan County, IN 

 Vermillion County, IN 

 Vigo County, IN 0.9220

45500 Texarkana, TX-Texarkana, AR 

 Miller County, AR 

 Bowie County, TX 0.7654

45780 Toledo, OH 

 Fulton County, OH 

 Lucas County, OH 

 Ottawa County, OH 

 Wood County, OH 0.9447

45820 Topeka, KS 

 Jackson County, KS 

 Jefferson County, KS 

 Osage County, KS 

 Shawnee County, KS 

 Wabaunsee County, KS 0.8967

45940 Trenton-Ewing, NJ 

 Mercer County, NJ 1.0167

46060 Tucson, AZ 

 Pima County, AZ 0.9495

46140 Tulsa, OK 

 Creek County, OK 

 Okmulgee County, OK 

 Osage County, OK 

 Pawnee County, OK 

 Rogers County, OK 

 Tulsa County, OK 

 Wagoner County, OK 0.8802

46220 Tuscaloosa, AL 

 Greene County, AL 

 Hale County, AL 

 Tuscaloosa County, AL 0.8003

46340 Tyler, TX 

 Smith County, TX 0.8078
CMS-1498-P 1198 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

46540 Utica-Rome, NY 

 Herkimer County, NY 

 Oneida County, NY 0.8485

46660 Valdosta, GA 

 Brooks County, GA 

 Echols County, GA 

 Lanier County, GA 

 Lowndes County, GA 0.7937

46700 Vallejo-Fairfield, CA 

 Solano County, CA 1.4939

47020 Victoria, TX 

 Calhoun County, TX 

 Goliad County, TX 

 Victoria County, TX 0.8232

47220 Vineland-Millville-Bridgeton, NJ 

 Cumberland County, NJ 1.0432

47260 Virginia Beach-Norfolk-Newport News, VA-NC 

 Currituck County, NC 

 Gloucester County, VA 

 Isle of Wight County, VA 

 James City County, VA 

 Mathews County, VA 

 Surry County, VA 

 York County, VA 

 Chesapeake City, VA 

 Hampton City, VA 

 Newport News City, VA 

 Norfolk City, VA 

 Poquoson City, VA 

 Portsmouth City, VA 

 Suffolk City, VA 

 Virginia Beach City, VA 

 Williamsburg City, VA 0.8975

47300 Visalia-Porterville, CA 

 Tulare County, CA 1.0756

47380 Waco, TX 

 McLennan County, TX 0.8417

47580 Warner Robins, GA 

 Houston County, GA 0.7951
CMS-1498-P 1199 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

47644 Warren-Troy-Farmington Hills, MI 

 Lapeer County, MI 

 Livingston County, MI 

 Macomb County, MI 

 Oakland County, MI 

 St. Clair County, MI 0.9662

47894 

Washington-Arlington-Alexandria, DC-VA-MD-WV

 District of Columbia, DC 

 Calvert County, MD 

 Charles County, MD 

 Prince George's County, MD 

 Arlington County, VA 

 Clarke County, VA 

 Fairfax County, VA 

 Fauquier County, VA 

 Loudoun County, VA 

 Prince William County, VA 

 Spotsylvania County, VA 

 Stafford County, VA 

 Warren County, VA 

 Alexandria City, VA 

 Fairfax City, VA 

 Falls Church City, VA 

 Fredericksburg City, VA 

 Manassas City, VA 

 Manassas Park City, VA 

 Jefferson County, WV 1.0722

47940 Waterloo-Cedar Falls, IA 

 Black Hawk County, IA 

 Bremer County, IA 

 Grundy County, IA 0.8476

48140 Wausau, WI 

 Marathon County, WI 0.9358

48300 Wenatchee- East Wenatchee, WA 

 Chelan County, WA 

 Douglas County, WA 0.9631

48424 West Palm Beach-Boca Raton-Boynton Beach, FL 

 Palm Beach County, FL 0.9949

48540 Wheeling, WV-OH 

 Belmont County, OH 

 Marshall County, WV 

 Ohio County, WV 0.6686
CMS-1498-P 1200 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

48620 Wichita, KS 

 Butler County, KS 

 Harvey County, KS 

 Sedgwick County, KS 

 Sumner County, KS 0.8913

48660 Wichita Falls, TX 

 Archer County, TX 

 Clay County, TX 

 Wichita County, TX 0.9581

48700 Williamsport, PA 

 Lycoming County, PA 0.7267

48864 Wilmington, DE-MD-NJ 

 New Castle County, DE 

 Cecil County, MD 

 Salem County, NJ 1.0597

48900 Wilmington, NC 

 Brunswick County, NC 

 New Hanover County, NC 

 Pender County, NC 0.9150

49020 Winchester, VA-WV 

 Frederick County, VA 

 Winchester City, VA 

 Hampshire County, WV 1.0018

49180 Winston-Salem, NC 

 Davie County, NC 

 Forsyth County, NC 

 Stokes County, NC 

 Yadkin County, NC 0.8953

49340 Worcester, MA 

 Worcester County, MA 1.1030

49420 Yakima, WA 

 Yakima County, WA 1.0083

49500 Yauco, PR 

 Guánica Municipio, PR 

 Guayanilla Municipio, PR 

 Peñuelas Municipio, PR 

 Yauco Municipio, PR 0.3542

49620 York-Hanover, PA 

 York County, PA 0.9542

49660 Youngstown-Warren-Boardman, OH-PA 

 Mahoning County, OH 

 Trumbull County, OH 

 Mercer County, PA 0.8639
CMS-1498-P 1201 

CBSA Code

Urban Area 

(Constituent Counties) 

Proposed 

LTCH PPS 

Wage Index

49700 Yuba City, CA 

 Sutter County, CA 

 Yuba County, CA 1.1061

49740 Yuma, AZ 

 Yuma County, AZ 0.9298
CMS-1498-P 1202 

TABLE 12B.—PROPOSED LTCH PPS WAGE INDEX FOR RURAL AREAS FOR 

DISCHARGES OCCURRING FROM 

OCTOBER 1, 2010 THROUGH SEPTEMBER 30, 2011

CBSA 

Code Nonurban Area

Proposed 

LTCH PPS 

Wage Index 

01 Alabama 0.7376

02 Alaska 1.2646

03 Arizona 0.9094

04 Arkansas 0.7234

05 California 1.2456

06 Colorado 0.9949

07 Connecticut 1.1139

08 Delaware 0.9771

10 Florida 0.8422

11 Georgia 0.7567

12 Hawaii 1.1100

13 Idaho 0.7568

14 Illinois 0.8357

15 Indiana 0.8404

16 Iowa 0.8584

17 Kansas 0.7994

18 Kentucky 0.7827

19 Louisiana 0.7724

20 Maine 0.8602

21 Maryland 0.9189

22 Massachusetts 1.1788

23 Michigan 0.8569

24 Minnesota 0.9053

25 Mississippi 0.7647

26 Missouri 0.7648

27 Montana 0.8531

28 Nebraska 0.8920

29 Nevada 0.9365

30 New Hampshire 0.9894

31 New Jersey* -------

32 New Mexico 0.8948

33 New York 0.8198

34 North Carolina 0.8379

35 North Dakota 0.6842

36 Ohio 0.8542

37 Oklahoma 0.7867

38 Oregon 1.0045
CMS-1498-P 1203 

CBSA 

Code Nonurban Area

Proposed 

LTCH PPS 

Wage Index 

39 Pennsylvania 0.8482

41 Rhode Island* -------

42 South Carolina 0.8431

43 South Dakota 0.8549

44 Tennessee 0.7879

45 Texas 0.7818

46 Utah 0.8663

47 Vermont 0.9606

49 Virginia 0.7853

50 Washington 1.0200

51 West Virginia 0.7484

52 Wisconsin 0.8976

53 Wyoming 0.9544

*

All counties within the State are classified as urban. 
CMS-1498-P 1204 

Appendix A: Regulatory Impact Analysis 

 Note: The impacts of the proposed FY 2011 policy changes and payment rates addressed 

in this Appendix do not reflect the provisions of the Patient Protection and Affordable Care Act 

(Pub. L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 

(Pub. L. 111-152. A number of the provisions of Pub. L. 111-148, as amended by Pub. L. 111-

152, affect the IPPS and the LTCH PPS and the providers and suppliers addressed in this 

proposed rule. However, due to the timing of the passage of the legislation, we are unable to 

address those provisions in this proposed rule. Therefore, the proposed policies and payment 

rates in this proposed rule do not reflect the new legislation. We plan to issue separate 

documents in the Federal Register addressing the provisions of Pub. L. 111-148, as amended, 

that affect our proposed policies and payment rates for FY 2011 under the IPPS and the LTCH 

PPS. In addition, we plan to issue further instructions implementing the provisions of 

Pub. L. 111-148, as amended, that affect the policies and payment rates for FY 2010 under the 

IPPS and for RY 2010 under the LTCH PPS. 

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), Executive Order 13132 on Federalism, 

and the Congressional Review Act (5 U.S.C. 804(2)). 

 Executive Order 12866 directs agencies to assess all costs and benefits of available 

regulatory alternatives and, if regulation is necessary, to select regulatory approaches that 

maximize net benefits (including potential economic, environmental, public health and safety 
CMS-1498-P 1205 

effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be prepared 

for major rules with economically significant effects ($100 million or more in any 1 year). 

 We have determined that this proposed rule is a major rule as defined in 5 U.S.C. 804(2). 

We estimate that the proposed changes for FY 2011 acute care hospital operating and capital 

payments will redistribute in excess of $100 million among different types of inpatient cases. 

The proposed 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 estimated $142 million 

decrease in FY 2011 operating payments (or -0.1 percent increase), and an estimated $20 million 

decrease in FY 2011 capital payments (or -0.2 percent change). The impact analysis of the 

capital payments can be found in section VIII. of this Appendix. In addition, as described in 

section IX. of this Appendix, LTCHs are expected to experience an increase in payments by 

$41 million (or 0.8 percent). 

 Our operating impact estimate includes the proposed -2.9 percent documentation and 

coding adjustment applied to the hospital-specific rates, the proposed -2.4 percent documentation 

and coding adjustment applied to the Puerto Rico-specific rates and the proposed -2.9 percent 

adjustment for documentation and coding changes to the IPPS standardized amounts. In 

addition, our operating impact estimate includes the proposed 2.4 percent market basket update 

to the standardized amount. The estimates of IPPS operating payments to acute care hospitals do 

not reflect any changes in hospital admissions or real case-mix intensity, which would also affect 

overall payment changes. 

 The RFA requires agencies to analyze options for regulatory relief of small businesses. 

For purposes of the RFA, small entities include small businesses, nonprofit organizations, and 

small government jurisdictions. Most hospitals and most other providers and suppliers are 
CMS-1498-P 1206 

considered to be small entities, either by being nonprofit organizations or by meeting the Small 

Business Administration definition of a small business (having revenues of $34.5 million or less 

in any 1 year). (For details on the latest standards for health care providers, we refer readers to 

the Table of Small Business Size Standards for NAIC 622 found on the Small Business 

Administration Office of Size Standards Web site at: 

http://www.sba.gov/contractingopportunities/officials/size/GC-SMALL-BUS-SIZESTANDARDS.html.) 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 the provisions of this proposed rule relating to acute care hospitals 

would have a significant impact on small entities as explained in this Appendix. Because we 

lack data on individual hospital receipts, we cannot determine the number of small proprietary 

LTCHs. Therefore, we are assuming that all LTCHs are considered small entities for the 

purpose of the analysis in section IX. of this Appendix. Medicare fiscal intermediaries and 

MACs are not considered to be small entities. Because we acknowledge that many of the 

affected entities are small entities, the analysis discussed throughout the preamble of this 

proposed rule constitutes our proposed regulatory flexibility analysis. Therefore, we are 

soliciting public comments on our estimates and analysis of the impact of this proposed rule on 

those small entities. 

 The Small Business Regulatory Enforcement Fairness Act of 1996 (SBREFA), 

Pub. L. 104-121, as amended by section 8302 of Pub. L. 110-28, requires an agency to provide 

compliance guides for each rule or group of related rules for which an agency is required to 

prepare a final regulatory flexibility analysis. The compliance guides associated with this 

proposed rule are available on the CMS IPPS Web page at 
CMS-1498-P 1207 

http://www.cms.hhs.gov/AcuteInpatientPPS/01_overview.asp. We also note that the Hospital 

Center Web page at http://www.cms.hhs.gov/center/hospital.asp was developed to assist 

hospitals in understanding and adapting to changes in Medicare regulations and in billing and 

payment procedures. This Web page provides hospitals with substantial downloadable 

explanatory materials.

 In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis 

for any proposed or final 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 now define a small rural hospital as a 

hospital that is located outside of an urban area 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 urban area. Thus, for purposes of the IPPS and the 

LTCH PPS, we continue to classify these hospitals as urban hospitals. (We refer readers to 

Table 1 and section VI. of this Appendix for the quantitative effects of the proposed policy 

changes under the IPPS for operating costs.) 

 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 $133 million. This proposed rule would not 

mandate any requirements for State, local, or tribal governments, nor would it affect private 

sector costs. 
CMS-1498-P 1208 

 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 proposed rule is consistent with the regulatory philosophy and principles identified in 

Executive Order 12866, the RFA, and section 1102(b) of the Act. The proposed rule would 

affect payments to a substantial number of small rural hospitals, as well as other classes of 

hospitals, and the effects on some hospitals may be significant. 

II. Objectives of the IPPS 

 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 the prospective payment systems 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 2011, on various hospital groups. We 
CMS-1498-P 1209 

estimate the effects of individual policy changes by estimating payments per case while holding 

all other payment policies constant. We use the best data available, but, generally, we do not 

attempt to make adjustments for future changes in such variables as admissions, lengths of stay, 

or case-mix. However, in the FY 2008 IPPS final rule with comment period, we indicated that 

we believe that implementation of the MS-DRGs would lead to increases in case-mix that do not 

reflect actual increases in patients’ severity of illness as a result of more comprehensive 

documentation and coding. As explained in section II.D. of the preamble of this proposed rule, 

the FY 2008 IPPS final rule with comment period established a documentation and coding 

adjustment of -1.2 percent for FY 2008, -1.8 percent for FY 2009, and -1.8 percent for FY 2010 

to maintain budget neutrality for the transition to the MS–DRGs. Subsequently, Congress 

enacted Pub. L. 110–90. Section 7 of Pub. L. 110-90 reduced the IPPS documentation and 

coding adjustment from -1.2 percent to -0.6 percent for FY 2008 and from -1.8 percent to -0.9 

percent for FY 2009. In the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43773), we 

postponed the documentation and coding adjustment to the average standardized amount until 

FY 2011 and did not apply the adjustment to the average standardized amount for FY 2010. An 

analysis of the FY 2008 IPPS claims data and the FY 2009 IPPS claims data found that an 

estimated recoupment adjustment of -5.8 percent applied to the national standardized amount is 

required to remove the full effects of documentation and coding due to the transition to 

MS-DRGs. Therefore, we are proposing to reduce the national standardized amount for IPPS 

hospitals by 2.9 percent in FY 2011 with additional reductions in subsequent years. 

 Furthermore, we believe that hospitals that are paid under the hospital-specific payment 

rate, specifically SCHs and MDHs, experience similar increases in case-mix due to 

documentation and coding changes that do not reflect real changes in case-mix. Our actuarial 
CMS-1498-P 1210 

office estimates that hospitals paid under the hospital-specific rate experienced a 4.8 percent 

increase in payments due to documentation and coding changes in FY 2008 and FY 2009. We 

did not apply a documentation and coding adjustment to the hospital-specific rates when we first 

implemented the MS-DRG system. In the FY 2010 IPPS/RY 2010 LTCH PPS final rule 

(74 FR43776 ), we postponed the documentation and coding adjustment to the hospital-specific 

payment rate until FY 2011 and did not apply the adjustment to hospital-specific payment rate 

for FY 2010. We believe that SCHs and MDHs paid under the hospital-specific rate also should 

receive an adjustment to the hospital-specific rate due to changes in documentation and coding 

that do not reflect real changes in case-mix. Our best estimate, based on the most recently 

available data, is that a cumulative adjustment of -5.4 percent to the hospital-specific payment 

rate would address the effect of the documentation and coding changes on future payments. 

Therefore, for FY 2011, we are proposing to apply a -2.9 percent documentation and coding 

adjustment to the hospital-specific payment rate. 

Our analysis, as described in section II.D. of the preamble of this proposed rule, shows 

that Puerto Rico hospitals experienced an increase in case-mix by 1.1 percent in FY 2008 due to 

changes in documentation and coding. We did not apply a documentation and coding adjustment 

to the Puerto Rico-specific rate when we first implemented the MS-DRG system. In the FY 

2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43777), consistent with our decision to 

postpone documentation and coding adjustments for the hospital-specific rate and the Federal 

standardized amount, we also postponed the documentation and coding adjustment to the PuertoRico specific payment rate Analysis of claims data from Puerto Rico hospitals found that a 

cumulative adjustment of -2.4 percent is required to eliminate the full effect of the 

documentation and coding changes on future payments from the Puerto Rico-specific rate. 
CMS-1498-P 1211 

Therefore, for FY 2011, we are proposing to apply a -2.4 percent adjustment to the Puerto Ricospecific rate to account for changes due to documentation and coding. 

 The impacts shown below illustrate the impact of the proposed FY 2011 IPPS changes on 

acute care hospital operating payments, including the proposed -2.9 percent FY 2011 

documentation and coding adjustment to the IPPS national standardized amount, the proposed 

-2.9 percent FY 2011 documentation and coding adjustment to the hospital-specific payment 

rates, and the proposed -2.4 percent FY 2011 documentation and coding adjustment to the Puerto 

Rico-specific standardized amount. The proposed documentation and coding adjustment that 

would be applicable to the Federal rate under the LTCH PPS for FY 2011 is discussed in section 

IX. of this Appendix. As we have done in the previous rules, we are soliciting public comments 

and information about the anticipated effects of the proposed changes on acute care 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 of acute care hospitals encompass most general short-term, acute care hospitals that 

participate in the Medicare program. There were 33 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 46 such hospitals in Maryland remain excluded from the IPPS pursuant to the 

waiver under section 1814(b)(3) of the Act. 

 As of March 2010, there are 3,472 IPPS acute care hospitals to be included in our 

analysis. This represents about 64 percent of all Medicare-participating hospitals. The majority 

of this impact analysis focuses on this set of hospitals. There are also approximately 1,338 
CMS-1498-P 1212 

CAHs. These small, limited service hospitals are paid on the basis of reasonable costs rather 

than under the IPPS. (We refer readers to section VII. of this Appendix for a further description 

of the impact of CAH-related proposed policy changes.) There are also 1,270 IPPS-excluded 

hospitals and 2,169 IPPS-excluded hospital units. These IPPS-excluded hospitals and units 

include IPFs, IRFs, LTCHs, RNHCIs, children's hospitals, and cancer hospitals, which are paid 

under separate payment systems. Changes in the prospective payment systems for IPFs and IRFs 

are made through separate rulemaking. Payment impacts for these IPPS-excluded hospitals and 

units are not included in this proposed rule. The impact of the proposed update and policy 

changes to the LTCH PPS for FY 2011 are discussed in section IX. of this Appendix. 

V. Effects on Hospitals and Hospital Units Excluded From the IPPS 

 As of March 2010, there were 3,439 hospitals and hospital units excluded from the IPPS. 

Of these, 78 children’s hospitals, 11 cancer hospitals, and 17 RNHCIs are being paid on a 

reasonable cost basis subject to the rate-of-increase ceiling under §413.40. The remaining 

providers, 228 rehabilitation hospitals and 961 rehabilitation units, and 429 LTCHs, are paid the 

Federal prospective per discharge rate under the IRF PPS and the LTCH PPS, respectively, and 

507 psychiatric hospitals and 1,208 psychiatric units are paid the Federal per diem amount under 

the IPF PPS. As stated above, IRFs and IPFs are not affected by rate updates in this proposed 

rule. The impacts of the changes to LTCHs are discussed in section IX. of this Appendix. 

 In the past, certain 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). Cancer and children's hospitals continue to be paid on a reasonable cost 

basis subject to TEFRA limits for FY 2011. For these hospitals (cancer and children's hospitals), 

consistent with the authority provided in section 1886(b)(3)(B)(ii) of the Act, the update is the 
CMS-1498-P 1213 

percentage increase in the FY 2011 IPPS operating market basket. In compliance with section 

404 of the MMA, in the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43930), we 

replaced the FY 2002-based IPPS operating and capital market baskets with the revised and 

rebased FY 2006-based IPPS operating and capital market baskets. Therefore, consistent with 

current law, based on IHS Global Insight, Inc.'s 2010 first quarter forecast, with historical data 

through the 2009 fourth quarter, we are estimating that the proposed FY 2011 update to the IPPS 

operating market basket would be 2.4 percent (that is, the current estimate of the market basket 

rate-of-increase). In addition, in accordance with §403.752(a) of the regulations, RNHCIs are 

paid under §413.40. Therefore, for RNHCIs, the proposed update is the same as for children’s 

and cancer hospitals, which is the percentage increase in the FY 2011 IPPS operating market 

basket increase, estimated to be 2.4 percent. 

 The impact of the proposed update in the rate-of-increase limit on those excluded 

hospitals depends on the cumulative cost increases experienced by each excluded hospital since 

its applicable base period. For excluded hospitals 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 excluded hospitals receive. Conversely, for excluded hospitals 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 that continues to be paid under 

the TEFRA system, whose costs exceed 110 percent of its rate-of-increase limit receives its rateof-increase limit plus 50 percent of the difference between its reasonable costs and 110 percent 

of the limit, not to exceed 110 percent of its limit. In addition, under the various provisions set 
CMS-1498-P 1214 

forth in §413.40, cancer and children's hospitals can obtain payment adjustments for justifiable 

increases in operating costs that exceed the limit. 

VI. Quantitative Effects of the 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 payment rate 

updates for the IPPS for operating costs of acute care hospitals. Updates to the capital payments 

to acute care hospitals 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 total FY 2011 operating payments would decrease by 0.1 

percent compared to FY 2010, largely due to the documentation and coding adjustments and 

market basket update to the IPPS rates. This amount reflects the proposed FY 2011 

documentation and coding adjustments described above and in section II.D. of the preamble of 

this proposed rule: -2.9 percent for the IPPS national standardized amounts, -2.9 percent for the 

IPPS hospital-specific rates, and -2.4 percent for the IPPS Puerto Rico-specific standardized 

amount. The impacts do not illustrate changes in hospital admissions or real case-mix intensity, 

which will also affect overall payment changes. 

 We have prepared separate impact analyses of the proposed changes to each system. 

This section deals with changes to the operating prospective payment system for acute care 

hospitals. Our payment simulation model relies on the most recent available data to enable us to 

estimate the impacts on payments per case of certain proposed 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 
CMS-1498-P 1215 

have attempted to predict the payment impacts based upon our experience and other more limited 

data. 

 The data used in developing the quantitative analyses of changes in payments per case 

presented below are taken from the FY 2009 MedPAR file and the most current 

Provider-Specific File that is used for payment purposes. Although the analyses of the proposed 

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 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 2009 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 the capital IPPS for FY 2011 are discussed in section VIII. of this 

Appendix. 

 The changes discussed separately below are the following: 
CMS-1498-P 1216 

● The effects of the proposed annual reclassification of diagnoses and procedures, full 

implementation of the MS-DRG system and 100 percent cost-based MS-DRG relative weights. 

● The effects of the proposed changes in hospitals' wage index values reflecting wage 

data from hospitals’ cost reporting periods beginning during FY 2007, compared to the FY 2006 

wage data. 

● The effects of the recalibration of the MS-DRG relative weights as required by section 

1886(d)(4)(C) of the Act, including the proposed wage and recalibration budget neutrality 

factors. 

● The effects of geographic reclassifications by the MGCRB that will be effective in FY 

2011. 

● The effects of the third year of the 3-year transition to apply rural floor budget 

neutrality adjustment at the State level. For purposes of this impact analysis, we assume that in 

FY 2011, hospitals will receive a wage index with the State level rural and imputed floor budget 

neutrality adjustment. Hiowever, we recognize that this policy was recently changed by the 

provisions of section 3141 of Pub. L. 111-148 and will address the new impact in a separate 

document in the Federal Register. 

● The effects of section 505 of Pub. L. 108-173, which provides for an increase in a 

hospital’s wage index if the hospital qualifies by meeting a threshold percentage of residents of 

the county where the hospital is located who commute to work at hospitals in counties with 

higher wage indexes. 

● The total estimated change in payments based on the proposed FY 2011 policies 

relative to payments based on FY 2010 policies that include the proposed market basket update 

of 2.4 percent. 
CMS-1498-P 1217 

 To illustrate the impacts of the proposed FY 2011 changes, our analysis begins with a 

FY 2010 baseline simulation model using: the proposed FY 2011 market basket update of 

2.4 percent; the FY 2010 MS-DRG GROUPER (Version 27.0); the most current CBSA 

designations for hospitals based on OMB's MSA definitions; the FY 2010 wage index; and no 

MGCRB reclassifications. Outlier payments are set at 5.1 percent of total operating MS-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 that this impact was prepared, 104 hospitals did 

not receive the full market basket rate-of-increase for FY 2010 because they failed the quality 

data submission process or did not choose to participate. For purposes of the simulations shown 

below, we modeled the proposed payment changes for FY 2011 using a reduced update for these 

104 hospitals. However, we do not have enough information at this time to determine which 

hospitals will not receive the full market basket rate-of-increase for FY 2011. 

 Each policy change, statutory or otherwise, is then added incrementally to this baseline, 

finally arriving at an FY 2011 model incorporating all of the 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 2010 to FY 2011. Three factors not discussed separately have significant impacts here. The 

first factor is the update to the standardized amount. In accordance with section 1886(b)(3)(B)(i) 

of the Act, we are proposing to update the standardized amounts for FY 2011 using the most 

recently forecasted hospital market basket increase for FY 2011 of 2.4 percent. (Hospitals that 
CMS-1498-P 1218 

fail to comply with the quality data submission requirements to receive the full update will 

receive an update reduced by 2.0 percentage points from 2.4 percent to 0.4 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 percentage increase, or 2.4 percent. 

 A second significant factor that affects the changes in hospitals' payments per case from 

FY 2010 to FY 2011 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 2010 that are 

no longer reclassified in FY 2011. Conversely, payments may increase for hospitals not 

reclassified in FY 2010 that are reclassified in FY 2011. 

A third significant factor is that we currently estimate that actual outlier payments during 

FY 2011 will be 5.1 percent of total MS-DRG payments. When the FY 2010 final rule was 

published, we projected FY 2010 outlier payments would be 5.1 percent of total MS-DRG plus 

outlier payments; the average standardized amounts were offset correspondingly. The effects of 

the higher than expected outlier payments during FY 2010 (as discussed in the Addendum to this 

proposed rule) are reflected in the analyses below comparing our current estimates of FY 2010 

payments per case to estimated FY 2011 payments per case (with outlier payments projected to 

equal 5.1 percent of total MS-DRG payments). 

B. Analysis of Table I

 Table I displays the results of our analysis of the proposed changes for FY 2011. 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 3,472 acute care hospitals included in the analysis. 
CMS-1498-P 1219 

 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 2,502 hospitals located in urban areas included in our analysis. Among these, there are 1,365 

hospitals located in large urban areas (populations over 1 million), and 1,137 hospitals in other 

urban areas (populations of 1 million or fewer). In addition, there are 970 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 2011 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 numbers 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 2,555, 1,403, 1,152 and 917, respectively. 

 The next three groupings examine the impacts of the 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 

2,434 nonteaching hospitals in our analysis, 798 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 or rural, in terms of whether they receive the IME adjustment, the 

DSH adjustment, both, or neither. 
CMS-1498-P 1220 

 The next five rows examine the impacts of the changes on rural hospitals by special 

payment groups (SCHs, RRCs, and MDHs). There were 183 RRCs, 340 SCHs, 187 MDHs, and 

108 hospitals that are both SCHs and RRCs, and 13 hospitals that are both an MDH and an RRC. 

 The next series of 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 2008 or FY 2007 Medicare cost reports. 

 The next two groupings concern the geographic reclassification status of hospitals. The 

first grouping displays all urban hospitals that were reclassified by the MGCRB for FY 2011. 

The second grouping shows the MGCRB rural reclassifications. 

 The final category shows the impact of the proposed policy changes on the 19 cardiac 

hospitals in our analysis. 
CMS-1498-P 1221 

TABLE I.--IMPACT ANALYSIS OF PROPOSED CHANGES TO THE IPPS FOR OPERATING COSTS FOR 

No. of 

Hospitals 

Proposed 

FY 2011 

Weights 

& MSDRG 

Change

s 

(1) 

Appli

cation 

of 

Recal

ibration 

Budg

et 

Neutrality 

(2) 

Proposed 

FY 

2011 

Wage 

Data 

(3) 

Application of 

Wage 

Budget 

Neu-trality 

(4) 

Proposed FY 

2011 

DRG, Rel. 

Wts., 

Wage 

Index 

Changes, 

with 

Wage 

and 

Recalibration 

Budget 

Neutrality 

(5) 

FY 2011 MGCRB 

Reclassifications 

(6) 

Proposed 

Rural 

Floor 

Budget 

Neutrality 

and 

Within 

State 

Rural 

Floor 

Budget 

Neutrality 

(7) 

Proposed FY 

2011 OutMigration 

Adjustment 

(8) 

All P

pos

FY 2

Chan

Prior t

CMI Ad

me

(9

All Hospitals 3,472 0.3

0

0

0

0

0

0

0 

By Geographic Location: Urban hospitals 2,502 0.3

0

0

0

0 -0.2

0

0 

Large urban areas 1,365 0.2 -0.1

0 0.1

0 -0.3 -0.1

0 

Other urban areas 1,137 0.4 0.1 -0.1 -0.1

0

0 0.1

0 

Rural hospitals 970 0.3

0

0

0

0 1.6 -0.1 0.1 

Bed Size (Urban): 0-99 beds 635 0.6 0.2

0

0 0.3 -0.5

0

0 

100-199 beds 791 0.2 -0.1

0

0

0

0 0.1

0 

200-299 beds 461 0.3

0

0

0

0 -0.1

0

0 

300-499 beds 425 0.3

0

0

0

0 -0.2

0

0 

500 or more beds 190 0.3

0 -0.1 -0.1

0 -0.2 -0.1

0 

Bed Size (Rural): 0-49 beds 337 0.6 0.3 0.1 0.1 0.3 0.6

0 0.2 

50-99 beds 366 0.3

0

0

0

0 0.6

0 0.1 

100-149 beds 164 0.3

0

0

0

0 2.1 -0.1 0.1 

150-199 beds 61 0.3

0

0

0 0.1 2.4 -0.1

0 

200 or more beds 42 0.2 -0.1

0 0.1 -0.1 2.3

0

0 

Urban by Region: New England 121 0.1 -0.2 -0.4 -0.4 -0.6 0.9

0

0 
CMS-1498-P 1222 

No. of 

Hospitals 

Proposed 

FY 2011 

Weights 

& MSDRG 

Change

s 

(1) 

Appli

cation 

of 

Recal

ibration 

Budg

et 

Neutrality 

(2) 

Proposed 

FY 

2011 

Wage 

Data 

(3) 

Application of 

Wage 

Budget 

Neu-trality 

(4) 

Proposed FY 

2011 

DRG, Rel. 

Wts., 

Wage 

Index 

Changes, 

with 

Wage 

and 

Recalibration 

Budget 

Neutrality 

(5) 

FY 2011 MGCRB 

Reclassifications 

(6) 

Proposed 

Rural 

Floor 

Budget 

Neutrality 

and 

Within 

State 

Rural 

Floor 

Budget 

Neutrality 

(7) 

Proposed FY 

2011 OutMigration 

Adjustment 

(8) 

All P

pos

FY 2

Chan

Prior t

CMI Ad

me

(9

Middle Atlantic 330 0.3

0 -0.3 -0.3 -0.3 0.2

0

0 

South Atlantic 383 0.1 -0.2

0

0 -0.2 -0.3

0

0 

East North Central 403 0.1 -0.1 0.2 0.2 0.1 -0.2

0

0 

East South Central 155 0.4 0.2 -0.5 -0.6 -0.4 -0.2

0

0 

West North Central 166 0.5 0.2 -0.1 -0.1 0.1 -0.7

0

0 

West South Central 342 0.5 0.2 0.2 0.2 0.4 -0.6

0

0 

Mountain 162 0.3

0

0

0

0 -0.3

0

0 

Pacific 390 0.6 0.2 0.4 0.4 0.5 -0.3

0

0 

Puerto Rico 50 0.9 0.7 -0.3 -0.3 0.4 -0.8

0

0 

Rural by Region: New England 24 0.2 -0.2

0

0 -0.2 0.5

0

0 

Middle Atlantic 70 -0.1 -0.4 0.4 0.4

0 1.4 -0.1

0 

South Atlantic 165 -0.2 -0.5 -0.3 -0.4 -0.9 2 0 0.1 East North Central 120 0.3

0 -0.1 -0.1 -0.2 1.3

0

0 

East South Central 175 0.6 0.3 0.2 0.2 0.5 2.4 -0.1 0.2 West North Central 100 0.7 0.4

0

0 0.4 0.5

0

0 

West South Central 214 0.7 0.5 0.3 0.4 0.8 1.9

0 0.1 

Mountain 71 0.7 0.4

0

0 0.4 0.1

0

0 

Pacific 31

0 -0.4 0.3 0.3 -0.1 0.9 -0.3

0 

By Payment Classification: Urban hospitals 2,555 0.3

0

0

0

0 -0.2

0

0 

Large urban areas 1,403 0.2

0

0 0.1

0 -0.3 -0.1

0 
CMS-1498-P 1223 

No. of 

Hospitals 

Proposed 

FY 2011 

Weights 

& MSDRG 

Change

s 

(1) 

Appli

cation 

of 

Recal

ibration 

Budg

et 

Neutrality 

(2) 

Proposed 

FY 

2011 

Wage 

Data 

(3) 

Application of 

Wage 

Budget 

Neu-trality 

(4) 

Proposed FY 

2011 

DRG, Rel. 

Wts., 

Wage 

Index 

Changes, 

with 

Wage 

and 

Recalibration 

Budget 

Neutrality 

(5) 

FY 2011 MGCRB 

Reclassifications 

(6) 

Proposed 

Rural 

Floor 

Budget 

Neutrality 

and 

Within 

State 

Rural 

Floor 

Budget 

Neutrality 

(7) 

Proposed FY 

2011 OutMigration 

Adjustment 

(8) 

All P

pos

FY 2

Chan

Prior t

CMI Ad

me

(9

Other urban areas 1,152 0.4 0.1 -0.1 -0.1

0

0 0.1

0 

Rural areas 917 0.3

0

0

0

0 1.4

0 0.1 

Teaching Status: Nonteaching 2,434 0.4

0 0.1 0.1 0.1 0.2

0

0 

Fewer than 100 residents 798 0.3

0 -0.1 -0.1 -0.1 -0.2

0

0 

100 or more residents 240 0.3

0 -0.1 -0.1 -0.1 -0.2 -0.1

0 

Urban DSH: Non-DSH 834 0.5 0.1

0

0

0 0.1

0

0 

100 or more beds 1,510 0.3

0

0

0

0 -0.2

0

0 

Less than 100 beds 340 0.2 -0.1

0

0

0 -0.3 -0.1

0 

Rural DSH: SCH 407 0.3

0

0

0

0 0.2

0 0.1 

RRC 209 0.2 -0.1 0.1 0.1

0 2.3 -0.1

0 

100 or more beds 30 0.1 -0.2 -0.3 -0.3 -0.5 1.2

0 0.3 

Less than 100 beds 142 0.4 0.2

0 0.1 0.2 0.9 -0.1 0.5 

Urban teaching and DSH: Both teaching and DSH 806 0.3

0 -0.1 -0.1 -0.1 -0.3

0

0 

Teaching and no DSH 169 0.3 -0.1 -0.2 -0.2 -0.2 0.4

0

0 

No teaching and DSH 1,044 0.3

0 0.2 0.2 0.2

0 0.1

0 
CMS-1498-P 1224 

No. of 

Hospitals 

Proposed 

FY 2011 

Weights 

& MSDRG 

Change

s 

(1) 

Appli

cation 

of 

Recal

ibration 

Budg

et 

Neutrality 

(2) 

Proposed 

FY 

2011 

Wage 

Data 

(3) 

Application of 

Wage 

Budget 

Neu-trality 

(4) 

Proposed FY 

2011 

DRG, Rel. 

Wts., 

Wage 

Index 

Changes, 

with 

Wage 

and 

Recalibration 

Budget 

Neutrality 

(5) 

FY 2011 MGCRB 

Reclassifications 

(6) 

Proposed 

Rural 

Floor 

Budget 

Neutrality 

and 

Within 

State 

Rural 

Floor 

Budget 

Neutrality 

(7) 

Proposed FY 

2011 OutMigration 

Adjustment 

(8) 

All P

pos

FY 2

Chan

Prior t

CMI Ad

me

(9

No teaching and no DSH 536 0.6 0.2

0

0 0.2 -0.2

0

0 

Special Hospital Types: RRC 183 0.4 0.1

0

0 0.2 2.9 -0.1

0 

SCH 340 0.3

0

0

0

0

0

0

0 

MDH 187 0.2 -0.1

0

0 -0.1 0.4 -0.1 0.2 

 SCH and RRC 108 0.2 -0.2 -0.1 -0.1 -0.2 0.7

0

0 

 MDH and RRC 13 0.4

0 0.2 0.2 0.2 0.2

0 0.1 

Type of Ownership: Voluntary 1978 0.3

0

0

0

0

0

0

0 

Proprietary 837 0.4 0.1 0.2 0.2 0.3 -0.1

0

0 

Government 577 0.3

0 -0.1 -0.1

0 0.1 0.1

0 

Medicare Utilization as a Percent of Inpatient Days: 0-25 353 0.2 -0.1

0

0

0 -0.4 -0.1

0 

25-50 1,593 0.3

0

0

0

0 -0.3

0

0 

50-65 1,202 0.3

0

0 -0.1 -0.1 0.6

0

0 

Over 65 237 0.4 0.2 -0.1 -0.2

0 0.6 0.1

0 

FY 2011 Reclassifications by the Medicare Geographic Classification Review Board: 
CMS-1498-P 1225 

No. of 

Hospitals 

Proposed 

FY 2011 

Weights 

& MSDRG 

Change

s 

(1) 

Appli

cation 

of 

Recal

ibration 

Budg

et 

Neutrality 

(2) 

Proposed 

FY 

2011 

Wage 

Data 

(3) 

Application of 

Wage 

Budget 

Neu-trality 

(4) 

Proposed FY 

2011 

DRG, Rel. 

Wts., 

Wage 

Index 

Changes, 

with 

Wage 

and 

Recalibration 

Budget 

Neutrality 

(5) 

FY 2011 MGCRB 

Reclassifications 

(6) 

Proposed 

Rural 

Floor 

Budget 

Neutrality 

and 

Within 

State 

Rural 

Floor 

Budget 

Neutrality 

(7) 

Proposed FY 

2011 OutMigration 

Adjustment 

(8) 

All P

pos

FY 2

Chan

Prior t

CMI Ad

me

(9

All Reclassified Hospitals 810 0.3

0 0.1 0.1

0 1.8 -0.1

0 

Non-Reclassified Hospitals 2,662 0.3

0

0

0

0 -0.6

0

0 

Urban Hospitals Reclassified 488 0.3

0 0.1 0.1

0 1.6 -0.2

0 

Urban Nonreclassified Hospitals, FY 2011: 1,985 0.3

0

0

0

0 -0.7 0.1

0 

All Rural Hospitals Reclassified FY 2011: 322 0.3

0 0.1 0.1 0.1 2.7 -0.1

0 

Rural Nonreclassified Hospitals FY 2011: 585 0.4

0

0

0 0.1 -0.3

0 0.2 

All Section 401 Reclassified Hospitals: 37 -0.1 -0.4 -0.1 -0.1 -0.5 -0.3

0

0 

Other Reclassified Hospitals (Section 1886(d)(8)(B)) 63 -0.2 -0.5 -0.2 -0.2 -0.6 2.9 -0.1

0 

Specialty Hospitals Cardiac specialty Hospitals 19 1.1 0.8 0.3 0.3 1.1 -0.8

0

0 

1 Because data necessary to classify some hospitals by category were missing, the total number of hospitals in each category may not equal the national total. Discharge 

hospital cost report data are from reporting periods beginning in FY 2008 and FY 2007.

2 This column displays the payment impact of the proposed changes to the Version 28 GROUPER and the recalibration of the MS-DRG weights based on FY 2009 MedP

section 1886(d)(4)(C)(iii) of the Act. 

3 This column displays the application of the recalibration budget neutrality factor of 0.996856, in accordance with section 1886(d)(4)(C)(iii) of the Act. 4.This column displays the proposed payment impact of the update to wage index data using FY 2007 cost report data. 5This column displays the payment impact of the application of the wage budget neutrality factor in accordance with section 1886(d)(3)(E)(i) of the Act. This factor is crecalibration budget neutrality factor. The wage budget neutrality factor is1.000107. 
CMS-1498-P 1226 

6 This column displays the combined payment impact of the proposed changes in Columns 2 through 5 and the proposed cumulative budget neutrality factor for MS-DRG accordance with section 1886(d)(4)(C)(iii) of the Act and section 1886(d)(3)(E) of the Act. The cumulative wage and recalibration budget neutrality factor of 0.996963ineutrality factor and the recalibration budget neutrality factor. 7 Shown here are the effects of geographic reclassifications by the Medicare Geographic Classification Review Board (MGCRB). The effects demonstrate the FY 2011 p

reclassifications to the reclassifications scheduled to be in effect for FY 2011. Reclassification for prior years has no bearing on the payment impacts shown here. This c

budget neutrality factor of 0.991756. 8 This column displays the effects of the rural floor and the imputed floor, including the transition to the rural floor budget neutrality adjustment at the State level. Under 

receive a blended wage index that is 100 percent of a wage index with the State level rural and imputed floor budget neutrality adjustment. 9 This column displays the impact of section 505 of Pub. L. 108-173, which provides for an increase in a hospital’s wage index if the hospital qualifies by meeting a thres

the county where the hospital is located who commute to work at hospitals in counties with higher wage indexes. 

10 This column shows the proposed changes in payments from FY 2010 to FY 2011. It reflects the impact of the proposed FY 2011 market basket update, and the propos

standardized amount due to the documentation and coding effect. The proposed FY 2011 documentation and coding adjustment is -2.9 percent to the IPPS standardized hospital-specific rates, and -2.4 percent to the Puerto Rico-specific amount. It also reflects changes in hospitals’ reclassification status in FY 2011 compared to FY 2010proposed changes displayed in Columns 5, 6, 7, and 8 (the changes displayed in Columns 2, 4 are included in Column 5). The sum of these impacts may be different frohere due to rounding and interactive effects. 
CMS-1498-P 1227 

C. Effects of the Proposed Changes to the MS-DRG Reclassifications and Relative Cost-Based 

Weights (Column 1)

 In Column 1 of Table I, we present the effects of the proposed MS-DRG reclassifications, 

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, the proposed FY 2011 MS-DRG 

relative weights will be 100 percent cost-based and 100 percent MS-DRGs. For FY 2011, the 

MS-DRGs are calculated using the FY 2009 MedPAR data grouped to the Version 28.0 (FY 

2011) MS-DRGs. The methods of calculating the proposed 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. The proposed changes to the relative weights and MS-DRGs 

shown in Column 2 are prior to any offset for budget neutrality. Overall, hospitals will 

experience a 0.3 percent increase in payments due to the changes in the MS-DRGs and relative 

weights prior to budget neutrality. Urban hospitals and rural hospitals will experience a 0.3 

percent increase in payments under the updates to the relative weights and MS-DRGs. 

D. Effects of the Application of Recalibration Budget Neutrality (Column 2)

 Column 2 shows the effects of the changes to the MS-DRGs and relative weights with the 

application of the recalibration budget neutrality factor to the standardized amounts. Consistent 

with section 1886(d)(4)(C)(iii) of the Act, we are calculating a recalibration budget neutrality 

factor to account for the changes in MS-DRGs and relative weights to ensure that the overall 

payment impact is budget neutral. In FY 2010, we began calculating a budget neutrality factor to 
CMS-1498-P 1228 

account for changes in MS-DRGs and relative weights separately from the budget neutrality 

factor to account for changes in wage data. In addition, as described in section II.A.4. of the 

Addendum to this proposed rule, we are including IME payments made on Medicare Advantage 

claims to IPPS hospitals in order to calculate budget neutrality. 

 The “All Hospitals” line in Column 1 indicates that proposed changes due to MS-DRGs 

and relative weights will increase payments by 0.3 percent before application of the budget 

neutrality factor. The proposed recalibration budget neutrality factor is 0.996856, which is 

applied to the standardized amount. Thus, the impact after accounting only for budget neutrality 

for changes to the MS-DRG relative weights and classification is somewhat lower than the 

figures shown in Column 1 (approximately 0.3 percent). Consequentially, urban and rural 

hospitals will not experience a change in payments when recalibration budget neutrality is 

applied. 

E. 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 acute care hospitals for FY 2011 is based on data submitted for hospital 

cost reporting periods beginning on or after October 1, 2006 and before October 1, 2007. The 

estimated impact of the updated wage data and labor share 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 change in payments when going from a model using the FY 2010 wage 

index, based on FY 2006 wage data, the current labor-related share and having a 100-percent 

occupational mix adjustment applied, to a model using the FY 2011 pre-reclassification wage 

index with the labor-related share, also having a 100-percent occupational mix adjustment 
CMS-1498-P 1229 

applied, based on FY 2007 wage data (while holding other payment parameters such as use of 

the Version 28.0 MS-DRG GROUPER constant). The occupational mix adjustment is based on 

the FY 2008/2009 occupational mix survey. 

 Column 3 shows the impacts of updating the wage data using FY 2007 cost reports. 

Overall, the new wage data will lead to a 0.0 percent change for all hospitals before being 

combined with the wage budget neutrality adjustment shown in Column 5. Among the regions, 

the largest increase is in the rural Middle Atlantic region, which experiences a 0.4 percent 

increase before applying an adjustment for budget neutrality. The largest decline from updating 

the wage data is seen in Urban East South Central (0.5 percent decrease). 

 In looking at the wage data itself, the national average hourly wage increased 1.2 percent 

compared to FY 2010. Therefore, the only manner in which to maintain or exceed the previous 

year's wage index was to match or exceed the national 1.2 percent increase in average hourly 

wage. Of the 3,442 hospitals with wage data for both FYs 2010 and 2011, 2,696, or 78.3 

percent, experienced an average hourly wage increase of 1.2 percent or more. 

 The following chart compares the shifts in proposed wage index values for hospitals for 

FY 2011 relative to FY 2010. Among urban hospitals, 39 will experience an increase of more 

than 5 percent and less than 10 percent and 7 will experience an increase of more than 

10 percent. Among rural hospitals, 2 will experience an increase of more than 5 percent and less 

than 10 percent, and none will experience an increase of more than 10 percent. However, 938 

rural hospitals will experience increases or decreases of less than 5 percent, while 2,415 urban 

hospitals will experience increases or decreases of less than 5 percent. Twenty-four urban 

hospitals will experience decreases in their wage index values of more than 5 percent and less 

than 10 percent. Sixteen urban hospitals will experience decreases in their wage index values of 
CMS-1498-P 1230 

greater than 10 percent. One rural hospital will experience a decrease of more than 10 percent. 

These figures reflect changes in the wage index which is an adjustment to either 68.8 percent or 

62 percent of a hospital’s standardized amount, depending upon whether its wage index is 

greater than 1.0 or less than or equal to 1.0. Therefore, these figures are illustrating a somewhat 

larger change in the wage index than will occur to the hospital’s total payment. 

 The following chart shows the projected impact for urban and rural hospitals. 

Percentage Change in Area Wage Index Values Number of Hospitals 

 Urban Rural 

Increase more than 10 percent 7 0

Increase more than 5 percent and less than 10 percent 39 2

Increase or decrease less than 5 percent 2,415 938

Decrease more than 5 percent and less than 10 percent 24 0

Decrease more than 10 percent 16 1

F. Application of the Wage Budget Neutrality Factor (Column 4)

 Column 4 shows the impact of the new wage data with the application of the wage budget 

neutrality factor. In FY 2010, we began calculating separate wage budget neutrality and 

recalibration budget neutrality factors, in accordance with section 1886(d)(3)(E) of the Act, 

which specifies that budget neutrality to account for wage changes or updates made under that 

subparagraph must be made without regard to the 62 percent labor-related share guaranteed 

under section 1886(d)(3)(E)(ii) of the Act. Therefore, for FY 2011, we are calculating the wage 

budget neutrality factor to ensure that payments under updated wage data and the proposed 

labor-related share are budget neutral without regard to the lower labor-related share of 62 

percent applied to hospitals with a wage index less than or equal to 1. In other words, the wage 

budget neutrality is calculated under the assumption that all hospitals receive the higher laborrelated share of the standardized amount. Because the wage data changes did not change overall 
CMS-1498-P 1231 

payments (displayed in Column 3), the wage budget neutrality factor is minimal at 1.000107, and 

the overall payment change is 0.0 percent. 

G. Combined Effects of Proposed MS-DRG and Wage Index Changes (Column 5)

 Section 1886(d)(4)(C)(iii) of the Act requires that changes to MS-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. We computed a proposed wage budget neutrality factor of 1.000107, and a 

proposed recalibration budget neutrality factor of 0.996856 (which is applied to the Puerto Rico 

specific standardized amount and the hospital-specific rates). The product of the two budget 

neutrality factors is the cumulative wage and recalibration budget neutrality factor. The 

proposed cumulative wage and recalibration budget neutrality adjustment is 0.996963, or 

approximately -0.3 percent, which is applied to the national standardized amounts. Because the 

wage budget neutrality and the recalibration budget neutrality are calculated under different 

methodologies according to the statute, when the two budget neutralities are combined and 

applied to the standardized amount, the overall payment impact is not necessarily budget neutral. 

However, in this proposed rule, we are estimating that the proposed changes in the MS-DRG, 

relative weights and updated wage data with wage and budget neutrality applied will result in a 

0.0 change in payments. The estimated changes shown in this column reflect the combined 

effects of the changes in Columns 2, 3, and 4 and the budget neutrality factors discussed 

previously. 

 We estimate that the combined impact of the proposed changes to the relative weights 

and MS-DRGs and the proposed updated wage data with budget neutrality applied will result in 

no change in payments for urban or rural hospitals. Urban New England would experience a 0.6 
CMS-1498-P 1232 

decrease in payments due to reductions in their case-mix and wages compared to the national 

average, while the urban Pacific area would experience a 0.5 percent increase in payments 

because of above average increases in wages and case-mix. Among the rural hospital categories, 

rural South Atlantic hospitals would experience the greatest decline in payment (-0.9 percent) 

primarily due to the changes to MS-DRGs and the relative cost weights. 

H. Effects of MGCRB Reclassifications (Column 6)

 Our impact analysis to this point has assumed acute care 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 

changes in Column 6 reflect the per case payment impact of moving from this baseline to a 

simulation incorporating the MGCRB decisions for FY 2011 which affect hospitals' wage index 

area assignments. 

 By spring 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. 

Hospitals may appeal denials of MGCRB decisions to the CMS Administrator. Further, 

hospitals have 45 days from publication of the IPPS rule in the Federal Register to decide 

whether to withdraw or terminate an approved geographic reclassification for the following year. 

This column reflects all MGCRB decisions, Administrator appeals and decisions of hospitals for 

FY 2011 geographic reclassifications. 

 The overall effect of geographic reclassification is required by section 1886(d)(8)(D) of 

the Act to be budget neutral. Therefore, for the purposes of this impact analysis, we are applying 

an adjustment of 0.991756 to ensure that the effects of the section 1886(d)(10) reclassifications 
CMS-1498-P 1233 

are budget neutral (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 1.6 percent. By region, 

all the rural hospital categories will experience increases in payments due to MGCRB 

reclassification where rural hospitals in the Mountain region will experience a 0.1 percent 

increase in payments and rural hospitals in the East South Central region will experience a 2.4 

percent increase in payments. 

 Table 9A of the Addendum to this proposed rule reflects the approved reclassifications 

for FY 2011. 

I. Effects of the Rural Floor and Imputed Floor, Including Application of Budget Neutrality at 

the State Level (Column 7)

 As discussed in section III.B. of the preamble of the FY 2009 IPPS final rule, the FY 

2010 IPPS/RY 2010 LTCH final rule and 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 wage index received by rural hospitals in the same State. In FY 2008, we 

changed how we applied budget neutrality to the rural floor. Rather than applying a budget 

neutrality adjustment to the standardized amount, a uniform budget neutrality adjustment is 

applied to the wage index. In the FY 2009 final rule, we finalized the policy to apply the rural 

floor budget neutrality at the State level with a 3-year transition. In FY 2009, hospitals received 

a blended wage index that is 20 percent of a wage index with the State level rural and imputed 

floor budget neutrality adjustment and 80 percent of a wage index with the national budget 

neutrality adjustment. In FY 2010, hospitals received a blended wage index that is 50 percent of 

a wage index with the State level rural and imputed floor budget neutrality and 50 percent of a 
CMS-1498-P 1234 

wage index with the national budget neutrality adjustment. For FY 2011, for purposes of this 

impact analysis, we assume application of the third year of the transitional period so that wage 

indices adjusted for the rural floor will have 100 percent of the wage index adjusted with a 

within-State rural budget neutrality factor. However, we recognize that this policy was recently 

changed by the provisions of section 3141 of Pub. L. 111-148. 

 Furthermore, the FY 2005 IPPS final rule (69 FR 49109) established a temporary 

imputed 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 floor was established for States that do not have rural areas or rural IPPS 

hospitals. In the FY 2008 IPPS final rule with comment period (72 FR 47321), we finalized our 

proposal to extend the imputed floor for 1 additional year. In the FY 2009 IPPS final rule (73 FR 

48573), we extended the imputed floor for an additional 3 years through FY 2011. Furthermore, 

as noted above, in that final rule we provided for a 3-year transition to the rural floor budget 

neutrality adjustment at the State level. Therefore, we also apply the imputed floor budget 

neutrality adjustment at the State level through a 3-year transition, so that, for FY 2011, wage 

indices adjusted for the imputed floor will have 100 percent of the wage index computed using 

the within-State rural and imputed budget neutrality adjustment. 

 Column 7 shows the projected impact of the rural floor and the imputed floor and the 

within-State rural and imputed floor budget neutrality. The column compares the proposed postreclassification FY 2011 wage index of providers before the rural floor adjustment and the postreclassification FY 2011 wage index of providers with the rural floor and imputed floor 

adjustment. Only urban hospitals can benefit from the rural floor provision. Because the 

provision is budget neutral, in prior years, all other hospitals (that is, all rural hospitals and those 
CMS-1498-P 1235 

urban hospitals to which the adjustment is not made) had experienced a decrease in payments 

due to the budget neutrality adjustment applied nationally. However, because, for FY 2011, this 

calculation assumes that the rural floor adjusted wage index is made budget neutral through a 

within-State budget neutrality factor, rural hospitals and urban hospitals located in States that do 

not benefit from the rural floor will not experience a change in payments attributable to the rural 

floor. Conversely, all hospitals in States with hospitals receiving a rural floor will have their 

wage indices downwardly adjusted to achieve budget neutrality within the State. 

 We project that, in aggregate, rural hospitals will experience a 0.1 percent decrease in 

payments as a result of the application of rural floor budget neutrality because the rural hospitals 

located in States with a rural floor do not benefit from the rural floor, but have their wage 

indexes downwardly adjusted to ensure that the application of the rural floor is budget neutral 

overall within the State. We project hospitals located in other urban areas (populations of 

1 million or fewer) will experience a 0.1 percent increase in payments because those providers 

benefit from the rural floor. Urban hospitals in the regions can expect 0 percent change in 

payments because within each state, the rural floor is budget neutral and increases in payments 

for providers receiving the rural floor re offset by the within-State budget neutrality factors 

applied to the wage index of the providers in States with a rural floor. Rural hospitals located in 

the Pacific area will experience a 0.3 percent decrease in payments because of the rural floor 

budget neutrality factor in California downwardly adjusts the wage index by 2.4 percent. Rural 

hospitals located in the Middle Atlantic area will experience a 0.1 percent decrease in payments 

because of the imputed rural floor budget neutrality factor (0.97946) in New Jersey downwardly 

adjusts the wage index for rural hospitals by approximately 2 percent. 
CMS-1498-P 1236 

J. Effects of the Proposed Wage Index Adjustment for Out-Migration (Column 8)

 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, small rural providers DSH providers 

with less than 100 beds will experience a 0.5 percent increase in payments in FY 2011 relative to 

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 $20 million. 

K. Effects of All Proposed Changes Prior to Documentation and Coding (or CMI) Adjustment 

(Column 9)

 Column 9 shows our estimate of the changes in payments per discharge from FY 2010 

and FY 2011, resulting from all proposed changes reflected in this proposed rule for FY 2011 

(including statutory changes), other than the proposed documentation and coding adjustment. 

Column 9 reflects the impact of all other FY 2011 changes relative to FY 2010, including those 

shown in Columns 1 through 8. The average increase in payments under the IPPS for all 

hospitals is approximately 2.8 percent. In addition, it reflects the estimated 0.5 percentage point 

difference between the projected outlier payments in FY 2010 (5.1 percent of total MS-DRG 

payments), the current estimate of the percentage of actual outlier payments in FY 2010 
CMS-1498-P 1237 

(4.7 percent) as described in the introduction to this Appendix and the Addendum to this 

proposed rule. 

 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 9 may not equal 

the sum of the percentage changes described above. 

L. Effects of All Proposed Changes With CMI Adjustment (Column 10)

 Column 10 shows our estimate of the changes in payments per discharge from FY 2010 

and FY 2011, resulting from all proposed changes reflected in this proposed rule for FY 2011 

(including statutory changes). This column includes the proposed FY 2011 documentation and 

coding adjustment of -2.9 percent on the national standardized amount, -2.9 percent on the 

hospital-specific rates, and –2.4 percent on the Puerto Rico-specific standardized amount, which 

overall accounts for a 2.9 percent decrease in payments. 

 Column 10 reflects the impact of all proposed FY 2011 changes relative to FY 2010, 

including those shown in Columns 1 through 9. The average decrease in payments under the 

IPPS for all hospitals is approximately -0.1 percent. As described in Column 9, this average 

decrease includes the effects of the 2.4 percent market basket update, the 0.5 percentage point 

difference between the projected outlier payments in FY 2010 (5.1 percent of total MS-DRG 

payments), and the current estimate of the percentage of actual outlier payments in FY 2010 (4.7 

percent). There might also be interactive effects among the various factors comprising the 

payment system that we are not able to isolate. For these reasons, the values in Column 10 may 

not equal the sum of the percentage changes described above. 

 The overall proposed change in payments per discharge for hospitals paid under the IPPS 

in FY 2011 is estimated to decrease by 0.1 percent. The payment decreases among the hospital 
CMS-1498-P 1238 

categories are largely attributed to the proposed documentation and coding adjustments. 

Hospitals in urban areas would experience an estimated 0.1 percent decrease in payments per 

discharge in FY 2011 compared to FY 2010. Hospital payments per discharge in rural areas are 

estimated to decrease by 0.5 percent in FY 2011 as compared to FY 2010. The decreases larger 

than the national average for rural areas are largely attributed to the differential impact of the 

MS-DRGs and wage data and due to the -2.9 percent documentation and coding adjustment 

applied to the national standardized amount and the -2.9 percent documentation and coding 

adjustment to the hospital-specific rate applied to SCHs and MDHs, which generally are 

classified as rural hospitals. 

 Among urban census divisions, the largest estimated payment decreases will be 0.9 

percent in the New England region and 0.6 percent in the Middle Atlantic region, while urban 

hospitals in the Pacific will see the largest payment increases (0.5 percent). Among the rural 

regions, the providers in the New England region will experience the largest decrease in 

payments (1.6 percent) because of reductions due to case-mix and the documentation and coding 

adjustments while rural hospitals in the West South Central region will experience an increase in 

payments by 0.4 percent due to increases in case-mix, wage data and MGCRB reclassification. 

 Among special categories of rural hospitals, MDHs will receive an estimated payment 

decrease of 0.6 percent. MDHs are paid the higher of the IPPS rate based on the national 

standardized amount, that is, the Federal rate, or, if the hospital-specific rate exceeds the Federal 

rate, the Federal rate plus 75 percent of the difference between the Federal rate and the hospitalspecific rate. MDHs will experience a decrease in payments because of the proposed 

documentation and coding adjustments applied to both the hospital-specific rate and the Federal 

rate. SCHs are also paid the higher of their hospital-specific rate or the federal rate. Overall, 
CMS-1498-P 1239 

SCHs will experience an estimated decrease in payments by 0.5 percent due to the proposed 

documentation and coding adjustments to the national standardized amount and the hospitalspecific rates. 

 Rural hospitals reclassified for FY 2011 are anticipated to receive a 0.3 percent payment 

decrease, and rural hospitals that are not reclassifying are estimated to receive a payment 

decrease of 0.7 percent. 

 Cardiac hospitals are expected to experience a payment increase of 0.8 percent in FY 

2011 relative to FY 2010 due to increases in payments attributable to changes in the MS-DRGs 

and relative weights. 

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

 For FY 2011, 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 will 

receive the low-volume adjustment for FY 2011. We estimate that low-volume hospitals will 

experience an increase of $114,000 in payments due to the low volume payment adjustment. 

N. Impact Analysis of Table II

 Table II presents the projected impact of the proposed changes for FY 2011 for urban and 

rural hospitals and for the different categories of hospitals shown in Table I. It compares the 

estimated average payments per discharge for FY 2010 with the proposed payments per 

discharge for FY 2011, 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 estimated percentage changes shown in the last column of Table II 

equal the estimated percentage changes in average payments per discharge from Column 10 of 

Table I. 
CMS-1498-P 1240 

TABLE II.--IMPACT ANALYSIS OF PROPOSED CHANGES FOR FY 2011 

ACUTE CARE HOSPITAL OPERATING PROSPECTIVE PAYMENT SYSTEM 

(PAYMENTS PER DISCHARGE) 

Number of 

Hospitals 

Average 

FY 2010 

Payment Per 

Discharge 

(2) 

Average 

Proposed 

FY 2011 

Payment 

Per 

Discharge 

(3) 

All 

Proposed 

FY 2011 

Changes 

(4) 

All hospitals 3,472 $10,179 $10,166 -0.1

By Geographic Location: 

 Urban hospitals 2,502 $10,607 $10,598 -0.1

 Large urban areas (populations over 1 

million) 1,365 $11,193 $11,181 -0.1

 Other urban areas 

(populations of 1 million or fewer) 1,137 $9,888 $9,882 -0.1

 Rural hospitals 970 $7,577 $7,536 -0.5

 Bed Size (Urban): 

 0-99 beds 635 $8,056 $8,057 0

 100-199 beds 791 $8,926 $8,908 -0.2

 200-299 beds 461 $9,861 $9,842 -0.2

 300-499 beds 425 $10,995 $10,984 -0.1

 500 or more beds 190 $13,104 $13,113 0.1

 Bed Size (Rural): 

 0-49 beds 337 $6,136 $6,137 0

 50-99 beds 366 $7,088 $7,030 -0.8

 100-149 beds 164 $7,485 $7,458 -0.4

 150-199 beds 61 $8,274 $8,249 -0.3

 200 or more beds 42 $9,405 $9,331 -0.8

 Urban by Region: 

 New England 121 $11,035 $10,937 -0.9

 Middle Atlantic 330 $11,677 $11,611 -0.6

 South Atlantic 383 $9,841 $9,827 -0.1

 East North Central 403 $9,967 $9,975 0.1

 East South Central 155 $9,510 $9,475 -0.4

 West North Central 166 $10,131 $10,138 0.1

 West South Central 342 $9,931 $9,961 0.3

 Mountain 162 $10,836 $10,841 0

 Pacific 390 $13,032 $13,092 0.5

 Puerto Rico 50 $5,133 $5,149 0.3

 Rural by Region: 

 New England 24 $9,980 $9,817 -1.6

 Middle Atlantic 70 $7,939 $7,874 -0.8

 South Atlantic 165 $7,348 $7,271 -1

 East North Central 120 $7,854 $7,800 -0.7

 East South Central 175 $6,872 $6,856 -0.2
CMS-1498-P 1241 

Number of 

Hospitals 

Average 

FY 2010 

Payment Per 

Discharge 

(2) 

Average 

Proposed 

FY 2011 

Payment 

Per 

Discharge 

(3) 

All 

Proposed 

FY 2011 

Changes 

(4) 

 West North Central 100 $8,013 $8,003 -0.1

 West South Central 214 $6,805 $6,835 0.4

 Mountain 71 $8,195 $8,184 -0.1

 Pacific 31 $10,340 $10,186 -1.5

By Payment Classification: 

 Urban hospitals 2,555 $10,584 $10,575 -0.1

 Large urban areas (populations over 1 

million) 1,403 $11,171 $11,159 -0.1

 Other urban areas 

(populations of 1 million or fewer) 1,152 $9,859 $9,853 -0.1

 Rural areas 917 $7,638 $7,596 -0.5

 Teaching Status: 

 Non-teaching 2,434 $8,547 $8,537 -0.1

 Fewer than 100 Residents 798 $10,088 $10,066 -0.2

 100 or more Residents 240 $15,040 $15,033 0

 Urban DSH: 

 Non-DSH 834 $8,866 $8,866 0

 100 or more beds 1,510 $11,163 $11,153 -0.1

 Less than 100 beds

 340 $7,594 $7,558 -0.5

 Rural DSH: 

 SCH 407 $7,022 $6,983 -0.6

 RRC 209 $8,414 $8,362 -0.6

 100 or more beds 30 $6,589 $6,547 -0.6

 Less than 100 beds

 142 $5,898 $5,854 -0.7

 Urban teaching and DSH: 

 Both teaching and DSH 806 $12,188 $12,173 -0.1

 Teaching and no DSH 169 $9,705 $9,686 -0.2

 No teaching and DSH 1,044 $9,130 $9,123 -0.1

 No teaching and no DSH 536 $8,468 $8,482 0.2

 Rural Hospital Types: 

 RRC 183 $8,527 $8,493 -0.4

 SCH 340 $7,998 $7,956 -0.5

 MDH 187 $6,325 $6,288 -0.6

 SCH and RRC 108 $9,479 $9,407 -0.8

 MDH and RRC 13 $8,007 $7,955 -0.6

Type of Ownership: 

 Voluntary 1,978 $10,331 $10,310 -0.2

 Proprietary 837 $9,122 $9,132 0.1

 Government 577 $10,688 $10,681 -0.1
CMS-1498-P 1242 

Number of 

Hospitals 

Average 

FY 2010 

Payment Per 

Discharge 

(2) 

Average 

Proposed 

FY 2011 

Payment 

Per 

Discharge 

(3) 

All 

Proposed 

FY 2011 

Changes 

(4) 

 Medicare Utilization as a Percent of 

Inpatient Days: 

 0-25 353 $13,589 $13,576 -0.1

 25-50 1593 $11,094 $11,088 -0.1

 50-65 1202 $8,511 $8,483 -0.3

 Over 65 237 $7,455 $7,438 -0.2

Hospitals Reclassified by the Medicare 

Geographic Classification Review Board: 

 FY 2011 Reclassifications: 

All Reclassified Hospitals FY 2011 810 $9,903 $9,889 -0.1

All Non-Reclassified Hospitals FY 2011 2,662 $10,282 $10,268 -0.1

Urban Reclassified Hospitals FY 2011: 488 $10,557 $10,549 -0.1

Urban Non-reclassified Hospitals FY 2011:..... 1,985 $10,632 $10,623 -0.1

Rural Reclassified Hospitals FY 2011:......: 322 $8,173 $8,145 -0.3

Rural Nonreclassified Hospitals FY 2011: 585 $6,872 $6,822 -0.7

All Section 401 Reclassified Hospitals: 37 $8,923 $8,825 -1.1

Other Reclassified Hospitals (Section 1886(d)(8)(B)) 63 $7,276 $7,190 -1.2

Specialty Hospitals 

 Cardiac Hospitals 19 $11,496 $11,584 0.8

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 changes. Our estimates of the likely impacts associated with these 

other proposed changes are discussed below. 

A. Effects of Proposed Policy on HACs, Including Infections

 In section II.F. of the preamble of this proposed rule, we discuss our implementation of 

section 1886(d)(4)(D) of the Act, which requires the Secretary to identify conditions that are: (1) 

high cost, high volume, or both; (2) result in the assignment of a case to an MS-DRG that has a 
CMS-1498-P 1243 

higher payment when present as a secondary diagnosis; and (3) 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, unless based on data and clinical judgment, it 

cannot be determined at the time of admission whether a condition is present. That is, the case 

will be paid as though the secondary diagnosis were 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 MS-DRG 

reclassifications and recalibration. Therefore, we will perform 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 results in 

cost savings to the Medicare program. 

 We note that the provision will only apply when one or more of the selected conditions 

are the only secondary diagnosis or diagnoses present on the claim that will lead to higher 

payment. Medicare beneficiaries will generally have multiple secondary diagnoses during a 

hospital stay, such that beneficiaries having one MCC or CC will frequently have additional 

conditions that also will generate higher payment. Only a small percentage of the cases will 

have only one secondary diagnosis that would lead to a higher payment. Therefore, if at least 

one nonselected secondary diagnosis that leads to higher payment is on the claim, the case will 

continue to be assigned to the higher paying MS-DRG and there will be no Medicare savings 

from that case. In addition, as discussed in section II.F.3.e. of the preamble of this proposed rule, 

it is possible to have two severity levels where the HAC does not affect the MS-DRG assignment 

or for an MS-DRG not to have severity levels. In either of these circumstances, the case will 
CMS-1498-P 1244 

continue to be assigned to the higher paying MS-DRG and there will be no Medicare savings 

from that case. 

 The HAC payment provision went into effect on October 1, 2008. Our savings estimates 

for the next 5 fiscal years are shown below: 

Year Savings 

(in 

millions)

FY 2011 $23

FY 2012 $24

FY 2013 $25

FY 2014 $26

FY 2015 $26

B. Effects of Proposed Policy Relating to New Medical Service and Technology Add-On 

Payments

 In section II.I. of the preamble to this proposed rule, we discuss the three applications for 

add-on payments for new medical services and technologies for FY 2011, as well as the status of 

the new technologies that were approved to receive new technology add-on payments in FY 

2010. As explained in that section, add-on payments for new technology under section 

1886(d)(5)(K) of the Act are not required to be budget neutral. As discussed in section II.I.4. of 

the preamble of this proposed rule, we have yet to determine whether any of the three 

applications we received for consideration for new technology add-on payments for FY 2011 

will meet the specified criteria. Consequently, it is premature to estimate the potential payment 

impact of any potential new technology add-on payments for FY 2011. We note that if any of 

the three applications are found to be eligible for new technology add-on payments for FY 2011, 

in the FY 2011 IPPS/LTCH PPS final rule, we would discuss the estimated payment impact for 

FY 2011 in that final rule. 
CMS-1498-P 1245 

 However, we are proposing to continue to make new technology add-on payments in FY 

2011 for the CardiowestTM Temporary Total Artificial Heart System (TAH-t) and the Spiration® 

IBV® Valve System. Therefore, we are providing an estimate of total payments for these 

technologies in FY 2011. We note that new technology add-on payments per case are limited to 

the lesser of: (1) 50 percent of the costs of the new technology; or (2) 50 percent of the amount 

by which the costs of the case exceed the standard MS–DRG payment for the case. Because it is 

difficult to predict the actual new technology add-on payment for each case, our estimate below 

is based on the increase in add-on payments for FY 2011 as if every claim that would qualify for 

a new technology add-on payments would receive the maximum add-on payment. Therefore, we 

currently estimate that payments for the TAH-t will increase overall FY 2011 payments by 

$9.54 million. For FY 2010, the applicant estimated that approximately 2,286 Medicare 

beneficiaries would be eligible for the Spiration® IBV® Valve System. Therefore, based on the 

applicant's estimate from FY 2010, we currently estimate that payments for the Spiration® 

IBV® Valve System will increase overall FY 2011 payments by $7.80 million. 

C. Effects of Proposed Requirements for Hospital Reporting of Quality Data for Annual 

Hospital Payment Update

 In Appendix A, section VII.C. of the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 

FR 44224), we discussed the impact of the FY 2011 RHQDAPU program requirements. In this 

proposed rule, we are proposing to retire one of the FY 2011 quality measures. We believe that 

this proposal would not have a significant effect on our previous analysis. We note that, in that 

final rule, we estimated that 96 hospitals would not receive the full payment update in FY 2010 

and that 96 hospitals would not receive the full payment update in FY 2011. As noted above, at 
CMS-1498-P 1246 

the time this analysis was prepared, 104 hospitals did not receive the full payment update in 

FY 2010. 

In section IV.A. of the preamble of this proposed rule, we discuss our proposed 

requirements for hospitals to report quality data under the RHQDAPU program in order to 

receive the full payment update for FY 2012, FY 2013, and FY 2014. We estimate that 

approximately 104 hospitals may not receive the full payment update in any fiscal year. We 

believe that most of these hospitals would be either small rural or small urban hospitals. 

However, at this time, information is not available to determine the hospitals that will not meet 

the requirements for the full hospital market basket increase for FY 2012, FY 2013, and 

FY 2014. 

 For the FY 2012 payment determination, hospitals would be required to submit 

all-patient volume data for selected MS-DRGs that relate to RHQDAPU program measures. The 

submission of all-patient volume data will occur free of charge to hospitals. Therefore, the 

additional resource burden to hospitals for this requirement is expected to be minimal. For the 

FY 2013 payment determination, we have proposed that hospitals will choose one of four 

proposed registry-based topics for which there are currently a number of nationwide registries 

each individually collecting data from a significant proportion of IPPS hospitals. We have 

proposed that hospitals will submit data on proposed measures included within the proposed 

registry-based topic to a registry that we qualify for this purpose. 

 For the proposed ICD Complications registry-based topic, currently, 100 percent of 

hospitals performing ICD implantation participate in the American College of CardiologyNational Cardiovascular Data Registry’s (ACC-NCDR) ICD registry and 78 percent of those 

hospitals are already submitting the additional data elements and secondary population needed to 
CMS-1498-P 1247 

calculate the ICD complication measure. For the proposed Cardiac Surgery registry-based topic, 

we have estimated that 80 to 90 percent of hospitals performing cardiac surgery currently 

participate in a cardiac surgery registry. Therefore, the number of additional hospitals not 

currently participating in a cardiac surgery registry that would choose this topic is expected to be 

minimal. For the proposed Stroke and Nursing Sensitive Care registry-based topics, there are a 

number of registries to which at least 25 percent of IPPS hospitals currently submit data. We 

currently do not know if hospitals would choose one of these two proposed topics if they are not 

already submitting data to one of these registries. The AMI-statin at discharge measure, 

proposed for FY 2013 payment determination, would create minimal additional burden as 

hospitals can collect the data elements from the same charts already being pulled for existing 

RHQDAPU program AMI measures. 

 For the FY 2014 payment determination, the proposed addition of four chart-abstracted 

measures that require hospitals to submit data on all inpatients is expected to create an additional 

burden for hospitals. The information needed for the proposed ED-Throughput measures is 

captured as routine documentation, and therefore is not expected to impose much additional 

burden. The proposed Global Immunization measures would require hospitals to collect 

information on all inpatients regarding flu and pneumonia vaccinations that they are currently 

only collecting for patients admitted for pneumonia. Therefore, the number of patients for which 

these data would need to be collected will increase. 

 We also note that, beginning with the FY 2012 payment update, hospitals must pass our 

validation requirement of a minimum of 75 percent reliability, based upon our chart-audit 

validation process, for three quarters of data from the first quarter of CY 2010 through the third 

quarter of CY 2010. These data are due to the QIO Clinical Warehouse by August 15, 2010 
CMS-1498-P 1248 

(first quarter CY 2010 discharges), November 15, 2010 (second quarter CY 2010 discharges), 

and February 15, 2011 (third quarter CY 2010 discharges). We have continued our efforts to 

ensure that QIOs provide assistance to all hospitals that wish to participate in the RHQDAPU 

program. The requirement of 12 charts per hospital submitted for validation would result in 

approximately 9,600 charts per quarter being submitted to CMS. We reimburse hospitals for the 

cost of sending charts to the Clinical Data Abstraction Center (CDAC) contractor 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 by the CDAC contractor is approximately 150 pages. 

Thus, as a result of the validation requirements we are proposing for the FY 2012 annual 

payment update, we estimate that CMS would have expenditures of approximately $212,000 per 

quarter, which is a reduction from the $597,600 per quarter to collect the charts for the FY 2010 

and FY 2011 annual payment updates. Given that we reimburse for the data collection effort, we 

believe that a requirement for 12 charts per hospital per quarter represents a minimal burden to 

participating hospitals. 

 We have finalized a new validation methodology for FY 2012. We believe that these 

modifications will not change the number of hospitals that fail the validation requirement for FY 

2012 from previous years. We are changing the way we calculate the validation matches (that is, 

all relevant data elements submitted by the hospital must match the independently re-abstracted 

data elements to count as a match), which will make it more difficult for hospitals to satisfy the 

validation requirement. However, we also will validate data for a smaller number of hospitals 

each year and we changed the validation threshold from 80 percent to 75 percent. In addition, 

we conducted analysis in FY 2010 of past validation data and found that at least 95 percent of 

sampled hospitals are expected to pass the 75 percent validation threshold starting in FY 2012. 
CMS-1498-P 1249 

In combination, we believe that these proposed revisions will counterbalance each other and 

result in no additional impact to the number of hospitals failing our validation requirement for 

FY 2012. 

 If we determine that a hospital is not entitled to receive the full FY 2012 payment update 

because it failed to satisfy the validation requirement, and the hospital asks for a reconsideration 

of that decision, we are proposing that the hospital submit complete copies of the medical 

records that it submitted to the CDAC contractor for purposes of the validation for which the 

hospital incurs the cost. We estimate that no greater than 40 hospitals would fail this 

requirement for FY 2012. We estimate that this proposal would cost hospitals approximately 

12 cents per page for copying and approximately $4.00 per chart for postage. We have found, 

based on experience, that an average sized medical chart is approximately 150 pages. Hospitals 

would be required to return all 36 sampled medical records for the three quarters of data from FY 

2010. We estimate that the total cost to the 40 impacted hospitals would be approximately 

$17,600, or $440 per hospital. We believe that this cost is minimal, compared with the 2.0 

percent RHQDAPU program component of the annual payment update at risk. This proposed 

requirement is necessary so that CMS has all the information it needs to fairly and timely make a 

decision on the hospital’s reconsideration request. We also anticipate that this proposed 

requirement would benefit hospitals seeking a reconsideration because it will enable us to 

resolve potential issues earlier in the appeals process, obviating the need for a hearing before the 

Provider Reimbursement Review Board (PRRB). We believe that this benefit would greatly 

outweigh the burden of copying and mailing the requested records. 

 We note that, beginning with FY 2014 and future years, we are considering adding two 

stratum to the current RHQDAPU validation sample of SCIP, AMI, HF, and PN cases. We will 
CMS-1498-P 1250 

consider selecting two additional samples of three cases per selected hospital per quarter to 

validate proposed surgical site infection, blood stream infection, ED-Throughput and Global 

Immunization measures. If we later propose this requirement and adopt it as final through 

rulemaking, we would randomly select a total of 18 records per quarter per validated hospital in 

6 strata (SCIP, AMI, HF, PN, CLABSI/SSI, and ED-Throughput/Immunization measures). The 

requirement of an additional 6 charts per hospital submitted for validation would result in 

approximately 4,800 additional charts per quarter being submitted to CMS. We reimburse 

hospitals for the cost of sending charts to the CDAC contractor 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 by the CDAC contractor is approximately 150 pages. Thus, we would 

expend approximately $105,600 per quarter to collect the charts for the annual payment update 

for FY 2014 and future years. Given that we reimburse for the data collection effort, we believe 

that a proposed requirement of the additional records in FY 2014 per hospital per quarter 

represents a minimal burden to the participating hospital. 

D. Effects of Proposed Policy on Payment for Transfer Cases from Medicare Participating 

Hospitals to Nonparticipating Hospitals and CAHs

 In section IV.B. of the preamble of this proposed rule, we are proposing to expand the 

acute care transfer policy to transfers to nonparticipating acute care hospitals and to CAHs. This 

proposed expansion of the acute care transfer policy aims to further align the policy with its 

original intent, that is, to pay a hospital commensurate with the resources it expends in treating a 

Medicare beneficiary who is transferred. However, the impacts of this change are not possible to 

measure, although we believe the any change in Medicare payments to hospitals associated with 

this proposed change would be negligible. Specifically, because there are relatively few 
CMS-1498-P 1251 

nonparticipating acute care hospitals, we expect that there would be few, if any, transfers to 

nonparticipating hospitals in a given period. In addition, based on the capped inpatient bed size 

of CAHs (that is, not more than 25 inpatient beds) and the CAH distance requirements (that is, a 

CAH must generally be located at least 35 miles from another hospital) , we believe that 

transfers from an IPPS acute care hospital to a CAH occur very infrequently. Therefore, we 

estimate that this proposed expansion of the acute care transfer policy would not have a material 

impact on Medicare payments to acute care hospitals. 

E. Effects of Proposed Change in Criteria for MDHs

 In section IV.D. of the preamble of this proposed rule, we discuss our proposal to revise 

the existing Medicare-dependency criterion for MDHs at §412.108(a)(1)(iii) of the regulations 

(that is, "At least 60 percent of the hospital's inpatient days or discharges were attributable to 

individuals receiving Medicare Part A benefits during the hospital's cost reporting period . . . .") 

by replacing the word “receiving” with the phrase “entitled to”. As a result, we would include in 

the count of Medicare inpatient days or discharges, all days or discharges attributable to 

individuals entitled to the Medicare Part A insurance benefit, including individuals who have 

exhausted their Medicare Part A hospital inpatient coverage benefit. 

 Based on our analysis of data for cost reporting periods beginning in FYs 2007 and 2008, 

we estimate that the proposed change to the MDH definition of Medicare-dependency may allow 

48 more IPPS hospitals to qualify as an MDH. We estimate that this proposed change would 

result in increased expenditure of $3.6 million in FY 2011. (We note that the PPACA (Pub. L. 

111-148) extended the sunset date for MDHs from the end of FY 2011 to the end of FY 2012. 

We plan to issue a separate rulemaking document in the Federal Register to address this 

statutory provision. 
CMS-1498-P 1252 

F. Effects of Proposed Change Relating to Payment Adjustment for Disproportionate Share 

Hospitals

 In section IV.E. of the preamble of this proposed rule, we are proposing to change, 

effective for FY 2011 and subsequent years, the data matching process used to calculate the SSI 

fraction for the Medicare DSH payment adjustment. The SSI fraction is part of the formula used 

to determine whether a subsection (d) hospital qualifies for a DSH payment adjustment and the 

amount of any DSH payment. 

The numerator of a hospital’s DSH SSI fraction is the number of inpatient days for the 

provider’s patients who were entitled to both Medicare Part A and SSI benefits. The 

denominator of the hospital’s SSI fraction is the total number of inpatient days for the provider’s 

patients who were entitled to Part A benefits. In order to calculate the numerator of a hospital’s 

DSH SSI fraction, CMS matches certain Medicare data files with SSI eligibility data files that 

are furnished by SSA. In Baystate Medical Center v. Leavitt (545 F. Supp. 2d 20, as amended, 

587 F. Supp. 2d 37, 44 (D.D.C. 2008)), the district court concluded that, in certain respects, 

CMS’ current matching process did not use the “best available data” to match Medicare patient 

day information with SSI eligibility data. In implementing the Baystate decision, CMS 

recalculated the plaintiff’s SSI fractions and DSH payments for its FYs 1993 through 1996 by 

using a revised data matching process that comports with the district court’s decision. 

We are now proposing to adopt the same revised data matching process for calculating 

hospitals’ DSH SSI fractions for FY 2011 and subsequent fiscal years. In addition, we are 

proposing to use, in the revised matching process, a later update of the MedPAR claims data file 

and the SSI eligibility data file. Specifically, we are proposing to use MedPAR claims files and 

SSI eligibility data that are updated 15 months after the end of the Federal fiscal year, rather than 
CMS-1498-P 1253 

continue with our current practice of using data updated 6 months after the end of the Federal 

fiscal year. We believe that our proposed revision to the timing of the data match would achieve 

an appropriate balance between accounting for additional retroactive SSI eligibility 

determinations and the lifting of SSI payment suspensions and facilitating administrative finality 

through the timely final settlement of Medicare cost reports. 

 We are not able to provide a detailed analysis of the potential impact of the proposed 

revised data matching process. That is, it is not possible to determine whether Medicare DSH 

adjustment payments to hospitals will generally increase or decrease, because hospitals’ SSI 

fractions will vary depending on various factors, including the use of a more updated MedPAR 

claims data file, use of a more updated SSI eligibility data file, and the other features of our 

proposed revised data matching process. 

 With respect to the use of a more updated MedPAR claims data file, we expect that using 

a later version of the MedPAR claims file would increase the number of inpatient claims for a 

given Federal fiscal year and, therefore, would increase the number of Medicare inpatient days 

included in the denominator of the SSI fraction. Depending on whether or not the additional 

claims in the MedPAR file were for Medicare patients who were also eligible for SSI during the 

inpatient stay, the numerator of the SSI fraction might increase or decrease. 

As for the use of an updated SSI eligibility file, we note that retroactive SSI eligibility 

determinations include both the granting and the denial of SSI benefits. Therefore, assuming that 

some of the retroactive SSI eligibility determinations were for Medicare patients, the use of an 

updated SSI eligibility file also could increase or decrease the numerator of the SSI fraction. We 

expect that, as a result of using an updated SSI eligibility file, the SSI fraction for some hospitals 

would increase while it would decrease for other hospitals. 
CMS-1498-P 1254 

We also note that, in the Baystate decision, the district court found that certain records 

(for example, “stale records” and “forced pay records”) were not included in the SSI eligibility 

data that SSA gave to CMS for use in the data matching process. However, the SSI eligibility 

data files began to include certain of these records in the mid-1990’s, and stale records and 

forced pay records were included in the SSI eligibility data files that CMS used in recalculating 

the specific SSI fractions and DSH adjustment payments at issue in the Baystate case. As certain 

of these records are already included in the data matching process and we are making no 

proposals that would change this policy, we are unable to determine if this issue has any cost or 

savings for FY 2011 and subsequent years. 

Finally, our proposed revised data matching process includes the use of SSNs and a 

greater number of Title II numbers and HICANs. As a result, we might be able to identify some 

individuals who were entitled to both Part A and SSI benefits that our current data matching 

process might not have identified. Therefore, we would expect an increase in the SSI fraction for 

certain providers, but we are unable to determine the extent to which DSH adjustment payments 

would increase. 

G. Effects of Proposed Changes Relating to Payments for IME and Direct GME

1. Identifying “Approved Medical Residency Programs” 

 In section IV.H.2. of the preamble of this proposed rule, we discuss our proposal to 

clarify our policy regarding whether an individual is considered to be training in an approved 

medical residency program such that the individual’s time should be included in the FTE count 

for IME and direct GME purposes, or whether that individual should be treated and bill as a 

physician. Specifically, our proposed clarification states that individuals should be treated as and 

bill as physicians if they have already successfully completed at least one residency program 
CMS-1498-P 1255 

(regardless of whether they have passed the board examination for that specialty program), and 

are engaged in subsequent training that will not provide them with knowledge or skills that could 

be applied for additional board certification in another subspecialty, nor do they need that 

training to satisfy requirements for board certification in the specialty program they already 

successfully completed. We also are proposing to revise the definition of “resident” at 

§413.75(b) to mean “an intern, resident, or fellow who is formally accepted, enrolled, and 

participating in an approved medical residency program, including programs in osteopathy, 

dentistry, and podiatry, as required in order to become certified by the appropriate specialty 

board.” 

 With respect to the policy regarding the treatment of trainees that have already 

successfully completed at least one residency program, there is no financial impact on the 

Medicare program because this is a proposed clarification of existing policy and is not a policy 

revision or addition of a new policy. The proposed policy change to the regulations might have 

some limited financial impact to the extent that a hospital previously included trainees who were 

not formally enrolled in an approved program in its FTE counts, and as a result of the proposed 

change to the regulations, would no longer be able to include such trainees in its FTE count for 

IME and direct GME purposes. However, we believe it would be rare for a hospital to have 

included in its FTE count trainees who are not formally enrolled in a residency program in the 

typical fashion. Further, we believe that it would be rare for such a hospital to have sufficient 

room under its IME and direct GME FTE resident caps to include any such “informally enrolled” 

residents in addition to the typically enrolled residents. Thus, the financial impact of the 

proposed change in the regulatory definition of “resident” would be insignificant. 

2. Submission of Electronic Affiliation Agreements 
CMS-1498-P 1256 

In section IV.H.3. of the preamble of this proposed rule, we discuss our proposal to allow 

hospitals to submit Medicare GME affiliation agreements to the CMS Central Office by 

electronic submission. Over the last several years, we have received numerous inquiries 

regarding the possibility of submitting the Medicare GME affiliation agreement electronically. 

To date, CMS has only accepted signed hard copies of Medicare GME affiliation agreements 

that are received through the mail. Facsimile (FAX) and other electronic submissions of 

affiliation agreements have not been an acceptable means of transmission of affiliation 

agreements to CMS Central Office in order for a hospital to meet the requirements of 

§§413.79(f) and 412.105(f)(1)(vi). 

The increasing frequency of these inquiries and our concerns regarding environmental 

and paperwork reduction have prompted us to reconsider our procedure for hospitals to submit 

Medicare GME affiliation agreements to the CMS Central Office. Accordingly, we are 

proposing to change our policy to provide for electronic submission of the affiliation agreement 

that is required to be sent to the CMS Central Office. This proposal would not affect the 

authority of the fiscal intermediary or MAC to continue to specify its requirements for 

submission for hospitals in its servicing area. 

We are proposing an electronic submission process that would consist of either an e-mail 

mailbox or a Web site where hospitals would submit their Medicare GME affiliation agreements 

to the CMS Central Office. As part of this process, a copy of the Medicare GME affiliation 

agreement would need to be received through the electronic system no later than 11:59 p.m. on 

July 1 of each academic year. We are proposing that the electronic affiliation agreement would 

need to be submitted either as a scanned copy or a PDF version of that hard copy agreement. We 

are proposing not to accept an agreement in any electronic format that could be subject to 
CMS-1498-P 1257 

manipulation. The scanned and/or PDF format will enable CMS to ensure that the agreements 

are signed and dated as required in the regulations at §413.75. 

We believe that allowing an electronic submission of the affiliation agreement to the 

CMS Central Office would assist us in more effectively tracking the groups of hospitals that 

become an affiliation as well as the numbers of FTE cap slots that are being transferred within 

those groups. In addition, we believe an electronic submission process would minimize the 

paperwork burden for hospitals. 

H. Effects of Proposed Changes Relating to CRNA Services Furnished in Rural Hospitals and 

CAHs

 In section IV.I. of the preamble of this proposed rule, we discuss our proposal to amend 

the regulations at §412.113(c)(2)(i)(A) to state that, effective for cost reporting periods beginning 

on or after October 1, 2010, hospitals and CAHs that have reclassified under section 

1886(d)(8)(E) of the Act and §412.103 are eligible to be paid based on reasonable cost for 

anesthesia and related care furnished by qualified nonphysician anesthetists. Under existing 

regulations, a hospital or CAH is not eligible to be paid based on reasonable cost for anesthesia 

and related care furnished by qualified nonphysician anesthetists if the hospital or CAH has been 

granted rural status under §412.103. However, because the Act, as revised by section 608 of 

Pub. L. 100–485, allows for reasonable cost payments for CRNA services if the facility is a 

hospital located in a rural area as defined for purposes of section 1886(d) of the Act, we are 

proposing to revise the regulations to permit urban hospitals that have been reclassified as rural, 

in accordance with section 1886(d)(8)(E) of the Act, to qualify for these payments. We are 

proposing to revise the regulations to state that, effective for cost reporting periods beginning on 

or after October 1, 2010, hospitals and CAHs that have reclassified pursuant to section 
CMS-1498-P 1258 

1886(d)(8)(E) of the Act and §412.103 of the regulations would be eligible to be paid based on 

reasonable cost for anesthesia services and related care provided by qualified nonphysician 

anesthetists. 

We believe it is difficult to quantify the payment impact of this proposed change because, 

in order to qualify for reasonable cost-based payment for anesthesia and related services 

provided by qualified nonphysician anesthetists, a rural hospital or CAH cannot exceed an 

annual limit of 800 surgical procedures requiring anesthesia. We cannot establish the number of 

facilities that would meet this threshold. In addition, although a hospital or CAH may contract 

with more than one qualified nonphysician anesthetist and be paid based on reasonable cost for 

anesthesia and related services performed by these nonphysician anesthetists, the total number of 

hours of service furnished by the nonphysician anesthetists may not exceed 2,080 hours 

annually. We also cannot determine the number of facilities that would exceed this threshold. 

Therefore, while we believe the impact would be relatively minor, we are unable to quantify the 

impact of the proposed change. 

I. Effects of Implementation of Rural Community Hospital Demonstration Program

 In section IV.J. of the preamble of this proposed rule, we discuss our implementation of 

section 410A of Pub. L. 108-173, which 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) requires that "[i]n 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.J. of the preamble of this proposed rule, in the 

IPPS final rule for each of the previous 6 fiscal years, we have estimated the additional payments 
CMS-1498-P 1259 

as a result of the demonstration for each of the participating hospitals. In order to achieve budget 

neutrality, we are proposing to adjust the national IPPS rates by an amount sufficient to account 

for the added costs of this demonstration. In other words, we are proposing to apply budget 

neutrality across the payment system as a whole rather than merely across the participants of this 

demonstration. We believe that the language of the statutory budget neutrality requirement 

permits the agency to implement the budget neutrality provision in this manner. 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. 

 An extension of this demonstration has been mandated by the Patient Protection and 

Affordable Care Act (Pub. L. 111-148). The provisions of Pub. L. 111-148 will be addressed in 

a separate notice in the Federal Register. For this proposed rule, because the mandated period 

for the demonstration was scheduled to end by the end of FY 2010, we are proposing no 

additional payment offset for upcoming years of the demonstration. However, we are proposing 

to make an adjustment in the FY 2011 IPPS final rule to the national IPPS rates to account for 

any differences between the cost of the demonstration program for hospitals participating in the 

demonstration during FY 2007, represented by their cost reports beginning in FY 2007, and the 

amount that was offset by the budget neutrality adjustment for FY 2007. The specific numeric 

value associated with the proposed adjustment to the national IPPS rates cannot be known until 

cost reports beginning in FY 2007 of the hospitals participating during FY 2007 in the 

demonstration are settled. We expect those cost reports to be settled prior to the publication of 

the FY 2011 IPPS final rule, and that we will be able to provide an estimated amount in the 

FY 2011 IPPS final rule. 
CMS-1498-P 1260 

J. Effects of Proposed Changes Relating to CAHs

1. CAH Optional Method of Payment for Outpatient Services 

In section VI.B.2. of the preamble of this proposed rule, we discuss our proposal to 

amend the regulations to permit a CAH to elect to be paid for outpatient services under the 

optional method on a continuous basis. Under existing regulations, if a CAH wishes to be paid 

under the optional method for outpatient services on a continuous basis, it must submit an annual 

election to the fiscal intermediary or MAC servicing the CAH at least 30 days prior to the cost 

reporting period for which the election is made. Due to the significant consequences that result 

if a CAH fails to make a timely election, we are proposing to amend the regulations at 

§413.70(b)(3)(i) to state that, effective for CAH cost reporting periods beginning on or after 

October 1, 2010, if a CAH has elected the optional method for its most recent cost reporting 

period beginning prior to October 1, 2010, or chooses to elect the optional method for its 

upcoming cost reporting period, that election will remain in place until it is terminated. If a 

CAH chooses to terminate its election, it must submit a termination request to the fiscal 

intermediary or MAC servicing the CAH at least 30 days prior to the start of the next cost 

reporting period. In order to provide CAHs that have cost reporting periods beginning in 

October or November 2010 time to choose to terminate an existing election of the optional 

method, we are proposing that these CAHs would have until December 1, 2010, to terminate 

their election. We anticipate that there would be no additional Medicare expenditure associated 

with this proposed change because we are not proposing any changes that govern payment rules 

for CAHs. Rather, we believe the regulatory changes we are proposing would reduce any 

perceived burden associated with the election process and make it easier for CAHs to maintain 

their election of the optional method on a continuous basis. 
CMS-1498-P 1261 

2. Consideration of Costs of Provider Taxes as Allowable Costs for CAHs 

 In section VI.B.3. of the preamble of this proposed rule, we discuss our proposal to 

clarify our policy on the determination of whether the costs of property taxes are allowable costs 

under Medicare, as described in sections 2212.1 and 2212.2 of the PRM. This is a clarification 

of our longstanding policy. Therefore, we have determined that there is no financial impact of 

the proposed change. 

K. Effects of Proposed Policy Relating to Effective Date of Provider Agreements and Supplier 

Approvals

 In section VIII. of the preamble of this proposed rule, we discuss our proposal to clarify 

the requirements supporting the existing process for assignment of an effective date for a 

provider agreement or supplier approval. Approximately 54,500 Medicare providers and 

suppliers are subject to survey and certification requirements under this proposal. However, the 

proposed clarification would not change the process for providers and suppliers. Therefore, the 

impact of our proposed clarification is negligible. 

L. Effects of Proposed Changes Relating to Hospital Rehabilitation Services and Respiratory 

Care Services Conditions of Participation

In section IX. of the preamble of this proposed rule, we discuss our proposed changes to 

the conditions of participation for hospital rehabilitation services and respiratory care services to 

clarify the categories of practitioners allowed to order rehabilitation services and respiratory care 

services. We believe that this proposal would impose minimal additional costs on hospitals. In 

fact, hospitals may realize some minimal cost savings due to the regulatory flexibility of these 

proposed changes, which may allow for greater consistency with existing State laws and with 

hospital policies and procedures. The cost of implementing these proposed changes would 
CMS-1498-P 1262 

largely be limited to the one-time cost related to the revision of a hospital’s medical staff bylaws 

and its policies and procedures as they relate to the proposed requirements for the categories of 

practitioners allowed to order rehabilitation and respiratory care services. There also may be 

some minimal cost associated with communicating these changes to affected hospital staff. 

However, we believe that these costs would be offset by the benefits derived from the 

overall intent of this proposed clarification to allow qualified, licensed practitioners, who are 

authorized by the medical staff, to order these services as long as they are responsible for the 

care of the patient for whom they are ordering the services and as long as such privileges are in 

accordance with hospital policies and applicable State laws and regulations. Furthermore, the 

proposed changes would clarify existing hospital conditions of participation to make them more 

consistent not only with each other, but also with many State laws and with current practice. 

Therefore, while this proposal would impose a minimal burden on hospitals, we believe that, in 

sum, the changes proposed would greatly benefit hospitals overall. 

VIII. Effects 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 (§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 (§412.344). As we state in section V. of 
CMS-1498-P 1263 

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. 

 The basic methodology for determining a capital IPPS payment is set forth at §412.312. 

The basic methodology for calculating capital IPPS payments in FY 2011 is as follows: 

 (Standard Federal Rate) x (DRG weight) x (GAF) x (COLA for hospitals located in 

Alaska and Hawaii) x (1 + DSH Adjustment Factor + IME adjustment factor, if applicable). 

 In addition to the other adjustments, 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 2009 update of the FY 2009 MedPAR file and the December 2009 update of the 

Provider-Specific File (PSF) that is used for payment purposes. Although the analyses of the 

changes to the capital prospective payment system do not incorporate cost data, we used the 

December 2009 update of the most recently available hospital cost report data (FYs 2006 and 

2007) to categorize hospitals. Our analysis has several qualifications. We use the best data 

available and make assumptions about case-mix and beneficiary enrollment as described below. 

In addition, as discussed in section V.E. of the preamble of this proposed rule, we are proposing 

a -2.9 percent documentation and coding adjustment to the capital Federal rate for FY 2011, in 

addition to the -0.6 percent adjustment established for FY 2008 and the -0.9 percent adjustment 

for FY 2009. This proposal results in a cumulative adjustment factor of 0.957 that we are 
CMS-1498-P 1264 

proposing to apply to the capital Federal rate to account for improvements in documentation and 

coding under the MS-DRGs in FY 2011. We also are proposing to adjust the Puerto Ricospecific capital rate in FY 2011 by -2.4 percent to account for changes in documentation and 

coding resulting from the adoption of the MS-DRGs. 

 Due to the interdependent nature of the IPPS, it is very difficult to precisely quantify the 

impact associated with each 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 2009 update of the FY 2009 MedPAR file, we simulated 

payments under the capital PPS for FY 2010 and FY 2011 for a comparison of total payments 

per case. Any short-term, acute care hospitals not paid under the general IPPS (Indian Health 

Service hospitals and hospitals in Maryland) are excluded from the simulations. 

 As we explain in section III.A.4. of the Addendum 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, and outliers, if applicable. For purposes 

of this impact analysis, the model includes the following assumptions: 

● We estimate that the Medicare case-mix index will increase by 1.0 percent in both 

FYs 2010 and 2011. 
CMS-1498-P 1265 

● We estimate that the Medicare discharges will be approximately 11.8 million in FY 

2010 and 12.1 million FY 2011. 

● 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 III.1.a. of the Addendum to this proposed 

rule, the proposed FY 2011 update is 1.5 percent. 

● In addition to the FY 2011 update factor, the proposed FY 2011 capital Federal rate 

was calculated based on a proposed GAF/DRG budget neutrality factor of 1.0000, a proposed 

outlier adjustment factor of 0.9424, and a proposed (special) exceptions adjustment factor of 

0.9997. 

● For FY 2011, as discussed above and in section V.E. of the preamble to this proposed 

rule, we also are proposing to apply a 0.957 adjustment to the proposed FY 2011 capital Federal 

rate for changes in documentation and coding that are expected to increase case-mix under the 

MS-DRGs. 

B. Results

 We used the actuarial model described above to estimate the potential impact of our 

proposed changes for FY 2011 on total capital payments per case, using a universe of 3,472 

hospitals. As described above, the individual hospital payment parameters are taken from the 

best available data, including the December 2009 update of the FY 2009 MedPAR file, the 

December 2009 update to the PSF, and the most recent cost report data from the December 2009 

update of HCRIS. In Table III, we present a comparison of estimated total payments per case for 

FY 2010 compared to FY 2011 based on the proposed FY 2011 payment policies. Column 2 
CMS-1498-P 1266 

shows estimates of payments per case under our model for FY 2010. Column 3 shows estimates 

of payments per case under our model for FY 2011. Column 4 shows the total percentage 

change in payments from FY 2010 to FY 2011. The change represented in Column 4 includes 

the proposed 1.5 percent update to the capital Federal rate and other proposed changes in the 

adjustments to the capital Federal rate. 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 in FY 2011 are 

expected to decrease as compared to capital payments per case in FY 2010. The proposed 

capital Federal rate for FY 2011 would increase 1.5 percent as compared to the FY 2010 capital 

rate. The proposed changes to the GAFs are expected to result, on average, in a slight decrease 

in capital payments, although, for rural areas, it is more of a contributing factor to the overall 

estimated decrease in capital payments than to urban areas mostly due to the application of the 

rural floor to the wage index. Our impact analysis includes actuarial assumptions of growth from 

FY 2010 to FY 2011 resulting in a slight increase in capital payments. The net result of these 

proposed changes is an estimated -0.2 percent change in capital payments per discharge from 

FY 2010 to FY 2011 for all hospitals (as shown below in Table III). 

The geographic comparison shows that, on average, all urban hospitals are expected to 

experience a 0.2 percent decrease in capital IPPS payments per case in FY 2011 as compared to 

FY 2010, while hospitals in large urban areas are expected to experience a 0.1 percent decrease 

in capital IPPS payments per case in FY 2011 as compared to FY 2010. Capital IPPS payments 

per case for rural hospitals are expected to decrease 0.7 percent. 

 The change comparisons by regions show some regions experiencing slight increases in 

total capital payments, while other regions are estimated to experience decreases in capital 
CMS-1498-P 1267 

payments from FY 2010 to FY 2011. For the urban regions, changes in capital payments range 

from a -1.3 percent for the New England urban region to a 0.5 percent for the Pacific urban 

region. Estimates for two urban regions, East North Central and West North Central, show no 

change in total capital payments from FY 2010 to FY 2011. Estimates of changes for the rural 

regions from FY 2010 to FY 2011 range from a 2.3 percent decrease in capital payments in the 

New England rural region to a 0.6 percent increase for the West South Central rural region. 

These regional differences are primarily due to the proposed changes to the GAFs and 

differences in the estimated increase in outlier payments from FY 2010 to FY 2011. 

By type of ownership, proprietary hospitals are estimated to experience an increase of 0.1 

percent in capital payments per case, and voluntary hospitals are estimated to experience a 0.3 

percent decrease in capital payments per case from FY 2010 to FY 2011. We estimate no change 

in capital payments per case for government hospitals from FY 2010 to FY 2011. 

 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 2011. Reclassification for wage index purposes also affects 

the GAFs because that factor is constructed from the hospital wage index. 

 To present the effects of the hospitals being reclassified for FY 2011, we show the 

average capital payments per case for reclassified hospitals for FY 2010. All classifications of 

reclassified hospitals are expected to experience a decrease in capital payments per case in FY 

2011 as compared to FY 2010. Urban reclassified and rural reclassified hospitals are expected to 
CMS-1498-P 1268 

have a decrease in capital payments of 0.2 percent and 0.3 percent, respectively. Capital 

payments for urban nonreclassified are estimated to decrease 0.1 percent while rural 

nonreclassified hospitals are estimated to decrease 1.1 percent. Other reclassified hospitals (that 

is, hospitals reclassified under section 1886(d)(8)(B) of the Act) are expected to experience a 

decrease of 1.6 percent in capital payment from FY 2010 to FY 2011. 

TABLE III.—COMPARISON OF TOTAL PAYMENTS PER CASE 

[FY 2010 Payments Compared To Proposed FY 2011 Payments] 

Number of 

hospitals 

Average FY 

2010 

payments/ 

case 

Average 

Proposed 

FY 2011 

payments/ 

case 

Change 

By Geographic Location: 

 All hospitals ....................................................................................................... 3,472 791 789 -0.2 

 Large urban areas (populations over 1 million) .................................................. 1,365 872 871 -0.1 

 Other urban areas (populations of 1 million of fewer) ......................................... 1,137 780 778 -0.2 

 Rural areas........................................................................................................ 970 549 545 -0.7 

 Urban hospitals.................................................................................................. 2,502 831 829 -0.2 

 0-99 beds....................................................................................................... 635 656 655 -0.1 

 100-199 beds................................................................................................. 791 714 711 -0.4

 200-299 beds................................................................................................. 461 782 779 -0.4

 300-499 beds................................................................................................. 425 854 852 -0.2

 500 or more beds........................................................................................... 190 1,005 1,007 0.2 

 Rural hospitals................................................................................................... 970 549 545 -0.7 

 0-49 beds....................................................................................................... 337 442 442 0.1 

 50-99 beds..................................................................................................... 366 509 504 -1.1 

 100-149 beds................................................................................................. 164 554 551 -0.5

 150-199 beds................................................................................................. 61 600 598 -0.3 

 200 or more beds........................................................................................... 42 670 663 -0.9 

By Region: 

 Urban by Region................................................................................................ 2,502 831 829 -0.2 

 New England ................................................................................................. 121 863 852 -1.3 

 Middle Atlantic ............................................................................................... 330 885 879 -0.7 

 South Atlantic................................................................................................. 383 783 781 -0.2 

 East North Central ......................................................................................... 403 806 806 0.0 

 East South Central......................................................................................... 155 742 739 -0.5 

 West North Central ........................................................................................ 166 817 817 0.0 

 West South Central........................................................................................ 342 776 778 0.3 

 Mountain........................................................................................................ 162 856 855 -0.1 

 Pacific............................................................................................................ 390 987 992 0.5 

 Puerto Rico.................................................................................................... 50 373 375 0.4

 Rural by Region................................................................................................. 970 549 545 -0.7 

 New England ................................................................................................. 24 724 708 -2.3 

 Middle Atlantic ............................................................................................... 70 565 558 -1.2

 South Atlantic................................................................................................. 165 540 534 -1.1 

 East North Central ......................................................................................... 120 574 569 -0.9 

 East South Central......................................................................................... 175 497 495 -0.4 

 West North Central ........................................................................................ 100 562 558 -0.8 

 West South Central........................................................................................ 214 514 517 0.6 

 Mountain........................................................................................................ 71 551 553 0.3 

 Pacific............................................................................................................ 31 693 685 -1.1 

By Payment Classification: 

 All hospitals ....................................................................................................... 3,472 791 789 -0.2 

 Large urban areas (populations over 1 million) .................................................. 1,403 871 870 -0.1 

 Other urban areas (populations of 1 million of fewer) ......................................... 1,152 779 777 -0.2 
CMS-1498-P 1269 

TABLE III.—COMPARISON OF TOTAL PAYMENTS PER CASE 

[FY 2010 Payments Compared To Proposed FY 2011 Payments] 

Number of 

hospitals 

Average FY 

2010 

payments/ 

case 

Average 

Proposed 

FY 2011 

payments/ 

case 

Change 

 Rural areas........................................................................................................ 917 546 542 -0.7 

 Teaching Status: 

 Non-teaching ................................................................................................. 2,434 674 672 -0.3 

 Fewer than 100 Residents ............................................................................. 798 793 790 -0.4 

 100 or more Residents 240 1,121 1,122 0.1 

 Urban DSH: 

 100 or more beds....................................................................................... 1,510 859 858 -0.1 

 Less than 100 beds.................................................................................... 340 593 589 -0.7 

 Rural DSH: 

 Sole Community (SCH/EACH) ................................................................... 407 480 477 -0.6 

 Referral Center (RRC/EACH)..................................................................... 209 603 598 -0.8 

 Other Rural: 

 100 or more beds ................................................................................... 30 500 495 -1.0 

 Less than 100 beds................................................................................ 142 453 448 -1.1 

 Urban teaching and DSH: 

 Both teaching and DSH.................................................................................. 806 929 928 -0.1 

 Teaching and no DSH.................................................................................... 169 807 804 -0.4 

 No teaching and DSH .................................................................................... 1,044 717 715 -0.3 

 No teaching and no DSH ............................................................................... 536 731 731 0.0 

 Rural Hospital Types: 

 Non special status hospitals........................................................................... 2,435 834 833 -0.1 

 RRC/EACH.................................................................................................... 59 747 743 -0.5 

 SCH/EACH.................................................................................................... 38 686 688 0.3 

 Medicare-dependent hospitals (MDH)............................................................ 10 472 468 -1.0 

 SCH, RRC and EACH.................................................................................... 13 830 824 -0.7 

Hospitals Reclassified by the Medicare Geographic Classification Review Board: 

 FY2011 Reclassifications: 

 All Urban Reclassified.................................................................................... 488 835 834 -0.2 

 All Urban Non-Reclassified ............................................................................ 1,985 831 830 -0.1 

 All Rural Reclassified..................................................................................... 322 590 588 -0.3 

 All Rural Non-Reclassified ............................................................................. 585 496 491 -1.1 

 Other Reclassified Hospitals (Section 1886(d)(8)(B)) ..................................... 55 557 548 -1.6 

 Type of Ownership: 

 Voluntary ....................................................................................................... 1,978 807 804 -0.3 

 Proprietary ..................................................................................................... 837 718 719 0.1 

 Government................................................................................................... 577 795 794 0.0 

 Medicare Utilization as a Percent of Inpatient Days: 

 0-25 ............................................................................................................... 353 966 967 0.1 

 25-50 ............................................................................................................. 1,593 859 859 -0.1 

 50-65 ............................................................................................................. 1,202 678 674 -0.5 

 Over 65.......................................................................................................... 237 583 580 -0.5 

IX. Effects of Proposed Payment Rate Changes and Policy Changes under the LTCH PPS

A. Introduction and General Considerations

 In section VII. of the preamble and section V. of the Addendum of this proposed rule, we 

are setting forth the proposed annual update to the payment rates for the LTCH PPS for FY 2011. 

In the preamble, we specify the statutory authority for the proposed provisions that are presented, 
CMS-1498-P 1270 

identify those proposed policies where discretion has been exercised, and present rationale for 

our decisions as well as alternatives that were considered. In this section of Appendix A to this 

proposed rule, we discuss the impact of the proposed changes to the payment rates, factors, and 

other payment rate policies related to the LTCH PPS that are presented in the preamble of this 

proposed rule in terms of their estimated fiscal impact on the Medicare budget and on LTCHs. 

 On March 23, 2010, the Patient Protection and Affordable Care Act, Pub. L. 111-148, 

was enacted. Following the enactment of Pub. L. 111-148, the Health Care and Education 

Reconciliation Act of 2010, Pub. L. 111-152 (enacted on March 30, 2010), amended certain 

provisions of Pub. L. 111-148. A number of the provisions of Pub. L. 111-148, as amended by 

Pub. L. 111-152, affect the IPPS and the LTCH PPS and the providers and suppliers addressed in 

this proposed rule. However, due to the timing of the passage of the legislation, we are unable to 

address those provisions in this proposed rule. Therefore, the proposed policies and payment 

rates in this proposed rule do not reflect the new legislation. We plan to issue separate 

documents in the Federal Register addressing the provisions of Pub. L. 111-148, as amended, 

that affect our proposed policies and payment rates for FY 2011 under the IPPS and the LTCH 

PPS. In addition, we plan to issue further instructions implementing the provisions of Pub. L. 

111-148, as amended, that affect the policies and payment rates for FY 2010 under the IPPS and 

for RY 2010 under the LTCH PPS. 

Currently, our database of 421 LTCHs includes the data for 77 nonprofit (voluntary 

ownership control) LTCHs and 301 proprietary LTCHs. Of the remaining 43 LTCHs, 12 

LTCHs are government-owned and operated and the ownership type of the other 31 LTCHs is 

unknown. In the impact analysis, we are using the proposed rates, factors, and policies presented 

in this proposed rule, including proposed updated wage index values and the labor-related share, 
CMS-1498-P 1271 

and the best available claims and CCR data to estimate the change in payments for FY 2011. 

The standard Federal rate for RY 2010 is $39,896.65. As discussed in section V.A.2. of the 

Addendum to this proposed rule, consistent with our historical practice, we are proposing to 

update the standard Federal rate for FY 2011 by -0.1 percent in order to establish the proposed 

FY 2011 standard Federal rate at $39,856.75. This includes a proposed market basket update of 

2.4 percent and a proposed documentation and coding adjustment of -2.5 percent to account for 

increases in case-mix that do not reflect real changes in patients’ severity of illness associated 

with the adoption of the MS-LTC-DRGs. Based on the best available data for the 421 LTCHs in 

our database, we estimate that the proposed update to the standard Federal rate for FY 2011 

(discussed in section VII.C. of the preamble of this proposed rule) and the proposed changes to 

the area wage adjustment (discussed in section V.B. of the Addendum to this proposed rule) for 

FY 2011, in addition to an estimated increase in HCO payments and an estimated increase in 

SSO payments, will result in an increase in estimated payments from RY 2010 of approximately 

$41 million (or about 0.8 percent). Based on the 421 LTCHs in our database, we estimate FY 

2011 LTCH PPS payments to be approximately $4.946 billion, an increase from RY 2010 LTCH 

PPS payments of approximately $4.905 billion. Because the combined distributional effects and 

estimated changes to the Medicare program payments would be greater than $100 million, this 

proposed rule is considered a major economic rule, as defined in this section. We note the 

approximately $41 million for the projected increase in estimated aggregate LTCH PPS 

payments from RY 2010 to FY 2011 does not reflect changes in LTCH admissions or case-mix 

intensity in estimated LTCH PPS payments, which also would affect overall payment changes. 

The projected 0.8 percent increase in estimated payments per discharge from RY 2010 to 

FY 2011 is attributable to several factors, including the proposed -0.1 percent decrease to the 
CMS-1498-P 1272 

standard Federal rate, proposed changes in the wage index values (including the proposed change 

to the labor-related share) and projected increases in estimated HCO and SSO payments. As 

Table IV shows, the proposed change attributable solely to the standard Federal rate is projected 

to result in an decrease of 0.1 percent in estimated payments per discharge from RY 2010 to FY 

2011, on average, for all LTCHs, while the proposed changes to the area wage adjustment are 

projected to result in an increase in estimated payments of 0.1 percent, on average, for all 

LTCHs. 

As discussed in section V.B. of the Addendum to this proposed rule, we are proposing to 

update the wage index values for FY 2011 based on the most recent available data. In addition, 

we are proposing to decrease the labor-related share slightly from 75.779 percent to 

75.407 percent under the LTCH PPS for FY 2011 based on the most recent available data on the 

relative importance of the labor-related share of operating and capital costs of the RPL market 

basket (discussed in section VII.C.2. of the preamble of this proposed rule). This proposed 

update to the wage data and the labor-related share is expected to increase LTCH PPS payments 

by 0.1 percent. 

Table IV below shows the impact of the proposed payment rate and proposed policy 

changes on LTCH PPS payments for FY 2011 by comparing RY 2010 estimated payments to FY 

2011 estimated payments. The projected increase in payments per discharge from RY 2010 to 

FY 2011 is 0.8 percent (shown in Column 8). This projected increase in payments is attributable 

to the impacts of the proposed change to the standard Federal rate (-0.1 percent in Column 6) and 

the proposed change due to the area wage adjustment (0.1 percent in Column 7), as well as the 

effect of the estimated increase in payments for HCO cases and SSO cases in FY 2011 as 

compared to RY 2010 (0.5 percent and 0.3 percent, respectively). That is, estimated total HCO 
CMS-1498-P 1273 

payments are projected to increase from RY 2010 to FY 2011 in order to ensure that estimated 

HCO payments will be 8 percent of total estimated LTCH PPS payments in FY 2011. An 

analysis of the most recent available LTCH PPS claims data (FY 2009 claims from the 

December 2009 update of the MedPAR files) indicates that the RY 2010 HCO threshold of 

$18,425 may result in HCO payments in RY 2010 that fall below the estimated 8 percent. 

Specifically, we currently estimate that HCO payments will be approximately 7.5 percent of 

estimated total LTCH PPS payments in RY 2010. We estimate that the impact of the increase in 

HCO payments would result in approximately a 0.5 percent increase in estimated payments from 

RY 2010 to FY 2011 on average for all LTCHs. Furthermore, in calculating the estimated 

increase in payments from RY 2010 to FY 2011 for HCO and SSO cases, we increased estimated 

costs by the applicable market basket percentage increase as projected by our actuaries, which 

increases payments by 0.3 percent relative to last year. We note that estimated payments for all 

SSO cases comprise approximately 14 percent of estimated total LTCH PPS payments, and 

estimated payments for HCO cases comprise approximately 8 percent of estimated total LTCH 

PPS payments. Payments for HCO cases are based on 80 percent of the estimated cost above the 

HCO threshold, while the majority of the payments for SSO cases (over 65 percent) are based on 

the estimated cost of the SSO case. 

 As we discuss in detail throughout this proposed rule, based on the most recent available 

data, we believe that the provisions of this proposed rule relating to the LTCH PPS will result in 

an increase in estimated aggregate LTCH PPS payments and that the resulting LTCH PPS 

payment amounts result in appropriate Medicare payments. 
CMS-1498-P 1274 

B. Impact on Rural Hospitals

 For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital 

that is located outside of a Metropolitan Statistical Area and has fewer than 100 beds. As shown 

in Table IV, we are projecting a 1.4 percent increase in estimated payments per discharge for FY 

2011 as compared to RY 2010 for rural LTCHs that would result from the proposed changes 

presented in this proposed rule (that is, the proposed update to the standard Federal rate 

discussed in section V.A. of the Addendum to this proposed rule and the proposed changes to the 

area wage adjustment as discussed in section V.B. of the Addendum to this proposed rule) as 

well as the effect of estimated changes to HCO and SSO payments. This estimated impact is 

based on the data for the 26 rural LTCHs in our database of 421 LTCHs, for which complete 

data were available. 

 The estimated increase in LTCH PPS payments from RY 2010 to FY 2011 for rural 

LTCHs is primarily due to the higher than average impacts from the proposed changes to the 

area wage adjustment and the proposed reduction in the labor-related share from 75.779 to 

75.407 percent, which results in an estimated 0.6 percent increase in payments. We believe that 

the proposed changes to the area wage adjustment presented in this proposed rule (that is, the 

proposed use of updated wage data and the proposed change in the labor-related share) would 

result in accurate and appropriate LTCH PPS payments in FY 2011 because they are based on 

the most recent available data. Such updated data appropriately reflect national differences in 

area wage levels and appropriately identifies the portion of the standard Federal rate that should 

be adjusted to account for such differences in area wages, thereby resulting in accurate and 

appropriate LTCH PPS payments. 
CMS-1498-P 1275 

C. Anticipated Effects of Proposed LTCH PPS Payment Rate Change and Policy Changes

 We discuss the impact of the proposed changes to the payment rates, factors, and other 

payment rate policies under the LTCH PPS for FY 2011 (in terms of their estimated fiscal impact 

on the Medicare budget and on LTCHs) in section VII. of the preamble of this proposed rule. 

1. Budgetary Impact 

Section 123(a)(1) of the BBRA requires that the PPS developed for LTCHs “maintain 

budget neutrality.” We believe that the statute's mandate for budget neutrality applies only to the 

first year of the implementation of the LTCH PPS (that is, FY 2003). Therefore, in calculating 

the FY 2003 standard Federal rate under §412.523(d)(2), we set total estimated payments for 

FY 2003 under the LTCH PPS so that estimated aggregate payments under the LTCH PPS were 

estimated to equal the amount that would have been paid if the LTCH PPS had not been 

implemented. 

As discussed in section IX.A. of this Appendix A, we project an increase in aggregate 

LTCH PPS payments in FY 2011 of approximately $41 million (or 0.8 percent) based on the 421 

LTCHs in our database. 

2. Impact on Providers 

The basic methodology for determining a per discharge LTCH PPS payment is set forth 

in §412.515 through §412.536. In addition to the basic MS-LTC-DRG payment (standard 

Federal rate multiplied by the MS-LTC-DRG relative weight), we make adjustments for 

differences in area wage levels, COLA for Alaska and Hawaii, and SSOs. Furthermore, LTCHs 

may also receive HCO payments for those cases that qualify based on the threshold established 

each year. 
CMS-1498-P 1276 

To understand the impact of the proposed changes to the LTCH PPS payments presented 

in this proposed rule on different categories of LTCHs for FY 2011, it is necessary to estimate 

payments per discharge for RY 2010 using the rates, factors, including the FY 2010 GROUPER 

(Version 27.0) and relative weights, and policies established in the FY 2010 IPPS/RY 2010 

LTCH PPS final rule (74 FR 43945 through 43994 and 44021 through 44030). It is also 

necessary to estimate the payments per discharge that would be made under the proposed LTCH 

PPS rates, factors, policies, and GROUPER (Version 28.0) for FY 2011 (as discussed in VII. of 

the preamble and section V. of the Addendum to this proposed rule). These estimates of 

RY 2010 and FY 2011 LTCH PPS payments are based on the best available LTCH claims data 

and other factors, such as the application of inflation factors to estimate costs for SSO and HCO 

cases in each year. We also evaluated the change in estimated RY 2010 payments to estimated 

FY 2011 payments (on a per discharge basis) for each category of LTCHs. 

Hospital groups were based on characteristics provided in the OSCAR data, FY 2006 

through FY 2007 cost report data in HCRIS, and PSF data. Hospitals with incomplete 

characteristics were grouped into the "unknown" category. Hospital groups include the 

following: 

● Location: large urban/other urban/rural. 

● Participation date. 

● Ownership control. 

● Census region. 

● Bed size. 

 To estimate the impacts of the payment rates and policy changes among the various 

categories of existing providers, we used LTCH cases from the FY 2009 MedPAR file to 
CMS-1498-P 1277 

estimate payments for RY 2010 and to estimate payments for FY 2011 for 421 LTCHs. We 

believe that the discharges based on the FY 2009 MedPAR data for the 421 LTCHs in our 

database, which includes 301 proprietary LTCHs, provide sufficient representation in the MSLTC-DRGs containing discharges for patients who received LTCH care for the most commonly 

treated LTCH patients' diagnoses. 

3. Calculation of Prospective Payments 

For purposes of this impact analysis, to estimate per discharge payments under the LTCH 

PPS, we simulated payments on a case-by-case basis using LTCH claims from the FY 2009 

MedPAR files. For modeling estimated LTCH PPS payments for RY 2010, we applied the RY 

2010 standard Federal rate (that is, $39,896.65, which is effective for LTCH discharges 

occurring on or after October 1, 2009, and through September 30, 2010). For modeling 

estimated LTCH PPS payments for FY 2011, we applied the proposed FY 2011 standard Federal 

rate of $39,856.75, which would be effective for LTCH discharges occurring on or after October 

1, 2010, and through September 30, 2011. 

Furthermore, in modeling estimated LTCH PPS payments for both RY 2010 and FY 

2011 in this impact analysis, we applied the RY 2010 and proposed FY 2011 adjustments for 

area wage differences and the COLA for Alaska and Hawaii. Specifically, we adjusted for area 

wage differences for estimated RY 2010 payments using the RY 2010 LTCH PPS labor-related 

share of 75.779 percent (74 FR 43968), the wage index values established in the Tables 12A and 

12B of the Addendum to the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 44192 

through 44213) and the RY 2010 COLA factors shown in the table in section V. of the 

Addendum to that final rule (74 FR 44026). Similarly, we adjusted for area wage differences for 

estimated FY 2011 payments using the proposed LTCH PPS FY 2011 labor-related share of 
CMS-1498-P 1278 

75.407 percent (section VII.C.2.d. of the preamble of this proposed rule), the FY 2011 proposed 

wage index values presented in Tables 12A and 12B of the Addendum to this proposed rule, and 

the FY 2011 COLA factors shown in the table in section V.B.5. of the Addendum to this 

proposed rule. 

As discussed above, our impact analysis reflects an estimated change in payments for 

SSO cases as well as an estimated increase in payments for HCO cases (as described in section 

V.C. of the Addendum to this proposed rule). In modeling proposed payments for SSO and 

HCO cases in RY 2010, we applied an inflation factor of 1.024 percent (determined by OACT) 

to the estimated costs of each case determined from the charges reported on the claims in the FY 

2009 MedPAR files and the best available CCRs from the December 2009 update of the PSF. In 

modeling proposed payments for SSO and HCO cases in FY 2011, we applied an inflation factor 

of 1.049 (determined by OACT) to the estimated costs of each case determined from the charges 

reported on the claims in the FY 2009 MedPAR files and the best available CCRs from the 

December 2009 update of the PSF. Furthermore, in modeling estimated LTCH PPS payments 

for both RY 2010 and FY 2011 in this impact analysis, we applied the RY 2010 HCO fixed-loss 

amount of $18,425 (74 FR 44029) and the proposed FY 2011 fixed loss amount of $18,692 (as 

discussed in section V.C.3. of the Addendum of this proposed rule). 

These impacts reflect the estimated "losses" or "gains" among the various classifications 

of LTCHs from the RY 2010 to FY 2011 based on the proposed payment rates and policy 

changes presented in this proposed rule. Table IV illustrates the estimated aggregate impact of 

the LTCH PPS among various classifications of LTCHs. 

● The first column, LTCH Classification, identifies the type of LTCH. 

● The second column lists the number of LTCHs of each classification type. 
CMS-1498-P 1279 

● The third column identifies the number of LTCH cases. 

● The fourth column shows the estimated payment per discharge for RY 2010 (as 

described above). 

● The fifth column shows the estimated payment per discharge for FY 2011 (as 

described above). 

● The sixth column shows the percentage change in estimated payments per discharge 

from RY 2010 to FY 2011 for proposed changes to the standard Federal rate (as discussed in 

section V.A. of the Addendum to this proposed rule). 

● The seventh column shows the percentage change in estimated payments per discharge 

from RY 2010 to FY 2011 for proposed changes to the area wage adjustment at §412.525(c) (as 

discussed in section V.B. of the Addendum to this proposed rule). 

● The eighth column shows the percentage change in estimated payments per discharge 

from RY 2010 (Column 4) to FY 2011 (Column 5) for all proposed changes (and includes the 

effect of estimated changes to HCO and SSO payments). 

TABLE IV: Impact of Proposed Payment Rate and Policy Changes to LTCH PPS 

Paymentsfor FY 2011 (Estimated FY 2010 Payments Compared to Estimated FY 2011 

Payments*

) 

LTCH Classification 

(1) 

Number 

of 

LTCHs 

(2) 

Number 

of LTCH 

PPS Cases 

(3) 

Average RY 

2010 LTCH 

PPS Rate 

Year 

Payment Per 

Case1 

(4) 

Average FY 

2011 LTCH 

PPS Rate 

Year 

Proposed 

Payment 

Per Case2 

(5) 

Percent 

Change in 

Estimated 

Payments 

Per 

Discharge 

from RY 

2010 to FY 

2011 for 

Proposed 

Changes to 

the Federal 

Rate 3 

(6) 

Percent 

Change in 

Estimated 

Payments 

Per 

Discharge 

from RY 

2010 to FY 

2011 for 

Proposed 

Changes to 

the Area 

Wage 

Adjustment4 

(7) 

Percent 

Change in 

Payments 

Per 

Discharge 

from RY 

2010 to FY 

2011 for 

All 

Proposed 

Changes5 

(8) 

ALL PROVIDERS 421 131,490 37,304 37,616 -0.1 0.1 0.8 

 

BY LOCATION: 

 RURAL 26 5,610 31,693 32,125 -0.1 0.6 1.4 

 URBAN 395 125,880 37,554 37,860 -0.1 0.1 0.8 
CMS-1498-P 1280 

LTCH Classification 

(1) 

Number 

of 

LTCHs 

(2) 

Number 

of LTCH 

PPS Cases 

(3) 

Average RY 

2010 LTCH 

PPS Rate 

Year 

Payment Per 

Case1 

(4) 

Average FY 

2011 LTCH 

PPS Rate 

Year 

Proposed 

Payment 

Per Case2 

(5) 

Percent 

Change in 

Estimated 

Payments 

Per 

Discharge 

from RY 

2010 to FY 

2011 for 

Proposed 

Changes to 

the Federal 

Rate 3 

(6) 

Percent 

Change in 

Estimated 

Payments 

Per 

Discharge 

from RY 

2010 to FY 

2011 for 

Proposed 

Changes to 

the Area 

Wage 

Adjustment4 

(7) 

Percent 

Change in 

Payments 

Per 

Discharge 

from RY 

2010 to FY 

2011 for 

All 

Proposed 

Changes5 

(8) 

 LARGE 204 75,855 39,025 39,364 -0.1 0.1 0.9 

 OTHER 191 50,025 35,324 35,580 -0.1 0.1 0.7 

 

BY PARTICIPATION DATE: 

 BEFORE OCT. 1983 17 6,244 32,058 32,423 -0.1 0.2 1.1 

 OCT. 1983 - SEPT. 1993 44 16,824 38,212 38,574 -0.1 0.1 0.9 

 OCT. 1993 - SEPT. 2002 189 63,987 36,781 37,053 -0.1 0.1 0.7 

 AFTER OCTOBER 2002 161 41,657 38,501 38,831 -0.1 0.1 0.9 

 UNKNOWN 

PARTICIPATION DATE 10 2,778 37,710 38,233 -0.1 0.3 1.4 

 

BY OWNERSHIP TYPE: 

 VOLUNTAFY 77 19,922 37,393 37,822 -0.1 0.2 1.1 

 PROPRIETARY 301 105,986 37,212 37,492 -0.1 0.1 0.8 

 GOVERNMENT 12 1,588 38,960 39,458 -0.1 -0.2 1.3 

 UNKNOWN OWNERSHIP 

TYPE 31 3,994 38,639 39,134 -0.1 0.1 1.3 

 

BY REGION: 

 NEW ENGLAND 15 7,584 32,848 33,213 -0.1 0.1 1.1 

 MIDDLE ATLANTIC 29 7,742 38,086 38,320 -0.1 -0.2 0.6 

 SOUTH ATLANTIC 55 14,665 40,522 40,765 -0.1 -0.2 0.6 

 EAST NORTH CENTRAL 68 19,194 40,304 40,652 -0.1 0.2 0.9 

 EAST SOUTH CENTRAL 31 7,909 37,380 37,569 -0.1 -0.2 0.5 

 WEST NORTH CENTRAL 24 5,178 38,607 38,834 -0.1 0.0 0.6 

 WEST SOUTH CENTRAL 142 50,537 32,924 33,239 -0.1 0.3 1 

 MOUNTAIN 32 6,268 40,358 40,725 -0.1 0.0 0.9 

 PACIFIC 25 12,413 46,801 47,221 -0.1 0.3 0.9 

 

BY BED SIZE: 

 BEDS: 0-24 42 5,288 32,969 33,438 -0.1 0.6 1.4 

 BEDS: 25-49 192 41,372 37,081 37,298 -0.1 0.0 0.6 

 BEDS: 50-74 101 32,024 38,230 38,567 -0.1 0.1 0.9 

 BEDS: 75-124 50 22,652 39,512 39,955 -0.1 0.3 1.1 

 BEDS: 125-199 21 15,145 35,296 35,660 -0.1 0.2 1 

 BEDS: 200 + 15 15,009 36,168 36,378 -0.1 0.0 0.6 

1

 Estimated RY 2010 payments based on the rates, factors, including the FY 2010 GROUPER (Version 27.0) and relative weights, and policies 

established in the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43945 through 43994 and 44021 through 44030). 
CMS-1498-P 1281 

2

 Estimated FY 2011 LTCH PPS payments based on the proposed payment rates and policy changes presented in the preamble and the 

Addendum of this proposed rule. 

3

 Percent change in estimated payments per discharge from RY 2010 to FY 2011 for the proposed changes to the standard Federal rate, as 

discussed in section V.A. of the Addendum to this proposed rule. 

4

 Percent change in estimated payments per discharge from RY 2010 to FY 2011 for proposed changes to the area wage adjustment at

§412.525(c) (as discussed in section V.B. of the Addendum to this proposed rule). 

5

 Percent change in estimated payments per discharge from RY 2010 LTCH PPS (shown in Column 4) to FY 2011 LTCH PPS (shown in Column 

5), including all of the proposed changes presented in the preamble of this proposed rule. Note, this column, which shows the percent change in 

estimated payments per discharge for all proposed changes, does not equal the sum of the percent changes in estimated payments per discharge 

for proposed changes to the standard Federal rate (column 6) and the proposed changes to the area wage adjustment (Column 7) due to the effect 

of estimated changes in both estimated payments to SSO cases that are paid based on estimated costs and aggregate HCO payments (as discussed 

in this impact analysis), as well as other interactive effects that cannot be isolated. 

4. Results 

Based on the most recent available data (as described previously for 421 LTCHs, we 

have prepared the following summary of the impact (as shown in Table IV) of the proposed 

LTCH PPS payment rate and policy changes presented in this proposed rule. The impact 

analysis in Table IV shows that estimated payments per discharge are expected to increase 

approximately 0.8 percent, on average, for all LTCHs from RY 2010 to FY 2011 as a result of 

the proposed payment rate and policy changes presented in this proposed rule, as well as 

estimated increases in HCO and SSO payments. We note that we are proposing a -0.1 percent 

decrease to the standard Federal rate for FY 2011, based on the latest market basket estimate 

(2.4 percent) and the adjustment for the cumulative effect of changes in documentation and 

coding in FYs 2008 and 2009 (-2.5 percent). We noted earlier in this section that for most 

categories of LTCHs, as shown in Table IV (Column 6), the impact of the proposed decrease of -

0.1 percent to the standard Federal rate is projected to result in approximately a -0.1 percent 

decrease in estimated payments per discharge for all LTCHs from RY 2010 to FY 2011. 

Furthermore, as discussed previously in this regulatory impact analysis, the average increase in 

estimated payments per discharge from the RY 2010 to FY 2011 for all LTCHs of approximately 

0.8 percent (as shown in Table IV) was determined by comparing estimated FY 2011 LTCH PPS 

payments (using the proposed rates and policies discussed in this proposed rule) to estimated RY 

2010 LTCH PPS payments (as described above in section IX.C. of this Appendix A). 
CMS-1498-P 1282 

a. Location 

Based on the most recent available data, the vast majority of LTCHs are located in urban 

areas. Only approximately 6 percent of the LTCHs are identified as being located in a rural area, 

and approximately 4 percent of all LTCH cases are treated in these rural hospitals. The impact 

analysis presented in Table IV shows that the average percent increase in estimated payments per 

discharge from RY 2010 to FY 2011 for all hospitals is 0.8 percent for all proposed changes. For 

rural LTCHs, the percent change for all proposed changes is estimated to be 1.4 percent, while 

for urban LTCHs, we estimate the increase to be 0.8 percent. Large urban LTCHs are projected 

to experience an increase of 0.9 percent in estimated payments per discharge from RY 2010 to 

FY 2011, while other urban LTCHs are projected to experience an increase of 0.7 percent in 

estimated payments per discharge from RY 2010 to FY 2011, as shown in Table IV. 

b. Participation Date 

LTCHs are grouped by participation date into four categories: (1) before October 1983; 

(2) between October 1983 and September 1993; (3) between October 1993 and September 2002; 

and (4) after October 2002. Based on the most recent available data, the majority (approximately 

49 percent) of the LTCH cases are in hospitals that began participating between October 1993 

and September 2002, and are projected to experience nearly the average increase (0.7 percent) in 

estimated payments per discharge from RY 2010 to FY 2011, as shown in Table IV. 

In the participation category where LTCHs began participating in Medicare before 

October 1983, LTCHs are projected to experience a higher than average percent increase (1.1 

percent) in estimated payments per discharge from RY 2010 to FY 2011, as shown in Table IV. 

Approximately 4 percent of LTCHs began participating in Medicare before October 1983. The 

LTCHs in this category are projected to experience a higher than average increase in estimated 
CMS-1498-P 1283 

payments because of estimated increases in payments due to the proposed change to the area 

wage adjustment, the proposed changes in the MS-LTC-DRG classifications and relative 

weights, and also because of estimated increases in their SSO payments relative to last year. 

Approximately 10 percent of LTCHs began participating in Medicare between October 1983 and 

September 1993. These LTCHs are projected to experience a slightly above average increase 

(0.9 percent) in estimated payments from RY 2010 to FY 2011. LTCHs that began participating 

in Medicare after October 2002 currently represent approximately 38 percent of all LTCHs, and 

are projected to experience a slightly above average increase (0.9 percent) in estimated payments 

from RY 2010 to FY 2011. 

c. Ownership Control 

Other than LTCHs whose ownership control type is unknown, LTCHs are grouped into 

three categories based on ownership control type: voluntary, proprietary, and government. 

Based on the most recent available data, approximately 18 percent of LTCHs are identified as 

voluntary (Table IV). We expect that, for these LTCHs in the voluntary category, estimated FY 

2011 LTCH payments per discharge will increase higher than the average (1.1 percent) in 

comparison to estimated payments in RY 2010 primarily because we project an increase in 

estimated HCO payments and SSO payments to be higher than the average for these LTCHs. 

The majority (71 percent) of LTCHs are identified as proprietary and these LTCHs are projected 

to experience an average increase (0.8 percent) in estimated payments per discharge from RY 

2010 to FY 2011. Finally, government-owned and operated LTCHs (3 percent) are expected to 

experience a higher than the average increase (1.3 percent) in estimated payments primarily due 

to a larger than the average increase in estimated HCO payments and increases under the 

proposed MS-LTC-DRG GROUPER (Version 28) and relative weights. 
CMS-1498-P 1284 

d. Census Region 

Estimated payments per discharge for FY 2011 are projected to increase for LTCHs 

located in all regions in comparison to RY 2010. Of the 9 census regions, we project that the 

increase in estimated payments per discharge will have the largest positive impact on LTCHs in 

the New England and West South Central regions (1.1 percent, 1.0, respectively, as shown in 

Table IV). The estimated percent increase in payments per discharge from RY 2010 to FY 2011 

for New England is largely attributable to the projected increase in estimated HCO and SSO 

payments (explained in greater detail above in section XV.B.4. of this Appendix A). The 

projected increase in estimated payments per discharge from RY 2010 to FY 2011 for LTCHs in 

the West South Central region is mostly due to the 43 percent of providers in this region that 

would receive a higher wage index in FY 2011 compared to RY 2010 and because all the 

providers have a proposed FY 2011 wage index less than 1, which results in an estimated 

payment increase because the proposed labor-related share (the portion of the rate adjusted by 

the wage index) is being reduced so their lower wage index adjusts a smaller portion of the rate. 

 In contrast, LTCHs located in the East South Central region are projected to experience a 

lower than average increase in estimated payments per discharge from RY 2010 to FY 2011. 

The less than average estimated increase in payments of 0.5 percent for LTCHs in the East South 

Central region is primarily due to estimated decreases in payments associated with the proposed 

wage index because 50 percent of LTCHs located in this region will have a proposed FY 2011 

wage index value that is less than their RY 2010 wage index value. Similarly, LTCHs in the 

Middle Atlantic and South Atlantic are expected to experience a below average increase in 

payments of 0.6 percent primarily due to an estimated decrease in payment because of the 

proposed FY 2011 wage index changes. 
CMS-1498-P 1285 

e. Bed Size 

 LTCHs were grouped into six categories based on bed size: 0-24 beds; 25-49 beds; 

50-74 beds; 75-124 beds; 125-199 beds; and greater than 200 beds. 

We project that payments for small LTCHs (0-24 beds) will experience a 1.4 percent increase in 

payments due to increases in their wage index while large LTCHs (200+ beds) will experience 

smaller than average increase in payments of 0.6 percent. LTCHs with between 75 and 124 beds 

and between 125 and 199 beds are expected to experience an above average increase in 

payments per discharge from RY 2010 to FY 2011 (1.1 percent and 1.0 percent, respectively) 

primarily due to a larger than average estimated increase in payments from the proposed 

FY 2011 changes to the area wage adjustment. 

D. Effect on the Medicare Program

 As noted previously, we project that the provisions of this proposed rule will result in an 

increase in estimated aggregate LTCH PPS payments in FY 2011 of approximately $41 million 

(or about 0.8 percent) for the 421 LTCHs in our database. 

E. Effect on Medicare Beneficiaries

Under the LTCH PPS, hospitals receive payment based on the average resources 

consumed by patients for each diagnosis. We do not expect any changes in the quality of care or 

access to services for Medicare beneficiaries under the LTCH PPS, but we expect that paying 

prospectively for LTCH services would enhance the efficiency of the Medicare program. 

X. Effects of Proposed Policy Changes Regarding Accreditation Requirements for 

Medicaid Providers of Inpatient Psychiatric Services for Individuals under Age 21 

In section X. of the preamble of this proposed rule, we discuss our proposal to remove the 

Medicaid requirement for Joint Commission accreditation of psychiatric hospitals, hospitals with 
CMS-1498-P 1286 

inpatient psychiatric programs, and PRTFs. Psychiatric hospitals would have the choice of 

meeting the requirements to participate in Medicare as a psychiatric hospital under 42 CFR 

482.60, or obtaining accreditation from a national accrediting organization whose psychiatric 

hospital accrediting program has been approved by CMS. Hospitals with inpatient psychiatric 

programs would have the choice of meeting the requirements for participation in Medicare as a 

hospital as specified in 42 CFR Part 482 or obtaining accreditation from a national accrediting 

organization whose hospital accreditation program has been approved by CMS. In addition, 

PRTFs would be afforded the flexibility in obtaining accreditation by a national accrediting 

organization whose program has been approved by CMS, or by any other accrediting 

organization with comparable standards that is recognized by the State. This proposal would 

remove specific references to national accrediting bodies to provide appropriate administrative 

flexibility to account for any changes in qualifying accrediting organizations. 

Ensuring access to services is a priority for CMS, and we believe that this proposal would 

result in psychiatric hospitals, hospitals with inpatient psychiatric programs, and PRTFs meeting 

comparable standards required in order to provide services. In addition, the proposed revision to 

the accreditation requirement aligns Medicaid standards with existing standards in the Medicare 

program. We believe that this flexibility in obtaining accreditation will facilitate the provision of 

medically necessary, Medicaid-reimbursable psychiatric services to vulnerable children, while 

maintaining the high quality of care demanded by the Medicaid program. 

We are not preparing an analysis for this proposal under the RFA because we have 

determined that the proposal would not have a significant economic impact on a substantial 

number of small entities. 
CMS-1498-P 1287 

We are not preparing an analysis for section 1102(b) of the Act because this proposal 

would not have a significant impact on the operations of a substantial number of small rural 

hospitals. 

 Section 202 of the Unfunded Mandates Reform Act of 1995 also requires that agencies 

assess anticipated costs and benefits before issuing any rule that may result in expenditure in any 

one year of $100 million in 1995 dollars, updated annually for inflation. That threshold level is 

currently approximately $135 million. This proposal would not result in an impact of $135 

million or more on State, local or tribal governments, in the aggregate, or on the private sector. 

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. Because this proposal does not impose any costs on State or local 

governments, the requirements of Executive Order 13132 are not applicable. 

XI. Alternatives Considered 

 This proposed rule contains a range of policies. The preamble of this proposed rule 

provides descriptions of the statutory provisions that are addressed, identifies implementing 

policies where discretion has been exercised, and presents rationales for our decisions and, where 

relevant, alternatives that were considered. 

XII. Overall Conclusion 

A. Acute Care Hospitals

Table I of section VI. of this Appendix demonstrates the estimated distributional impact 

of the IPPS budget neutrality requirements for the proposed MS-DRG and wage index changes, 

and for the wage index reclassifications under the MGCRB. Table I also shows an overall 
CMS-1498-P 1288 

decrease of 0.1 percent in operating payments. We estimate that operating payments will 

decrease by approximately $142 million in FY 2011. In addition, this estimate includes the 

reporting of hospital quality data program costs of $2.4 million, and a savings of $21 million 

associated with the proposed HACs policies and all other proposed operating payment policies 

described in section VII. of this Appendix. We estimate that capital payments will experience 

-0.2 percent change in payments per case, as shown in Table III of section VIII. of this 

Appendix. We estimate that capital payments will decrease by approximately $20 million in 

FY 2011 compared to FY 2010. The proposed cumulative operating and capital payments 

should result in a net decrease of $181 million to IPPS providers. The discussions presented in 

the previous pages, in combination with the rest of this proposed rule, constitute a regulatory 

impact analysis. 

B. LTCHs

Overall, LTCHs are projected to experience an increase in estimated payments per 

discharge in FY 2011. In the impact analysis, we are using the proposed rates, factors, and 

policies presented in this proposed rule, including proposed updated wage index values and 

relative weights, and the best available claims and CCR data to estimate the change in payments 

under the LTCH PPS for FY 2011. Accordingly, based on the best available data for the 421 

LTCHs in our database, we estimate that FY 2011 LTCH PPS payments will increase 

approximately $41 million (or about 0.8 percent). 

XIII. Accounting Statements 

A. Acute Care Hospitals

 As required by OMB Circular A-4 (available at 

http://www.whitehousegov/omb/circulars/a004/a-4.pdf), in Table V below, we have prepared an 
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accounting statement showing the classification of the expenditures associated with the 

provisions of this proposed rule as they relate to acute care hospitals. This table provides our 

best estimate of the change in Medicare payments to providers as a result of the proposed 

changes to the IPPS presented in this proposed rule. All expenditures are classified as transfers 

to Medicare providers. 

Table V.—Accounting Statement: Classification of Estimated Expenditures under the 

IPPS from FY 2010 to FY 2011 

Category Transfers 

Annualized Monetized Transfers -$181 million 

From Whom to Whom Federal Government to IPPS Medicare Providers 

Total -$181 million 
CMS-1498-P 1290 

B. LTCHs

As discussed in section IX. of this Appendix, the impact analysis for the proposed 

changes under the LTCH PPS for this proposed rule projects an increase in estimated aggregate 

payments of approximately $41 million (or about 0.8 percent) for the 421 LTCHs in our database 

that are subject to payment under the LTCH PPS. Therefore, as required by OMB Circular A-4 

(available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table VI below, we 

have prepared an accounting statement showing the classification of the expenditures associated 

with the provisions of this proposed rule as they relate to changes to the LTCH PPS. Table VI 

provides our best estimate of the proposed increase in Medicare payments under the LTCH PPS 

as a result of the proposed provisions presented in this proposed rule based on the data for the 

421 LTCHs in our database. All expenditures are classified as transfers to Medicare providers 

(that is, LTCHs). 

TABLE VI. —Accounting Statement: Classification of Estimated Expenditures from the 

2010 LTCH PPS Rate Year to the FY 2011 LTCH PPS 

Category Transfers 

Annualized Monetized Transfers Positive transfer--Estimated increase in 

expenditures: $41 million 

From Whom to Whom Federal Government to LTCH PPS Medicare 

Providers 

Total $41 million 

XIV. Executive Order 12866 

In accordance with the provisions of Executive Order 12866, the Executive Office of 

Management and Budget reviewed this proposed rule. 
CMS-1498-P 1291 

Appendix B: Recommendation of Update Factors for Operating Cost Rates of Payment for 

Inpatient Hospital Services 

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) 

of the Act, we are required to publish update factors recommended by the Secretary in the 

proposed and final IPPS rules, respectively. Accordingly, this Appendix provides the 

recommendations for the update factors for the IPPS national standardized amount, the Puerto 

Rico-specific standardized amount, the hospital-specific rates for SCHs and MDHs, and the rateof-increase limits for certain hospitals excluded from the IPPS, as well as LTCHs, IPFs, and 

IRFs. We also discuss our response to MedPAC’s recommended update factors for inpatient 

hospital services. 

II. Inpatient Hospital Update for FY 2011 

 On March 23, 2010, the Patient Protection and Affordable Care Act (PPACA), 

Pub. L. 111-148 was enacted. Following the enactment of Pub. L. 111-148, the Health Care and 

Education Reconciliation Act of 2010, Public L. 111-152 (enacted on March 30, 2010), amended 

certain provisions of Pub. L. 111-148. A number of the provisions of Pub. L. 111-148, as 

amended by Pub. L. 111-152, affect the IPPS and the LTCH PPS and the providers and suppliers 

addressed in this proposed rule. However, due to the timing of the passage of the legislation, we 

are unable to address those provisions in this proposed rule. Therefore, the proposed policies 

and payment rates in this proposed rule do not reflect the new legislation. We plan to issue 
CMS-1498-P 1292 

separate documents in the Federal Register addressing the provisions of Pub. L. 111-148, as 

amended, that affect our proposed policies and payment rates for FY 2011 under the IPPS and 

LTCH PPS, as well as the provisions of Pub. L. 111-148, as amended, that affect the policies and 

payment rates for FY 2010 under the IPPS and LTCH PPS. 

 Section 1886(b)(3)(B)(i)(XX) of the Act, as amended by section 5001(a) of Pub. L. 

109-171, sets the FY 2011 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 section 1886(b)(3)(B)(viii) of the Act. For hospitals that do not provide these data, the 

update is equal to the market basket percentage increase less 2.0 percentage points. 

 Consistent with current law, based on IHS Global Insight, Inc.'s first quarter 2010 

forecast, with historical data through the 2009 fourth quarter, of the FY 2011 IPPS market basket 

increase, we are estimating that the FY 2011 update to the standardized amount will be 2.4 

percent (that is, the current estimate of the market basket rate-of-increase) for hospitals in all 

areas, provided the hospital submits quality data in accordance with our rules. For hospitals that 

do not submit quality data, we are estimating that the update to the standardized amount will be 

0.4 percent (that is, the current estimate of the market basket rate-of-increase minus 

2.0 percentage points). 

Section 1886(d)(9)(C)(1) of the Act is the basis for determining the percentage increase 

to the Puerto Rico-specific standardized amount. For FY 2011, we are proposing to apply the 

full rate-of-increase in the hospital market basket for IPPS hospitals to the Puerto Rico-specific 

standardized amount. Therefore, the update to the Puerto Rico-specific standardized amount is 

estimated to be 2.4 percent. 
CMS-1498-P 1293 

 Section 1886(b)(3)(B)(iv) of the Act sets the FY 2011 percentage increase in the hospitalspecific 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 estimated to be 2.4 or 0.4 percent, depending upon 

whether the hospital submits quality data. 

 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. In addition, section 124 of Pub. L. 

106-113 provides the statutory authority for updating all aspects of the payment rates for IPFs. 

 Currently, children's hospitals, cancer hospitals, and RNHCIs are the remaining three 

types of hospitals still reimbursed under the reasonable cost methodology. We are proposing to 

provide our current estimate of the FY 2011 IPPS operating market basket percentage increase 

(2.4 percent) to update the target limits for children’s hospitals, cancer hospitals, and RNHCIs. 

 For FY 2011, as discussed in section VII. of the preamble to this proposed rule, we are 

proposing an update of -0.1 percent to the LTCH PPS standard Federal rate, which is based on a 

proposed market basket increase of 2.4 percent (based on IHS Global Insight, Inc.'s first quarter 
CMS-1498-P 1294 

2010 forecast of the FY 2002-based RPL market basket increase for FY 2011) and an adjustment 

of -2.5 percent to account for the increase in case-mix in a prior year that resulted from changes 

in coding practices rather than an increase in patient severity. 

 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. 

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 (69 FR 45721). 

III. Secretary’s Recommendations 

 MedPAC is recommending an inpatient hospital update equal to the market basket rate of 

increase for FY 2011. MedPAC’s rationale for this update recommendation is described in more 

detail below. As mentioned above, 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. 

Consistent with the update factor in the President’s budget, we are recommending an update to 

the standardized amount of 2.9 percent. We are recommending that this same update factor 

apply to SCHs and MDHs. 

 Section 1886(d)(9)(C)(i) of the Act is the basis for determining the percentage increase to 

the Puerto Rico-specific standardized amount. For FY 2011, we are proposing to apply the full 
CMS-1498-P 1295 

rate-of-increase in the hospital market basket for IPPS hospitals to the Puerto Rico-specific 

standardized amount. Therefore, the update to the Puerto Rico-specific standardized amount is 

estimated to be 2.4 percent. 

 In addition to making a recommendation for IPPS hospitals, in accordance with section 

1886(e)(4)(A) of the Act, we also are recommending update factors for all other types of 

hospitals. Consistent with the update factor in the President’s budget, we are recommending an 

update for children's hospitals, cancer hospitals, and RNHCIs of 2.9 percent. 

 For FY 2011, consistent with the proposal set forth in section VII. of the preamble of this 

proposed rule, we are recommending an update of -0.1 percent to the LTCH PPS standard 

Federal rate. In addition, based on IHS Global Insight, Inc.'s first quarter 2010 forecast of the 

RPL market basket increase, we are recommending an update of 2.4 percent to the IRF PPS 

Federal rate for FY 2011 and an update of 2.4 percent to the IPF PPS Federal rate for RY 2011 

for the Federal per diem payment amount. 

IV. MedPAC Recommendation for Assessing Payment Adequacy and Updating Payments 

in Traditional Medicare 

 In its March 2010 Report to Congress, MedPAC assessed the adequacy of current 

payments and costs, and the relationship between payments and an appropriate cost base. 

MedPAC recommended an update to the hospital inpatient rates equal to the increase in the 

hospital market basket in FY 2011, concurrent with implementation of a quality incentive 

program. MedPAC’s reasoning is that under a quality program, an individual hospital’s quality 

performance should determine whether its net increase in payments is above or below the market 

basket increase. MedPAC noted the importance of hospitals to control their costs rather than 

accommodate the current rate of cost growth. 
CMS-1498-P 1296 

 MedPAC also noted that indicators of payment adequacy are positive. MedPAC expects 

Medicare margins to remain low in 2011. At the same time though, MedPAC’s analysis finds 

that high-performing hospitals have been able to maintain relatively low costs while maintaining 

a relatively high quality of care. In addition, roughly half of these providers are generating a 

profit on their Medicare business. 

 Response: Similar to our response last year, we agree with MedPAC that hospitals 

should control costs rather than have Medicare accommodate the current rate of growth. As 

MedPAC noted, the lack of financial pressure at certain hospitals can lead to higher costs and in 

turn bring down the overall Medicare margin for the industry.

 In addition to the quality data that hospitals are required to submit to CMS, as discussed 

in section II. of the preamble of this proposed rule, CMS implemented the MS-DRGs in FY 2008 

to better account for severity of illness under the IPPS and is basing the DRG weights on costs 

rather than charges. We continue to believe that these refinements will better match Medicare 

payment of the cost of care and provide incentives for hospitals to be more efficient in 

controlling costs. 

 We note that, because the operating and capital prospective payment systems remain 

separate, we are continuing to use separate updates for operating and capital payments. The 

proposed update to the capital rate is discussed in section III. of the Addendum to this proposed 

rule. 

[FR Doc. 2010-9163 Filed 04/19/2010 at 4:15 pm; Publication Date: 05/04/2010]